Modulation of Existent Obstetrics EHRs to the openEHR Speciﬁcation

ao Carlos Menezes de Magalh

aes

and Ricardo Jo

ao Cruz Correia

2,3

Mestrado Integrado em Medicina, Faculdade de Medicina da Universidade do Porto, Porto, Portugal

CINTESIS, Faculdade de Medicina da Universidade do Porto, Porto, Portugal

Department of Health Information and Decision Sciences, Faculdade de Medicina da Universidade do Porto,

Keywords:

Interoperability, Semantic Interoperability, openEHR, e-Health.

Abstract:

Objective: Create templates in OpenEHR through the modulation of existing electronic health records deﬁned

in OpenObsCare platform. Materials and Methods: Apply a 4 step process: select data ﬁelds already existent

in OpenObscare; search both in openEHR and NEHTA clinical knowledge manager (CKM) for the archetypes

that contain these data ﬁelds; create new archetypes when a data ﬁeld doesn’t have an existent one in both

CKM’s; develop templates from all the information gathered in the previous steps. Results: Development of 6

templates available online via http://joaomagalhaes.me/admission templates and 1 archetype (openEHR-EHR-

CLUSTER.exam-vagina.v1). Discussion: The process of modulation from existent EHR to the openEHR was

possible since the standardization of clinical concepts allowed the re-utilization of a lot of already existent

archetypes. This speeds up the development process by deﬁning earlier the domain knowledge necessary

for the HIS. Some hurdles faced in the process were due to the necessity of translation of all the archetypes

to use at a national level and also due to the lack of national wide accepted terminologies. As this process is

eased by the robustness of existent archetypes, the creation of default obstetric templates validated by a special

commission, would probably be advantageous since the interoperability and semantics standardization would

allow effective transmission of information between all the health care agents. Conclusion: The modulation

of admission data existent in the HIS OpenObsCare to openEHR was easier than the ”traditional” way of doing

it which is by specifying requirements. This is due to the fact that a lot of the existent archetypes are already

robust enough and the number of them is enough to represent several clinical concepts contained in the created

templates.

1 INTRODUCTION

The widespread use of electronic health records de-

mands the need of a electronic health record (EHR)

that can resist during a patient entire lifetime. The

quality of the EHR can enhance the health care qual-

ity(Delpierre et al., 2004) and can also facilitate

the research for academic purposes contributing for

a more evidence based medical practice(Zeng and

Cimino, 1999). There is a consensus about the need of

a system that is designed to allow maintainability and

interoperability of this records(Hovenga, 2010)(Beale

and Heard, 2007)(Xiao et al., 2011). The interoper-

ability is the ability of different software systems to

interpret clinical information in the same way. For

this to be achieved the advantages of standardized

clinical concepts and reference models comes as a

need (Hovenga, 2010). This is the goal that OpenEHR

foundation and others such as HL7(Dolin et al., 2001)

proposed to reach.

The openEHR architecture is a two level mod-

elling approach for EHRs. The ﬁrst level is the

reference model which is a relatively small set of

classes used to support the medico-legal requirements

and record management functions (Beale and Heard,

2007). The ﬁrst level stands for functional inter-

operability. It provides the communication between

different HIS (Health Informatic Systems).The sec-

ond level represents the openEHR archetype method-

ology. Archetypes map clinical knowledge, there-

fore each archetype represents one clinical concept

by constraining instances of the openEHR reference

model. This dual approach allows a fundamental ab-

stract concept which is the independence of the devel-

opment of domain knowledge (clinical content) which

is delegated to medical specialists and technical im-

plementation which is a concern for the software de-

velopment team. This has an enormous advantage

since there is no need to transmit clinical require-

ments to non specialized people.

OpenEHR Templates(Leslie, 2008) are created by

the clinicians and are used to create deﬁnitions of con-

439

Carlos Menezes de Magalhães J. and João Cruz Correia R..

