OpenEHR in Healthcare a Review

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15 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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1

OpenEHR

in H
ealthcare


a Review


AGUIAR, Filipa

(
mimed08081@med.up.pt)
;

CORDEIRO,
Amílcar (
mi
med08007@med.up.pt)
; DIAS,
André

(
mimed08041@med.up.pt
)
; DUARTE, Mariana

(
mimed08182@med.up.pt)
; FONSECA,
Raquel

(
mimed08201@med.up.pt)
; FRANÇA, Cíntia

(
mimed08049@med.up.pt
)
; MACEDO, Luís

(
mimed08146@med.up.pt
)
; MELO, Luís

(
mimed08250@med.up.pt)
; PINTO, J
oana

(
mimed08098@med.up.pt)
; PIRES, Sara

(
mimed08221@med.up.pt)
; RODRIGUES, Pedro

(
mimed08211@med.up.pt)
; SANTOS, Paulo

(
mimed08247@med.up.pt)
; SOUSA, Manuel

(
mimed08139@med.up.pt)
; TELES, Ana

(
mimed08028@med.up.pt)
; VIANA, João

(
mimed08052@med.up.pt)


Adv
iser:

PhD
Ricardo Correia
-

Class 14



ABSTRACT

Problem and
Background
:

The spread of Information and Communication Technologies promoted
the use of new medical software and innovative computer databases. However, lack of
communication between
standard
s is

nowadays a major obstacle to the sharing of clinical information
and integrated and sustainable management of the disease. The
openEHR

arose from a
n attempt to
standardization, seeking

functiona
l and semantic interoperability
, having a greater contributio
n of
clinicians.

Because

electronic health records are, undoubtedly,
an emerging reality
, our project is
clearly useful, overcoming

the lack
of
reviews on the topic and
describing

the actual state of art
concerning
openEHR
.

Aim
:

To determine the extent of
current application of the
standard

to the various
clinical

sectors
.
E
valuate advantages and discuss limitations inherent to the
standard
.

Make a Global review on the
implementation of this standard
.


Methods
:

A review
was

performed, based on articles

from

Scopus, ISI Web
of Knowledge and

Pubmed
. These databases were searched using

the keyword
openEHR
.

Each article

abstract

was
reviewed

by three reviewers
. The
selected

articles were totally read

by two reviewers

and relevant
data was

extracted from the
m, fo
llowing a data extraction questionnaire.

If the article was not found
to be useful by the two reviewers than it was excluded. The extracted data was analysed in SPSS.

2

Results
:

Among 42 non
-
repeated articles

initially found, 21 were included
. 2008 was found

to be the
main year of publication (23,8%

of the articles). 19

articles mention advantages/disadvantages
concerning
openEHR
. S
emantic interoperability
s
eem
s

to be

the most notorious
advantage. On the
opposite, authors point out difficulties in sharing the

data

as
openEHR
’s main limitation.

Nursing was
the most common clinical area

(14
%
)
.

Key
-
words:

openEHR


INTRODUCTION

Background and justification

The development of computing technology in health environment was initiated in the sixties. The first
stand
ards included statistical and epidemiological analysis. At present, an information standard is
defined as a mechanism, automatic or manual, which involves people, machines, and/or organized
methods for the collection, processing and reporting of data that
represent information to the user.
The implementation of information standards in health aims, in the first instance, the management of
clinical information.

An EHR (Electronic Health Register) is defined as an archive of clinical data processed by a
compu
ter. Contains three levels of communication:









The evolution of data management standards for health should focus on the user, improving the
quality of delivery of health services in an integrated management of the disease.

In opposition to the ov
erly technological approach in the dynamics of health standards, adopted due
to the increasing availability of innovative tools and techniques, the actual demand is for a
multidimensional organizational transformation that provides the obtainment of more a
nd better
health for all.

Therefore, the new demands in this area are that the growing number of available clinical data that
require the creation of an appropriate, and at the same time not complex, mechanism for access and
Figure
1
.

