Modeling Magnetic Resonance Clinical Reports of the Lumbar Spine Using Openehr Archetypes

This work discusses the modeling of clinical data using openEHR archetypes. The openEHR project aims at developing an open and interoperable health computational platform, and an important component in this effort is the development of electronic health records (EHRs) that are clinically effective and interoperable. The project publishes specifications, implementations and archetypes with that goal in mind. Archetypes are an expression of clinical concepts, created by domain specialists. In the modeling proposed by openEHR, that kind of information shall be separated from the stable reference model, leading to simpler and more maintainable systems and empowering clinicians by giving them the opportunity to work developing the standards they will use in a real clinical environment. The main objective of this work is to introduce the openEHR specifications and its main features, the concept of archetypes and show the possibility of creating an archetype from an initial clinical concept, using magnetic resonance clinical reports of the lumbar spine as an example.