# Articles on Healthcare, Complexity, Change, Process, IT and the role of openEHR etc **Category:** [Technical (archive)](https://discourse.openehr.org/c/technical-archive/156) **Created:** 2010-10-22 16:12 UTC **Views:** 3 **Replies:** 77 **URL:** https://discourse.openehr.org/t/articles-on-healthcare-complexity-change-process-it-and-the-role-of-openehr-etc/15024 --- ## Post #1 by @Derek_Meyer Tony, This is very impressive piece of work. Every since I first came across openEHR I have intuitively felt that it is closer to the 'solution' than more static attempts at standardization. So why is progress so slow? I've appplied some lateral thinking to this, and come up with what many people on this list may (at best) think contrarian - but at the risk of being flamed.... The Case for NPfIT 2.0 www.nationalhealthexecutive.com page 52-53. (I'll go get my hard hat now...) Best wishes, Derek. --- ## Post #2 by @William_E_Hammond Tony, I agree thanks for the work and for sharing\. W\. Ed Hammond, Ph\.D\. Director, Duke Center for Health Informatics              Derek Meyer              <dmeyer@sgul\.ac\.u              > To              Sent by: For openEHR technical discussions              openehr\-technical <openehr\-technical@openehr\.org>              \-bounces@openehr\. cc              org                                                                    Subject                                        Re: Articles on Healthcare,              10/22/2010 12:16 Complexity, Change, Process, IT              PM and the role of openEHR etc                                                                                          Please respond to                 For openEHR                  technical                 discussions              <openehr\-technica               l@openehr\.org>                                                                             Tony, This is very impressive piece of work\. Every since I first came across openEHR I have intuitively felt that it is closer to the 'solution' than more static attempts at standardization\. So why is progress so slow? I've appplied some lateral thinking to this, and come up with what many people on this list may \(at best\) think contrarian \- but at the risk of being flamed\.\.\.\. The Case for NPfIT 2\.0 www\.nationalhealthexecutive\.com page 52\-53\. \(I'll go get my hard hat now\.\.\.\) Best wishes, Derek\. --- ## Post #3 by @Tim_Cook2 All I can say Derek; is that if you think my past medical, mental and social history older than six months is useless information\. Much less my familial history of a few generations\. I am very happy that you are not my physician\. Maybe if you had all of that information in a meaningful semantically connected network\. You could practice better preventive healthcare as opposed to band\-aid, reactive medicine??? :\-\) Cheers, Tim --- ## Post #4 by @thomas.beale Hi Derek, it is very simple. Not being an official standard has been a real problem for government agencies, obsessed with official standards. - thomas beale [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #5 by @Derek_Meyer Tim, I don't claim that all old information is useless. My hypothesis is that clinical care generates vast amounts of information, and very little of this vast amount is useful. (This is an empirical hypothesis, and so could be measured, although I don't know of a study that has. Perhaps a study that a) converts real patient records into facts, and the counts the number of facts, b) requires patients to be seen without a written health record and a treatment plan formulated, c) reviews the treatment plans in the light of the written record, and d) counts facts which result in changes to the treatment plan, e) calculates the ratio of facts that were useful in altering the treatment plan compared with the total number of facts.) My hunch is that there are gold nuggets in historical records, but we have to capture and store too many pebbles to get the nuggets we need. If there was zero cost to capture and storage this wouldn't matter, but unfortunately this is not the case with current technology. This is an economic problem, and the solution is to look for economic benefits at the other side of the time spectrum. If information could be sent to the person who needs it quickly, this time saving could justify the cost of capturing and structuring the information. Once data are structured and captured, it becomes cost effective to do a large number of other things with these data. This is not an argument against openEHR - just another way of using openEHR. Best, Derek. --- ## Post #6 by @thomas.beale I think that the 'pebbles & nuggets' characterisation is probably right, although I don't think anyone knows what the balance is, i.e. at what point it ceases to be worthwhile to trawl back in time. The trouble is you get patients like a 12 yo child with a history of chronic tonsilitis that is only visible by looking at say 10 years of data. Or try the other end of the spectrum - notes by GPs over some years may turn out to be indicative of alzheimers, but only when a diagnostic guideline is applied to say 5 or even 10 years of data. So how far is far enough? I think that what will be needed in the future is a way of filtering out the useless pebbles on the way so to speak. Perhaps when data were archived onto slower media. I wonder if anyone has seen research to indicate how far back data might be useful based on specific morbidities? - thomas beale [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #7 by @Karsten_Hilbert > I think that the 'pebbles & nuggets' characterisation is probably > right, although I don't think anyone knows what the balance is, It isn't even easy to \(sometimes not even possible\) to know what are the pebbles and what are the nuggets\. In fact, pebbles may turn into nuggets\. > I think that what will be needed in the future is a way of filtering > out the useless pebbles on the way so to speak\. Perhaps when data > were archived onto slower media\. I wonder if anyone has seen research > to indicate how far back data might be useful based on specific > morbidities? That probably wouldn't be useful because we don't yet know which morbidities are going to be relevant for a given not\-yet\-patient\. Karsten --- ## Post #8 by @Karsten_Hilbert > I don't claim that all old information is useless\. > > My hypothesis is that clinical care generates vast amounts of information, and > very little of this vast amount is useful\. Make that "\.\.\. at any one time\." > a\) converts real patient records into facts, and the counts the number of > facts, > b\) requires patients to be seen without a written health record and a treatment > plan formulated, > c\) reviews the treatment plans in the light of the written record, and > d\) counts facts which result in changes to the treatment plan, > e\) calculates the ratio of facts that were useful in altering the treatment > plan compared with the total number of facts\.