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openEHR process model

We model health care delivery as two kinds of process: a clinical process, corresponding to the interaction between a 'clinical investigator system' and a 'patient system', situated within a business process, which is owned by an 'administrative context'. The clinical process constitutes a sub-process of the business process, i.e. it is the main mechanism for the business process to achieve its goal, which is to satisfy a demand for care on the part of the patient. The administrative context corresponds to the health system as a whole, rather than a single enterprise, since from the patient care point of view, the mobilisation of care delivery is carried out by a network of provider organisations. The model can be illustrated in two equivalent ways, as shown in Figure 3. more....

openEHR Entry process

The terms 'observation', 'evaluation' etc defined above are not themselves the same as information types, since they refer to a variety of phenomena within the process: information from observations, the activity of evaluation, acts of intervention, and goal statements. To be more precise, we are mainly interested in information created by the investigator system, since this notional agent encompasses any person or device who/which performs any healthcare related task, including the patient herself. The investigator system is therefore the creator of all clinical information in the health record, including patient-entered data. A small amount of administrative information may also end up in the EHR, generally created by non-clinical actors in the organisational context.
We can redraw the investigator system in order to more clearly show the types of information created during the care process, as shown in Figure 4. Five types of information are identified, as follows:

• observation: information created by an act of observation, measurement, questioning, or testing of the patient or related substance (tissue, urine etc), including by the patient himself (e.g. taking own blood glucose measurement), in short, the entire stream of information captured by the investigator, used to characterise the patient system;
• opinion: thoughts of the investigator about what the observations mean, and what to do about them, created during the evaluation activity, including all diagnoses, assessments, speculative plans, goals;
• instruction: opinion-based instructions sufficiently detailed so as to be directly executable by investigator agents (people or machines), in order to effect a desired intervention (including obtaining a sample for further investigation, as in a biopsy);
• action: a record of intervention actions that have occurred, due to instructions or otherwise;
• administrative event: a record of a business event occurring within the administrative context, such as admission, booking, referral, discharge etc.

openEHR Entry ontology

The Clinical Investigator Record (CIR) ontology:
An ontology of types of recorded health information. This ontology is probabaly the main starting point for analysing the ontological qualities of openEHR.