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Hildegard McNicoll
openEHR Archetypes:
Classes Overview
Generic RM Classes
EHR
FOLDER (optional)
COMPOSITION
SECTION (optional)
ENTRY
ELEMENT
ELEMENT
ENTRY
ELEMENT
ELEMENT
ENTRY
...
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vital signs)
OBSERVN. (BP)
ELEMENT (S...
Composition
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vital signs)
OBSERVN. (BP...
Composition
Section
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vital signs)
OBSE...
Composition
Section
Entry
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vital signs...
Composition
Section
Entry
Element
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vit...
Archetypes: recipes for clinical content
COMPOSITIONCOMPOSITION (Encounter)
SECTION (Vital signs)
OBSERVN. (BP)
ELEMENT (S...
COMPOSITION archetypes
‘Top level document’ container
All clinical data inside a Composition
Represent generic document ty...
COMPOSITION archetypes
Report, Published Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited:
2015-10-11]. Availa...
SECTION archetypes
Sub-divide complex compositions
No ‘semantic’ meaning
Meaning carried in ENTRY archetypes inside
SECTIO...
SECTION archetypes
Vital signs, Draft Archetype [Internet]. openEHR Foundation, openEHR
Clinical Knowledge Manager [cited: 2016-03-09]. Avail...
ENTRY archetypes
Carry key clinical content payload
Carry clinical meaning
Carry sufficient clinical context
‘Clinical sta...
Clinical Investigator Cycle
ENTRY reference model features
Provider
Subject
Data
History
Event
Protocol State Activities Pathway
OBSERVATIONS Yes Yes ...
ENTRY: Provider/Subject/Participation
Provider of care
Optional where provider <> composer
Subject of care
Optional where ...
ENTRY: Data
The data of primary clinical interest
Sometimes nested within another feature
inside INSTRUCTION ‘activities’
...
ENTRY: ’Protocol’ feature
Secondary information about the method or
circumstances of data collection
Observations
Device/ ...
OBSERVATION archetypes
Gathering of evidence
Measurable / observable data
Patient history, physical
examination
Lab tests,...
Laboratory test, Draft Archetype [Internet]. openEHR
Foundation, openEHR Clinical Knowledge Manager
[cited: 2016-03-09]. A...
EVALUATION archetypes
Outcomes of a clinical assessment
or decision
Clinically interpreted findings
“I think the problem i...
Problem/Diagnosis, Published Archetype [Internet]. openEHR Foundation,
openEHR Clinical Knowledge Manager [cited: 2016-03-...
INSTRUCTION archetypes
Orders that arise from clinical assessment
Initiation of workflow process
“I will order some blood ...
Service request, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. A...
ACTION archetypes
Activities that result from an
Instruction
“Lab test performed”
“Medication prescribed, administered”
“P...
Admin entry - for non-clinical data
No special RM attributes
other than subject, provider
No special features
Inpatient admission, Draft Archetype [Internet]. UK Clinical Models, UK Clinical Models Clinical Knowledge Manager [cited:...
Archetype naming
Concept name: the human name of the clinical
concept
‘Blood pressure’, ’Report’
ArchetypeID: the technica...
Naming examples
Naming examples
Naming examples
Naming examples
Naming examples
2 2 open_ehr archetypes classes
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2 2 open_ehr archetypes classes

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This presentation provides an overview of archetype classes in openEHR clinical modelling.

Publicada em: Tecnologia
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2 2 open_ehr archetypes classes