\) Once it was said "If human beings were alike medicine could become a natural science\." That is why the above plan is doomed to fail\. > This is an economic problem, Health is NOT an economic problem\. Care can be, but health is not\. Karsten --- ## Post #9 by @thomas.beale Sorry, I was not clear enough. I meant: if it could be shown that certain patters over time corresponded to certain morbidities, then in new patients (as yet undiagnosed) these patterns could be detected early on. - thomas [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #10 by @Karsten_Hilbert I see\. I can easily agree to that\. But I don't think that it would warrant classifying any EMR entries as pebbles\. Karsten --- ## Post #11 by @ricardo.jc.correia Dear all, I have spent some time studying how doctors used an EPR using log data ([Determinants of frequency and longevity of hospital encounters` data use](http://www.biomedcentral.com/1472-6947/10/15/abstract)). I must say that some of our results were not so expected, namely the difference on the usage of past information according to patient age (reports of children and older are less used much faster). I am currently leading a research team to repeat the same study on other logs and so I am very interested in collaborations. Regards Ricardo Correia [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #12 by @williamtfgoossen Interesting comment Thomas, I think " official standards " have nothing to do with obsession, but with governments that have a legal obligation to ascertain some equality on markets, regulations, and ensuring free access and opportunities for all. Maybe I miss a few here, but I am convinced that at least in democratic societies, it is what we as citizens want. E.g. EHR laws do require official and public accessible standards from official SDO's with formal balloting and procedures in place in which all parties concerned can participate. In particular the obsession might be on market dominance. I am currently working on an ISO standard. One of the member countries was commenting that choosing one particular approach in this standard might favor that approach, hence blocking free trade. Vriendelijke groet, William Goossen directeur Results 4 Care [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #13 by @williamtfgoossen Tom, I think it really does depend on the purpose of further use of the data. clinical : in th e juvenile care record, data on growth and development and vaccinations are stored for 19 year of follow up (in NL). Then archiving is 10 years from that. clinical: if a diabetes diagnosis is based on particular blood glucose tests, and still there is no cure, it will last a lifetime. I have not seen research, but assume that the formal diagnoses and the glucose test this was based on, are stored a lifetime. Statistics: if aggregated from records, depending on architecture decisions, you might want to store the data e.g. on population diseases, over many centuries. Of course the stats themselves are kept in the research db, but how long do we want to trace back the source data for quality assurance and analysis of outliers. So I agree, we need data. The only real research in this area I know about is the algorythms for eg monitors that average the heartrate and similar measures continuously. Although never searched this further, just assumed vendors do their jobs. Vriendelijke groet, William Goossen directeur Results 4 Care [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #14 by @thomas.beale I take your points, but there is a clear priority for quality, not just equality. In all other industries, the quality of standards is measured initially against public safety and then against criteria of effectiveness and economic qualities. No standard gets through (or if it does, survives long) if it a) endangers the public or b) doesn't do its purported job properly. In all other industries that i know of, standards are created by a process whose inputs are already developed and productised offerings from companies (or sometimes other entities, e.g. universities). The process is usually one of choosing or it may be one of a compromise agreement. Whatever the detail, the outcome is usually dependable, certainly in modern times. An 'obsession' with standards of this kind would be reasonable. However, this is not what are produced in health informatics. In our domain, the standards are created in committee rooms, and are issued, pretty much untested, with no real proof of public safety, utility, fitness for purpose, maturity or value for money. And yet the governments who run e-health programmes remain attached to these de jure standards, despite their obvious shortcomings. People working for such programmes have trouble engaging with organisations that produce implementation validated outputs, because use of such materials is not sanctioned. Until this underlying problem in e-health is resolved by a major reform in how standards are actually produced, validated, and maintained, I don't see much hope for efficient progress in this domain. - thomas --- ## Post #15 by @system > In all other industries, the quality of standards is > measured initially against public safety and then > against criteria of effectiveness and economic qualities\. it seems you mean, by market testing\. If not, do you have an example? > In all other industries that i know of, standards are > created by a process whose inputs are already developed > and productised offerings from companies I presume you refer to non\-it industries\. In IT the picture is rather more mixed\. You certainly aren't describing the omg process, or the itu process, or the w3c process here\. A truly valid comparison would be with IT standards in other vertical markets\. Insurance always strikes me as applicable\. Do you have any examples from these spaces? Grahame --- ## Post #16 by @thomas.beale > > ``` > > In all other industries, the quality of standards is > > measured initially against public safety and then > > against criteria of effectiveness and economic qualities. > > > > ``` > > ``` > it seems you mean, by market testing. If not, do you have an example? > > ``` well yes and no. Products produced by big companies of course have to undergo all kinds of testing to do with safety. With respect to fitness for purpose, the market will certainly sort a lot out. But to get to market, you have to have completely implemented and productised the offering - which means going way past the paper stage. By the time standards agencies see these things, they are guaranteed to 'work', the only question is to do with what they interoperate with. > > ``` > > In all other industries that i know of, standards are > > created by a process whose inputs are already developed > > and productised offerings from companies > > > > ``` > > ``` > I presume you refer to non-it industries. In IT the picture is rather > more mixed. You certainly aren't describing the omg process, or the > itu