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openEHR Based Contextual Problem List.

John Meredith1, Ian McNicoll2, Nik Whitehead3

  • 1Wales Institute for Digital Information, Cardiff UK.

Studies in Health Technology and Informatics
|May 27, 2021
PubMed
Summary

This study introduces a contextual problem list implementation using openEHR, improving digital patient records. The approach enhances the Problem Oriented Medical Record for better clinical data management.

Keywords:
Contextual problem listclinical modelsdiagnosisdigital healthopenEHRproblem oriented medical record

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Area of Science:

  • Health Informatics
  • Electronic Health Records
  • Clinical Data Management

Background:

  • The problem list is crucial for digital patient records but historically challenging to maintain.
  • Accurate problem lists are essential for effective patient care and medical record management.

Purpose of the Study:

  • To present an implementation of a contextual problem list using the openEHR standard.
  • To describe the modeling approach and key elements for a Problem Oriented Medical Record.

Main Methods:

  • Utilized openEHR archetypes and templates for modeling the contextual problem list.
  • Developed a system to integrate the problem list within a Problem Oriented Medical Record framework.

Main Results:

  • Successfully implemented a functional contextual problem list within the openEHR framework.
  • Demonstrated the assembly of model elements to support a Problem Oriented Medical Record.

Conclusions:

  • The openEHR implementation offers a viable solution for curating digital patient problem lists.
  • Further discussion is needed on the optimal utilization and implications of contextual problem lists in clinical practice.