The different levels of communication of
EHR.


3

transmission of information. Wi
th the spread of Information and Communication Technologies
medical software was acquired and informatic databases were designed. However, these standards
were not designed to enable communication between them, making it difficult to use

and to share the
c
linical information. The proliferation of standards whose communication is nonexistent generates
replicated data and/or contradictory. Moreover, the absence of terminology or even a single global
patient identifier makes it even more difficult to integrate

these standards.

The creation of standards in this area of health services is then necessary due to several factors, of
which we can highlight: the plethora of terms, the variety of hardware platforms and software, the
need for search and report the infor
mation and optimization of the use of decision support standards.
These proposals are based on two main pillars:
functional interoperability

(communication between 2
or more standards, according to defined rules) and
semantic interoperability

(definition o
f concepts of
field).


One of the latest international standards developed to provide the exchange of information on health
is the
openEHR
.


openEHR


The
openEHR

is the result of the concerted efforts of a nonprofit organization. The founders are the
Univ
ersity College London (United Kingdom) and Ocean Informatics Pty Lda (Australia). The
foundation responsibles are in charge of the available funds application and the compliance of the
rules and aims to be achieved. The technical work of supervision is in
charge of the Architectural
Review Board (ARB) and the Clinical Review Board (CRB).

The
openEHR

foundation has been dedicated to the development of an interoperable computing
platform for the field of medicine, whose basic principle is based on intercommun
ication between
technical activities and medical records. Its creation was influenced by standards as CEN prEN
13606, GEHR Australia and HL7.

With the aim of providing, in the same standard, both technical and clinical records, the
openEHR

involves the mem
orization of complex clinical information such as laboratorial test results and
diagnostic auxiliary examinations, and even treatment plans and clinical situation evaluation.

This new standard revolutionizes previous attempts to standardize the health sta
ndards in the sense
that its methodology was designed to involve the medical community in building the platform, along
with software design technicians.

In fact, the health professionals are the ones who define which parameters will be released, the
langu
age to apply, and the specifications of the user interface. First, the software engineers create
4

simple and generic models that can be implemented in the users standards, along with tools needed
to support the remodeling of the program. This remodeling is
the construction of archetypes, with
changes in terminology carried out by specialists in the field of health. The standard is then able to
use.









The
openEHR

only encodes information essential, unlike other standards such as HL7. However, it
inte
grates HL7 messaging services, a standard which also provides information exchange.

About the terminology, the
openEHR

uses ontologies, allowing the use of terminologies such as
SNOMED
-
CT, LOINC and ICDx.

Another concern of the standard developers is its d
uration, looking up, obviously, a long
-
term
effectiveness.


The

aim of this review
was

t
o determine

the
current application of the
openEHR

on

the various
clinical
areas
.
A
dvantages
, disadvantages

and discuss limitations inherent to the
openEHR

were also
ta
ke in account
.


PARTICIPANTS AND METHODS

Study Design

Given the nature of the proposed work


the systematic review

article
-

the study was not developed
around a direct target population, but around previously published articles. The

syst
ematic review

is
based on secondary data research.


Work Phases

The work had four main phases: Search Phase, Screening/Including Phase and Data Collect.


Figure
2
.

Interoperability of standards
.


5

Eligible
studies

All studies are f
rom different data bases (SCOPUS, PubMed, ISI). Only studies describing or
evaluating
openEHR

were selected
.


Review team

The review team was composed by
fifteen

medicine students from
Faculdade de Medicina


Universidade do Porto

(eight

males and
seven

females).


Search methods

Studies were searched between October 2008 and April 2009 in bibliographic databases. Since there
is no specific
standardized

MeSH term, articles with the keyword
openEHR

were included and only
articles with

an abstract in English were considered. Given the significant evolution in this area, only
studies published after 2002
(and before April 2009)
were included.


Three distinct bibliographic databases were searched: Medline (via Pubmed), ISI (ISI Web of
Kno
wledge) and Scopus.
T
he query search string used in each database was
openEHR
.