process, or the w3c process here. > > ``` IT in recent decades has become quite poor, no doubt about it. Older standards (e.g. older network standards) tended to have hardware implications, and they simply could not be issued without having being implemented somewhere. In more recent times, W3C does at least manage some implementations of what it issues, but is mainly helped by major tech companies implementing the standards. Nevertheless, standards like XML Schema are still horrible, very weak formal underpinning, and hardly fit for purpose (being a document-based idea trying to satisfy data representation requirements). See [http://en.wikipedia.org/wiki/XML_Schema_Language_Comparison](http://en.wikipedia.org/wiki/XML_Schema_Language_Comparison) . OMG has better process than any SDO in e-health, but the output is not always that inspiring. UML 2 is awful (try reading the 'infrastructure' and 'superstructure' specs - you really have to wonder what drugs they were taking), as is XMI. Which is why the Eclipse Modelling Framework (EMF) sprung up in the modelling space - to provide a usable alternative to XMI. > ``` > A truly valid comparison would be with IT standards in other vertical > markets. Insurance always strikes me as applicable. Do you have any > examples from these spaces? > > ``` I know a bit about investment, and there is to be sure, less to standardise. The interesting comparisons I think are in construction, mobile telephony, automotive, telecomms, etc. Standards just don't get issued as paper with no products behind them in these industries. - thomas --- ## Post #17 by @system Well, your specific comments certainly don't back your general statement up. Looking at the question of the other industries, what specific standard would you point to as an example we should follow, and how was it developed? Grahame --- ## Post #18 by @thomas.beale > Well, your specific comments certainly don't back your general statement up. Looking at the question of the other industries, what specific standard would you point to as an example we should follow, and how was it developed? - safety goggles and other personal safety equipment - nearly every part of a modern car that has safety implications for passengers - all telecoms signalling standards, including over radio, microwave tightbeam, and cable - any physical digital media, including DVD, Bluray, DAT, etc - nearly every thing to do with the motherboard and disk bus in a PC - VMEbus ([http://en.wikipedia.org/wiki/VMEbus](http://en.wikipedia.org/wiki/VMEbus)) - standards for energy efficiency of building materials - standards for nearly all building components, including steel beams, concrete and so on - etc None of the standards used in these areas were developed in a committee room with a random assortment of people who turned up a few times a year. Instead, companies (e.g. Ericsson, Morotola, Toshiba, Philips, BMW, etc) created products and brought them to market, and then brought the relevant interoperability specifications to standards forums. E-health should follow the lead of e.g. the telecoms and computer components industries and standardise on things that actually have been shown to work. As I said earlier, it doesn't just have to be companies that make things that work. Linux, Apache and the IETF standards came from different places. But in all of these situations, the relevant standards were first validated by implementation, deployment before being proposed as a standard. What is happening in e-health is just bizarre. And the results show it. - thomas [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #19 by @grahamegrieve And none of your examples are vertical industry IT standards. Mark Bezzina for Stds Australia pointed out to me that IT vertical standards are a totally different thing to every other kind of standard. You're trying to portray Health IT as some kind of bizarre exemption, in that things are totally done in a weird way. But I don't think it's an exemption: I think most IT verticals have the same problem, which is that standards are being used as a stalking horse for research. Grahame [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #20 by @thomas.beale > And none of your examples are vertical industry IT standards. > Mark Bezzina for Stds Australia pointed out to me that IT > vertical standards are a totally different thing to every other > kind of standard. Telecoms, to take one example, consists of many layers of protocols and technologies, most standardised, which form a very impressive stack. It's all IT, it just isn't seen as vertical any more because it is such an assumed part of our technological infrastructure. In terms of basic development process, I don't see IT 'vertical' standards as any different from any other standard. I just can't think of any kind of standard at all that should be developed in committees of randomly self-selected participants, many with no design or other professional experience. Let's be clear - all such standards are engineering specifications of one kind or another, and argumentation by committee simply is not a recognised or valid development paradigm for elaborating any kind of technical artefact. It could be used to discuss one, talk about its requirements, but it won't be able to build the thing in question. And yet this is what happens in health informatics. In finance, the standardisation that occurs is mostly by industry agreements, +/- government involvement, to set e.g. agreed classification of industry sectors, security types, and so on. The finally agreed schemes come from existing schemes used by companies in the industry, not from committee discussions. Much standardisation in the military sector comes from defence forces institutions and supplier companies. > You're trying to portray Health IT as some kind of > bizarre exemption, in that things are totally done > in a weird way. But I don't think it's an exemption: I > think most IT verticals have the same problem, which > is that standards are being used as a stalking horse > for research. I would certainly agree with this last statement for e-health - and it is a terrible way to do research. I have not encountered it in any other IT area, though. - thomas --- ## Post #21 by @Tim_Cook2 I am getting mixed signals from what Tom is saying\. I am not sure if he is suggesting that Health IT \(as in EHR/EMR, DSS, CPOE, etc\.