Sistema de registro eletrônico de saúde baseado na Norma ISO 13606: aplicações na Secretaria de Estado de Saúde de Minas Gerais

Abstract

Achieving semantic interoperability between Electronic Health Record (EHR) systems is critical to the future of health services. Therefore, global initiatives have developed information models that seek to promote such interoperability. The openEHR Foundations two-level modelling is one of those proposals, and the ISO 13606 standard has adopted the principles of this modeling approach. While this discussion about EHR interoperability unfolds on the world stage, health institutions around the world increasingly are facing challenges in the context of interoperability. This is the case of the Secretariat of Health of State of Minas Gerais (SES / MG), which intends to create an EHR system at the state level, aiming at the consolidation of demographic data and the patient's clinical summary to support Family Health in primary care. Due to the complexity and the theoretical challenges, and the importance of the issue to the Information Science field, this EHR project was chosen as a practical case study for the development of a conceptual approach to semantic interoperability in this research. Thus, the objective was to develop a proposal for a shareable EHR system architecture for primary care within the State of Minas Gerais, based on reference models and archetypes of the ISO 13606 standard. The development of this research contributed to an understanding of the use of the two-level modelling, more specifically, of the ISO 13606 standard and of archetypes as the basis for creating architecture, organizing and documenting important points for this work. As result, a shareable EHR system architecture proposal was designed and 20 archetypes were developed for primary care. Under the theoretical point of view, the research has concluded that the separation of roles proposed by the two level modeling has potential to add value for governmental projects, and that the information model of ISO 13606, together with the archetypes, are important semantic artifacts that could be considered in this kind of architecture.