Modulation of Existent Obstetrics EHRs to the openEHR Speciﬁcation.

DOI: 10.5220/0005220804390445

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2015), pages 439-445

ISBN: 978-989-758-068-0

 2015 SCITEPRESS (Science and Technology Publications, Lda.)

tent such as a particular document or message, re-

quired for speciﬁc use cases, such as speciﬁc screen

forms, message types or reports. They contain dif-

ferent archetypes that have meaning all together (e.g.

obstetrics hospitalization entrance note, obstetrics ul-

trasound report) and that can be assigned to the same

template or to different templates several times mak-

ing it re-usable.

In an effort to implement this change of paradigm

in the Obstetrics department at Hospital de S

ao Jo

ao,

Porto, we propose the creation of templates to be

used by an experimental version of the OpenObsCare

health information system (HIS) that is currently be-

ing used in this department. Since there are differ-

ent ways of collecting data for an obstetrics EHR the

analysis and comparison of this data between differ-

ent institutions an countries is hard.

In this work we aim at creating openEHR tem-

plates for a pregnant woman hospitalization admis-

sion in an obstetrics department. We also want to

document the process in order to evaluate its advan-

tages and disadvantages compared to a more tradi-

tional way of creating HIS.

2 MATERIALS AND METHODS

As data source for the templates’ creation we used the

current HIS implemented in the obstetrics department

at Hospital de S

ao Jo

ao - OpenObscare. To create

openEHR templates 4 stages were deﬁned:

1. Select data ﬁelds already existent in OpenObscare

2. Search both in openEHR and NEHTA clinical

knowledge manager (CKM) for the archetypes

that contained those data ﬁelds

3. Create new archetypes for data that doesn’t have

a corresponding archetype in the openEHR and

National E-Health Transition Authority (NEHTA)

clinical knowledge managers (CKM).

4. Create Templates

This similar process has already been used by oth-

ers (G.M. Bacelar-Silva, 2012).

2.1 Select Data Fields from

OpenObsCare

OpenObsCare (Figure 1) is an opehEHR solution still

in development that derives from the already existent

ObsCare. Obscare is a software that was designed

to be used by OB/GYN doctors, anesthesiologists,

nurses and administrative staff and is used to regis-

ter patient admission and discharge, as well as child-

birth and newborn data. It is also used to register sur-

gical and anesthetic procedures, nursing records, as

well as gynecological interventions. It is currently

in use at Hospital de S.Jo

ao and will soon be in-

stalled in several other hospitals in northern Portugal.

These ﬁelds were extracted from the hospitalization

admission section of this HIS which is composed of

several main tabs. We only included the Admission

Note, General information and Ultrasound Exams for

this modulation. The General Information contains

5 more sub-tabs which were each counted as main

tabs. For each of these tabs a google spreadsheet was

created to describe the different forms they contain.

The spreadsheet information was gathered regarding

the following parameters: Data ﬁelds, Description,

OpenEHR archetype corresponding ﬁeld, Archetype

ID and Note.

2.2 Search for Archetypes

OpenEHR maps the clinical statements using speciﬁc

types of Entries (Administrative, Observation, Evalu-

ation, Instruction and Action) according to the nature

of the statement. Archetypes were chosen according

to the clinical concept the data ﬁeld was part of. As

an example, the pattern of uterine contraction data

ﬁeld present in OpenObsCare could be represented

by the ﬁeld Pattern of the archetype openEHR-EHR-

Observation.uterine contractions.v1. Preference was

given to the openEHR CKM and only when a clin-

ical concept wasn’t found on it, the NEHTA reposi-

tory was used. This archetypes were found in both the

referred CKM’s by submitting a ”Complete search”,

which searches ”inside” resources, including all meta-

data, and for archetypes, archetype deﬁnition, and the

archetype ontologies. The last search was performed

on August 27th.

