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Towards interoperable and knowledge-based electronic health records using archetype methodology
Linköping University, Department of Biomedical Engineering. Linköping University, The Institute of Technology.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The use of Electronic Health Records (EHR) is wide spread in healthcare today. EHRs are not only used to support daily care but also used to support important secondary uses, e.g. clinical research, quality assurance and education. Although considered advantageous compared to paper-based records, EHRs still have a long way to go in realizing its full potential as an integral part of a safe, effective and efficient health care system.

Making EHRs interoperable is a prerequisite to support increasingly distributed and diverse healthcare. Bringing up-to-date knowledge into EHRs for decision support is a critical step to foster evidence based care. EHR data from different sources need to be analyzed in research in order to find new evidence for improvement of the current practice. Knowledge in the form of guidelines needs to be disseminated and applied in practice through continuous education. This cyclic flow of information and knowledge between care, research and education must be facilitated in order to achieve a safer and more efficient healthcare. An interoperable EHR framework can facilitate the sharing of information and knowledge between not only human users but also participating software systems. This is the aim of this thesis, which is built upon the research in the field of semantic interoperability, in particular the pioneering work by the openEHR Foundation.

The journey of this thesis started with a template-based supplementary EHR system - Julius, which allows clinicians to define and share record structures for care and research. The formalism behind Julius is comparable to the openEHR archetype formalism but less expressive and without the backing of international standards. This finding led to an open source implementation of the openEHR design, which in turn initiated the validation and further improvements of the archetype formalism. The software components made the archetype formalism more accessible to academic and commercial projects around the world.

The investigation of the convertibility between a legacy EHR content model and the archetype model showed that the archetype format is more expressive and thus can be used to preserve legacy EHR content definitions. A general strategy for migration from legacy EHRs to archetype-based EHRs was formulated. A novel way of representing clinical practice guidelines using archetype formalism was proposed and tested on a lymphoma chemotherapy guideline. The implication of this study is improved interoperability between guidelines and EHRs that could facilitate both clinical decision support and guideline-compliance checking. Maintainability of guidelines could be increased through reuse of EHR content models as building blocks of guidelines. In the last part of the research, a way of expressing fully structured care plans using openEHR and CONTsys has been explored based on the requirements for elderly home care. A sharable and semantically well-defined care plan could contribute to the coordination of shared care.

The key contribution of the thesis can be summarized as the validation and further improvement of the openEHR archetype formalism through software implementation and the explorations on clinical guidelines, shared care plans and legacy EHR content models in relation to archetypebased EHR framework.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 44 p.
Series
Linköping Studies in Science and Technology. Dissertations, ISSN 0345-7524 ; 1280
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-54822ISBN: 978-91-7393-504-3 (print)OAI: oai:DiVA.org:liu-54822DiVA: diva2:310580
Public defence
2009-11-05, Eken, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2010-04-14 Created: 2010-04-14 Last updated: 2012-11-15Bibliographically approved
List of papers
1. Julius--a template based supplementary electronic health record system
Open this publication in new window or tab >>Julius--a template based supplementary electronic health record system
2007 (English)In: BMC Medical Informatics and Decision Making, ISSN 1472-6947, Vol. 7, no 10Article in journal (Refereed) Published
Abstract [en]

Background: EHR systems are widely used in hospitals and primary care centres but it is usually difficult to share information and to collect patient data for clinical research. This is partly due to the different proprietary information models and inconsistent data quality. Our objective was to provide a more flexible solution enabling the clinicians to define which data to be recorded and shared for both routine documentation and clinical studies. The data should be possible to reuse through a common set of variable definitions providing a consistent nomenclature and validation of data. Another objective was that the templates used for the data entry and presentation should be possible to use in combination with the existing EHR systems.

Methods: We have designed and developed a template based system (called Julius) that was integrated with existing EHR systems. The system is driven by the medical domain knowledge defined by clinicians in the form of templates and variable definitions stored in a common data repository. The system architecture consists of three layers. The presentation layer is purely webbased, which facilitates integration with existing EHR products. The domain layer consists of the template design system, a variable/clinical concept definition system, the transformation and validation logic all implemented in Java. The data source layer utilizes an object relational mapping tool and a relational database.