\) should go through the same rigorous government controlled testing that drugs and biomedical equipment go through? Or, if he is saying that "an" implementation proves usefulness? I think that there is a good case for the former\. Sure it would increase costs, but at least they would work as advertised\. :\-\) \-\-Tim --- ## Post #22 by @Tim_Cook2 Might want to re\-think that one Tom\. Can we start with DARPA? :\-\) \-\-Tim --- ## Post #23 by @thomas.beale --- ## Post #24 by @Byron_Davies DARPA doesn't "do" anything. DARPA sets goals, offers money, and lets the smartest people compete to achieve the goals. --- ## Post #25 by @pablo Hi Thomas, My opinion is the grade of adoption of a standard depend in some aspects of goverment agencies, in some of the industry and some of the academy. DICOM is a good example of an open standard heavily supported by the industry, that's the point of it success. Can't be OpenEHR a de-facto standard for EHRs? Like DICOM is for imaging. I think yes, but the progress of OpenEHR to solve real the problems and make it usable, is slow. I think OpenEHR is strong on the academy area. It has poor industry penetration (I mean enterprises developing tools and aplying a good part of the OpenEHR specification in their systems, and that these systems where used in some hospitals). I don't know what's the penetration of OpenEHR on goverment agencies. There are some open tools but there is some stillness on making improvements on them. For example, here in Latin America, almost nobody knows about OpenEHR in the industry area, and very very few knows about it in the academy area. There are some ideas that may help de difusion and adoption of OpenEHR: - I think that regional OpenEHR communities are needed to empower the adoption and spreading of the standard. In 2009 I send a message to the mailing lists, but I get no answer from the community (this mail is below). Now we have 36 members from Uruguay, Argentina, Chile, Colombia, Spain, and more. They work on goverment agencies, big enterprises (like IBM), developers and physicians. I think the international OpenEHR community needs to support these regional communities, providing guidelines, general objectives, and following their work. Here in South America, only few people know about OpenEHR, that's a shame. People in goverment are making decissions, without knowing that are good and open standards out there. - Formal training and education in OpenEHR is needed. It's very hard to the newcomer to understand how to use OpenEHR, and people interested on the main ideas of OpenEHR may be dissapointed when they try to use it in a real-world software application. People in the industry must be trained, but how many OpenEHR trainers are out there? In Set-2010 I've done a hands-on OpenEHR tutorial in Argentina, and people (medics and TIC people) where amazed about building their archetypes and having a tool that generates the EHR (this is my degree project). This was done in the context of the "Argentine Congress of informatics and Health 2010". Now, the organizers want to make more time to discuss OpenEHR and its posibilities. This is just an example that great things can happen if someone has interest. Regional OpenEHR communities can build courses fucused on the regional needs, may be made some money to support the open tool development (*). - Building and supporting open tools. The current tools have no regular updates. We need developers to build new tools and improve the current tools. We can use the money of the training courses (*) to pay developers to do this job. If this depends only on the free time we have, tools just can die before they are implemented. - In order to help any goverment adoption of OpenEHR, the decission makers have some questions that today OpenEHR can't answer. - What is the state of the standard? - Is it stable? - Wich parts are stable? - Is there any return of investment study done on efective use of OpenEHR? - Or just, how much time and money I have to spend to effectively use OpenEHR in a real world application? (I have to train people to make things happen, not in an investigation project, but in a production project) - What real world products are using OpenEHR? - How these products are using OpenEHR? (they adopt the RM? the AOM? the SM?) There is page on "who is using OpenEHR" in the portal, but it is outdated. My proposal is to do regular polls on the community in order to know: who is working on what, and how they're using OpenEHR. - Formal links with "formal" SDOs are needed. I think that OMG is in tune with the way OpenEHR do things. They have the COAS standard, and OpenEHR RM is mapped to COAS. This is a good starting point to have something in common. I think there are very good posibilities in the OpenEHR adoption on the industry adn goverment areas, but we need to build improve the lines of action of the community to reach that. Just my humble opinions. Best regards, - Pablo. --- ## Post #26 by @Hugh_Leslie1 Hi Pablo I think that there is beginning to be serious industry penetration in many parts of the world. We are seeing this in the Asia Pacific region as well as many countries across Europe. I think that we will soon start to see a lot more interest in South America as well - certainly there is more than academic interest in Chile and Brazil I believe. I think that we will start to see a growing number of enterprise development tools - there are certainly a number of commercial and open source development platforms that are available now and are quite mature. regards Hugh --- ## Post #27 by @pablo Hi Hugh, > I think that there is beginning to be serious industry penetration > in many parts of the world. We are seeing this in the Asia Pacific > region as well as many countries across Europe. Do you have any concrete examples? I mean, do you know who is working on what? As I say, we need to make some polls to know what people is working, where are this people, and how they are using OpenEHR. With this information updated we can set links between projects and improve collaboration. In Brazil there is work on 13606, and some work on OpenEHR, but now they want to make their own standard based on OpenEHR. In Argentina, Uruguay, Colombia and some other countries here in South Amercia, nobody knows more than the name of OpenEHR, and that's a shame. > I think that we will soon start to see a lot more interest in > South America as well - certainly there is more than academic > interest in Chile and Brazil I believe. Is the OpenEHR boards doing something for this to happen? Or this is just a feeling? I think real actions must take place here to reach success. > I think that we will start to see a growing number of > enterprise development tools - there are certainly a > number of commercial and open source development platforms > that are available now and are quite mature. What are those tools you mentions? How do you know they are mature? There are tools, I use them, 1. some have a lot of problems, 2. some are not being updated for a while. I don't want to sound rude, but with feelings and thoughts we can't convince goverments to look at OpenEHR, we need facts and numbers. Soon or later we must focus on "formalize" this standard. I'm convinced that we need regional groups to focus on regional needs, with action lines provided by the international community. This will empower the standard all around the globe, but we need support. Cheers, Pablo. http://informatica-medica.blogspot.com/ --- ## Post #28 by @thomas.beale > Hi Thomas, > > My opinion is the grade of adoption