In eHealth4U, we are focusing in implementing the primary care specialties, being the general internal medicine, the general paediatrics and the family medicine. From the analysis of the requirements, we are separating the general components of the EHR system into two main categories, being (a) the healthcare related and (b) the administrative related requirements. The healthcare related requirements are further split into 3 main sub-categories which reflects how the healthcare providers use this information in their routine workflows. Aided by the medical team, these are the Medical History, the Clinical Examination and the Laboratory Results. The Medical History includes the total set of a citizen’s personal and health data which are captured during an interview between the citizen and the doctor. These data are further analyzed into the following sub-categories: Demographics, Family History, Vaccinations, History, Personal History, Epidemiological History, Gynaecological History, Social History and Systems Review. The clinical examination sub-category defines most of the possible clinical findings that might be observed by a doctor through a visit with a citizen. This category contains many sub-categories related to health, including vital signs, level of consciousness, the cardiovascular system, the musculoskeletal system, among others. In the laboratory exams sub-category we define findings from laboratory tests (e.g. chemistry, toxicology, etc.), imaging tests (e.g. MRI) and other instrumental diagnostic techniques. One example of such a scheme is shown in Figure below.