This search method found 36 articles in Scopus, 15 in ISI and 31 in Pubmed, a total of 82 articles.
After eliminating dupl
icate articles 42 were selected (figure
3
).





Figure 3.

Venn’s diagram related to repeated articles
elimination
.

6

Selec
tion of studies for the review



Screening Phase

After a long session of discussing the including and excluding criteria all 15 reviewers from the review
team were involved in study selection. All articles were read by three different reviewers following a
n
arbitrary order. The first selection was based on the study title and abstract.
The study was
considered eligible when it corresponds at least to one of the
inclusion criteria
:


-

Refers specifically
openEHR

-

Refers implementation in the health area,
c
onsidering:

-

Advantages/disadvantages

-

Exemplification with systems already
implemented (products) in other countries

-

Semantic interoperability of
openEHR

in
comparison to other systems

-

Refers innovations in
openEHR

-

Refers clinical aspects

-

Discus
s the effectiveness and efficiency of

openEHR


The
exclusion criteria

were the following:

-

Refers extensive clinical details

-

Irrelevant issue


To maximize specificity, only selection by at least two reviewers was considered adequate.
In case of
disagr
eement a third reviewer was called to decide.

A total of 26 articles out of 42 articles were selected to be read entirely. Full articles were searched,
but
some couldn’t

be possible to get, so a new exclusion criteria appeared. After this process

only 21
articles were obtained (figure
4
).


Figure
4
.

Diagram showing the

methods used
for study selection.

7

Definition of variables

The variables were selected according to the aims of the review. This way, they try, generically, to
easy the identification of major contributors in these papers and its time distribution (author
, year of
article publication), the main application fields of this standard (Clinical application fields
,
Implementation of
openEHR
), its advantages/disadvantages (Benefits, Limitations, Comparison with
similar systems), as well as to characterize the cur
rent dynamic of
openEHR

(Innovations in
openEHR
, Effectiveness and efficiency)

So, the variables are:

-

Author

that invested preferentially on the topic;

-

Year of article publication

-

Clinical application fields

(Emergency department, neonatology, Chronic di
seases, Pediatric
hearing loss assessment, nursing, Healthcare environments/ Health system administrators,
Pediatric oncology)


Multiple values are accepted.

-

Implementation of
openEHR

-

its uses in multiple areas (clinical trials, improvement of other
sys
tems, standardization of clinical concepts)
-

Multiple values are accepted.

-


Benefits

obtained through its application
-

(Semantic interoperability, interoperability between
systems, less bureaucracy, international acceptance)
-

Multiple values are accepte
d.

-

Limitations/Disadvantages

detected


(Lack of mechanisms for clinical inference, difficulties
in sharing data, problems concerning
openEHR
’s maintenance)
-

Multiple values are accepted

-

Comparison with similar standards/other systems


which medical info
rmatics standards
or systems are compared and what kind of topics support this relation (HL7, Julius,…)
-

Multiple values are accepted

-

Innovations
that involve
openEHR



(
Graphical user interfaces, communication worldwide
through
Google E
arth, guidelines fo
r different procedures)


Multiple values are accepted.


Questionnaires

Two questionnaires were made. The first one was to apply the Screening Phase (
annex
A
)

and the
second one to Data Collect (
annex
B
)
.

8

Data Collect Phase

In this phase, a full questionna
ire (check list type with text boxes to add any other information) was
answered by two reviewers for each article. Then a third reviewer compared the two questionnaires
and done a final one.


Stati
sti
cal analysis

All data were processed

with SPSS® 16.0 [3
5]


RESULTS

Screening phase

results

Table 1

shows the results of the questionnaire applied on screening phase. Statistical analysis was
provided in order to notice how many articles
answer positively to the questions considered.




