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The openEHR Reference Model defines 6 kinds of Entry. Five of these are found in the openEHR EHR Information Model|svn/specification/TRUNK/publishing/architecture/rm/ehr_im.pdf\, and are illustrated below.
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The 6th type is called GENERIC_ENTRY, and is designed for mapping into and out of legacy and integration structures such as CEN EN13606, HL7 CDA, message and relational databases. The UML model of this type is here|uml/release-1.0.1/Browsable/_9_5_1_76d0249_1140530578205_529440_4046Report.html\; it is documented in the openEHR Integration IM|svn/specification/TRUNK/publishing/architecture/rm/integration_im.pdf\. All of these types are extremely generic and archetypes are used to define the specific business/domain content models under each of these types - see archetype mindmap|svn/knowledge/archetypes/dev/html/en/ArchetypeMap.html\ for examples.
Why not just have one Entry type?
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The various Entry types have differing structural models due to the fact that they record qualitatively different things. See the EHR Information Model|svn/specification/TRUNK/publishing/architecture/rm/ehr_im.pdf\ and UML for details.
Are there different basic patterns of information?
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Clinical Statement | Entry type | Example archetype | Comments |
simple measurement | Observation | The simplest 'point' measurements are still situated in time: there is always at least one 'event' or time-point. The openEHR model guarantees that the event-time information in single-point measurements is the same as for mult-sample measurements. | |
time-series measurement | Observation | Blood pressure measurement | Many phenomena have the potential form of a series of samples in time |
difference over time | Observation | The History part of the model accommodates changes over time. | |
maxima, minima, rolling averages etc | Observation | The 'math function' attribute in the INTERVAL_EVENT class\ accommodates all kinds of time-based averages and finite duration states. | |
diagnosis | Evaluation | Times of some events may be mentioned, but the structure of the Entry is not the time-history of an observed phenomenon, but a report or summary, often of several phenomena, supporting a conclusion, which is the point of the Entry. | |
adverse reaction | Evaluation | Adverse reaction assessment is an assessment of condition or propensity of the patient to react to particular substances. |
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Grey-zone examples
Some of the examples below have confused people. One reason for confusion is that a single health event may lead to a recording of an instance of the phenomenon, and a diagnosis of a condition - in other words, 2 Entries.
Clinical Statement | Entry type | Example archetype | Comments |
Physician: | Observation | There will be an observation since it is a real-world phenomenon that has been observed e.g. by listening. There seems to be an element of 'inference' about it; this is the clinician's assessment of the heart sounds heard to be leaking of blood through the mitral valve of the left side of the heart. | |
Evaluation | A diagnosis of mitral valve disease may be made; this will usually describe the severity, indicate what studies were done to establish the nature of the disease etc. This is not the same statement as any of the original observations, but would normally summarise them. | ||
Patient: | Observation | Anything interesting the patient says may be recorded in the story, depending on the clinician and system. | |
Evaluation | The clinician may or may not record a 'story'; if his assessment is that the patient is indeed diabetic, he would normally record a diagnosis; this has the same status as any other diagnosis recorded by a clinical professional. | ||
Allied health professional: | Observation | Facts about the patient's capabilities in living independently are recorded as Observation(s), and gathered according to a protocol, such as a questionnaire, functional test by occupational therapist etc. How good the information is may depend on the protocol, but in all cases, the result is an observation of various phenomenon in time. | |
Evaluation | An assessment will be made about the subject based on all the information gathered; some of the evidence might lead to the establishment of a problem of incontinence. |