Residential aged care is largely considered a ‘green field’ with regard to Information Technology (IT). Systems that already exist usually have their own system architectures, which results in a lack of interoperability within the aged care sector as a whole. The provision, administration and funding of aged care consist of a complex and varied set of arrangements which requires an IT infrastructure that meets the needs of many stakeholders including nurses and personal carers in the aged care residential sector. These health workers must be able to comply with contemporary best practice, and meet all quality and reporting requirements. In this scenario, the implementation of Electronic Health Records (EHRs) is a key strategy for improving the quality, safety and efficiency of residential aged care delivery. The openEHR approach (http://www.openEHR.org) is one of the most recognised approaches for EHR systems. The definition and use of aged care openEHR Archetypes (clinical models representing semantic constructs) can contribute to interoperability of EHRs as well as various health information systems. Based on a review of scientific literature, other relevant documents and stakeholder identification and consultation, this paper describes the current state of play with regard to EHRs in residential aged care. The paper further compares openEHR archetypes, clinical guidelines, terminologies and standards as well as the processes needed for their development to enable the capturing of expert aged care knowledge for multiple purposes. It is argued that a clear process capturing expert knowledge relevant to the aged care sector is required for the purpose of automating all data capture and enabling these data to be used to support clinical practice in accordance with aged care standards as well as to meet various reporting, management, research and planning requirements. This archetype development process should be based on existing clinical guidelines and standard development processes, and enable international collaboration where possible.
Semantic Interoperability; Aged Care; Archetypes; openEHR; Electronic Health Records; Computerised Medical Record Systems; openEHR