2.3 Create New Archetypes for Data

that doesn’t have a Corresponding

Archetype in the openEHR and

NEHTA Clinical CKM’s

If after searching on the referred repositories no avail-

able archetype could be found to represent a clinical

statement, the creation of a new archetype would be

considered. For this purpose the Ocean Archetype

Editor, a tool to support the authoring of archetypes

was used.

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440

Figure 1: OpenObsCare platform.

2.4 Create Templates

The structured spreadsheets created helped in creat-

ing the framework for the development of the tem-

plate, where the archetypes will be arranged. This

was made using Ocean Template Designer – software

that allows composing a set of archetypes into a tem-

plate.

3 RESULTS

From the modulation of OpenObsCare IHS, spread-

sheets with the speciﬁcations necessary for the devel-

opment of templates were created (Fig.3). From this

framework 6 templates were developed:

• Admission Note(Fig.3)

• Ultrasounds

• Current Pregnancy

• Obstetric history

• Family history

• Personal history

They are all available for download in

the following url http://joaomagalhaes.me/

admission templates.

The archetypes used for creating the mentioned

templates are presented in Table 1. Only 1 of the con-

cepts used is taken from the NEHTA repository and

also only 1 was created (Fig. 4). The reason for this

has to do with the fact that no archetype could deﬁne

with clinical rigor the concept of the pelvic examina-

tion.

4 DISCUSSION

The process of creating templates for an obstetrics

pregnancy hospitalization admission was possible by

mostly using archetypes already deﬁned in OpenEHR

and NEHTA CKM’s. This is an advantage compared

to the process of creating new ones from scratch since

those already available to be shared have been val-

idated by a group of specialists and so its robust-

ness is inevitable. One archetype was created be-

ing derived from a pre-existent cluster - openEHR-

EHR-CLUSTER.exam-vagina.v1. This was neces-

sary since there wasn’t an already available archetype

to represent the ﬁndings of a speculum examination

performed on a pregnant woman. This archetype can

also be used in a more general context e.g. in a gy-

necology routine consult. However it still lacks the

analysis of obstetrics specialists by being submitted

to validation in openEHR CKM. Another limitation

has to do with the fact that the archetypes and their

ﬁelds were chosen according to the pre-existent spec-

iﬁcations of ObsCare platform.

This migration from traditional HIS to a more

standardized and consistent OpenEHR speciﬁcation

ModulationofExistentObstetricsEHRstotheopenEHRSpecification

441

Table 1: List of archetypes used - all taken from the openEHR CKM except for the Pregnancy Summary which was taken

from NEHTA CKM and Examination of the vulva which was newly created.

