Modelling pregnancy

How to go about using openEHR archetypes to model a shared pregnancy record?

Step 1:  Analyse the existing resources; identify each of the discrete clinical concepts that contribute to the whole record.



24 clinical concepts have been identified within this example Pregnancy Health Record.

Step 2: Map clinical concepts to archetypes

Map them to existing archetypes or determine which new ones we need. Determine the state of the existing archetypes – do we need to modify or enhance with additional requirements? Consider all possible use cases for each archetype – the end result will be better if we can be as inclusive as possible for all clinical scenarios.

The archetypes identified for this Pregnancy record are:

Clinical Concept Comment

Corresponding archetype concept name
NOTE: is linked to the
actual archetype in a CKM instance

Antenatal Plan An overarching plan for the patient’s antenatal care Antenatal Plan <INSTRUCTION.antenatal_plan>
Information Provided Details of each piece of health education information discussed or provided to patient Information Provided
<ACTION.health_education>
Social Summary Social Summary
<EVALUATION.social_summary>
Adverse Reaction List Adverse Reaction list is made up of multiple Adverse Reaction entries Adverse Reaction
<EVALUATION.adverse_reaction>
Family History List Family History list is made up of multiple Family History entries Family History
<EVALUATION.family_history>
Diagnosis Problem lists, whether current or past are made up of multiple Problem/Diagnosis entries – the same data pattern will be used in all instances Problem/Diagnosis
<EVALUATION.problem_diagnosis>
Problem/Diagnosis List
Recent Problem/Diagnosis List
Procedure list Procedure list is made up of multiple Procedure entries Procedure
<ACTION.procedure>
Smoking consumption Tobacco use
<OBSERVATION.substance_use-tobacco>
Alcohol consumption Alcohol consumption
<OBSERVATION.substance_use-alcohol>
Obstetric Summary Obstetric summary
<EVALUATION.obstetric_summary>
Pregnancy Summary An evolving summary of key data about a single pregnancy – either current or past Pregnancy summary
<EVALUATION.pregnancy_summary>
Examination Findings Examination Findings
<OBSERVATION.exam>
Examination of the uterus
<CLUSTER.exam-uterus>
Examination of the fetus
<CLUSTER.exam-fetus>
Current Medication List Medication list is made up of multiple Medication instruction entries Medication instruction
<INSTRUCTION.medication>
Medication administered Medication action
<ACTION.medication>
Height Height/Length
<OBSERVATION.height>
Weight Body weight
<OBSERVATION.body_weight>
Body Mass Index Body Mass Index
<OBSERVATION.body_mass_index>
Blood Pressure Blood Pressure
<OBSERVATION.blood_pressure>
Fetal Movements Fetal Movements
<OBSERVATION.fetal_movements>
Fetal heart sounds Heart rate and rhythm
<OBSERVATION.heart_rate>
Urinalysis The pattern for urinalysis is identical to the pathology test results, and in some cases will be performed in the lab, so the same pattern will be used Pathology test result
<OBSERVATION.pathology_test>
Pathology Test results
Ultrasound results Imaging examination result
<OBSERVATION.imaging_exam>

KEY:
Pink archetype names indicate those that are early drafts.
Green archetype names indicate those that are reasonably mature – through previous reviews within CKM
Red archetype names indicate those yet to be developed.

Step 3: CKM Review

Within CKM each archetype will undergo review rounds by a range of clinicians, terminologists, software engineers, informaticians and other interested experts. The purpose of each review round will be to fine-tune each archetype so that it meets the requirements for each stakeholder group.

CKM Videos:

Step 4: Create an openEHR template

Once community consensus is reached within CKM, the archetypes will be aggregated and constrained in a template to accurately meet the specific use-case requirements for this particular Pregnancy Health Record. Each bold, black heading in the the following screenshot represents an archetype. The Pregnancy Summary archetype has been opened up to see the details. Black text indicates data elements that will be utilised in this use case; grey text indicates inactive data elements.

Other groups may use the same archetypes aggregated in a different order and constrained in a different way to represent their version of the Pregnancy Health Record. As the data in both Pregnancy Records is being recorded according to the same pattern, dictated by the underlying archetype, the information can be exchanged without ambiguity or loss of meaning.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s