Electronic Health Record Communication Research Articles

Targeted electronic health record-based recruitment strategy to enhance COVID-19 vaccine response clinical research study enrollment

Efficient recruitment of eligible participants is a significant challenge for clinical research studies. This challenge was exacerbated during the COVID-19 pandemic when in-person recruitment was not an option. In 2020, the University of Minnesota was tasked, as part of the National Cancer Institute's Serological Sciences Network for COVID-19 (SeroNet), to recruit participants for a longitudinal serosurveillance clinical research study with a goal of characterizing the COVID-19 vaccine-elicited immune response among immunocompromised individuals, which necessitated reliance on non-traditional strategies for participant recruitment. To meet our enrollment target of 300 transplant patients, 300 cancer patients, 100 persons living with HIV, and 200 immunocompetent individuals, we utilized targeted electronic health record (EHR)-based recruitment in addition to traditional recruitment tools, which was an effective combination of recruitment strategies. A significant advantage of patient portal messaging or other digital recruitment strategies such as email communication is timing. We reached 85 % (769 out of 900) of our enrollment target within one year with a 14.3 % response rate to invitations to participate in our study. This achievement is perhaps more salient given the COVID-19 pandemic-related constraints within which we were operating. We demonstrated that the EHR can be leveraged to quickly identify potentially eligible study participants either via EHR communication or mail. We also illustrate how the online portal MyChart can be used to efficiently send targeted recruitment messages.

Improving Interprofessional Collaboration Between Behavioral Mental Health and Pediatric Primary Care Providers Through Standardized Communication

Pediatric mental health crisis increases demand for integrated behavioral health and pediatric primary care providers (PPCP). Communication is key to successful integrated pediatric behavioral-mental health, but studies demonstrate gaps between existing and desired communication practices. Project aims to improve PPCP factors and patient outcomes by implementing standardized communication tool in the Electronic Health Record (EHR). Pre-post 20-week intervention. Pediatric primary care and affiliated pediatric behavioral-mental health clinic of academic health system. PBMH patients and referring PPCPs. PPCP satisfaction with communication, comfort and confidence continuing mental health care pre-post PBMH consult, and patient appointment attendance. PPCP confidence and comfort treatingmental health in primary careincreased. No significant change in PPCP satisfaction after implementing standardized communication. Identified factors associated with patient appointment continuity. Standardized EHR communication tools and enhancing PPCP confidence in managing common pediatric mental health conditions are effective collaboration strategies.

Effect of a Multicomponent Sepsis Transition and Recovery Program on Mortality and Readmissions After Sepsis: The Improving Morbidity During Post-Acute Care Transitions for Sepsis Randomized Clinical Trial.

To evaluate whether a nurse navigator-led, multicomponent Sepsis Transition And Recovery program improves 30-day mortality and readmission outcomes after sepsis hospitalization. n: Multisite pragmatic randomized clinical trial. Three hospitals in North Carolina from January 2019 to March 2020. Eligible patients hospitalized for suspected sepsis and deemed high-risk for mortality or readmission by validated internal risk models. Patients were randomized to receive usual care alone (i.e., routine transition support, outpatient care; n = 342) or additional Sepsis Transition And Recovery support (n = 349). The 30-day intervention involved a multicomponent transition service led by a nurse navigator through telephone and electronic health record communication to facilitate best practice postsepsis care strategies during and after hospitalization including: postdischarge medication review, evaluation for new impairments or symptoms, monitoring comorbidities, and palliative care approach when appropriate. Clinical oversight was provided by a Hospital Medicine Transition Services team. The primary outcome was a composite of mortality or hospital readmission at 30 days. Logistic regression models were constructed to evaluate marginal and conditional odds ratios (adjusted for prognostic covariates: age, comorbidity, and organ dysfunction at enrollment). Among 691 randomized patients (mean age = 63.7 ± 15.1 yr; 52% female), a lower percentage of patients in the Sepsis Transition And Recovery group experienced the primary outcome compared with the usual care group (28.7% vs 33.3%; risk difference, 4.7%; odds ratio, 0.80; 95% CI, 0.58-1.11; adjusted odds ratio, 0.80; 95% CI, 0.64-0.98). There were 74 deaths (Sepsis Transition And Recovery: 33 [9.5%] vs usual care: 41 [12.0%]) and 155 rehospitalizations (Sepsis Transition And Recovery: 71 [20.3%] vs usual care: 84 [24.6%]). In a multisite randomized clinical trial of patients hospitalized with sepsis, patients provided with a 30-day program using a nurse navigator to provide best practices for postsepsis care experienced a lower proportion of either mortality or rehospitalization within 30 days after discharge. Further research is needed to understand the contextual factors associated with successful implementation.

