Approach

The Northern Territory approach to the creation of an electronic Pregnancy Health Record is to use clinically-agreed archetypes as the basis for a shared Pregnancy Health Record.

An archetype is a structured, computable specification for one single, discrete clinical concept. Examples include Blood Pressure; Clinical Synopsis; Medication order; or Adverse Reaction.

In fact, each archetype is a rich pattern for health data, defined and agreed by the clinicians and other stakeholders. Clinician leadership and involvement is critical to ensure the quality of clinical data in our EHRs and to warrant that it is safe and 'fit for purpose'.

The agreed archetype is the basis for a coherent and consistent approach for the whole continuum of electronic clinical care and related activities:

Each archetype is designed:

Archetype types

There are four main types (or classes) of archetypes that are useful to understand – each corresponding to classes in the openEHR Reference Model and each has particular attributes that correspond to clinical processes.

1.  Compositions – which correspond to commonly used clinical documents, such as 'antenatal visit' or 'care plan'. (Think of these as the equivalent to the blank piece of paper in a current paper record, before you start to write.)
2.  Sections – these are effectively used to assist with human navigation within EHRs and correspond to document headings, for example 'antenatal examination' or 'summary'. (Think of these as the headings that provide a framework for writing on a blank piece of paper.)

3.  Entries – these are the most common and are fundamental building blocks of EHRs and will contain most of the 'stand-alone' structured clinical information. There are four main types of Entry archetypes:

4. Clusters – think of these as re-usable fragments of clinical information. They do not 'stand-alone' within a health record but provide a way to re-use a common clinical data patterns within many of the Entry archetypes. Examples include: dimension; anatomical location; change; and specimen.

Process

Candidate archetypes have been developed to represent the wide range of clinical concepts that are used in the NT Pregnancy Health Record.

Content for each of these archetypes have drawn heavily from existing resources such as the NT Pregnancy Health Record, the Queensland Antenatal Health Record, the National Hand Held Maternity record and international resources. Sometimes the content alignment with the existing resources is easily recognisable; sometimes it may appear a little different. This is because in all situations the data needs to be represented so that it can be re-used in many different potential activities and scenarios, including safe and sensible clinical decision support.

1. Identify clinical concepts

The existing resources have been analysed and the discrete clinical concepts that contribute to the whole document have been identified - see the images below.

24 concepts have been identified within the current NT Antenatal Record. Each clinical concept needs to be represented as a separate archetype

2. Map clinical concepts to archetypes

Each of the clinical concepts were mapped to existing archetypes within the NEHTA Clinical Knowledge Manager (CKM), or the need identified for creation of a new archetype.

Some of the existing archetypes meet the requirements for the NT Pregnancy Record already; others needed modification or enhancement to meet the requirements.

3. Analysis

The archetypes identified for this Pregnancy Health record are:

Clinical Concept

Comment

Corresponding archetype concept name

NOTE: <archetype.name> is linked to the
latest version of the archetype in CKM

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/Diagnosis List

- Recent Problem/Diagnosis List

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>

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 administered

List of Medications currently being taken and those administered as part of pregnancy
care use the same Medication actions archetype

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 >

- Urinalysis
- All Pathology test results

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 >

Ultrasound results

 

Imaging examination result
<OBSERVATION.imaging_exam >

23 clinical concepts were identified; represented by 21 archetypes.

The newly created archetypes have been uploaded to the CKM, and the ones requiring modification have been updated.

Click on the links in the table, above, to view the latest version of each of the archetypes in CKM.

4. 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:

For the clinicians we seek to ensure that all relevant date elements are included, that the names and descriptions are correct etc – the end goal being that the archetype at the end of all review rounds is regarded as safe and 'fit for clinical purpose'. Any and all contributions are gratefully received from all reviewers, ranging from simple typo and grammar corrections, through word-smithing descriptions, to challenges about incorrect or missing content.

Similarly terminologists, vendors, informaticians will all contribute according to their expertise, intending that the archetype is also fit for their purpose.

The aim is to collaboratively build a data pattern for a single clinical content that meets all stakeholder requirements.

Reviewers will receive email invitations to participate in the online review, which will usually be open for comment for a period of a few weeks. After each review round, Editors will review all comments from all reviewers, provide feedback to reviewers, update the archetype and initiate another review round.

Review rounds will continue until consensus has been achieved – surprisingly, in experience to date, the inclusive nature of the maximal data set has enabled consensus on the structure of the archetypes. If consensus is not achieved, then it will need a resolution process will allow for publication of the agreed parts of the model, allowing for further research and discussion and potential future revision of the archetype.

5. Create an openEHR template

Once community consensus is reached within CKM, the archetypes will be aggregated and constrained in a template to accurately represent the data requirements for the NT 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.

Decision Support

Possible functions:

References

Background documents on NT project

Other Pregnancy Health records:

Link to relevant sections of CARPA Manual