The percents refer
to the articles initially found (n=4
2)
. 59,5% of the articles mentioned
openEHR
,
40,5% referred semantic interoperability, 35,7% stated implementation, 23,8% talked about
advantages
/d
isadvantages, 14,3% cited

Clinical aspects and/
or innovations and 9,5 % pointed out
eff
ectiveness and efficie
ncy and/
or systems with
openEHR

already implemented.


Question

Yes
(n)


Positive
%

Refers specifically openEHR?

25

59,5

Refers advantages/disadvantages?

10

23,8

Refers exemplification with systems already implemented in other countries?

4

9,5

Refers a semantic interoper
ability of openEHR in comparison to other systems?

17

40,5

Refers innovations in openEHR
?

6

14,3

Refers the implementation of openEHR in the health area?

15

35,7

Refers clinical aspects?

6

14,3

Discusses the e
ffectiveness and
e
fficiency of openEHR
?

4

9
,5

Table 1.

Screening phase statistical analysis.

9

Table 2

summarizes the complete
list of articles that were included on the review. It describes its
reference number


applied after an alphabetical organization
-
, title, authors and publication date o
f
the articles.


Article
reference
number

Title

Authors

Publication
date

1

Advanced and secure architectural EHR approaches

Blobel B





2006

2

An archetype
-
based testing framework

Chen R.; Garde S.; Beale T.; Nystrom M.; Karlsson D.;
Klein G.O.; Ahlfeldt H.



2006

3

An ontological infrastructure for the semantic integration
of clinical arc
hetypes

Fernandez
-
Breis, JT; Menarguez
-
Tortosa, M; Martinez
-
Costa, C; Fernandez
-
Breis, E; Herrero
-
Sempere, J;
Moner, D; Sanchez, J; Valencia
-
Garcia, R; Robles, M


2008

4

Can openEHR Archetypes Empower Multi
-
Centre Clinical
Research?

Sebastian Garde, Petra Knaup, Thilo Schuler, Evelyn
Hovenga


2005

5

Collaborative development of clinical templates as a
national resource

Hoy D.; Hardiker N.R.; McNicoll I.T.; Westwell P.;
Bryans A.



2009

6

Combining OpenEHR archetype definitions with SWRL
rules
-

a translation approach

Lezcan
o L.; Sicilia M.
-
A.; Serrano
-
Balazote P.


2008

7

Comparing different approaches to two
-
level modelling of
electronic health records

Michelsen L, Pedersen SS, Tilma HB, Andersen SK



2005

8

EHR query language (EQL)
--
a query language for
archetype
-
based health records

Ma C.; Frankel H.; Beale T.; Heard S.




2007

9

Evaluation of documents that integrate knowledge;
terminology and informat
ion models

Van der Kooij J.; Goossen W.T.; Goossen
-
Baremans
A.T.; Plaisier N.


2006

10

Expressing clinical data sets with openEHR archetypes: A
solid basis for ubiquitous computing

Garde S.; Hovenga E.; Buck J.; Knaup P.



2007

11

Graphical overview and navigation of electronic health
records in a prototyping environment using Google Earth
and openEHR archetypes.

Sundvall

E.; Nystrom M.; Forss M.; Chen R.; Petersson
H.; Ahlfeldt H.


2007

1
2

Integration of tools for binding archetypes to SNOMED
CT

Sundvall E.; Qamar R.; Nystrom M.; Forss M.;
Petersson H.; Karlsson D.; Ahlfeldt H.; Rector A.



2008

13

International developments in openEHR archetypes and
templates

Leslie H.




2008

14

Julius
-

A template based supplementary electronic health
record system

Chen R.; Enberg G.; Klein G.O.



2007

10

15

Linking guidelines to Electroni
c Health Record design for
improved chronic disease management

Barretto S.A.; Warren J.; Goodchild A.; Bird L.; Heard
S.; Stumptner M.



