## 4 Discussion  
The MedicalForms system successfully managed and ensured semantic consistency in defined EHR specifications and forms for clinical practice and research. It was able to establish a coordinated management of information between EHR, CTMS, analytics platform and mobile apps. In addition, the system demonstrated the potential for reusing standardized approaches across multiple clinical domains. There were no particularities found in any of the clinical domains where the system was applied. Clinician involvement: This research expects to contribute to guide future evolution of existing CIMTs towards obtaining a greater involvement of clinicians. Our survey based on the TAM questionnaire shows a good level of acceptance. The proposed simplified language that does not require learning new concepts reduces the learning curve associated with other approaches. Our approach confirmed results from a previous international survey [14] pointing out that applying screens and forms as part of the CIP is beneficial for clinicians in understanding system requirements. Obtaining consensus in large healthcare providers is a time-consuming task. The proposed functionalities for supporting coordination between multiple clinical experts are expected to contribute towards systemizing this process resulting in a reduction of time in the long term. Combined information modeling process with form design and data analytics: It is possible to find CIMTs that define how the information is to be structured in the screen form (for example, those based on the openEHR template), but these are not capable of producing implementable forms because this specification does not determine the options for representing a cluster such as dropdown, checkbox or radiobutton. Our research aims to provide a complementary approach that is not only focused on the definition of interoperability specifications for EHR communication, but on producing implementable forms for patient care and research with integrated data analytics. Screen presentation harmonization: The necessity for finding a balance between standardization of common data elements and allowing for innovation, in order to preserve the capability for different interfaces to be created by vendors, has previously been reported [14]. It has been identified that several systems allow the definition of screen forms by importing a configuration file. It is of no surprise that more systems adopt this approach and possible advances in the harmonization of definitions could be implemented. Semantic infrastructure definition: Our initiative is based on the CIMs since it can be identified as the more generic mechanism to adopt the two-level modeling approach. Based on CIM, we were able to produce forms and semantic structures compatible with existing tools such as openClinica, RedCap, Diraya and TranSMART with a reduced level of complexity compared to existing EHR specifications. In addition, we took care to satisfy requirements included as part of the ISO 13606, openEHR and CDISC reference models. Last, we analyzed existing HL7 specifications (v2, CD and FHIR) and planned a journey to support future compliance as long as we are involved in projects related to these specifications. Semantic Web technologies: Associated with the capabilities for exporting CIMs in OWL format, it is expected that the MedicalForms system contributes towards the adoption of ontology-based tools. These technologies apply defined relationships between concepts from existing medical ontologies to provide advanced capabilities for clinical decision support, healthcare data analysis, retrieving synthesis information from the entered data and visualization capabilities. Issues exporting semantic structures as implementable forms: The MedicalForm system was designed with the goal of supporting the definition of CIMs according to multiple EHR interoperability specifications.