Assessing Physician Assistant Student Electronic Health Record Competency Using an Objective Structured Clinical Examination.

Evaluate didactic year physician assistant (PA) student competency in electronic health record (EHR) communication and data management. This study used an Objective Structured Clinical Examination (OSCE) to measure PA students' EHR patient communication and data skills. Most students demonstrated good EHR communication skills overall, while few students moved the computer to better facilitate the visit or verified the patient's identity. Additionally, few students demonstrated EHR data skills by reviewing patient history and medications. Utilizing an OSCE to assess EHR competence can highlight areas for curricular improvement in order to improve EHR skills.

A Curriculum for Teaching Clinical Efficiency Focusing on Specific Communication Skills While Maximizing the Electronic Health Record.

IntroductionAll physicians must learn comprehensive patient care delivery within the electronic health record (EHR). No studies have considered EHR communication training with an emphasis on clinical efficiency. This curriculum provides a method of teaching clinic efficiency while practicing effective patient communication in any EHR clinical situation. The target audience is resident physicians, fellow physicians, faculty physicians, and physician extenders practicing in a primary care setting where the EHR is present.MethodsThis curriculum of four separate workshops provides a structured EHR approach while addressing communication strategies for preclinical preparation, rapport building, encounter initiation, agenda setting, and visit closure. The curriculum contains interactive presentations, tools, and an evaluation survey. Presenting efficiency issues with the EHR using the ATTEND mnemonic and agenda setting allows documentation while practicing communication techniques that maximize efficiency.ResultsPostworkshop surveys revealed that participants felt the workshops were helpful (84%). One measurement of efficiency revealed improvement through decreased number of days to note completion after workshop participation. At the Program Directors Workshop, curriculum value was demonstrated by high attendance, with 94% feeling the workshops provided easily utilizable strategies.DiscussionThe curriculum utilized only the EPIC EHR but would be generalizable. Future directions could include measurement of effective communication and visit efficiency through direct observation and expanded EHR timing data.

The Electronic Health Record Objective Structured Clinical Examination Station: Assessing Student Competency in Patient Notes and Patient Interaction.

IntroductionThe ability to utilize the electronic health record (EHR) without compromising the doctor-patient relationship (DPR) is an essential skill of all physicians and trainees, yet little time is spent on educating or assessing learners on needed techniques. To address this gap, we developed a conventional OSCE station coupled with a simulated patient chart within the Epic program in order to assess our students' skills utilizing the EHR during a patient encounter.MethodsOf third-year medical students, 119 were given full access to the patient's simulated chart 24 hours in advance of their OSCE to review clinical data. During an in-person OSCE with a standardized patient (SP), students performed a focused history and physical, using the EHR to verify allergies and medications. Students completed an electronic patient note graded by faculty. SPs evaluated the students on communication and interpersonal skills with specific rubric elements. Faculty graded the students' notes to evaluate their expression of clinical reasoning in the assessment and plan.ResultsTraining SPs and faculty to assess students on EHR skills was feasible. After implementation of a comprehensive curriculum focused on EHR and DPR, there was a significant difference on EHR-related communication skills (M = 76.4, SD = 17.6) versus (M = 37, SD = 28.9) before curriculum enhancement t (117.9) = −12.4, p <.001.DiscussionThe EHR OSCE station provided a standardized method of assessing students' EHR skills during a patient encounter. Challenges still exist in the technological requirements to develop and deliver cases in today's EHR platform.

