Towards a Better Understanding of EHR Systems using Architectural

Views

Liliana Dobrica

, Cernian Alexandra

and Traian C. Ionescu

Faculty of Automation and Computers, University POLITEHNICA of Bucharest, Bucharest, Romania

SIVECO Romania SA, Sos. Bucuresti-Ploiesti, Bucharest, Romania

Keywords: EHR, HL7, Standards, Architecture Views, Models, UML.

Abstract: The content of this paper addresses the issue of understanding electronic health records (EHRs) systems

under a developer perspective on the existent confusion about this concept. The current standard definition

of EHR is discussed in terms of the main characteristics, data models and functional decomposition for

clinical research. The key components of these models are identified and specified under two considerations

namely, direct care and support. Also they are organized in architectural views describing an EHR system

infrastructure for records management. The value of this work is the architecture centric approach by

creating graphical representations of the system architecture based on top level standard descriptions.

1 INTRODUCTION

All healthcare and scientific authorities worldwide

are realising the importance of developing global

infrastructures for exchange of patient and

healthcare data, services and provide wider

opportunities for clinical research. In European

countries health policy is influenced by the

developments at the international level and by the

standards set by the World Health Organisation

(Ribeiro et al., 2010). Enabling EHR systems

implementations provides many benefits, including

improved access, quality and efficiency of patient

care, as well as promoting research and coordination

of services at lower costs (Vdovjak et al., 2012)

(Bonney, 2012) . Nowadays an integrated system in

the health care domain represents one of the most

challenging problem. Its realization is not only

difficult, but also poorly understood by system

developers. The literature very clearly indicates that

a clean, simple and easy to operate concept of an

EHR system does not exist (EHR-IMPACT, 2008).

Among the requirements and constraints that have to

be satisfied we can mention a higher diversity and

complexity, increased quality, productivity and reuse

content, standardization. Due to the escalating

complexity level of EHR systems and the

technology trends, a coherent and integrated strategy

for EHR systems development is required.

Architecture-based development of a system is a

solution to solving these problems. There are well-

known benefits of the introduction of this concept in

the life-cycle development of software systems.

Architecture is considered the first asset in an

architecture-centric development process and from

this point of view an analysis at this level should

reveal requirements conflicts and incomplete design

descriptions from a particular stakeholder

perspective. Many research efforts have been

concentrated on ensuring that these major issues are

addressed at the architectural level.

This paper introduces the EHR vision shedding

also light on the existent confusion about this

concept. In literature several types of health records

have been used with approximately the same

meaning. The current standard definition of EHR is

discussed in terms of the main characteristics and

their variability of levels in sharing patient health

information. Thereafter, the key components of an

EHR system are identified and discussed under

various considerations.

In particular, the rest of this paper is structured as

follows: Section 2 presents an overview of the EHR

definition and architecture-based software systems

development concepts. The major concepts that

could be included in data and functional models with

the focus on architectural structural and behaviour

views are detailed and graphically represented in

section 3. Conclusions state the value of

362

Dobrica L., Alexandra C. and C. Ionescu T..

Towards a Better Understanding of EHR Systems using Architectural Views.

DOI: 10.5220/0004246603620365

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2013), pages 362-365

ISBN: 978-989-8565-37-2

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

architecture-centric development of integrated EHR

systems.

2 EHR OVERVIEW

The idea of EHR was born as an alternative to an

existent healthcare system (Waegemann, 2003). The

added value of EHR services aims to improve

patient safety, quality and efficiency of patient care,

and reduce healthcare delivery costs. (Hoffman and

Podgurski, 2008). The major value of integrated

EHRs is that they collect data once, then use it

multiple times to serve different needs of the

administrator to obtain data for billing, a nurse to

report an adverse reaction, and a researcher to

analyze the efficacy of medications (MITRE, 2006).

EHR has been a key research in medical

informatics for many years. The literature provides

several concepts that are used with approximately

the same meaning including Personal Health Record

(PHR), Electronic Medical Record (EMR),

Electronic Patient Record (EPR), Electronic Health

Record (EHR) and Computerized Patient Record

(CPR). Most of them refer to the electronic

collection of medical information, performed by the

patient himself or herself, by a particular healthcare

institution, or by a global, integrated system. Overall

it is a systematic collection of electronic health

information about individual patients or populations

in a digital form. In particular, electronic health

record is defined as “digitally stored health care

information about an individual’s lifetime with the

purpose of supporting continuity of care, education

and research, and ensuring confidentiality at all

times” (Iakovidis, 1998). An idealistic definition and

concept, probably not yet brought to real life is that

“EHRs are repositories of electronically maintained

information about individuals’ lifetime health status

and healthcare, stored such that they can serve the

multiple legitimate users of the record” (EHR-

IMPACT, 2008). EHR contains all possible health

relevant data of a person and other health-related

information, always established beyond an

institutional framework (regional, national, global),

web-based, and participation of citizen in creating

the record (Edwards, 2007). HIMSS Analytics

differentiates between EMR and EHR in order to

reduce confusion (Garets and David, 2006).