2003

16

Nursing constraint models for electronic health records: a
vision for domain knowledge governance

Hovenga E, Garde S, Heard S



2005

17

The openEHR Java reference implementation project

Chen R, Klein G



2007

18

Towards a compr
ehensive electronic patient record to
support an innovative individual care concept for
premature infants using the openEHR approach

Buck J, Garde S, Kohl CD, Knaup
-
Gregori P



2009

19

Towards semantic interoperability for electronic health
records

Garde S, Knaup P, Hovenga E, Heard S



2007

20

Using OpenEHR in SICTI an electronic he
alth record
system for critical medicine

Filgueira R.; Odriazola A.; Simini F.



2007

21

Using semantic technologies to promote interoperability
between electronic healthcare records' information
models

Fernandez
-
Breis J.T.; Vivancos
-
Vicente P.J.;
Menarguez
-
Tortosa M.; Moner D.; Maldonado J.A.
;
Valencia
-
Garcia R.; Miranda
-
Mena T.G.


2006



Data
c
ollect
p
hase

results

Advantages

Semantic interoperability was referred by 5
2% of the articles and Inter
-
system interoperability by
48%. 14% mentioned the ability to standardize, independence between technology and data format,
being a life
-
long EHR and refining information recording through archetypes. The acceptance of the
syste
m internationally, ability to consult and registry faster and more efficiently and information
transfer were cited by 10%. 5% stated about quality of the system in comparison to other existing
systems, the use in the clinic practice (integration of termino
logy services, priority to interaction
between patient and clinician), less bureaucracy and it is non
-
profit.


Disadvantages

openEHR

presents difficulties in sharing data (mentioned by 14% of the articles) and 5% referred the
lack of mechanisms of adaptati
on to Clinical Data Systems, complexity of archetypes and the need to
develop a model
-
independent archetype management system.


Table 2.

List of articles included in the work
.

11

Comparison between
openEHR

and other systems

OpenEHR

is compared to
HL7

(33% of the total of the articles),
CEN

(19%),
Sistema

J
ulius

(14%),
Australian

GEHR
(10%),
UML
(5%) and
Denmark

EHR

project
(5%).


Innovations in
openEHR

openEHR

uses a two
-
level modelling approach relating to information and knowledge models, using
of archetypes and is capable of exchanging information using
worldwide systems. 5% of the articles
mentioned that
OpenEHR

is centred on the user (graphical user interfaces, priority to patient, flexible,
scalable and user
-
friendly), harmonizes and standardizes the
EHR

systems in use, employs
OWL

and
SWRL

as rule bas
ed systems and approaches to European Standard.


Implementation of
openEHR

openEHR

is implemented to standardize clinical concepts (43% of the total articles referred this
topic), used in Investigation
-
clinical trials (19%), a model for the improvement of

other systems
(10%). 5% of the articles mention the compatibility with other systems, using of Java Reference,
supporting function (with lists, tables) and allowing a multi
-
centre research.


Clinical Aspects

openEHR

is being used on nursing (14% of the ar
ticles), by administrators (10%) and 5% referred
chronic diseases, neonatology, pediatric oncology and as upgrade to provide an aid critical medicine
processes.

62% of the results were missing values.


Systems with
OpenEHR

already implemented (products) in

other countries

OpenEHR

is already implemented in National ICT Institute


stroke patients (Holand), National
Ehealth Transation Authority (Australia) and Conversion of data stored in clinical data sets for
OpenEHR

archetypes (Germany).



12

Graph 1
: Year of publication of included articles.
Articles from 2009 were only collected until April


Year of publicat
ion


T
he year of publication was also a
parameter of analysis. Based on the results
illustrated in graphic 1 there is an obvious
increase in the number of articles published
until 2007 (this was, in fact, the year in which
most of the articles read were
published),
followed by a decrease of one article.


Only one of the total articles read was from the year 2003. Instead, two of them were published in
2004. Followed by the inclusion of one more article is the year 2005 (with the total number of 3
articles

published, from those that were included in our paper), as well as 2006 (with the total number
of four articles published from those that were included in our review). As mentioned before, most of
the articles included had 2007 as their publication year (
specifically, with the total number of seven
articles). The remaining six articles had the following publication year distribution: four of them were
published in the year 2008, and the other two in 2009 (For this year, there were only considered
those whi
ch date of publication did not exceed the month of April).





