openEHR Clinical modelling workshop
Silje Ljosland Bakke a, Ian McNicoll b,c, Hildegard Franked
a Nasjonal IKT HF, b openEHR Foundation, c CHIME UCL, d freshEHR Clinical Informatics Ltd.
Abstract. openEHR is an open specification for the information model required to underpin an open digital care record platform. A key feature in openEHR architecture is the direct, collaborative involvement of clinicians in the design, review, curation and governance of open source clinical content definitions ‘archetypes’. This workshop will discuss the implications of this evolutionary approach to shared content development based on international, national and vendor-level experience as a means of maximizing benefit within a highly dynamic, culturally-mediated complex system.
Keywords. openEHR, archetype, clinical content, interoperability, platform, open source
1. Introduction
As healthcare moves towards the end of the second decade of the 21st century, the complexity of delivering a coherent eHealth architecture to support agile application development and information sharing, remains a global challenge. While other economies reap benefits from the ‘apps revolution’ much equivalent effort in the eHealth space remains disconnected from core systems, and if anything, the market is consolidating around the shrinking number of vendors able to cope with the complexity of health data implementation and ever-expanding clinical and legislative demands.
Top-down international standards developments have, in general had limited impact, and while newer, lightweight, developer-focused technologies1 hold promise for interfacing between systems, they do not address directly the core difficulty of capturing and rapidly implementing detailed, complex clinical requirements for application development and information sharing.
openEHR2, which grew out of academic enquiry into approaches to EHR architecture3, draws heavily from approaches to distributed open source development in attempting to maximise the implementation of high-quality clinical content models, whilst supporting the competing need to reflect local requirements and innovation.
openEHR is both ‘cathedral and bazaar’ in Raymond’s4 terms. A carefully controlled and slowly developing core ‘cathedral’ information model underpins technical implementation but is designed to consume arbitrary clinical concept models designed and developed by a set of collaborating clinical communities operating rather more as ‘bazaar’, as a means of maximizing value within the highly complex and diverse domain of healthcare documentation.
The emergent methodology draws heavily on the paradigms of open source distributed development5 and ‘crowd-sourcing’. It expects organic and evolutionary development6, anticipates and accepts speciation and ‘forking’ of assets. It tolerates and includes local, national7 and international perspectives to have to be supported, and that full international alignment/ adoption will not be a smooth journey8, understanding that short-term imperatives will always trump longer-term aspirations9. Nevertheless, steady progress is being made, largely due to considerable voluntary commitment from the community with the output of openEHR clinical modelling becoming apparent through implemented national and international standards, as well as significant system implementations.
2. Workshop
2.1 Workshop speakers
- Silje Ljosland Bakke, RN BSN, Nasjonal IKT HF, Bergen, Norway
- Ian McNicoll, MSc, MbChB, openEHR, CHIME UCL London, UK
- Hildegard Franke, BA (Psych), MBA, freshEHR Clinical Informatics Ltd., Kettering, UK
2.2 Workshop structure
Three short presentations will be followed by a practical modelling session.
2.3 Introduction to openEHR clinical modelling methodology and vendor engagement (Ian McNicoll)
openEHR is an open-source specification for a clinical information model with a specific aim of enabling the direct design input and quality assurance of detailed clinical models via the use of 'archetypes' and 'templates' These models can be consumed immediately in openEHR-compliant systems and used to define persistence and querying schema without any need for re-engineering but are also used as part of national and international standardisation efforts to help define the detailed clinical content of interfaces and messages.
The openEHR clinical modelling approach, and associated tooling, has evolved with experience but remains true to it's open-source philosophy, with a focus on collaborative and distributed governance.
2.4 International and national perspectives: managing international clinical modelling collaboration and governing national clinical model standardisation (Silje Ljosland Bakke)
The collaborative and largely voluntary development of a library of open source clinical content models ‘archetypes’ is one of the core programs of openEHR. The clinical program is built on clinical informatics leadership and clinical assurance/review from using web-based tools and broad, democratized clinical input. We will give a a background to the chosen approach and highlight the practical implications, touching on both successes and challenges.
Norway's situation is unusual in that it has both an active community of openEHR vendors, a national clinical modelling program, and an aspiration to reuse international models where possible. This leads to both opportunities and challenges, especially related to combining national and international governance, and doing modelling as fast as implementers require. We will present methods, experiences and progress.
2.5 Managing the diversity of operational and research requirements in a real life project (Hildegard Franke)
Genomics Medicine Centres in the UK face the diverse and sometimes conflicting requirements of creating and managing a rich dataset which can be used for the dual purpose of day-to-day operational use and of creating standardised reports for research and population analysis. We will present the methodology for managing and attempting to reconcile this diversity and report on progress to data working with one of the Genomics Medicine Centres.
2.6 Practical modelling
The openEHR clinical modelling methodology has evolved over more than a decade, and has adopted several thought processes, methods and tools over the years. We will demonstrate the initial steps of modelling a generally relatable clinical concept, where all workshop participants are encouraged to participate, and introduce questions and reflections from their experience.
3. Target audience
This session is directed at students, clinicians, clinical informaticians and system implementers who are interested in the clinical modelling methodologies used by the openEHR community, and how these are reflected in clinical requirements gathering/ clinical content development/governance at implementer, national and international levels.
4. Educational goals
Participants will gain a better understanding of the philosophical / methodological background to the openEHR approach and how this has been carried through to relate to real-world clinical modelling challenges and experience, with learning applicable to other related projects beyond those interested in a pure-openEHR approach.
5. References
[1] HL7 Fast Healthcare Interoperability Resources, https://www.hl7.org/fhir [Accessed December 8, 2016]
[2] openEHR Foundation, openEHR.org [Accessed December 8,2016]
[3] Beale T. Archetypes: Constraint-based Domain Models for Future-proof Information Systems. In: Baclawski K, Kilov H. (eds.) Eleventh OOPSLA Workshop on Behavioral Semantics: Serving the Customer (Seattle, Washington, USA, November 4, 2002). Boston, 2002.
[4] Raymond, Eric. "The cathedral and the bazaar." Knowledge, Technology & Policy 12, no. 3 (1999): 23-49.
[5] Curto-Millet, Daniel Adrian. To Be or To Become? An Enquiry into the Changing Nature of Requirements in Open Source Health IT. Diss. London School of Economics and Political Science, 2014.
[6] Leslie, Heather, Sam Heard, Sebastian Garde, and Ian McNicoll. Engaging clinicians in clinical content: herding cats or piece of cake?. In MIE, pp. 125-129. 2009.
[7] Silje Ljosland Bakke, National governance of archetypes in Norway, In: Sarkar, I. N., Georgiou, A., & de Azevedo Marques, P. M. (Eds.). (2015).MEDINFO 2015: EHealth-enabled Health: Proceedings of the 15th World Congress on Health and Biomedical Informatics (Vol. 216). IOS Press.
[8] Sundvall, E. (2013). Scalability and Semantic Sustainability in Electronic Health Record Systems. http://www.diva-portal.org/smash/record.jsf?pid=diva2%3A599752&dswid=-8106 [Accessed December 8, 2016]
[9] Christensen, B., & Ellingsen, G. (2016). Evaluating Model-Driven Development for large-scale EHRs through the openEHR approach. International Journal of Medical Informatics, 89, 43-54.