Name ID

Adhoc heading openEHR-EHR-SECTION.adhoc.v1

Adverse Reaction openEHR-EHR-EVALUATION.adverse reaction.v1

Alcohol Use openEHR-EHR-OBSERVATION.alcohol use.v1

Blood Matching openEHR-EHR-OBSERVATION.blood match.v1

Blood Pressure openEHR-EHR-OBSERVATION.blood pressure.v1

Body Mass Index openEHR-EHR-OBSERVATION.body mass index.v1

Body Surface Area openEHR-EHR-OBSERVATION.body surface area.v1

Body Temperature openEHR-EHR-OBSERVATION.body temperature.v1

Body Weight openEHR-EHR-OBSERVATION.body weight.v1

Examination of the cervix openEHR-EHR-CLUSTER.exam-uterine cervix.v1

Examination of the fetus openEHR-EHR-CLUSTER.exam-fetus.v1

Examination of the uterus openEHR-EHR-CLUSTER.exam-uterus.v1

Examination of the vulva openEHR-EHR-CLUSTER.exam-vagina.v1

Examination openEHR-EHR-CLUSTER.exam.v1

Family History openEHR-EHR-COMPOSITION.family history.v1

Family History openEHR-EHR-EVALUATION.family history.v1

Fetal Heart Monitoring openEHR-EHR-OBSERVATION.fetal heart-monitoring.v1

Fetal Movement openEHR-EHR-OBSERVATION.fetal movement.v1

Free text openEHR-EHR-CLUSTER.free text.v1

Gestation openEHR-EHR-OBSERVATION.gestation.v1

Height/Length openEHR-EHR-OBSERVATION.height.v1

Imaging examination openEHR-EHR-ACTION.imaging exam.v1

Imaging examination result openEHR-EHR-OBSERVATION.imaging exam.v1

Medication Order List openEHR-EHR-SECTION.medication order list.v1

Medication Order openEHR-EHR-INSTRUCTION.medication order.v1

Oedema openEHR-EHR-CLUSTER.oedema.v1

Physical Examination openEHR-EHR-OBSERVATION.exam.v1

Pregnancy Summary openEHR-EHR-EVALUATION.pregnancy.v1

Problem/Diagnosis openEHR-EHR-EVALUATION.problem diagnosis.v1

Procedure Report openEHR-EHR-COMPOSITION.report-procedure.v1

Procedure undertaken openEHR-EHR-ACTION.procedure

.v1 Report openEHR-EHR-COMPOSITION.report.v1

Review openEHR-EHR-COMPOSITION.review.v1

Story/History openEHR-EHR-OBSERVATION.story.v1

Substance Use openEHR-EHR-OBSERVATION.substance use.v1

Tobacco Use openEHR-EHR-OBSERVATION.tobacco use.v1

Urinalysis openEHR-EHR-OBSERVATION.urinalysis.v1

Uterine contractions openEHR-EHR-OBSERVATION.uterine contractions.v1

has already been performed by others (Bernstein

et al., 2009)(Tapuria et al., 2013). As in the current

paper the advantages of using pre-existent archetypes

was valued and the biggest disadvantage resides in the

translation of the concepts when creating templates.

Other common problem noticed was the difference

between terminologies (Bernstein et al., 2009) (e.g.

degree and extent of oedema and fetal contractions)

which can indicate the need for a national or interna-

tional level standardization.

As the modulation of an existent EHR was pos-

sible and bearing in mind the advantages of using

openEHR to achieve national interoperability we can

see the enormous advantages of creating a national

level comission to create obstetrics templates. They

would have the minimal acceptable content. The ad-

vantages of this approach would be a common lan-

guage spoken by all HIS in the country, a consensus

on what is essential for an obstetrics EHR and the

ﬂexibility to allow different regions or locals to add

more archetypes since the database schema doesn’t

have to suffer big changes thus also being very well

supported economically. The local archetype addi-

tion could be useful in cases where a speciﬁc detail

of the obstetric history that isn’t contained in one the

national accepted templates is necessary for academic

purposes.

Since the templates were created but not translated

to HTML and implemented in the OpenObscare ver-

sion that was built with a database schema that adapts

to OpenEHR speciﬁcation, there is no information

about the possible easiness or difﬁculty in perform-

ing this process.

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Figure 2: OpenObsCare form modulation spreadsheet for the Admission note.

Figure 3: Admission Template.

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443

Figure 4: Vulva examination archetype.

5 CONCLUSION

In the current paper the modulation of clinical hos-

pitalization data existent in an obstetrics HIS to the

OpenEHR speciﬁcation was performed. The process

was easier than the ”classic” one by which medical

specialists transmit the requirements of the system

and then these data models are created from scratch

since it can be easily achieved by reusing existent

validated archetypes. Both OpenEHR and NEHTA

CKM’s contain good solid archetypes with a com-

munity of medical specialists reviewing them in an

iterative process that aims to achieve an EHR stan-

dardization that allows interoperability between dif-

ferent systems. There was only the need to create 1

new archetype and to edit other. Using the method

described here in this paper the transition process to

an interoperable and semantics standardized EHR can

start. However there are still more steps ahead and the

process of application and maintainability of this type

of EHR must be ascertained. Furthermore this is an

effort that we would expect to be more effective if

there were nationwide standard templates deﬁned by

a special comission of specialists.

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