13

Frequencies (and percentages) for each variable analysed among the 21 data integration projects reviewed:



Variable

n

(%)

Article Number





Advantages




Semantic Interoperability

14

(67)

1, 2, 3, 4, 6, 8, 10, 12, 13, 16, 17, 19, 20, 21

Effectiveness and efficiency of openEHR

5

(24)

3, 5, 19, 20, 21

Acceptance

4

(19)

5, 10, 11, 16

Capacity to regist/consult any clinical information, fast and efficiently

2

(10)

16, 20

Improve quality of

health and documentation level

2

(10)

7, 16

Information trade in a more reliable and safer way

2

(10)

12, 16

Non
-
profit organization

1

(5)

21

Priority to the patient/ clinician interaction

1

(5)

3

Tested on real life

1

(5)

9

Two model Approach

1

(5)

7














Disadvantages




Difficulties in sharing data

3

(14)

8, 9, 14

Difficulties using archetypes

3

(14)

7, 9, 10

Impossibility of overcoming all barriers of Ubiquitous Computing

1

(5)

10

Lack of standardized language

1

(5)

8

Need of the
development of a model
-
independent archetype management system

1

(5)

3














Examples of systems already implemented (products)




Australian´s National Ehealth Transation Authority (NEHTA)

1

(5)

19

Coversion of data stored in CDS (clinical da
ta sets) for openEHR arquetypes (Germany)

1

(5)

9

Large organisations such as the UK National Health Service Connecting for Health have started to express clinical
content using
open
EHR archetypes.

1

(5)

18

National ICT Institute (NICTIZ)
-
stroke patients

(Netherlands)

1

(5)

9

14


Variable

n

(%)

Article Number





Comparison between openEHR and other systems




HL7

7

(33)

1, 3, 5, 6, 7, 9, 19

CEN

4

(19)

1, 3, 17, 21

System Julius

3

(14)

5, 6, 19

Aarhus EHR

1

(5)

7

Australian GEHR

1

(5)

1

Dynamic/
Capacity of updating the system according to the evolvement of different models

1

(5)

20

Eardap

1

(5)

4

ISO 11404

1

(5)

10














Other considerations related to openEHR




Two
-
level modeling

3

(14)

7, 16, 18

Considering modelling at a meta
-
level and allow re
-
use of models via different routes (refering to openEHR and
other EHR systems).

1

(5)

5

Creation of open, user
-
centric, user
-
friendly, flexible, scalable, portable core application in health information
systems and health networks

1

(
5)

1

Graphical user interface (GUIs)

1

(5)

14

Implementation using Java

1

(5)

17

Information exchange using worldwidesystems (ex.Google Earth)

1

(5)

11

Introduction of a systematic approach (
odma
) for the modeling of
open
EHR archetypes and templates i
n a real
clinical setting

1

(5)

18

Introduction of new clinical archetypes and validation of existing archetypes

1

(5)

18

openEHR approach as the basis for the new European standard

1

(5)

4

OWL (Web Ontology Language) and SWRL as rule
-
based systems orie
nted to the Semantic Web and semantic
interoperability.

1

(5)

6

Priority to the patient/clinician interaction

1

(5)

3

Upgrade of openEHR to a software tool for registering health records in critical medicine environments (named
SICTI)

1

(5)

20

Use fram
eworks that help with the semantic interoperability

1

(5)

2

15









Variable

n

(%)

Article Number





Aims of using openEHR




Standardization

10

(48)

1, 2, 3, 10, 12, 13, 14, 16, 17, 21

Clinical research

6

(29)

1, 4, 14, 16, 18, 19

Model for the i
mprovement of other systems

2

(10)

20,21

Change of geographic information in 2D and 3D formats

1

(5)

11

Support for clinical data structures: lists, tables, time
-
series, including point and interval events