Results: The Julius system has been implemented, tested and deployed to three health care units in Stockholm, Sweden. The initial responses from the pilot users were positive. The template system facilitates patient data collection in many ways. The experience of using the template system suggests that enabling the clinicians to be in control of the system, is a good way to add supplementary functionality to the present EHR systems.

Conclusion: The approach of the template system in combination with various local EHR systems can facilitate the sharing and reuse of validated clinical information from different health care units. However, future system developments for these purposes should consider using the openEHR/CEN models with shareable archetypes.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-38662 (URN)10.1186/1472-6947-7-10 (DOI)45253 (Local ID)45253 (Archive number)45253 (OAI)
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2010-06-07Bibliographically approved
2. The openEHR Java Reference Implementation Project
Open this publication in new window or tab >>The openEHR Java Reference Implementation Project
2007 (English)In: Proceedings of the 12th World Congress onHealth (Medical) Informatics / [ed] K.A. Kuhn, J.R. Warren and T.-Y. Leong, IOS Press , 2007, 58-62 p.Conference paper, Published paper (Refereed)
Abstract [en]

The openEHR foundation has developed an innovative design for interoperable and future-proof Electronic Health Record (EHR) systems based on a dual model approach with a stable reference information model complemented by archetypes for specific clinical purposes.

A team from Sweden has implemented all the stable specifications in the Java programming language and donated the source code to the openEHR foundation. It was adopted as the openEHR Java Reference Implementation in March 2005 and released under open source licenses. This encourages early EHR implementation projects around the world and a number of groups have already started to use this code.

The early Java implementation experience has also led to the publication of the openEHR Java Implementation Technology Specification. A number of design changes to the specifications and important minor corrections have been directly initiated by the implementation project over the last two years. The Java Implementation has been important for the validation and improvement of the openEHR design specifications and provides building blocks for future EHR systems.

Place, publisher, year, edition, pages
IOS Press, 2007
Keyword
Electronic Health Records, Health Information Systems, openEHR, Java, open source
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-38638 (URN)45134 (Local ID)978-1-58603-774-1 (ISBN)45134 (Archive number)45134 (OAI)
Conference
12th World Congress on Health (Medical) Informatics Brisbane Convention Centre, 20–24 August, Brisbane, Australia
Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2010-04-14Bibliographically approved
3. Archetype-based conversion of EHR content models: pilot experience with a regional EHR system
Open this publication in new window or tab >>Archetype-based conversion of EHR content models: pilot experience with a regional EHR system
Show others...
2009 (English)In: BMC Medical Informatics and Decision Making, ISSN 1472-6947, Vol. 9, no 33Article in journal (Refereed) Published
Abstract [en]

Background: Exchange of Electronic Health Record (EHR) data between systems from different suppliers is a major challenge. EHR communication based on archetype methodology has been developed by openEHR and CEN/ISO. The experience of using archetypes in deployed EHR systems is quite limited today. Currently deployed EHR systems with large user bases have their own proprietary way of representing clinical content using various models. This study was designed to investigate the feasibility of representing EHR content models from a regional EHR system as openEHR archetypes and inversely to convert archetypes to the proprietary format. Methods: The openEHR EHR Reference Model (RM) and Archetype Model (AM) specifications were used. The template model of the Cambio COSMIC, a regional EHR product from Sweden, was analyzed and compared to the openEHR RM and AM. This study was focused on the convertibility of the EHR semantic models. A semantic mapping between the openEHR RM/AM and the COSMIC template model was produced and used as the basis for developing prototype software that performs automated bidirectional conversion between openEHR archetypes and COSMIC templates. Results: Automated bi-directional conversion between openEHR archetype format and COSMIC template format has been achieved. Several archetypes from the openEHR Clinical Knowledge Repository have been imported into COSMIC, preserving most of the structural and terminology related constraints. COSMIC templates from a large regional installation were successfully converted into the openEHR archetype format. The conversion from the COSMIC templates into archetype format preserves nearly all structural and semantic definitions of the original content models. A strategy of gradually adding archetype support to legacy EHR systems was formulated in order to allow sharing of clinical content models defined using different formats. Conclusion: The openEHR RM and AM are expressive enough to represent the existing clinical content models from the template based EHR system tested and legacy content models can automatically be converted to archetype format for sharing of knowledge. With some limitations, internationally available archetypes could be converted to the legacy EHR models. Archetype support can be added to legacy EHR systems in an incremental way allowing a migration path to interoperability based on standards.