Improving infant sleep safety via electronic health record communication: a randomized controlled trial

BackgroundWith increased use of telehealth, interventions to improve infant sleep environments have not been explored. This study sought to assess the feasibility and efficacy of using electronic health record patient portals to transmit photographs of infant sleep between mothers and healthcare professionals as part of an intervention to promote sleep environments consistent with AAP guidelines.MethodsOne hundred eighty-four mother-newborn dyads consented to participate in a randomized trial requiring patient portal registration within 1 month of delivery. We first assessed feasibility as measured by a) the proportion of consented mothers enrolling in the portal and b) maternal adherence to prompts to submit photographs of their infant sleeping to the research team through the patient portal. Intervention group mothers were prompted at 1 and 2 months; controls were prompted only at 2 months. Efficacy was determined via research assistant review of submitted photographs. These assistants were trained to detect sudden unexplained infant death risk factors utilizing AAP guidelines. Standardized feedback was returned to mothers through the patient portal. We used Fisher’s Exact test to assess group differences in guideline adherence at 2 months.ResultsOne hundred nine mothers (59%) enrolled in the patient portal and were randomized to intervention (N = 55) and control (N = 54) groups. 21 (38, 95% CI 25–52%) intervention group participants sent photographs at 1 month and received personalized feedback. Across both groups at 2 months, 40 (37, 95% CI 28–46%) sent photographs; 56% of intervention group participants who submitted photographs met all safe sleep criteria compared with 46% of controls (difference 0.10, 95% CI − 0.26 to 0.46, p = .75). Common reasons for guideline non-adherence were sleeping in a room without a caregiver (43%), loose bedding (15%) and objects (8%) on the sleep surface.ConclusionsUtilizing the patient portal to individualize safe infant sleep is possible, however, we encountered numerous barriers in this trial to assess its effects on promoting safe infant sleep. Photographs of infants sleeping showed substantial non-adherence to AAP guidelines, suggesting further needs for improvement to promote safe infant sleep practices.Trial registrationName: Improving Infant Sleep Safety With the Electronic Health Record; Clinicaltrials.gov: NCT03662048; Date of Registration: September 7, 2018;Data Sharing Statement: None

200. EAT-26 Performance In Gender Health Clinic Patients

Emerging literatures suggests that transgender individuals report higher rates of eating disorder (EDO) symptomatology than their cis-gender counterparts. This association is supported by population-level data, but there is a paucity of information on the clinical practice level. This study seeks to characterize the experiences of individuals with gender dysphoria through analysis of their responses to the EAT-26 questionnaire, which is a robust clinical screening tool. We aimed to examine EDO prevalence, characterized by a positive or negative overall EAT score, as well as prevalence of disordered eating behaviors, within a transgender patient population. Eligible individuals between the ages of 18-25 engaged with the University of Rochester’s Gender Health Services for transgender adolescents and young adults were sent an EAT-26 questionnaire via electronic health record communication. Of 107 invited individuals, 66 completed the EAT-26 questionnaire (response rate 61.6%). Chart review data included items and scores from the EAT-26 questionnaire, demographics, and treatment information including presence of hormonal or surgical treatment for gender dysphoria. Data analysis included descriptive statistics and Wilcoxon rank-sum test of equality. The study was reviewed by the URMC IRB. Forty-six (79.3%) of screened patients had a negative EAT-26 screen; 12 (20.7%) were positive for eating disorder concerns. Responses had a mean of 10.2, SD of 8.4 and range of 0-29. Alpha coefficient of the scale is 0.82. There were no statistically significant differences in performance on the EAT-26 based on the demographic or clinical factors examined (age, affirmed gender, typic of health insurance, race or ethnicity). For individual items, responses of “never”, “rarely” or “sometimes” were considered negative, while “often”, “usually” and “always” were considered positive responses. Frequently positive items included "display of self-control around food” (n=35, 60%), “think about burning calories exercising” (n=25, 41%), “preoccupied with desire to be thinner” (n=24, 41%), “aware of calorie content of foods” (n=22, 38%), preoccupied with thought of fat on body (n=21, 36%) and “terrified about being overweight” (n=20, 34%). Items with relatively low positivity were “vomiting after eating” (n=1, 2%), “vomiting after eating” (n=1, 2%), and “impulse to vomit after meals” (n=3, 5%) and “gone on eating binges, not able to stop” (n=4, 7%). This study serves as a pilot to describe the experiences of eating disorder symptoms in individuals with gender dysphoria presenting for gender related medical care. Our overall prevalence of a positive EAT screen was 21%, where a positive screen is defined by a score equal to or greater than 20. This is higher than the general adolescent/young adult population which has been estimated at 7-10%. We did not find the use of hormones and gender affirming surgery to be significantly associated with the EAT-26 score, although low sample size likely precluded sufficient statistical power. A number of individual disordered eating behaviors were present in our sample, regardless of EAT positive/negative status, which offers initial insights into eating disorder symptoms and experiences within this population.

