openEHR in the Clinical Process space

When one speaks to working clinicians about what they want from IT and informatics, they generally say: support for ‘process’. This may mean a variety of things, but there are core challenges that most agree on, such as supporting teamwork, hand-overs, ensuring continuity of care across referrals and discharges, and proper up-to-date shared medication lists.

The openEHR specifications have historically supported one aspect of clinical process: orders and actions, via the INSTRUCTION and ACTION types in the Reference Model, which enables the execution of orders, such as medication administration, to be tracked through time. The archetyping approach enables care journey steps to be associated with the states in the Instruction State Machine, so that the Actions performed for any Instruction can be queried in a standard way – e.g. by searching for ‘active’ + ‘suspended’ Instructions based on the medication order archetype, we see what medications the patient is currently on.

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