Presented by Sam Heard Chair, International HL7 EHR Technical Committee Chairman, openEHR Foundation

1. eHealth
Foundations:
Can openEHR
provide one
layer?
Sam Heard
Chair, openEHR Foundation
Practicing Family Physician
Bill Aylward, OpenEYEs, Rong Chen Cambio, Ian McNicoll Ocean

2. Declarations of interest
A clinician who wants a genuine electronic health record that
can be utilised at the point of care wherever a person interacts
with the health service. This record should not have to be
complete or unitary. The technology should not dictate the
information flow. I want to see it in my lifetime.
HL7Rim
RIM
HL7
I am chairperson of the openEHR Foundation, Ocean Informatics
and Northern Territory General Practice Education. I earn money
seeing patients and some consulting with Ocean Informatics who
were awarded as a Microsoft Health Partner of the Year for 2013.
RIM Free Zone

3. People
Discourse in
eHealth
Health
Portal, A
pps
Consultation
TeleHlth
Multiple barriers to
communications:
•
Languages and behaviour
•
Clinical language and
behaviour
•
Technical language and
behaviour
IT
Clinicians
Developer
Clinical
Software

4. Balance
•
―If it doesn‘t work for the clinicians then it isn‘t a
health record‖
•
Ownership not a useful concept, Access is.
•
Masking information can rarely be done safely
without referral or a new point of care
•
•
Other information available gives diagnosis (e.g.
medication, test results)
Documents are statements for which clinicians are
medico-legally accountable

5. Some facts are unpalatable
•
Breast self examination does
harm - sacking of the UK
NHS Chief Medical Officer
•
A CT of your brain is more
likely to cause a brain
tumour than detect one
•
PSA‘s do harm – but are
widely promoted by
Urologists direct to
consumers
•
PAP Tests under 25 do harm

6. Domains of Standardisation in Health
•
Evidence-based practice
•
•
Quality and Safety
•
•
Synthesis of the latest research
generates best practice
recommendations
Performance indicators flag
when processes are suboptimal
Technical operations
•
•
For interoperability
Safe operation

8. Why does standardisation fail?
•
The standard fails to get started
•
The standards group fails to achieve consensus and
overcome deadlocks
•
The standard suffers from ‘feature creep’ and misses
the market opportunity
•
The standard is finished but ignored by the market
•
The standard is finished and implementations are
incompatible
•
The standard is accepted and is used to manage
the market
Carl F Cargill: http://dx.doi.org/10.3998/3336451.0014.103

9. Why does standardisation fail?
•
CEN: New Work
•
•
Title: Service Excellence Systems – requirements and
guidelines for service excellence systems in order to
achieve customer delight
Scope: This Technical Specification specifies
requirements and guidelines for service excellence
systems in order to achieve customer delight. This
Technical Specification applies to all organizations
delivering services like commercial service
providers, public services and service departments of
manufacturers.
http://www.nsai.ie/Our-Services/Standardization/Get-Involved-in-Standards-Development/New-Fields-of-Standardization.aspx

10. Standards
Domain Experts
Clinicians, Consumers,
Research, Administration

11. Interoperability is not a tech problem
•
Interoperability is a clinical problem
•
Diverse recording practice (sometimes arbitrary)
Diverse recording requirements
Complexity / contextual nature of health data
•
Lack of clinical involvement in standards development
•
•
Too technical, too philosophical
• Too time-consuming, too slow
•

12. Archetype Reviews

13. Template Reviews
© 2012 Ocean Informatics

14. CKM Users
•
International
openEHR CKM
instance
•
•
•
•
> 1000 users
From 80
countries
From all Health
professions and
many health
domains
Also National
programs with an
instance of CKM
Countries