EHR complexity resides in a multitude of

interdependent elements which must be organized.

To handle this complexity, a software architectural

(SA) approach is necessary as it helps to consider

separation of concerns realized through different

levels of abstraction, dynamism and aggregation

levels and (static/dynamic, local/global,

functional/extra-functional) (Dobrica and Ovaska,

2010). As is often the case in the field of eHealth,

the knowledge acquired in software engineering is

not really exploited, although it helps to manage

complexity. In particular, they can be used to

develop EHR systems architecture. SA description is

designed to address the different perspectives one

could have on the system. Each perspective is a view

(Bass et al, 2011).The information relevant to one

view is different from that of others and should be

described using the most appropriate technique.

Several models have been proposed that include a

number of views that should be described in the

software architecture. The view models address the

static structure, the dynamic aspect, the physical

layout and the development of the system. In

general, it is the responsibility of the architect to

decide which view to use for describing SA.

3 EHR SYSTEM MODELS

A clear distinction is made between the EHR and an

EHR system. The standard ISO/TR 20514:2005

discusses about two different views of the scope of

the EHR, which are Core EHR and Extended EHR.

Core EHR is limited to clinical information and is

defined by the requirements for its record

architecture. It is based on the adoption of the

system-of-systems approach. This allows more

modular health information systems to be built,

ranging from a simple environment with just the

EHR, a terminology service and some reference

data, to a much bigger and more elaborate

environment including many additional services

such as decision support, workflow management,

order management, patient administration, billing,

scheduling, resource allocation, etc. Extended EHR

is a superset of the Core EHR and includes not only

clinical information, but the whole health

information landscape.

Currently there is a standardization effort

towards consensus on EHR system functionality

(ANSI/HL7 EHR CRFP, 2009) in the definition of

an EHR system functional model and functional

profiles for various dedicated functionalities

including clinical research (EHR-CR) (ANSI/HL7

EHR CRFP, 2004). The EHR system functional

model is decomposed in three important sections:

Direct Care, Supportive and Information

Infrastructure. These sections gather functions which

are grouped in several important categories and sub-

categories. An UML Component diagram as shown

TowardsaBetterUnderstandingofEHRSystemsusingArchitecturalViews

363

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Figure 1: EHR – CR functional model.

Fig. 1 presents the EHR functional model for a

better understanding of the domain, concepts and

relations among them.

EHR-CR data model may be graphically

represented as an UML Class Diagram. Complex

data types specified by names, attributes and

operations are interconnected based on composition,

aggregation, generalization or other association

relationships. The static aspect is represented and

realized by attributes and behaviour/ dynamic aspect

is visible and realized by using operations of classes.

HL7-CR Direct Care Data Model includes classes

such as Electronic Health Record, Patient,

PatientRecord, Demographic Information,

PatientDeographics, KeyDemographic Information,

PatientHistory, etc. PatientRecord Class includes

attributes such as ID, Name, Demographic

Information, LabResults, Current medication lists

and Problem List. Behavior is given by operations

like create, identify, maintain and,

calculatePatientAge.

A standardized solution of EHR Records

Management based on a HL7 needs to pay attention

to six key infrastructure components: security, health

record information and management, standard

terminologies and terminology services, standards-

based interoperability, business rules management

and workflow management. A conceptual structural

view, based on UML component diagram is

represented in Fig. 2.

4 CONCLUSIONS

In this paper we analyzed the recent standards on

EHR-related concepts to facilitate exchange of

EHRs between EHR systems. The aim was the

understanding of standard requirements in order to

develop compliant EHR systems. Our method was

based on architecture-centric software systems

development. The current standard definition of

EHR concept has been discussed in terms of the

main characteristics, data models and functional

decomposition for clinical research. The key

components of these models have been identified

and specified under various considerations namely,

direct care and support. Also they have been

organized in architectural views describing an EHR

system infrastructure for records management. The

value of this work is the architecture centric

approach by creating graphical representations of the

system architecture based on top level descriptions

of standards.

Our approach based on architectural views has

an immense potential to improve the understanding

of EHR systems as well as reduce time and risks in

development stages. However, for this approach’s

success it is necessary to create a cooperation culture

among stakeholders.

HEALTHINF2013-InternationalConferenceonHealthInformatics

364



Figure 2: HL7 EHR records management profile.

ACKNOWLEDGEMENTS

This work is supported by a grant of Romanian

National Authority for Scientific Research CNDI-

UEFISCDI, project number E! 7201 and the

European Research Project Linked2Safety

(www.linked2safety-project.eu).

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