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

PURPOSE: This paper introduces the modelling of a prototype neonatology electronic patient record (EPR) using openEHR archetypes. The EPR is necessary to support the complex communication tasks of the innovative concept of 'Developmental, Family-Centred, Individual Care of Premature Infants and Newborns' established for the Department of Neonatology at Heidelberg University Hospital.

METHODS: The data to be documented was analysed and modelled using the five step openEHR data modelling approach (odma).

RESULTS: The analysis revealed a total of 1818 items, which could be arranged into 70 clinical concepts. The items and concepts were then mapped to 132 openEHR archetypes. Fifty-eight of these archetypes could be reused either directly or via specialisation from the existing openEHR archetypes. A further 67 archetypes were newly developed. To combine and constrain archetypes for local settings 16 templates were developed.

CONCLUSION: By using the five step openEHR data modelling approach, semantic interoperability, and a reduced need for repeated documentation of the same data can be realised. This is of major importance within the hospital as well as for trans-institutional data exchange.