Towards a comprehensive electronic patient record to support an innovative individual care concept for premature infants using the openEHR approach.
OBJECTIVE
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.


CONCLUSIONS
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.
Faculty of Informatics, University of Applied Sciences Heilbronn, Heilbronn, Germany. buck@hs-heilbronn.de
Jasmin
J
Buck
Sebastian
S
Garde
Christian D
CD
Kohl
Petra
P
Knaup-Gregori
D006801:Humans; D007224:Infant Care; D007231:Infant, Newborn; D007234:Infant, Premature; D016347:Medical Records Systems, Computerized