Clinical Databases with openEHR (tutorial)

...

...

...

...

...

Abstract

Databases for Clinical Information Systems are difficult to design and implement, especially specially when the design involves the implementation of a formal specification or standard. The openEHR specifications offer a very expressve expressive an generic model for clinical data structures, allowing semantic interoperability and compatibility with other standards like HL7 CDA, FHIR, and ASTM CCR. But openEHR is not only for data modeling, it specifies an EHR Computational Platform designed to create highly modifiable future-proof EHR systems, and to support long term economically viable projects, with a knowledge-oriented approach that is independent from specific technologies. Software Developers find a great complexity in designing openEHR compliant databases since the specifications do not include any guidelines in that area. The authors of this tutorials aer developers that had to overcome these complexities. This tutorial will expose different requirements, design principles, technologies and techniques that can be used to tackle that problem, techniques and main challenges of implementing an openEHR-based Clinical Database, with  examples and lessons learned to help designers and developers to overcome those challenges.

Keywords:

EHRElectronic Health Record; Clinical Database Design; openEHR; Clinical Information Systems; EHR.

...

Tutorial Description

The main

...

motivation of this tutorial is to

...

help reducing the gap between the openEHR formal specifications and concrete database

...

implementation

...

Expected outcomes

After the tutorial, we expect attendees to have a better understanding of the openEHR specifications and scope, to know the main requirements of clinical data structures and database technologies that meet those requierments, to learn techniques and good practices that can be used to create different kinds of openEHR-compliant clinical data repositories.

Expected attendees

Software Developers, Database Managers, Software Architects Technical Leaders, Decision Support Specialists, and Business Intelligence Experts, participating in healthcare informatics projects or planning to.

Tutorial description

...

. Considering that openEHR is an EHR standard adopted by the Brazilian government and by other countries [1], and it's gaining momentum at the Latim America eHealth community because of the dissemination and training activities created by the openEHR en Español community [2], and supported by ACHISA, we think this tutorial might be a good fit for the MedInfo conference.

This tutorial will expose the key challenges software developers have when designing and implementing Clinical Databases for Clinical Information Systems

...

, including EHR data requirements, data organization, use, modification and evolution. Next, the tutorial will be centered on using the openEHR specifications [3] to tackle some of those challenges, adding other difficulties to the database design and implementation. The rest of the tutorial will be focused on giving proven solutions and lessons learned to create openEHR-based Clinical Databases.

We'll not only center on clinical data storage, but how that that is queried and used for healthcare (documentation, order management, Clinical Decision Support, healthcare plan follow-up for chronic diseases and other conditions, etc.), and secondary uses

...

(clinical research, education, public health, quality assurance, and complying with medico-legal requirements

...

).

The main content of the tutorial will include an overview of different technologies (relational, document-oriented, key/value) and techniques to actually design and implement openEHR-based databases, including lessons learned from implementation experiences and good practices that may help to tackle implementation problems. We'll overview the key concepts of the openEHR

...

specifications that affect database design (EHR, Folder, Composition, Entry,

...

Item Structure,

...

Data Value) and the openEHR dual-model (information + archetypes)

...

. This will help attendees to understand how to design

...

Clinical Databases to create systems that provide services for storing

...

health records and query those records in the “openEHR way”, by creating queries that use clinical concept definitions (Archetypes) instead of relying on

...

a specific database technology (SQL, XQuery, JSON-based queries, OO queries, etc.), making queries a generic, reusable and shareable artifact between implementations

...

.

The main content of the tutorial will include a review of different technologies (relational, document-oriented, key/value) and techniques to actually design and implement openEHR-based databases, including lessons learned from implementation experiences and good practices that may help to tackle implementation problems.

We'll explain how to implement some functional requirements related to health record versioning (to support modifications, amendments and corrections at the database level), clinical data validation and indexing to improve query performance.

Will end with the conclusions about the different approaches to Clinical openEHR Database design and implementation.

...

During the tutorial, audience participation and discussion will be encouraged.

1. General Organization of the Tutorial Proposal

The tutorial general topics will include:

• Clinical Database requirements that are derived from EHR/EMR requirements and Clinical Documentation standards requirements (ISO 18308, CEN/ISO 13606, openEHR, HL7 CDA, ASTM CCR)
• Review of the core concepts of the openEHR specification, focusing on the ones that will affect the Clinical Database Design (e.g. EHR, Folder, Composition, Section, Entry, DataStructure, ItemStructure and DataValue).
• Implementation methodologies, techniques, good practices and experiences for different types of databases (relational, document-oriented, key/value).
• Considerations about clinical data validation, storage, versioning, indexing and querying.