1

(5)

3














Administrative or Clini
cal use of OpenEHR




Missing

13

(62)

2, 3, 4, 6, 7, 8, 9, 11, 12, 13, 14, 17, 21

Nursing

3

(14)

5, 16,19

Healthcare environments/ Health system administrators (ex: administrative, legal, medical, technical…)

2

(10)

1, 19

Chronic diseases

1

(5)

15

Neo
natology

1

(5)

18

Pedriatic oncology

1

(5)

10

16

DISCUSSION

The results show an increasing number of publications relating to the foundation
OpenEHR
, referring
advantages, disadvantages, applicability and lacks of the standard. This may reflect an increase

of
interest in implementing it. Although in 2008 there has been a decrease in the number of articles
published, these result may be inherent to the selection method.

Results analysis allows us to verify that the semantic interoperability and interoperabil
ity between
systems are the most frequently cited advantages. This goes for our initial assumption, in that
currently the sharing of information is a barrier that arises between different health systems. At this
level, the standards proposed by
OpenEHR

may

be an alternative way which allows to solve this
problem, when applied at a global level. As referred as a standard of superior quality compared to
other currently implemented, consists in a potential means of bridging the differences between
information
systems in the clinical area.

Despite of being just a few, the disadvantages associated with this standard focus on the
implementation associated with the handling of complex archetypes. These require a system itself,
which involves high costs. At this lev
el, are made few references to the implementation of
OpenEHR
;
according to our results, there are principal references to their application in Australia, Germany and
Holland. In the application fields, the main implementation of this standard is important
in nursing and
the results were less significative in what regards to Hospital Administration and other services, such
as Chronic Diseases, Neonatology and Pediatric Oncology. Those aspects indicate that it requires
more involvement and interest of the com
munity regarding the proposed standards in an attempt to
overcome the gaps.

Limitations

One of the main limitations is only considering papers published in three bibliographic data bases,
although we believe that those include the most relevant articles sa
mple.

Despite of only considering papers published in the last seven years that may exclude previous work
on integration of
openEHR
, we feel it is justifiable given the significant evolution of this foundation in
the last decade.

The fact that we have def
ined too restricted inclusion and exclusion criteria may have biased some
results, including the case cited of the declining number of articles published in 2008.

Another of the main limitations of this review is lack of detail reported in most of the arti
cles, and
especially the non existence of clinical application fields information.

17

Conclusion

The large scale application of the standards proposed by the foundation
OpenEHR

need a greater
contribution of the community and means to implement them. So far,

those patterns have achieved
some acceptance, contributing to a more efficient sharing of information and increment of the clinical
knowledge. However, before its real implementation, it is necessary to increase the participation and
research in the area
in an attempt to bridge the gaps currently inherent in this standard. It is
necessary to gather experts in the development of robust applications that will contribute to an
effective relationship between clinical and clinical
-
patient, moving towards the pr
ovision of better
health care.


ACKNOWLEDGEMENTS

The authors thank PhD

Ricardo Correia
for his help and
dedication along our review and MD
PhD
Altamiro Pereira and all the other teachers of
Introdução à Medicina I

and
II
for their contribute to
this
projec
t
. We would also like to thank to SBIM’s

FMUP

staff for their
availability

and for the material
provided.














18

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21

Annex A



Screening Phase Questionnaire


#
: ___


I. Inclusion Criteria

i.

Refers specifically openEHR?



ii.

Ref
ers advantages/disadvantages?



iii.

Refers exemplification with systems already implemented in other countries?



iv.

Refers a semantic interoperability of openEHR in comparison to other systems?



v.

Refers innovations in openEHR
?



vi.

Refers the im
plementation of openEHR in the health area?



vii.

Refers clinical aspects?



viii.

Discusses the e
ffectiveness and
e
fficiency of openEHR
?




II.Exclusion Criteria

i.
Refers
technical details.



ii. Irrelevant issue.





22

Annex B


Data Collect Questi
onnaire