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Standardizing Corneal Transplantation Records Using openEHR: Case Study.

Diana Ferreira1, Cristiana Neto1, Francini Hak1

  • 1ALGORITMI Research Center, Intelligent Systems Associate Laboratory (LASI), School of Engineering, University of Minho, Guimarães, Portugal.

JMIR Medical Informatics
|September 16, 2024
PubMed
Summary
This summary is machine-generated.

Standardizing corneal transplantation records with openEHR structures improves electronic health record (EHR) quality and interoperability. This approach enhances patient data management and clinical workflow for better outcomes in keratoplasty.

Keywords:
EHRarchetypescorneal transplantationdata exchangedata representationelectronic health recordformskeratoplastyopenEHRstandardizationtemplates

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Area of Science:

  • Ophthalmology
  • Health Informatics
  • Medical Record Management

Background:

  • Corneal transplantation (keratoplasty) restores vision but relies on accurate patient data.
  • Fragmented and non-standardized electronic health records (EHRs) hinder data sharing, increase errors, and compromise patient safety.
  • There is a critical need for standardized EHRs to ensure data accuracy and consistency in healthcare organizations.

Purpose of the Study:

  • To propose and implement openEHR structures for standardizing corneal transplantation records.
  • To enhance the quality and interoperability of EHRs within the corneal transplantation domain.
  • To facilitate easier capture, sharing, and analysis of clinical information by healthcare providers.

Main Methods:

  • Employed openEHR specifications for methodical development of high-quality clinical records.
  • Conducted meetings with healthcare professionals to inform the modeling process.
  • Modeled archetypes, templates, forms, decision rules, and work plans for EHR standardization.

Main Results:

  • Successfully integrated openEHR components (forms, Decision Logic Modules, Work Plans) into a Portuguese hospital's corneal transplantation workflow.
  • Observed an overall improvement in task control and patient clinical process follow-up.
  • Data analysis from May 2022 to March 2023 indicated the practical application of new technologies, despite a 63.9% completion rate due to external factors.

Conclusions:

  • Adopting openEHR structures significantly advances the standardization and optimization of corneal transplantation records.
  • The study demonstrates a practical implementation of openEHR specifications and their benefits for EHR standardization in ophthalmology.
  • This research serves as a valuable reference for improving EHR utilization in healthcare, particularly for complex procedures like keratoplasty.