The EHR Information Model

Overview

The figure below illustrates the package structure of the openEHR EHR information model.

Figure 1. EHR Packages

The packages are as follows:

ehr: this package contains the top level structure, the EHR, which consists of an EHR_ACCESS object, an EHR_STATUS object, versioned data containers in the form of VERSIONED_COMPOSITIONs, optionally indexed by a hierarchical directory of FOLDERs. A collection of CONTRIBUTIONs which document the changes to the EHR over time is also included.
composition: the Composition is the EHR’s top level "data container", and is described by the COMPOSITION class.
content: this package contains the Navigation and Entry packages, whose classes describe the structure and semantics of the contents of Compositions in the health record.
- navigation: the SECTION class provides a navigational structure to the record, similar to "headings" in the paper record. ENTRYs and other SECTIONs can appear under SECTIONs.
- entry: This package contains the generic structures for recording clinical statements. Entry types include ADMIN_ENTRY, OBSERVATION (for all observed phenomena, including mechanically or manually measured, and responses in interview), EVALUATION (for assessments, diagnoses, plans), INSTRUCTION (actionable statements such as medication orders, recalls, monitoring, reviews), and ACTION (information recorded as a result of performing Instructions).

The figure below illustrates an overview of the class structure of the EHR Information Model, along with the main concepts on which they rely, namely Data Types, Data Structures, Archetyped, and Identification.

Figure 2. EHR Information Model Overview