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The quality of delivery of care is closely related to the availability of information sources (e.g. the patient's clinical record) and access to knowledge sources (e.g. decision support systems) with quality and in a timely manner. The current information systems (IS) have not been able to provide the necessary features to fulfill these requirements. The difficulty mainly arises from problems with the structuring of information, the non-use of standards and problems in using the most current clinical knowledge within these IS. New ways of representing knowledge and information have been developed recently. One of these is the openEHR standard that has a promising approach to change the current situation for the better.
The VCObsGynCare software is a gynecological and obstetrics electronic medical record. It was designed to be used by OB/GYN doctors, anesthesiologists, nurses and administrative staff and is used to register patient admission and discharge, as well as childbirth and newborn data. It is also used to register surgical and anesthetic procedures, nursing records, as well as gynecological interventions. It is currently in use at Hospital de S. João and will soon be installed in several other hospitals in northern Portugal.
With this project we aim to investigate the way the openEHR standard can be implemented in electronic medical records. We aim to study the dynamic generation of clinical record modules, the development of forms based in clinical concepts (openEHR archetypes) defined by the international openEHR community, and the way that patient data can be stored, optimizing its future reuse in, for example, clinical research.
As results we intend to have several scientific publications and at least one installation of an openEHR based obstetrics clinical record (VCObsGynCare) in a Portuguese health institution.
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