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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

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2 2 open_ehr archetypes classes

  1. 1. Hildegard Franke 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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