of a standard depend in some aspects of goverment agencies, in some of the industry and some of the academy. > > DICOM is a good example of an open standard heavily supported by the industry, that's the point of it success. Can't be OpenEHR a de-facto standard for EHRs? Like DICOM is for imaging. I think yes, but the progress of OpenEHR to solve real the problems and make it usable, is slow. > > I think OpenEHR is strong on the academy area. It has poor industry penetration (I mean enterprises developing tools and aplying a good part of the OpenEHR specification in their systems, and that these systems where used in some hospitals). I don't know what's the penetration of OpenEHR on goverment agencies. There are some open tools but there is some stillness on making improvements on them. > > For example, here in Latin America, almost nobody knows about OpenEHR in the industry area, and very very few knows about it in the academy area. > > There are some ideas that may help de difusion and adoption of OpenEHR: > > - I think that regional OpenEHR communities are needed to empower the adoption and spreading of the standard. In 2009 I send a message to the mailing lists, but I get no answer from the community (this mail is below). Now we have 36 members from Uruguay, Argentina, Chile, Colombia, Spain, and more. They work on goverment agencies, big enterprises (like IBM), developers and physicians. I think the international OpenEHR community needs to support these regional communities, providing guidelines, general objectives, and following their work. Here in South America, only few people know about OpenEHR, that's a shame. People in goverment are making decissions, without knowing that are good and open standards out there. > > - Formal training and education in OpenEHR is needed. It's very hard to the newcomer to understand how to use OpenEHR, and people interested on the main ideas of OpenEHR may be dissapointed when they try to use it in a real-world software application. People in the industry must be trained, but how many OpenEHR trainers are out there? not enough yet ;-) But there are two things that will improve the situation: - with the arrival of better, more open tooling for templates and operational templates, and downstream transformations, much of the need to understand the mechanics of openEHR goes away; software developers can use the generated products, which could be openEHR XSDs, or even HL7v2 message definitions. - in the future we would aim for more web-available self learning material > In Set-2010 I've done a hands-on OpenEHR tutorial in Argentina, and people (medics and TIC people) where amazed about building their archetypes and having a tool that generates the EHR (this is my degree project). This was done in the context of the "Argentine Congress of informatics and Health 2010". Now, the organizers want to make more time to discuss OpenEHR and its posibilities. This is just an example that great things can happen if someone has interest. > > Regional OpenEHR communities can build courses fucused on the regional needs, may be made some money to support the open tool development (*). this is the key; to get the money, authorities need to be convinced it is a) going to do what they need and b) not going to isolate them. They are very scared of the second, even though it is not rational (since most of the standards in their comfort zone really don't work that well, and not at all together). > - Building and supporting open tools. The current tools have no regular updates. We need developers to build new tools and improve the current tools. We can use the money of the training courses (*) to pay developers to do this job. If this depends only on the free time we have, tools just can die before they are implemented. actually, the ADL workbench and Archetype Editor are constantly being updated. However, I only just realised that the link for the latter is not visible. I will look into this. > - In order to help any goverment adoption of OpenEHR, the decission makers have some questions that today OpenEHR can't answer. > - What is the state of the standard? > - Is it stable? > - Wich parts are stable? should be fairly clear from the release page, [http://www.openehr.org/releases/1.0.2/roadmap.html](http://www.openehr.org/releases/1.0.2/roadmap.html) > - Is there any return of investment study done on efective use of OpenEHR? that's a harder question ;-) > - Or just, how much time and money I have to spend to effectively use OpenEHR in a real world application? (I have to train people to make things happen, not in an investigation project, but in a production project) > - What real world products are using OpenEHR? > - How these products are using OpenEHR? (they adopt the RM? the AOM? the SM?) > > There is page on "who is using OpenEHR" in the portal, but it is outdated. My proposal is to do regular polls on the community in order to know: who is working on what, and how they're using OpenEHR. more up to date information would be good, however the information there is not more than about 18months out of date, and in some cases more recent. However, there is much activity that has no entry at all in these pages - it would be good to obtain information on that. > - Formal links with "formal" SDOs are needed. I think that OMG is in tune with the way OpenEHR do things. They have the COAS standard, and OpenEHR RM is mapped to COAS. This is a good starting point to have something in common. in fact, there are ongoing talks with IHTSDO about close cooperation and development. Making someting happen in the 'official' standards space is the key. Currently, many governments have been too scared to go away from the official standards, even though they have had little success with them > I think there are very good posibilities in the OpenEHR adoption on the industry adn goverment areas, but we need to build improve the lines of action of the community to reach that. agree. - thomas --- ## Post #29 by @pablo Hi Thomas, My opinion is the grade of adoption of a standard depend in some aspects of goverment agencies, in some of the industry and some of the academy. DICOM is a good example of an open standard heavily supported by the industry, that's the point of it success. Can't be OpenEHR a de-facto standard for EHRs? Like DICOM is for imaging. I think yes, but the progress of OpenEHR to solve real the problems and make it usable, is slow. I think OpenEHR is strong on the academy area. It has poor industry penetration (I mean enterprises developing tools and aplying a good part of the OpenEHR specification in their systems, and that these systems where used in some hospitals). I don't know what's the penetration of OpenEHR on goverment agencies. There are some open tools but there is some stillness on making improvements on them. For example, here in Latin America, almost nobody knows about OpenEHR in the industry area, and very very few knows about it in the academy area. There are