The growth of electronic health records (EHR) produced by health facilities has been exponential, leading to massive and heterogeneous data storage. This raises the need for secure, continuous, and interoperable data structuring between different legacy systems. The OpenEHR standard provides open data specifications that aim to overcome recognized gaps in the collection, storage, and management of clinical records. In this sense, this chapter describes a case study applied in an emergency context, where 14-year clinical records were restructured to an interoperable and standardized environment, according to the OpenEHR specifications.
TopIntroduction
Aside from the significant evolution of the Electronic Health Records (EHR), the digitalization of clinical records has resulted in the creation of extravagant amounts of data every day, stored in dedicated repositories and afterwards used or not. In this context, multidisciplinary teams in the fields of Information Systems (IS) and Medical Informatics (MI) have arisen in healthcare institutions, particularly the biomedical engineer specializing in MI, which has proven to be crucial in data control, developing tools to use them and managing healthcare institution’s Health Information Systems (HIS), to provide a complete symbiosis and interoperability between all systems (Bernstam et al., 2010). Therefore, research in this area has opened new horizons in recent years, through innovative techniques and solutions to reach more and more in terms of HIS efficient use, adopting new methodologies and worldwide recognized clinical standards for its ergonomic use.
The continuous marathon of data structuring contributes to the knowledge extraction following a specific purpose. In the healthcare field, a lot of information present in diaries and clinical reports are written in an unstructured way and may not be possible to acquire the necessary knowledge about a specific clinical case. Furthermore, nowadays, many clinical encounters and procedures still occur in an isolated way, making it difficult to access more patient information in real time, which can negatively influence decision-making (Murdoch & Detsky, 2013).
This massive and heterogeneous creation of clinical records raises concerns regarding the processing and storage of these data. The use of unstructured data generated some problems in the use of HIS, such as failure in communication between systems, lack of data standardization, difficulty in acquiring clinical knowledge, and others.
In a particular Portuguese Healthcare Institution, the described problem scenario also exists. Millions of 20-year Electronic Health Records were stored in an unused Legacy System (LS). This uselessness and non-use of data generated data loss due to the lack of a standard and data structuring, leading to the inability to interoperate with each other. In addition, data held in the LS could have been leveraged for data analysis and to support decision making.
In order to respond to the identified problem, a preventive and collaborative approach to developing the widely used HIS by healthcare professionals is proposed. Thus, this book chapter will describe a case study in a Portuguese Healthcare Institution where millions clinical records were recovered from a discontinued and offline system that was used in emergency context, being mapped to an intelligent and standardized way. To maintain standardization and data interoperation, an open data model strategy was adopted resorting the specifications of the OpenEHR standard.
This chapter is structured in five sections. First, the research background is presented. Secondly, it is described the methods used to develop the present study. The third section presents the results obtained. In section four, a discussion of the findings is held and the direction of future work is pointed out. Finally, some conclusions are drawn.