Model-based Approach For Building Structured Templates Of EHR

EHR is a digital medical and health service record that addresses the clinicaldiagnosis, treatment and health guidance information of outpatients and inpatients inmedical institutions. It contains integrated, detailed clinical information of individuals thatgenerated and recorded in the whole healthcare process. Sharing of the EHR informationcan effectively improve the availability of medical record information, so that doctors areable to access the accurate information of patients where and when they need it, thusreducing medical errors, improving quality and efficiency of care. In addition, the sharedEHR can improve the accuracy of collection and analysis of clinical data，which canpromote medical research. The structuring and coding of EHR information is the basis forsharing and semantic interoperability of patient information.The objectives of this study are to provide a set of basic documents of medicalservice through collecting the content of clinical information record forms, extract structured document sections and entries for reuse by decomposing the basic documents;develope a Common Information Model of EHR by refering to the dual-modeling methodand considering the actual needs of hospital business specifications; constrain concepts ofthe Common Information Model using clinical information models and builde structuredtemplate of the EHR. Because the clinical information models bind clinical conceptsinvolved to standard terminology systems, clinical information is not only structrued butalso coded through the process. Building information model and template can guide thedevelopment of EHR system, and lay the foundation for the standardization entry ofmedical record information and effective use of data.The study is based on the national agreed medical records documentationspecifications, diagnostics and internal medicine, and the hospital medical recordsinformation record forms. By collecting the contents of the medical record extensively forpreliminary sorting and classification according to the categories of information, wedefined the basic documents of the EHR. With reference to the structured approach ofHL7CDA and its application templates, we classified the documents into a numbers ofsection and entry components. We built the Common Information Model to have aframework of EHR information by refering to the EHR Reference Model of openEHR.Then, we defined its classes and attributes which are associated with the EHR content andidentified relationships between the contents of the structured documents and the classes.Finally, we built a template for application with structured and coded information by usingthe clinical information model to constrain and instantiate the Common InformationModel.The main results of this research are as follows:1. A set of basic documents was provided by collecting and processing clinical recordinformation, and the sections and entries were extracted for some of the documents.Through collating and analysing the content of clinical information record forms, wedefined105basic documents for the routine clinical activities. Using the national agreedmedical records documentation specifications, diagnostics and internal medicine, and alsoreferring to HL7CDA approach, we abstracted63structured sections and127entries, and built a structural model of the EHR clinical documents.2. A Common Information Model for EHR standardization was developed as thesemantic infrastructure of the structural model of the EHR. The Common InformationModel consisted mainly of Administration and Medical Care classes. Administration classdescribes the document itself, such as the information of the identifier of document,authors, subjects and related medical service providers. Medical care class describesclinical information including four subclasses, such as Observation, Evaluation,Instruction and Treatment. Observation was divided further into Main Health Problemsand History, Sign and Physical Examination, Laboratory and Auxiliary Examination;Evaluation into Diagnosis, Risk and Quality Assessment; Instruction into Care Plan andRecommendation; and Treatment into Medication, Procedure/operation and OtherTreatment. The classes in the information model are corresponding to sections or entries inthe structure model.3. A structured template was built for case records of coronary heart disease using theappropriate sections and entries. The sections and entries of the medical record were givenstandard representation using corresponding clinical information models, includingstandard terminology codes. By taking the case of coronary heart disease as an example,the templates were tried to be adopted in patient admission record and the XML style sheetand XML document of the template was provided.The main conclusions of this research are as follows:1. The clinical documents in the medical records can be disassembled step by stepinto smaller units, such as sections and entries. Standard clinical documents can bedeveloped through reuse of these standardized units to meet the needs of standardrepresentation of various clinical documents. Such, the standardization of EHR is able tobe efficienct and sustainable.2. The development of the Common Information Model can be semanticallyfoundmental for the standardization of the documents and their components in EHR,allowing the structure to be independent of the semantics. The stability of systemdevelopment and the feasibility of information representaion can be maintained. EHR systems developed on the same information model are characterized with the sameinformation scope and framework, making the understanding and interoperability ofinformation between different systems much easier. The information model was builtbased on the needs of various discipline and sufficiently reflect the diversity of themedical information.3. Sufficient cooperation across information technology and clinical professionals isnecessary for developing electronic records documents and its components. Both of thenecessity, feasibility and rationality of the structuring and coding of medical documentsneed knowledge from both aspects. Sections and the entries in this study are for parts ofthe documents and the rationality of them should be validated further. In addition, a largenumber of clinical information models/archetypes required in standardization of EHRdocuments needs long-term and continuing participation of professionals from medicaldomain. In this study, we just used a few of available archetypes.In this study, we explored the processes and methods of using dual model tostandardize the representation of clinical information, which provides a way forstructuring, coding the EHR content. Meanwhile, in accordance with the needs ofapplication of EHR, we developed a method for building structured template. Theconclusions of this study are expected to be helpful to meaningful sharing andtransmission of clinical information.