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Prof Dipak Kalra, Dr Archana Tapuria, Prof Georges de Moor

The contribution of Clinical Archetypes, and the challenges, towards achieving semantic interoperability for EHRs. Prof Dipak Kalra, Dr Archana Tapuria, Prof Georges de Moor ARGOS Project meeting 15 March 2010, Barcelona on behalf of The EuroRec Institute.

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Prof Dipak Kalra, Dr Archana Tapuria, Prof Georges de Moor

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  1. The contribution of Clinical Archetypes, and the challenges, towards achieving semantic interoperability for EHRs • Prof Dipak Kalra, Dr Archana Tapuria, Prof Georges de Moor • ARGOS Project meeting 15 March 2010, Barcelona • on behalf of The EuroRec Institute This project is funded by the European Union

  2. Teaching Research Clinical trials Education Research Epidemiology Data mining Public health Health care management Clinical audit rapid bench to bed translation real-time knowledge directed care implied consent de-identified explicit consent +/- consent Long-term shared care (regional national, global) Continuing care (within the institution) A pan-European Health Infostructure Citizen in the community Wellness Fitness Complementary health Social care Occupational health School health Point of care delivery

  3. Goals for EHR semantic interoperability • Enable the safe, meaningful sharing and combining of health record data between heterogeneous systems and actors / care providers • Enable the integration and safe use of computerised protocols, alerts and care pathways by EHR systems • Link EHR data to explanatory and educational materials to support patient and family engagement and professional development • Improve data quality to enable meaningful and reliable use of longitudinal and heterogeneous data for public health, research, health service management

  4. The challenge of SIOP • Many clinical systems can today achieve semantic interoperability using data that has been captured within their own applications, because the organisation and meaning of the data can be dictated in advance by each system designer • Semantic interoperability is most needed when EHR data are to be shared and combined from different systems (or across modules within a large system) Clinical meaning (data, information, knowledge) must be capable of being represented consistently in order to be shared and understood: Semantic Equivalence

  5. Representing meaning in EHRs • Generic reference models for representing clinical (EHR) data • e.g. ISO/EN 13606 Part 1, HL7 CDA Release 2, the openEHR Reference Model • Clinical terminology systems • e.g. LOINC and SNOMED-CT • Agreed clinical data structure definitions • e.g. openEHR archetypes, ISO/EN 13606 Part 2, HL7 templates, generic templates and data sets.

  6. The problem with plugging terms into a reference model • Record structures and terminology systems have been developed in relative isolation • with no co-operation on their mutual requirements or scope • resulting in overlapping coverage or clumsy fit • both often still fail to meet the needs of clinical practice! • With co-ordinated terminology and sophisticated EHR architectures • there is a risk of introducing further inconsistency • making semantic equivalence harder to determine

  7. What is a clinical archetype? • a clinical archetype is an agreed, formal and interoperable specification • for representing a given clinical entity such as a clinical observation, a finding, a plan or a treatment • within an electronic health record • invented and maintained by openEHR • ratified by CEN and ISO: 13606 Part 2 • to be quality labelled by EuroRec

  8. What value do archetypes add? • A user friendly means to capture and collate professional consensus on how clinical data should be represented • A formal model of clinical domain concepts • e.g. “blood pressure”, “discharge summary”, “fundoscopy” • Specifies a context of use for clinical terms • Can be published and shared within a clinical community, or globally • Can be imported by vendors into EHR system data dictionaries • Defines a systematic EHR target for queries and for decision support

  9. openEHR Clinical Knowledge Managerhttp://www.openehr.org/knowledge/

  10. openEHR Clinical Knowledge Managerhttp://www.openehr.org/knowledge/

  11. openEHR Clinical Knowledge Managerhttp://www.openehr.org/knowledge/

  12. openEHR Clinical Knowledge Managerhttp://www.openehr.org/knowledge/

  13. Activities supporting the wide-scale use of archetypes • Growing communities to author, review and adopt archetypes for different domains • Enriching the tools to support clinicians using archetypes • Improving the binding between archetypes and co-ordinated terminologies, especially SNOMED-CT • Defining good practice for archetype authorship • Establishing quality, governance and certification processes for archetypes and their repositories

  14. EuroRec’s role in Archetype quality labelling • EuroRec is leading the European development of archetype quality criteria, in areas such as: • clinical usage requirements • domain coverage • evidential basis • conformance to standards • modelling requirements • authorship, version management • access and licensing • endorsement, quality labelling, certification • archetype repository requirements • EuroRec will establish a formal certification process • EuroRec is actively involved in European semantic interoperability research

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