Ferreira Diana, Neto Cristiana, Hak Francini, Abelha António, Santos Manuel, Machado José
ALGORITMI Research Center, Intelligent Systems Associate Laboratory (LASI), School of Engineering, University of Minho, Guimarães, Portugal.
JMIR Med Inform. 2024 Sep 16;12:e48407. doi: 10.2196/48407.
Corneal transplantation, also known as keratoplasty, is a widely performed surgical procedure that aims to restore vision in patients with corneal damage. The success of corneal transplantation relies on the accurate and timely management of patient information, which can be enhanced using electronic health records (EHRs). However, conventional EHRs are often fragmented and lack standardization, leading to difficulties in information access and sharing, increased medical errors, and decreased patient safety. In the wake of these problems, there is a growing demand for standardized EHRs that can ensure the accuracy and consistency of patient data across health care organizations.
This paper proposes the use of openEHR structures for standardizing corneal transplantation records. The main objective of this research was to improve the quality and interoperability of EHRs in corneal transplantation, making it easier for health care providers to capture, share, and analyze clinical information.
A series of sequential steps were carried out in this study to implement standardized clinical records using openEHR specifications. These specifications furnish a methodical approach that ascertains the development of high-quality clinical records. In broad terms, the methodology followed encompasses the conduction of meetings with health care professionals and the modeling of archetypes, templates, forms, decision rules, and work plans.
This research resulted in a tailored solution that streamlines health care delivery and meets the needs of medical professionals involved in the corneal transplantation process while seamlessly aligning with contemporary clinical practices. The proposed solution culminated in the successful integration within a Portuguese hospital of 3 key components of openEHR specifications: forms, Decision Logic Modules, and Work Plans. A statistical analysis of data collected from May 1, 2022, to March 31, 2023, allowed for the perception of the use of the new technologies within the corneal transplantation workflow. Despite the completion rate being only 63.9% (530/830), which can be explained by external factors such as patient health and availability of donor organs, there was an overall improvement in terms of task control and follow-up of the patients' clinical process.
This study shows that the adoption of openEHR structures represents a significant step forward in the standardization and optimization of corneal transplantation records. It offers a detailed demonstration of how to implement openEHR specifications and highlights the different advantages of standardizing EHRs in the field of corneal transplantation. Furthermore, it serves as a valuable reference for researchers and practitioners who are interested in advancing and improving the exploitation of EHRs in health care.
角膜移植术，也称为角膜成形术，是一种广泛开展的外科手术，旨在恢复角膜受损患者的视力。角膜移植的成功依赖于对患者信息的准确及时管理，而使用电子健康记录（EHR）可增强这一管理。然而，传统的电子健康记录往往零散且缺乏标准化，导致信息获取和共享困难，医疗差错增加，患者安全性降低。鉴于这些问题，对能够确保跨医疗保健机构的患者数据准确性和一致性的标准化电子健康记录的需求日益增长。
本文提议使用openEHR结构来规范角膜移植记录。本研究的主要目的是提高角膜移植中电子健康记录的质量和互操作性，使医疗保健提供者更容易获取、共享和分析临床信息。
本研究采取了一系列循序渐进的步骤，以使用openEHR规范来实现标准化临床记录。这些规范提供了一种系统的方法，可确保高质量临床记录的开发。概括而言，所遵循的方法包括与医疗保健专业人员举行会议以及对原型、模板、表单、决策规则和工作计划进行建模。
本研究得出了一个量身定制的解决方案，该方案简化了医疗保健服务的提供，满足了参与角膜移植过程的医疗专业人员的需求，同时与当代临床实践无缝接轨。所提议的解决方案最终成功地将openEHR规范的3个关键组件集成到一家葡萄牙医院：表单、决策逻辑模块和工作计划。对2022年5月1日至2023年3月31日收集的数据进行的统计分析，有助于了解角膜移植工作流程中新技术的使用情况。尽管完成率仅为63.9%（530/830），这可能由患者健康状况和供体器官可用性等外部因素来解释，但在患者临床过程的任务控制和随访方面总体有所改善。
本研究表明，采用openEHR结构是角膜移植记录标准化和优化方面向前迈出的重要一步。它详细展示了如何实施openEHR规范，并突出了角膜移植领域电子健康记录标准化的不同优势。此外，它为有兴趣在医疗保健领域推进和改进电子健康记录应用的研究人员和从业者提供了有价值的参考。
