A conceptual model for documentation of clinical information in the EHR

At a national level in Denmark the development of a Conceptual Model for Communication in Electronic Health Records (EHR) has moved towards a two-folded structure, i.e. a conceptual model for documentation of clinical information, the Clinical Process, and a Reference Information Model. The coupled structure derived in the final phase of the development of the Conceptual Model for Communication in EHR by the end of year 2001. This was inspired by the in-put and collaboration of several parties in the Danish healthcare sector throughout the period of development from 1999 to the current version 1.01 of the national standard was launched by The National Board of Health in January 2002. The modelling of the Clinical Process meets the need for a more clinical understanding of how the use of information technology, i.e. EHR, can support the work processes of shared-care and continuity of care in hospital settings. The Clinical Process as a model for documentation in EHR facilitates the capturing of clinical information where it emerges in the clinical work processes. The model retains in a logical way the clinical relevant relations between different information elements that comply with the concept of problem-oriented documentation. A comparison between European Pre-standard CEN/ENV 13606 and the Danish Conceptual Model reveals different approaches with regard to the focus of modelling the EHR information.