Electronic Health Record Tool to Promote Team Communication and Early Patient Mobility in the Intensive Care Unit.

Intensive care unit early mobility programs improve patients' outcomes while reducing costs for both patients and institutions. Inadequate interprofessional communication is a known barrier to achieving good early mobility program outcomes. Electronic health record communication tools promoting interprofessional communication have demonstrated improved patient outcomes, but have not been evaluated for mobility in the intensive care unit. To implement an early mobility collaboration program in an existing early mobility program, consisting of protocol education and an electronic health record tool designed to improve interprofessional communication and collaboration. In phase 1, staff members viewed an online educational module, the existing mobility protocol, and the "Mobility Levels" grading scale. In phase 2, an electronic health record communication tool displayed recently recorded mobility levels to all care providers. Staff knowledge of the early mobility program and perceptions of mobility-related communication were assessed by survey; patient outcomes including mobility goals, mechanical ventilation time, length of intensive care unit stay, and cost were assessed by records review. Statistically significant increases were found for staff satisfaction with mobility-related communication (P < .001) and communication frequency (P = .02), but not for staff knowledge (P = .28). Hours to achievement of mobility goal (P = .02) and length of intensive care unit stay (P = .02) decreased significantly. Average ventilation time decreased by 27 hours. Discharge recommendations at higher functional levels increased. Total intensive care unit cost decreased significantly (-39.5%; P = .04). Interprofessional communication and collaboration can lead to improved outcomes. Combining routine educational reviews and an electronic health record communication tool may improve patient and system outcomes for intensive care unit early mobility program patients.

Physicians speak: Medicine’s point of view on working with pharmacy

Physicians speak: Medicine’s point of view on working with pharmacy

Integrating Patient-Centered Electronic Health Record Communication Training into Resident Onboarding: Curriculum Development and Post-Implementation Survey Among Housestaff.