2. The workshop structure and arguments

The speaker will lead help the attendees to understand key points of openEHR database design, based on previous experiences working on clinical database design and implementation and a deep knowledge of the openEHR specifications. This tutorial will expose the general topics aforesaid following this organization:

• Requirements
  • EHR purposes from ISO 18308 that guide to different uses of data in healthcare:
    • Transactional
    • Aggregated data
    • Charting
    • Reporting
    • Analysis
    • Research
    • Education
    • Medico-legal proof
  • Clinical records organization and main entities (based on EHRA from ISO 18308)
    • Concepts modeled by different standards like HL7, openEHR and CEN/ISO 13606.
    • Clinical information hierarchy
• openEHR Information Model core concepts, Archetypes and Operational Templates
  • Structure, content definition, ways of implementation at a database level.
  • Discussion about difficult areas of implementing openEHR-based clnical databases, opinions from developers.
    • The need of openEHR metadata in the database alongside with data.
• Implementation technologies
  • Different database models to fufill different kinds of requirement: relational, document-oriented, key/value.
  • Relational model techniques
    • Object-Relational Mapping
    • Schema auto-generation from archetypes
    • High level data indexing
    • Pros and cons of the relational model for clinical databases
  • General concepts about document-oriented approach, storing and querying for openEHR clinical documents.
    • XML and JSON databases.
    • openEHR in XML and JSON.
    • Querying mechanisms.
    • Pros and cons of the document-oriented approach for clinical databases.
  • General concepts about key/value approach, storing and querying for openEHR clinical data.
    • openEHR Archetype/Template paths and instance paths.
    • Pros and cons of the key/value approach.
• Clinical databases and information management summary:
  • Data validation
  • Data storage
  • Data versioning (an openEHR requirement, mentioned in ISO 18308, and supported by HL7 CDA documents)
  • Data indexing
  • Data querying
• Practical experience and conclusion.
  • Brief discussion about requirements, approaches and techniques.

Workshop speakers

• Pablo Pazos; openEHR en español, ACHISA, CaboLabs; Uruguay
• Koray Atalag, openEHR New Zealand, University of Auckland, New Zealand
• ...

Resources

...

Tutorial Structure

This tutorial will be organized by the following structure, that is based on the openEHR Clinical Database Design and Implementation course content [4].

Introduction

• Requirements for data access

-      EHR purposes from ISO 18308 [5], guiding different uses of clinical data in healthcare (primary and secondary uses).

-      Information System classification by data-base uses (write-oriented, read-oriented, read/write-oriented).

-      Organization and access to clinical informa-tion (chronologic, by health problem, by medical specialty, by logical or physical lo-cation, by episode).

• Requirements for data structures

-      Paper-based health record structure analysis.

-      Minimal EHR content from ISO 18308.

-      Clinical records organization and main enti-ties from the openEHR Information Model (Free text vs. semi-structure vs. fully structured clinical records, support for different data types and temporal series, times in the EHR).

• Requirements for EHR audit.
• Design principles for openEHR databases

-      Introduction to Archetypes and Operational Templates (big archetypes).

-      Data and metadata in the database.

-      Generic data storage and data query design using openEHR Archetypes and Information Model.

-      OpenEHR Information Model details (com-positions, sections, entries, structures, items, data values).

Technologies and Techniques

• Different kinds of database management systems (re-lational, document-oriented, object-oriented, key/value, graphs, multidimensional, etc.)
• The Object-Relational Mapping technique

-      Mapping classes, relationships and inheri-tance for an OO model into a relational da-tabase.

-      Database schema generation techniques and normal forms.

-      Examples of implementation.

• openEHR data in XML and JSON

-      Communication and storage of XML and JSON documents.

-      Tools to work with XML and JSON.

-      Examples of implementation.

• Working with openEHR Archetypes in software

-      Introduction to the Archetype Definition Language (ADL).

-      Parsing and using archetypes for data valida-tion and terminology extraction.

Advanced concepts

• EHR change control and versioning, implementation at the database level.
• Data indexing and performance.
• Synchronization / Replication for high availability and backup.
• System integration and the Extraction-Transformation-Loading (ETL) process using openEHR.

Specific educational goals

The main goal of this tutorial is to shorten the gap between the openEHR specifications and real world Clinical Database design and implementation for software developers.

Secondary goals include: sharing experiences and lessons learned, enabling discussion about Clinical Database implementation (a topic that is not discussed or taught often enough), and spreading the use of eHealth standards at the database level on Clinical Information System development.

Expected outcomes

After the tutorial, we expect attendees to have a better understanding of the openEHR specifications and scope, to know the main requirements of clinical data structures and database technologies that meet those requierments. Also to learn techniques and good practices that can be used to create different kinds of openEHR-compliant clinical data repositories.

Expected Attendees

Software Developers, Database Managers, Software Architects, Technical Leaders, Decision Support Specialists, and Business Intelligence Experts, participating in healthcare informatics projects or planning to.

Tutorial Speakers

Pablo Pazos Gutiérrez, Ingeniero en Computación, UdelaR,Montevideo,Uruguay.

Clinical Informatics Consultant at CaboLabs Medical Informatics and Standards, Lecturer at Chilean Association of Healthcare Informatics (ACHISA), Coordinator at the openEHR-ES community, Qualified member of the openEHR Foundation - Localization Programme Member for LatAm.

PLEASE ADD A MINI BIO HERE!

References

[1]   Who is using openEHR? http://www.openehr.org/who_is_using_openehr/healthcare_providers_and_authorities

[2]   Comunidad de openEHR en Español http://openehr.org.es

[3]   openEHR Specifications, openEHR Foundation. http://openehr.org/programs/specification/releases/1.0.2

[4]   Curso de Diseño e Implementación de Bases de Datos Clínicas con openEHR, edición 2014, Asociación Chilena de Informática en Salud (ACHISA).

[5]   ISO/TC 215, ISO 18308: Health informatics – Requirements for an electronic health record architecture.