Place, publisher, year, edition, pages
BMC, 2009
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-19912 (URN)10.1186/1472-6947-9-33 (DOI)
Note
Original Publication: Rong Chen, Gunnar O Klein, Erik Sundvall, Daniel Karlsson and Hans Åhlfeldt, Archetype-based conversion of EHR content models: pilot experience with a regional EHR system, 2009, BMC MEDICAL INFORMATICS AND DECISION MAKING, (9), 33. http://dx.doi.org/10.1186/1472-6947-9-33 Licensee: BioMed Central http://www.biomedcentral.com/ Available from: 2009-08-25 Created: 2009-08-14 Last updated: 2010-04-14Bibliographically approved
4. Representing a chemotherapy guideline using openEHR and rules
Open this publication in new window or tab >>Representing a chemotherapy guideline using openEHR and rules
2009 (English)In: Medical Informatics in a United and Healthy Europe / [ed] Klaus-Peter Adlassnig, Bernd Blobel, John Mantas, Izet Masic, IOS Press, 2009, Vol. 150, 653-657 p.Conference paper, Published paper (Refereed)
Abstract [en]

Computerized guidelines can provide decision support and facilitate the use of clinical guidelines. Several computerized guideline representation models (GRMs) exist but the poor interoperability between the guideline systems and the Electronic Health Record (EHR) systems limits their clinical usefulness. In this study we analyzed the clinical use of a published lymphoma chemotherapy guideline. We found that existing GRMs have limitations that can make it difficult to meet the clinical requirements. We hypothesized that guidelines could be represented as data and logic using openEHR archetypes, templates and rules. The design was tested by implementing the lymphoma guideline. We conclude that using the openEHR models and rules to represent chemotherapy guidelines is feasible and confers several advantages both from a clinical and from an informatics perspective.

Place, publisher, year, edition, pages
IOS Press, 2009
Series
Studies in Health Technology and Informatics, ISSN 0926-9630 ; 150
National Category
Computer and Information Science Medical Laboratory and Measurements Technologies
Identifiers
urn:nbn:se:liu:diva-21864 (URN)10.3233/978-1-60750-044-5-653 (DOI)000326889500137 ()978-1-60750-044-5 (ISBN)
Conference
MIE 2009 – The XXIInd International Congress of the European Federation for Medical Informatics
Available from: 2009-10-06 Created: 2009-10-06 Last updated: 2015-06-10Bibliographically approved
5. Modelling Shared Care Plans Using Contsys and OpenEHR to Support Shared Homecare of Elderly
Open this publication in new window or tab >>Modelling Shared Care Plans Using Contsys and OpenEHR to Support Shared Homecare of Elderly
2011 (English)In: JAMIA Journal of the American Medical Informatics Association, ISSN 1067-5027, E-ISSN 1527-974X, Vol. 18, no 1, 66-69 p.Article in journal (Refereed) Published
Abstract [en]

This case report describes how two complementary standards, CONTsys (the continuity of care standard EN 13940-1) and the reference model (RM) of openEHR, were applied in modeling a shared care plan for shared homecare based on requirements from the OLD@HOME project. The OLD@HOME shared care plan conceptual model is used to verify these standards against real world requirements. Our study shows that these requirements are matched by CONTsys on a general level. However, certain attributes are not explicit in CONTsys, e.g. agents responsible for performing planned interventions, and support for monitoring outcome of interventions. We further studied how the care plan conceptual model can be implemented using the openEHR RM. The study demonstrates the

Place, publisher, year, edition, pages
B M J PUBLISHING GROUP, 2011
Keyword
Medical Informatics; Integrated Advanced Information Management Systems; Information Storage and Retrieval; Home Care Services; Nursing Record; Electronic Health Records, Archetypes
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-54821 (URN)10.1136/jamia.2009.000216 (DOI)000289218000011 ()
Available from: 2010-04-14 Created: 2010-04-14 Last updated: 2011-04-26

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