BackgroundElectronic health record (EHR) use can enhance or undermine the ability of providers to deliver effective, humanistic patient-centered care. Given patient-centered care has been found to positively impact patient health outcomes, it is critical to provide formal education on patient-centered EHR communication skills. Unfortunately, despite increasing worldwide EHR adoption, few institutions educate trainees on EHR communication best practices.ObjectiveThe goal of this research was to develop and deliver mandatory patient-centered EHR training to all incoming housestaff at the University of Chicago.MethodsWe developed a brief patient-centered EHR use curriculum highlighting best practices based on a literature search. Training was embedded into required EHR onboarding for all incoming housestaff (interns, residents, and fellows) at the University of Chicago in 2015 and was delivered by institutional Clinical Applications Trainers. An 11-item posttraining survey consisting of ten 5-point Likert scale questions and 1 open-ended question was administered. Responses at the high end of the scale were grouped to dichotomize data.ResultsAll 158 of the incoming 2015 postgraduate trainees participated in training and completed surveys (158/158, 100.0%). Just over half (86/158, 54.4%) were interns and the remaining were residents and fellows (72/158, 45.6%). One-fifth of respondents (32/158, 20.2%) were primary care trainees (defined as internal medicine, pediatric, and medicine-pediatric trainees), and the remaining 79.7% (126/158) were surgical or specialty trainees. Self-perceived pre- versus posttraining knowledge of barriers, best practices, and ability to implement patient-centered EHR skills significantly increased (3.1 vs 3.9, P<.001 for all). Most felt training was effective (90.5%), should be required (86.7%), and would change future practice as a result (70.9%). The only significant difference between intern and resident/fellow responses was prior knowledge of patient-centered EHR use barriers; interns endorsed higher prior knowledge than resident peers (3.27 vs 2.94 respectively, P=.03). Response comparison of specialty or surgical trainees (n=126) to primary care trainees (n=32) showed no significant differences in prior knowledge of barriers (3.09 vs 3.22, P=.50), of best practices (3.08 vs 2.94, P=.37), or prior ability to implement best practices (3.11 vs 2.84, P=.15). Primary care trainees had larger increases posttraining than surgical/specialty peers in knowledge of barriers (0.8 vs 0.7, P=.62), best practices (1.1 vs 0.8, P=.08), and ability to implement best practices (1.1 vs 0.7, P=.07), although none reached statistical significance. Primary care trainees also rated training as more effective (4.34 vs 4.09, P=.03) and felt training should be required (4.34 vs 4.09, P=.10) and would change their future practice as a result (4.13 vs 3.73, P=.02).ConclusionsEmbedding EHR communication skills training into required institutional EHR training is a novel and effective way to teach key EHR skills to trainees. Such training may help ground trainees in best practices and contribute to cultivating an institutional culture of humanistic, patient-centered EHR use.

Electronic Health Record (EHR) Organizational Change: Explaining Resistance Through Profession, Organizational Experience, and EHR Communication Quality

ABSTRACTThe American Recovery and Reinvestment Act passed by the U.S. government in 2009 mandates that all healthcare organizations adopt a certified electronic health record (EHR) system by 2015. Failure to comply will result in Medicare reimbursement penalties, which steadily increase with each year of delinquency. There are several repercussions of this seemingly top-down, rule-bound organizational change—one of which is employee resistance. Given the penalties for violating EHR meaningful use standards are ongoing, resistance to this mandate presents a serious issue for healthcare organizations. This study surveyed 345 employees in one healthcare organization that recently implemented an EHR. Analysis of variance results offer theoretical and pragmatic contributions by demonstrating physicians, nurses, and employees with more experience in their organization are the most resistant to EHR change. The job characteristics model is used to explain these findings. Hierarchical regression analyses also demonstrate the quality of communication surrounding EHR implementation—from both formal and informal sources—is negatively associated with EHR resistance and positively associated with perceived EHR implementation success and EHR’s perceived relative advantage.

Developing an evidence base of best practices for integrating computerized systems into the exam room: a systematic review.