some ideas that may help the difusion and adoption of OpenEHR: - I think that regional OpenEHR communities are needed to empower the adoption and spreading of the standard. In 2009 I send a message to the mailing lists, but I get no answer from the community (this mail is below). Now we have 36 members from Uruguay, Argentina, Chile, Colombia, Spain, and more. They work on goverment agencies, big enterprises (like IBM), developers and physicians. I think the international OpenEHR community needs to support these regional communities, providing guidelines, general objectives, and following their work. Here in South America, only few people know about OpenEHR, that's a shame. People in goverment are making decissions, without knowing that are good and open standards out there. - Formal training and education in OpenEHR is needed. It's very hard to the newcomer to understand how to use OpenEHR, and people interested on the main ideas of OpenEHR may be dissapointed when they try to use it in a real-world software application. People in the industry must be trained, but how many OpenEHR trainers are out there? In Set-2010 I've done a hands-on OpenEHR tutorial in Argentina, and people (medics and TIC people) where amazed about building their archetypes and having a tool that generates the EHR (this is my degree project). This was done in the context of the "Argentine Congress of informatics and Health 2010". Now, the organizers want to make more time to discuss OpenEHR and its posibilities. This is just an example that great things can happen if someone has interest. Regional OpenEHR communities can build courses fucused on the regional needs, may be made some money to support the open tool development (*). - Building and supporting open tools. The current tools have no regular updates. We need developers to build new tools and improve the current tools. We can use the money of the training courses (*) to pay developers to do this job. If this depends only on the free time we have, tools just can die before they are implemented. - In order to help any goverment adoption of OpenEHR, the decission makers have some questions that today OpenEHR can't answer. - What is the state of the standard? - Is it stable? - Wich parts are stable? - Is there any return of investment study done on efective use of OpenEHR? - Or just, how much time and money I have to spend to effectively use OpenEHR in a real world application? (I have to train people to make things happen, not in an investigation project, but in a production project) - What real world products are using OpenEHR? - How these products are using OpenEHR? (they adopt the RM? the AOM? the SM?) There is page on "who is using OpenEHR" in the portal, but it is outdated. My proposal is to do regular polls on the community in order to know: who is working on what, and how they're using OpenEHR. - Formal links with "formal" SDOs are needed. I think that OMG is in tune with the way OpenEHR do things. They have the COAS standard, and OpenEHR RM is mapped to COAS. This is a good starting point to have something in common. I think there are very good posibilities in the OpenEHR adoption on the industry adn goverment areas, but we need to build improve the lines of action of the community to reach that. Just my humble opinions. Best regards, - Pablo. [details="(attachments)"] [ATT00001|attachment](upload://3cWYAkjiyIWIj2ho4IRFjpwhoGy) (177 Bytes) [/details] --- ## Post #30 by @lavanian Dear All, I think Pablo has a very pertinent point. Theory and armchair discussions are good, but applicability in real life situations, and painlessly, is the need of the hour. If I were an implementor I would need a (no nonsense) 'openEHR for dummies', an SDK, sample code, a ready out-of-the-box installation with all the components in place (probably in ISO format) and a HUGE FAQ. End of the day, what a guy need for his requirement - is what he actually need - nothing more, nothing less. I am sure, somewhere in the www, many of these components do exist. Now it would be nice if we could get it all together on a single page. With warm regards, Dr D Lavanian MBBS,MD CEO and MD HCIT Consultant [www.hcitconsultant.com](http://www.hcitconsultant.com) Certified HL7 Specialist Member- American Medical Informatics Association Member HIMSS Senior Consultant and Domain Expert - Healthcare Informatics and TeleHealth Former Vice President - Healthcare Products, Bilcare Ltd Former Vice President - Software Division, AxSys Healthtech Ltd Former Co-convener Sub committee on Standards , Governmental Task force for Telemedicine Former Vice President - Telemedicine (Technical), Apollo Hospitals Group Former Deputy Director Medical Services, Indian Air Force Office: +91 20 32345045 Mobile: +91-9970921266 --- ## Post #31 by @Nsshiv dear Lavanian. Nice to hear from u after a long time. Agreed about the need for practical and deplouable models. Curremtly open EHR is perceived as an academic theoretical exercise by many IT savvy doctors in UK. There is als a lack in clarity on who is the right recepient of this. Is it product companies is it the clinician. Is it the healrh informatics teams. Thanks Dr. Shivam. MS FRCS Head Clinical Transformation Royal Free Hospitals Dr. Shivam. 00447814708199 --- ## Post #32 by @Tim_Cook2 Pablo does make some good points\. That is why I started the OSHIP project instead of just sticking with an RM implmentation\. http://www.oship.org http://launchpad.net/oship If Python isn't your thing we are also starting up OSHIPrb \(Ruby\) and OSHIPjava \(Java\)\. Using the same concepts of full development platforms SDK\) so that implementers can start with a full OPEN SOURCE software stack in order to quickly build applications\. We are also improving tooling using completely cross platform and open source tools\. Join the Launchpad development team\(s\) of your choice via the umbrella project at http://launchpad.net/mlhim Cheers, Tim --- ## Post #33 by @Seref Hi Pablo, A very useful insight into the issues indeed. This is one topic that may end up being a quite long discussion, but I feel it is a topic that is worth laying out, not only today, but every couple of years or so, to see where we are. I'll provide my personal views here. openEHR is not a small specification. It is not a simple one either. Considering the problem it is trying to solve, I do not expect it to be. Therefore, the complexity of implementation is significant. The nature of the problem openEHR is trying to solve inevitably creates the blind men and the elephant situation [http://en.wikipedia.org/wiki/Blind_men_and_an_elephant](http://en.wikipedia.org/wiki/Blind_men_and_an_elephant) In explaining what openEHR is, we are faced with the problem of communicating the whole picture. In my experience, partial views or decriptions of openEHR lead to confusion, even if every bit of information provided is correct. Technical people and clinicians alike have a hard time seeing the big picture, and who can blaim