An OpenEHR Adoption in a Portuguese Healthcare Facility

Abstract The quality and safety of clinical decisions depend to a large extent on the knowledge acquired by the records of health professionals. However, a traditional Electronic Health Record (EHR) has become insufficient in terms of knowledge acquisition and clinical decision support. The development of these aspects may bring marked improvements in the quality and safety of health care. The usage of open models promotes interoperability between systems, minimizing the impact of information systems on the efficient production of knowledge useful for clinical decisions. In this sense, this article describes an implementation project of a system that support the production and use of knowledge in clinical environments, based on OpenEHR two levels modelling open data approach, in a healthcare facility on the north of Portugal.