The introduction of health information technology systems, electronic health records in particular, is changing the nature of how clinicians interact with patients. Lack of knowledge remains on how best to integrate such systems in the exam room. The purpose of this systematic review was to (1) distill "best" behavioral and communication practices recommended in the literature for clinicians when interacting with patients in the presence of computerized systems during a clinical encounter, (2) weigh the evidence of each recommendation, and (3) rank evidence-based recommendations for electronic health record communication training initiatives for clinicians. We conducted a literature search of 6 databases, resulting in 52 articles included in the analysis. We extracted information such as study setting, research design, sample, findings, and implications. Recommendations were distilled based on consistent support for behavioral and communication practices across studies. Eight behavioral and communication practices received strong support of evidence in the literature and included specific aspects of using computerized systems to facilitate conversation and transparency in the exam room, such as spatial (re)organization of the exam room, maintaining nonverbal communication, and specific techniques that integrate the computerized system into the visit and engage the patient. Four practices, although patient-centered, have received insufficient evidence to date. We developed an evidence base of best practices for clinicians to maintain patient-centered communications in the presence of computerized systems in the exam room. Further work includes development and empirical evaluation of evidence-based guidelines to better integrate computerized systems into clinical care.

Teaching Electronic Health Record Communication Skills.

This pilot study investigated nurse practitioner students' communication skills when utilizing the electronic health record during history taking. The nurse practitioner students (n = 16) were videotaped utilizing the electronic health record while taking health histories with standardized patients. The students were videotaped during two separate sessions during one semester. Two observers recorded the time spent (1) typing and talking, (2) typing only, and (3) looking at the computer without talking. Total history taking time, computer placement, and communication skills were also recorded. During the formative session, mean history taking time was 11.4 minutes, with 3.5 minutes engaged with the computer (30.6% of visit). During the evaluative session, mean history taking time was 12.4 minutes, with 2.95 minutes engaged with the computer (24% of visit). The percentage of time individuals spent changed over the two visits: typing and talking, -3.1% (P = .3); typing only, +12.8% (P = .038); and looking at the computer, -9.6% (P = .039). This study demonstrated that time spent engaged with the computer during a patient encounter does decrease with student practice and education. Therefore, students benefit from instruction on electronic health record-specific communication skills, and use of a simple mnemonic to reinforce this is suggested.

Teaching Electronic Health Record Communication

Teaching Electronic Health Record Communication

Patient and provider perceptions of advance care planning using electronic health record patient portals

The electronic health record (EHR) and EHR-tethered patient portals provide innovative opportunities for patient-provider advance care planning (ACP) communication. Development of patient-centred ACP tools for EHR-tethered patient portals requires investigation...

A logical approach to semantic interoperability in healthcare.

Singapore is in the process of rolling out a number of national e-health initiatives, including the National Electronic Health Record (NEHR). A critical enabler in the journey towards semantic interoperability is a Logical Information Model (LIM) that harmonises the semantics of the information structure with the terminology. The Singapore LIM uses a combination of international standards, including ISO 13606-1 (a reference model for electronic health record communication), ISO 21090 (healthcare datatypes), and SNOMED CT (healthcare terminology). The LIM is accompanied by a logical design approach, used to generate interoperability artifacts, and incorporates mechanisms for achieving unidirectional and bidirectional semantic interoperability.

Archetype-based conversion of EHR content models: pilot experience with a regional EHR system

BackgroundExchange of Electronic Health Record (EHR) data between systems from different suppliers is a major challenge. EHR communication based on archetype methodology has been developed by openEHR and CEN/ISO. The experience of using archetypes in deployed EHR systems is quite limited today. Currently deployed EHR systems with large user bases have their own proprietary way of representing clinical content using various models. This study was designed to investigate the feasibility of representing EHR content models from a regional EHR system as openEHR archetypes and inversely to convert archetypes to the proprietary format.MethodsThe openEHR EHR Reference Model (RM) and Archetype Model (AM) specifications were used. The template model of the Cambio COSMIC, a regional EHR product from Sweden, was analyzed and compared to the openEHR RM and AM. This study was focused on the convertibility of the EHR semantic models. A semantic mapping between the openEHR RM/AM and the COSMIC template model was produced and used as the basis for developing prototype software that performs automated bi-directional conversion between openEHR archetypes and COSMIC templates.ResultsAutomated bi-directional conversion between openEHR archetype format and COSMIC template format has been achieved. Several archetypes from the openEHR Clinical Knowledge Repository have been imported into COSMIC, preserving most of the structural and terminology related constraints. COSMIC templates from a large regional installation were successfully converted into the openEHR archetype format. The conversion from the COSMIC templates into archetype format preserves nearly all structural and semantic definitions of the original content models. A strategy of gradually adding archetype support to legacy EHR systems was formulated in order to allow sharing of clinical content models defined using different formats.ConclusionThe openEHR RM and AM are expressive enough to represent the existing clinical content models from the template based EHR system tested and legacy content models can automatically be converted to archetype format for sharing of knowledge. With some limitations, internationally available archetypes could be converted to the legacy EHR models. Archetype support can be added to legacy EHR systems in an incremental way allowing a migration path to interoperability based on standards.

