JMIR Publications

ABSTRACT

Background:

Corneal transplantation, also known as Keratoplasty, is a widely performed surgical procedure that aims to restore vision in patients with corneal damage. The success of corneal transplantation relies on the accurate and timely management of patient information, which can be enhanced with Electronic Health Records (EHRs). However, conventional EHRs are often fragmented and lack standardization, leading to difficulties in information access and sharing, increased medical errors, and decreased patient safety. In the wake of these problems, there is a growing demand for standardized EHRs that can ensure the accuracy and consistency of patient data across healthcare organizations.

Objective:

This paper proposes the use of openEHR structures for standardizing corneal transplantation records. The main objective of this research is to improve the quality and interoperability of EHRs in corneal transplantation, making it easier for healthcare providers to capture, share, and analyze clinical information.

Methods:

A series of sequential steps were carried out in this study for implementing standardized clinical records using openEHR specifications. These specifications furnish a methodical approach that ascertains the development of high-quality clinical records. In broad terms, the methodology followed encompasses the conduction of meetings with healthcare professionals and the modeling of archetypes, templates, forms, decision rules and work plans.

Results:

This research resulted in a tailored solution that streamlines healthcare delivery and meets the needs of medical professionals involved in the corneal transplantation process, while seamlessly aligning with contemporary clinical practices. The proposed solution culminated in the successful integration within a Portuguese hospital of three key components of openEHR specifications: forms, Decision Logic Modules (DLMs), and Work Plans (WPs). A statistical analysis of data collected from May 1st, 2022 to March 31st, 2023 allowed to perceive the usage of the new technologies within the corneal transplantation workflow. Despite the completion rate being only 64%, which can be explained by external factors such as patient health and availability of donor organs, there was an overall improvement in terms of task control and follow-up of the patients' clinical process.

Conclusions:

This study shows that the adoption of openEHR structures represents a significant step forward in the standardization and optimization of corneal transplantation records. It offers a detailed demonstration of how to implement openEHR specifications and highlights the different advantages of standardizing EHRs in the field of corneal transplantation. Furthermore, it serves as a valuable reference for researchers and practitioners who are interested in advancing and improving the exploitation of EHRs in healthcare.