Hi all,
Remember.
EN13606, openEHR are about documenting by a healthcare provider what he has (or want) to document about the treatment of his patient in an EHR.
So any investigation or treatment protocol, used as a plan, is part of the EHR.
Based on the protocol
And is not about a complete hospital information system, a system to perform quality control management related information.
Although these types of systems will use data and information documented in the EHR.
When talking about these concepts may I point at the European Norm System of Concepts for Continuity of Care. (ContSys)
The next url downloads the definitions.
http://tinyurl.com/2gfm42
The next url download the complete ContSys standard
http://tinyurl.com/2xx7g4
The next couple of relevant definitions occur in ContSys:
3.1
activities bundle
internally consistent set of health care activities (3.39) to be performed, being performed, or having been
performed for a subject of care (3.89) by one or more health care providers (3.52), in the context of one or
more care plans (3.6), within the framework of a programme of care (3.76)
3.6
care plan
description of planned and duly personalised activities bundles (3.1), addressing one or more health issues
(3.55), and encompassing all health care activities (3.53) to be provided to a subject of care (3.89) by one
health care professional (3.49), or several health care professionals having the same health care
professional entitlement (3.51)
3.10
clinical guideline
set of systematically developed statements to assist the decision of health care parties (3.48) about health
care activities (3.39) to be provided with regard to a health issue (3.55) in specified clinical circumstances
3.39
health care activity
activity performed for a subject of care (3.89) by a health care agent (3.40) with the intention of directly or
indirectly improving or maintaining the health of that subject of care
NOTE: Health Care Activity is an abstract construct, without any direct instantiation.
3.45
health care goal
desired achievement of a care plan (3.6), considered as an intermediate operational step to reach the
ultimate objective of a programme of care (3.76)
3.46
health care objective
desired ultimate achievement of a programme of care (3.76)
3.76
programme of care
description of planned and duly personalised activities bundles (3.1) adopted by one healthcare organisation,
typically informed by one or more protocols (3.77), addressing one or more health issues (3.55), accounting
for one or more health issue threads (3.56), and encompassing all health care activities (3.39) to be
performed for a subject of care (3.89) by one or more health care parties (3.48)
3.77
protocol
customisation of a clinical guideline (3.10) for use in a local context
NOTE: critical path(s), care plan(s), clinical pathway(s): plan, based on data gathered during (subject’s of
care) assessment, that identifies the care needs, lists the strategy for providing services to meet those needs,
documents treatment goals and objectives, outlines the criteria for terminating specified interventions, and
4
documents the (subject’s of care) progress in meeting specified goals and objectives. [ISO TR 18307:2001]
[JCAHO]
Gerard