Semantic Interoperability

To meet the challenge for high quality and efficient care, highly specialized and distributed healthcare establishments have to communicate and co-operate in a semantically interoperable way. Information and communication technology must be open, flexible, scalable, knowledge-based and service-oriented as well as secure and safe. For enabling semantic interoperability, a unified process for defining and implementing the architecture, i.e. structure and functions of the cooperating systems' components, as well as the approach for knowledge representation, i.e. the used information and its interpretation, algorithms, etc. have to be defined in a harmonized way. Deploying the Generic Component Model, systems and their components, underlying concepts and applied constraints must be formally modeled, strictly separating platform-independent from platform-specific models. As HL7 Version 3 claims to represent the most successful standard for semantic interoperability, HL7 has been analyzed regarding the requirements for model-driven, service-oriented design of semantic interoperable information systems, thereby moving from a communication to an architecture paradigm. The approach is compared with advanced architectural approaches for information systems such as OMG's CORBA 3 or EHR systems such as GEHR/openEHR and CEN EN 13606 Electronic Health Record Communication. HL7 Version 3 is maturing towards an architectural approach for semantic interoperability. Despite current differences, there is a close collaboration between the teams involved guaranteeing a convergence between competing approaches.

Advanced and secure architectural EHR approaches

Electronic Health Records (EHRs) provided as a lifelong patient record advance towards core applications of distributed and co-operating health information systems and health networks. For meeting the challenge of scalable, flexible, portable, secure EHR systems, the underlying EHR architecture must be based on the component paradigm and model driven, separating platform-independent and platform-specific models. Allowing manageable models, real systems must be decomposed and simplified. The resulting modelling approach has to follow the ISO Reference Model - Open Distributing Processing (RM-ODP). The ISO RM-ODP describes any system component from different perspectives. Platform-independent perspectives contain the enterprise view (business process, policies, scenarios, use cases), the information view (classes and associations) and the computational view (composition and decomposition), whereas platform-specific perspectives concern the engineering view (physical distribution and realisation) and the technology view (implementation details from protocols up to education and training) on system components. Those views have to be established for components reflecting aspects of all domains involved in healthcare environments including administrative, legal, medical, technical, etc. Thus, security-related component models reflecting all view mentioned have to be established for enabling both application and communication security services as integral part of the system's architecture. Beside decomposition and simplification of system regarding the different viewpoint on their components, different levels of systems' granularity can be defined hiding internals or focusing on properties of basic components to form a more complex structure. The resulting models describe both structure and behaviour of component-based systems. The described approach has been deployed in different projects defining EHR systems and their underlying architectural principles. In that context, the Australian GEHR project, the openEHR initiative, the revision of CEN ENV 13606 "Electronic Health Record communication", all based on Archetypes, but also the HL7 version 3 activities are discussed in some detail. The latter include the HL7 RIM, the HL7 Development Framework, the HL7's clinical document architecture (CDA) as well as the set of models from use cases, activity diagrams, sequence diagrams up to Domain Information Models (DMIMs) and their building blocks Common Message Element Types (CMET) Constraining Models to their underlying concepts. The future-proof EHR architecture as open, user-centric, user-friendly, flexible, scalable, portable core application in health information systems and health networks has to follow advanced architectural paradigms.