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Title Towards a comprehensive electronic patient record to support an innovative individual care concept for premature infants using the openEHR approach.
Author(s) Buck J, Garde S, Kohl CD, Knaup-Gregori P.
Source Int J Med Inform., Vol. 78, No. 8, Pages 521-531
Publication Date August 2009
Abstract PURPOSE: This paper introduces the modelling of a prototype neonatology electronic patient record (EPR) using openEHR archetypes. The EPR is necessary to support the complex communication tasks of the innovative concept of 'Developmental, Family-Centred, Individual Care of Premature Infants and Newborns' established for the Department of Neonatology at Heidelberg University Hospital. METHODS: The data to be documented was analysed and modelled using the five step openEHR data modelling approach (odma). RESULTS: The analysis revealed a total of 1818 items, which could be arranged into 70 clinical concepts. The items and concepts were then mapped to 132 openEHR archetypes. Fifty-eight of these archetypes could be reused either directly or via specialisation from the existing openEHR archetypes. A further 67 archetypes were newly developed. To combine and constrain archetypes for local settings 16 templates were developed. CONCLUSION: By using the five step openEHR data modelling approach, semantic interoperability, and a reduced need for repeated documentation of the same data can be realised. This is of major importance within the hospital as well as for trans-institutional data exchange.

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