15. Use the Same Archetypes in Various
Applications, Worldwide
...
© 2012 Ocean Informatics

16. If not then ―Clinical systems‖….
•Moorfields: 68
•Leeds: 320
•St Thomas‘: 760

17. The Role of Standards 2000-2013
•
To ensure massive human and financial waste via:
•
•
•
Over claiming benefits
Employment of consultants
Making something quite easy very costly
•
To stifle innovation and ensure everyone waits as long as
possible
•
To exclude domain experts
•
•
•
•
Cost of attendance
Opportunity cost to other functions
Obfuscation
Language

18. I've searched all the parks in all the cities — and found
no statues of Committees.
G K Chesterton

19. NEHTA Tool Chain
Self validating XML
Schema

20. Tool Chain
Governance
1.
Clinicians and/or
Consumers determine
content
2.
On line review
(maintenance cycles
as required)
3.
Use case dependent
aggregation, term
sets and extension
4.
On line review (and
maintenance cycles
as required)
3.
Generate artefacts
4.
Publish

21. Tool Chain
Archetype
Archetype
Archetype
Archetype
Template
CDA Spec
FIHR Resource
Template
Data
Schema
CDA Instance
openEHR
Repository
FHIR Instance

22. Quality and Safety in
Healthcare
Why have we failed to improve outcomes?

23. Quality and Safety Agenda
•
―Despite huge investment in quality and safety over the
past two decades, healthcare is still failing to learn the
lessons from its mistakes.‖
•
1995 Australia: 16.6% of patients had one or more adverse
events
Only 38%
Of these events 18.4% resulted in death (4.9%) or major of adverse
events occurred in
disability (13.7%)
hospital
• 50% of these were considered preventable
• 1000 patients
• 32
• 900m over 5 years established an industry with Serious events
• 16 preventable
commissions, standards etc
• 6 were ‗visible‘
• 2 died
• Clinicians remain disengaged.
•
BMJ 2013;347:f5800 doi: 10.1136/bmj.f5800 Sep 2013

24. Quality and Safety Agenda
•
1999 Australia: 70% of adverse events due to
human error
•
•
•
•
Failure of technical performance
Failure to decide or act on available information
Failure to investigate or consult
Lack of care or failure to attend
•
50% associated with an operation
•
Internal medicine - highest incidence - highest
deaths

25. Models of Failure
Futile Circles Model: Michael Bruist
Swiss Cheese Model: James Reason

26. Questions for the future
•
Why do doctors not act on available information?
•
Why is there lack of concern?
•
Why is there failure in care and attendance?
•
Clinical Engagement, Ownership, Responsibility
•
Leadership and Mentorship

27. Guidelines and Checklists
Preoperative Surgical
Checklist
•
Death rate
Before
• After
•
•
•
1.5%
0.8%
Inpatient complications
Before
• After
•
Febrile Child Guideline
11%
7%
NEJM DOI: 10.1056/NEJMsa0810119 Jan 2009
Derived from evidence
•
Traffic light system
•
Dealing with rare conditions
•
BUT
•
Other extremely rare
conditions occur at
considerable rate

29. How can we improve healthcare with IT?
Positive Deviance
•
•
•
Jerry and Monique
Sternin
Save the children
(Vietnam 1990)
Reduced malnutrition
by 85% in 2 years
without supplements
Antifragility
•
Nassim Nicholas Taleb
•
Author of ‗The Black
Swan‘
•
•
Can‘t predict
unexpected events
Antifragility
•
Fragile v. Robust v.
Antifragile

30. Positive Deviance
•
Communities are the best experts to solve their own
problems with existing solutions.
•
Communities self-organize and have the human resources
and social assets to solve an agreed-upon problem.
•
Collective intelligence and apply it to a specific problem
requiring behavior or social change.
•
Sustainable and demonstrably successful uncommon
behaviours are already practiced in that community within
the constraints and challenges of the current situation.
•
―It is easier to act your way into a new way of thinking than
think your way into a new way of acting‖.
http://en.wikipedia.org/wiki/Positive_Deviance

