Kropf Stefan, Chalopin Claire, Lindner Dirk, Denecke Kerstin
Stefan Kropf, Innovation Center Computer Assisted Surgery (ICCAS), Leipzig University, Semmelweisstraße 14, 04103 Leipzig, Germany, Email:
Appl Clin Inform. 2017 Jun 28;8(2):660-679. doi: 10.4338/ACI-2017-01-RA-0009.
Access to patient data within the hospital or between hospitals is still problematic since a variety of information systems is in use applying different vendor specific terminologies and underlying knowledge models. Beyond, the development of electronic health record systems (EHRSs) is time and resource consuming. Thus, there is a substantial need for a development strategy of standardized EHRSs. We are applying a reuse-oriented process model and demonstrate its feasibility and realization on a practical medical use case, which is an EHRS holding all relevant data arising in the context of treatment of tumors of the sella region. In this paper, we describe the development process and our practical experiences.
Requirements towards the development of the EHRS were collected by interviews with a neurosurgeon and patient data analysis. For modelling of patient data, we selected openEHR as standard and exploited the software tools provided by the openEHR foundation. The patient information model forms the core of the development process, which comprises the EHR generation and the implementation of an EHRS architecture. Moreover, a reuse-oriented process model from the business domain was adapted to the development of the EHRS.
The reuse-oriented process model is a model for a suitable abstraction of both, modeling and development of an EHR centralized EHRS. The information modeling process resulted in 18 archetypes that were aggregated in a template and built the boilerplate of the model driven development. The EHRs and the EHRS were developed by openEHR and W3C standards, tightly supported by well-established XML techniques. The GUI of the final EHRS integrates and visualizes information from various examinations, medical reports, findings and laboratory test results.
We conclude that the development of a standardized overarching EHR and an EHRS is feasible using openEHR and W3C standards, enabling a high degree of semantic interoperability. The standardized representation visualizes data and can in this way support the decision process of clinicians.
由于医院内部或医院之间使用了各种信息系统，这些系统应用了不同供应商特定的术语和基础知识模型，获取患者数据仍然存在问题。此外，电子健康记录系统（EHRS）的开发既耗时又耗资源。因此，迫切需要一种标准化EHRS的开发策略。我们正在应用一种面向重用的过程模型，并在一个实际的医学用例中展示其可行性和实现方式，该用例是一个EHRS，包含蝶鞍区肿瘤治疗过程中产生的所有相关数据。在本文中，我们描述了开发过程和实际经验。
通过与神经外科医生访谈和患者数据分析收集对EHRS开发的需求。对于患者数据建模，我们选择openEHR作为标准，并利用openEHR基金会提供的软件工具。患者信息模型构成了开发过程的核心，包括电子健康记录（EHR）生成和EHRS架构的实现。此外，将业务领域的面向重用的过程模型应用于EHRS的开发。
面向重用的过程模型是一种对EHR集中式EHRS的建模和开发进行适当抽象的模型。信息建模过程产生了18个原型，这些原型被汇总在一个模板中，并构建了模型驱动开发的样板。EHR和EHRS是根据openEHR和W3C标准开发的，并得到成熟的XML技术的有力支持。最终EHRS的图形用户界面集成并可视化来自各种检查、医学报告、检查结果和实验室测试结果的信息。
我们得出结论，使用openEHR和W3C标准开发标准化的总体EHR和EHRS是可行的，能够实现高度的语义互操作性。标准化表示使数据可视化，并以此方式支持临床医生的决策过程。