  1. 1. Hildegard McNicoll openEHR Archetypes: Classes Overview
  2. 2. Generic RM Classes EHR FOLDER (optional) COMPOSITION SECTION (optional) ENTRY ELEMENT ELEMENT ENTRY ELEMENT ELEMENT ENTRY ELEMENT ELEMENT ELEMENT ELEMENT CLUSTER ELEMENT SECTION (optional)
  3. 3. Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  4. 4. Composition Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  5. 5. Composition Section Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  6. 6. Composition Section Entry Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  7. 7. Composition Section Entry Element Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  8. 8. Archetypes: recipes for clinical content COMPOSITIONCOMPOSITION (Encounter) SECTION (Vital signs) OBSERVN. (BP) ELEMENT (Systolic) ELEMENT (Diastolic) OBSERVN. (Pulse) ELEMENT (Rate) ELEMENT (Comment) Venison Wellington Fillings Mushroom Duxelles 100g Wild Mushrooms 25g Butter Herb Pancakes Pastry Puff Pastry ingredients SECTION (Allergies) EVAL (Adverse Reaction) ELEMENT (Substance) ELEMENT (Status) ELEMENT (Category) 100g Plain Flour 1 egg Meat Venison 1 kg Venison Loin
  9. 9. COMPOSITION archetypes ‘Top level document’ container All clinical data inside a Composition Represent generic document types Encounter, Report, Lab Report Problem List, Discharge Summary, End of Life Care plan Simple Do not define detailed content
  10. 10. COMPOSITION archetypes
  11. 11. Report, Published Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2015-10-11]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.677
  12. 12. SECTION archetypes Sub-divide complex compositions No ‘semantic’ meaning Meaning carried in ENTRY archetypes inside SECTIONS Very few pre-defined SECTION archetypes
  13. 13. SECTION archetypes
  14. 14. Vital signs, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http:// openehr.org/ckm/#showArchetype_1013.1.278 Ad hoc heading, Published Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.631
  15. 15. ENTRY archetypes Carry key clinical content payload Carry clinical meaning Carry sufficient clinical context ‘Clinical statement’ Blood pressure, Diagnosis Lab test, ECG, Procedures Must use one of the ENTRY sub-types
  16. 16. Clinical Investigator Cycle
  17. 17. ENTRY reference model features Provider Subject Data History Event Protocol State Activities Pathway OBSERVATIONS Yes Yes Yes Yes Yes EVALUATIONS Yes Yes Yes INSTRUCTIONS Yes Yes Yes Yes ACTIONS Yes Yes Yes Yes ADMIN_ENTRY Yes Yes
  18. 18. ENTRY: Provider/Subject/Participation Provider of care Optional where provider <> composer Subject of care Optional where subject <> patient Participation Optional where other individuals involved, e.g. MDT Hidden in the tooling but can be exposed if required
  19. 19. ENTRY: Data The data of primary clinical interest Sometimes nested within another feature inside INSTRUCTION ‘activities’ inside OBSERVATION ‘events’
  20. 20. ENTRY: ’Protocol’ feature Secondary information about the method or circumstances of data collection Observations Device/ methodology e.g. Cuff size Evaluations/Instructions Links to guidance or criteria Instructions / Actions Workflow identifiers
  21. 21. OBSERVATION archetypes Gathering of evidence Measurable / observable data Patient history, physical examination Lab tests, imaging Scores and scales
  22. 22. Laboratory test, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http:// openehr.org/ckm/#showArchetype_1013.1.2191 Apgar score, Published Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.172
  23. 23. EVALUATION archetypes Outcomes of a clinical assessment or decision Clinically interpreted findings “I think the problem is …” I think there is a risk of … The treatment goal is …’
 Diagnosis, synthesis Genetic risk, Risk of Adverse reaction CPR Decision
  24. 24. Problem/Diagnosis, Published Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http://openehr.org/ckm/#showArchetype_1013.1.169 CPR decision, Draft Archetype [Internet]. UK Clinical Models, UK Clinical Models Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http://clinicalmodels.org.uk/ckm/ #showArchetype_1051.32.205
  25. 25. INSTRUCTION archetypes Orders that arise from clinical assessment Initiation of workflow process “I will order some blood tests” “I would like you to start this medication” “I would like to refer you to a specialist” Lab test request, referral Medication order Nursing task
  26. 26. Service request, Draft Archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http:// openehr.org/ckm/#showArchetype_1013.1.614
  27. 27. ACTION archetypes Activities that result from an Instruction “Lab test performed” “Medication prescribed, administered” “Procedure performed" “Lab test tracking” “Medication supply”
  28. 28. Admin entry - for non-clinical data No special RM attributes other than subject, provider No special features
  29. 29. Inpatient admission, Draft Archetype [Internet]. UK Clinical Models, UK Clinical Models Clinical Knowledge Manager [cited: 2016-03-09]. Available from: http:// clinicalmodels.org.uk/ckm/#showArchetype_1051.32.291
  30. 30. Archetype naming Concept name: the human name of the clinical concept ‘Blood pressure’, ’Report’ ArchetypeID: the technical name used by tooling and CDRs ‘openEHR-EHR-OBSERVATION.blood_pressure.v1’ ‘openEHR-EHR-COMPOSITION.report.v1’
  31. 31. Naming examples
  32. 32. Naming examples
  33. 33. Naming examples
  34. 34. Naming examples
  35. 35. Naming examples

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