31. Positive Deviance
1.
Don‘t presume you
have the answer
5.
Identify and analyse
the deviants
2.
Don‘t think of it as a
dinner party
6.
3.
Let them do it
themselves
Let the deviants
adopt deviations on
their own
7.
Track results and
publicise them
4.
Identify conventional
wisdom
http://www.fastcompany.com/42075/positive-deviant

32. Antifragile
•
Biological systems are
antifragile by nature
•
•
•
•
Physical death is necessary
Biological decay not
oxidation
Support the emergence of
new life
Can we build systems that
benefit from shocks and
assaults?
•
•
Managing the market with
standards is opposing this
Introduce appropriate
components into a given
functionally-based
arrangement
•
•
•
Most ideal relationships and
interactions
Self-selection
Antifragility is the property
of complex organic
systems that have survived
•
Depriving them of
volatility, randomness, and
stressors will harm them

33. What does openEHR provide?
Positive Deviance
•
•
•
Only in kind resources for 10
years
Uptake in
Slovenia, Sweden, Norway, Brazil
, Uruguay, Australia, United
Kingdom, Portugal, Angola
First 7 Industry Partners have
committed to collective activity
and funding
Antifragility
•
Software in
Java, Eiffel, .Net, Ruby, Python
•
Three Java Servers
•
Two open source
•
One Ruby Server
•
One .Net Server
•
Supporting the Clinical
Information Modelling Initiative
(CIMI)
•
Federated governance

34. What does openEHR provide?
•
A technical specification genuinely independent of
technology
•
An increasingly comprehensive approach to
recording, querying and sharing health information
•
A health record platform that:
•
•
•
•
•
Does not know what will be stored in it
Returns data to browsers in default format or any other format
required
Supports a query language independent of database technology
Supports distributed editing of health information
A federated international environment for clinicians to
agree what structured data they want to collect

35. openEHR in Use
•
NT My eHealth Record
•
Western Sydney Shared Care Planning (incl. mobile app)
•
Queensland and NT Infection Control
•
UK: Leeds Trust Clinical Data Repository
•
UK: Orsini Project – Open Eyes, Open ENT, Open Cardiac, Open Oncology
•
Slovenia: Hospitals
•
Moscow: Shared Health Record
•
Japan: Major Disease Register
•
Uruguay: Shared EHR Service
•
Brazil: Private Health Record Aggregation
•
Angola: Hospitals

36. NT My eHealth Record: Health Index

37. NT My eHealth Record: Antenatal

38. OpenEyes
•Web application
•Open Source
•Clinically led
•Flexible
•Modular

39. OpenEyes
•Web application
•Open Source
•Clinically led
•Flexible
•Modular

40. Prescribing

41. Detailed clinical info

46. The Work of openEHR.jp
•
The first regional activity of the openEHR project
•
Translation
Architectural over view, openEHR licensing
• openEHR primer, Eiffel FAQ
• openEHR Models, Archetypes and Biomedical Ontologies
•
•
Delegation to international community
•
•
Implementation
•
•
International congress, Medinfo2007, 2010 and 2013.
Ruby implementation for openEHR specifications
Seminars
•
MOSS, Seagaia meeting, This EMBC2013 workshop!

47. EMBC2013, Osaka
Hiroyuki Yoshihara Shinji KOBAYASHI Koray Atalag
Jussara Rotzch John Halamka

48. openEHR Archetypes:
open source Clinical information components
•
Clinically-led + collaboratively authored
•
•
•
•
open-source ‗crowd-sourcing‘ methodology
democratised clinical content development
Shared open repository CC-BY-SA licence
Agility to respond to continually changing clinical demand
•
•
Clear ownership, change request mechanism
Tight version control

49. INDUSTRY/Profession-driven standardisation
‗open Governance‘
Implementation
Clinical
Knowledge
Administrators
Blood pressure
Archetype
Editors
Secondary
endorsement
Opthalmology
Project Editors
Archetype
Reviewer
Visual fields
archetype
Archetype
Reviewer
Visual acuity
archetype
Reviewer
Review

