Development of an Open Metadata Schema for Clinical Pathway (openCP) in China.

BACKGROUND: By the end of the first quarter of 2017, 1212 standard Clinical Pathways (CPs) had been developed and implemented in China since 2009, however, Chinese standard CPs are still paper-based CPs.

OBJECTIVES: To optimize the data structure and content of Chinese standard CPs based on Chinese health standards by two-level modeling approach and archetype method, and develop an Open Metadata Schema for Clinical Pathway (openCP) in China.

METHODS: We chose 43 diseases covering 7 departments of internal medicine as samples and source materials including Respiratory, Gastroenterology, Neurology, Cardiology, Nephrology, Endocrinology, and Hematology, and we followed 4 steps to develop openCP: identify reference model of openCP; develop archetype models; standardize archetype terms and metadata; and evaluate its functionality.

RESULTS: We have built hierarchical reference model and archetypes of openCP, created and standardized archetype terms and metadata, and evaluate the functionality of openCP. The qualitative comments from 5 doctors were inspiring.

DISCUSSION AND CONCLUSIONS: Medical staff may easily build localized CPs in openCP which can be integrated into EHR systems and shared among different hospitals and clinics.