50. openEyes Glaucoma : Initial authoring
Gather evidence
Refine mindmap (inclusive dataset)
First draft mindmap
Create /Upload Initial archetype

51. openEyes Glaucoma : Implementation
Template Data Schema

52. Professional oversight
[1] Clinical content
NHSvista
Care API
[3a]
LCR apps
(Leeds)
NHSvista
Reporting API
[3b]
ESB / ITK / Spine components [2]
NHS vistaopenEHR
Adaptors [8]
openENT
(UCLP)
Wardware2
(Kings)
OpenEyes
(Moorfields)
openEHR API integration [7]
Local
SQL DB
EHRPaaS [9]
openEHR API
openEHR
Repository
(vendor #1)
openEHR API
openEHR
Repository
(vendor #2)
openEHR API
openEHR
Repository [10]
(open source)

53. Leeds NHS Care Record: open Platform
OpenEHR Clinical Content “Archetypes”:
•
•
•
•
Medication, allergies (GP2GP/ RCP/NHSS)
Problems, procedures (international)
End of Life content (ISB)
Vital Signs, NEWS (international)
Open
APIs:
ESB/Spine
ITK Integration component
openEHR Foundation accredited
Open Standards CDR Service layer
SMARTPlatforms
Commit
Retrieve
Query
N3
hosted
Leeds Clinical Portal
Clinical
data repository

54. Leeds Innovation Lab: open Platform Demonstrator
OpenEHR open source Clinical Content : “Archetypes”:
•
•
•
•
Medication, allergies (GP2GP/ RCP/NHSS)
Problems, procedures (international)
End of Life content (ISB)
Vital Signs, NEWS (international)
Open
APIs:
FHIR
ITK Integration component
openEHR Foundation accredited
Open Standards CDR Service layer
SMARTPlatforms
Commit
Retrieve
Query
N3
hosted
Leeds Clinical Portal
Clinical
data repository

55. openEHR CLOUD ‗Platform as a Service‘
ITK Integration component
N3
hosted
ESB/Spine
Value-add
components
openEHR Foundation accredited
Terminology
Server
Pathways KB
Commit
Retrieve
Implementation-agnostic CDR Service layer
Query
Oracle
Marand
SQL
Server
Ocean
NHS OSS?
openEyes
Postgres
SQL
Code24
CDR
Solutions

56. Think!EHR PlatformTM
November 2013
Tomaž Gornik

57. eHealth – City of Moscow
Moscow city medical institutions network comprises 780
medical and preventive treatment facilities, including:
•
149 hospitals, 76 health centers, 428 policlinic institutions, 28 centers, 63
maternal and child health care institutions, 36 extended care facilities, 12
special type health care institutions
Numbers:
•
Patients- 12 million, Beds in hospitals – 83,000
•
Physicians – 45,000, all users – 130,000
•
Patient Visits/year - 161 million
•
Documents/year - 1 Billion, 25TB
Based on IHE and Think!EHRTM Platform!
57

58. SMART API integration
58

59. Medication Prescribing
59

60. Fluid Balance
60

61. Lines, Tubes, Drains
61

62. Care Protocols
62

63. Nursing Care Plan
63

64. EHR Search

65. CDS/GDL Integration

66. Think!EHR Explorer 4.0
66

67. Overview Introduction of
Guideline Definition
Language (GDL)
Rong Chen MD, PhD
CMIO, Cambio
HINZ 2013

68. Guide Definition Language (GDL) Design
A minimum language to glue together
archetypes, terminologies and rules
Three Pillars
•
Bindings between archetype elements and
variables in the rules
•
Rule expressions easily converted to industry rule
engine languages
•
Bindings between local concepts used in the rules
and concepts from reference terminologies

69. EhrGen: Pablo Pazos
Open source openEHR server
and test environment.

70. Paul Downey: ―Standards are Great! Standardisation is a really bad idea..‖
2009

71. There are no shortcuts
Sam Heard
Chair openEHR Foundation
Sam.Heard@openehrfoundation.org