them? The picture is really, really big. Be warned: the kind of statements I've just started to make are usually perceived so that one gets the message "this needs to change". No. When I say openEHR is complex, openEHR is big, openEHR is not easy to implement, I don't mean openEHR is more complex than it needs to be, or openEHR is bigger than it needs to be, or openEHR is harder than it should be to implement. We are attempting to solve a huge problem, and complexity of the solution will enevitably rise in response. The instinct to simplify the solution usually cripples the solution by pruning its support for less frequently required features, but most of the time, this leads to an unsatisfactory outcome. Surprisingly, everyone seems to follow the instinct. In my opinion, tooling and education are the two most important fronts we need to make progress. The mechanics of an MRI is very complex, and yet, due to way it was implemented, it is a practical, useful clinical tool. The implementation of the very complex solution is designed so that without knowing anything about the underlying mechanics, it can be used. Clinicians and developers need tooling to take control of complex concepts, and not having enough tooling is leading to lots and lots of angels and pinheads type of discussions. The chain of problems go like this: not enough tooling -> not enough implementation -> not enough understanding & feedback -> lots and lots of hypothetical discussions. So if (at least according to me) the biggest problem is tooling, why not build the tools and solve the problem? Because no one is paying for it. Whatever we have out there in terms of actual tools and implemenation is mostly out there thanks to good intentions and hard work of people. I've opened up the code I'm writing for my PhD, Ocean, Zilics, and people Rong Chen and Tim Cook are doing the same, but with limited resources it is hard to trigger a mass adoption. We are moving forward, no doubt, but people staying up in the middle of the night are usually paying the steepest price, and the most interesting thing in all this is that the expectations are huge. Please do not get me wrong, I'm not saying this in response to your analysis, but most of the time, when people encounter openEHR, they are amazingly expecting a piece of software to install, which will deliver everything openEHR can deliver, out of the box. And of course they want it to be open source. When they can't find this, they say it is not there yet. I think this is also related to education; personally I think that we need to stop people from having unrealistic expectations, and clearly explain what the offer is, and what it takes to turn that offer into value added. Anyway, this is a big topic, and I can't put everything I have in my mind into one e-mail. Still wanted to say these bits. BTW, I've written about openEHR almost two years ago, trying to explain it to novice, though my own understanding at the time was not very clear. [http://www.serefarikan.com/?p=97](http://www.serefarikan.com/?p=97) may be of help, next time you're trying to describe what it is, at least some of it. Best Regards Seref 2010/11/2 pablo pazos <[pazospablo@hotmail.com](mailto:pazospablo@hotmail.com)> --- ## Post #34 by @Tim_Cook2 Hi Seref, An excellent definition of the problem space\. Thanks, Tim --- ## Post #35 by @system Hi Pablo, I also think regional community is necessary for this project. I launched openEHR.jp in 2007 in Japan. This is the first regional community of the openEHR project. We have provided Japanese translation and promotion for multilevel clinical modeling technology. We have implemented on Ruby as OSS and been trying national intractable disease surveillance database by openEHR technology. Your idea, to make a guideline is interesting. We will also try to do it. Cheers, Shinji KOBAYASHI 2010/11/2 pablo pazos <[pazospablo@hotmail.com](mailto:pazospablo@hotmail.com)> --- ## Post #36 by @Ignacio_Valdes Iron law of oligarchy: [http://en.wikipedia.org/wiki/Iron_law_of_oligarchy](http://en.wikipedia.org/wiki/Iron_law_of_oligarchy) --- ## Post #37 by @thomas.beale > Hi Thomas, > > My opinion is the grade of adoption of a standard depend in some aspects of goverment agencies, in some of the industry and some of the academy\. > > DICOM is a good example of an open standard heavily supported by the industry, that's the point of it success\. Can't be OpenEHR a de\-facto standard for EHRs? Like DICOM is for imaging\. I think yes, but the progress of OpenEHR to solve real the problems and make it usable, is slow\. > > I think OpenEHR is strong on the academy area\. It has poor industry penetration \(I mean enterprises developing tools and aplying a good part of the OpenEHR specification in their systems, and that these systems where used in some hospitals\)\. I don't know what's the penetration of OpenEHR on goverment agencies\. There are some open tools but there is some stillness on making improvements on them\. > > For example, here in Latin America, almost nobody knows about OpenEHR in the industry area, and very very few knows about it in the academy area\. > > There are some ideas that may help de difusion and adoption of OpenEHR: > > \- I think that regional OpenEHR communities are needed to empower the adoption and spreading of the standard\. In 2009 I send a message to the mailing lists, but I get no answer from the community \(this mail is below\)\. Now we have 36 members from Uruguay, Argentina, Chile, Colombia, Spain, and more\. They work on goverment agencies, big enterprises \(like IBM\), developers and physicians\. I think the international OpenEHR community needs to support these regional communities, providing guidelines, general objectives, and following their work\. Here in South America, only few people know about OpenEHR, that's a shame\. People in goverment are making decissions, without knowing that are good and open standards out there\. > > \- Formal training and education in OpenEHR is needed\. It's very hard to the newcomer to understand how to use OpenEHR, and people interested on the main ideas of OpenEHR may be dissapointed when they try to use it in a real\-world software application\. People in the industry must be trained, but how many OpenEHR trainers are out there? not enough yet ;\-\) But there are two things that will improve the situation:     \* with the arrival of better, more open tooling for templates and operational templates, and downstream transformations, much of the need to understand the mechanics of openEHR goes away; software developers can use the generated products, which could be openEHR XSDs, or even HL7v2 message definitions\.     \* in the future we would aim for more web\-available self learning material > In Set\-2010 I've done a hands\-on OpenEHR tutorial in Argentina, and people \(medics and TIC people\) where amazed about building their archetypes and having a tool that generates the EHR \(this is my degree project\)\. This was done in the context of the "Argentine Congress of informatics and Health 2010"\. Now, the organizers want to make more time to discuss OpenEHR and its posibilities\. This is just an example that great things can happen if someone has interest\. > > Regional OpenEHR communities can build courses fucused on the regional needs, may be made some money to support the open tool development \(\*\)\. this is the key; to get the money, authorities need to be convinced it is a\) going to do what they need and b\) not going to isolate them\. They are very scared of the second, even though it is not rational \(since most of the standards in their comfort zone really don't work that well, and not at all together\)\. > \- Building and supporting open tools\. The current tools have no regular updates\. We need developers to build new tools and improve the current tools\. We can use the money of the training courses \(\*\) to pay developers to do this job\. If this depends only on the free time we have, tools just can die before they are implemented\. actually, the ADL workbench and Archetype Editor are constantly being updated\. However, I only just realised that the link for the latter is not visible\. I will look into this\. > \- In order to help any goverment adoption of OpenEHR, the decission makers have some questions that today OpenEHR can't answer\. >   \- What is the state of the standard? >   \- Is it stable? >   \- Wich parts are stable? should be fairly clear from the release page, http://www.openehr.org/releases/1.0.2/roadmap.html >   \- Is there any return of investment study done on efective use of OpenEHR? that's a harder question ;\-\) >   \- Or just, how much time and money I have to spend to effectively use OpenEHR in a real world application? \(I have to train people to make things happen, not in an investigation project, but in a production project\) >   \- What real world products are using OpenEHR? >   \- How these products are using OpenEHR? \(they adopt the RM? the AOM? the SM?\) > > There is page on "who is using OpenEHR" in the portal, but it is outdated\. My proposal is to do regular polls on the community in order to know: who is working on what, and how they're using OpenEHR\. more up to date information would be good, however the information there is not more than about 18months out of date, and in some cases more recent\. However, there is much activity that has no entry at all in these pages \- it would be good to obtain information on that\. > \- Formal links with "formal" SDOs are needed\. I think that OMG is in tune with the way OpenEHR do things\. They have the COAS standard, and OpenEHR RM is mapped to COAS\. This is a good starting point to have something in common\. in fact, there are ongoing talks with IHTSDO about close cooperation and development\. Making someting happen in the 'official' standards space is the key\. Currently, many governments have been too scared to go away from the official standards, even though they have had little success with them > I think there are very good posibilities in the OpenEHR adoption on the industry adn goverment areas, but we need to build improve the lines of action of the community to reach that\. > agree\. \- thomas --- ## Post #38 by @Tim_Cook2 Hi Igancio, Very true\. But\! There are different approaches to leadership\. Some proven to be more effective than others\. Cheers, Tim --- ## Post #39 by @pablo Hi Seref and Shinji, I share your opinions. Once in a while, we need discussions like this, since we have to lead ourselves somewhere and combine efforts if we want to support the difussion and adopton of the standard. The domain is complex, the problem is complex, the solution must be complex, but if we add the complexity of the standard to the complexity of understanding another language (the specs are english only), we have a serious problems for a worldwide adoption. I share Shinji's vision, we must support and encourage regional OpenEHR communities, specs translation, and "open source multilingual up-to-date tools" (most tools available are: or not multiligual or the translations are horrible, or not open source, or not updated recently). I think regional communities can create courses, resources, materials, etc... and share them with other communities, throught OpenEHR foundation. Guidelines to do this must be set from the OpenEHR Foundation Boards (I think they are there to lead the community, to encourage the spread and adoption of the standard, I can't remember the last time I saw an email of the OpenEHR Boards in the mailling lists). Within those guidelines, we can be coordinated, and maybe set year-based goals. And once a year or two we can make some event to share our experiences and progress from our local communities (can be local or regional events, since for most of ours it's hard to travel so far). These ideas are not new, just look at the HL7 coutry based structure. I know this words may sound hard to someone, I just want to support the success of the standard, but I think if we keep doing things the same way, we'll end with a high quality standard with no one to implement it. Kind regards, --- ## Post #40 by @pablo Hi Seref and Shinji, I share your opinions. Once in a while, we need discussions like this, since we have to lead ourselves somewhere and combine efforts if we want to support the difussion and adopton of the standard. The domain is complex, the problem is complex, the solution must be complex, but if we add the complexity of the standard to the complexity of understanding another language (the specs are english only), we have a serious problems for a worldwide adoption. I share Shinji's vision, we must support and encourage regional OpenEHR communities, specs translation, and "open source multilingual up-to-date tools" (most tools available are: or not multiligual or the translations are horrible, or not open source, or not updated recently). I think regional communities can create courses, resources, materials, etc... and share them with other communities, throught OpenEHR foundation. Guidelines to do this must be set from the OpenEHR Foundation Boards (I think they are there to lead the community, to encourage the spread and adoption of the standard, I can't remember the last time I saw an email of the OpenEHR Boards in the mailling lists). Within those guidelines, we can be coordinated, and maybe set year-based goals. And once a year or two we can make some event to share our experiences and progress from our local communities (can be local or regional events, since for most of ours it's hard to travel so far). These ideas are not new, just look at the HL7 coutry based structure. I know this words may sound hard to someone, I just want to support the success of the standard, but I think if we keep doing things the same way, we'll end with a high quality standard with no one to implement it. Kind regards, [details="(attachments)"] [ATT00001|attachment](upload://ooyGbGbOXGnb9Q7SxgWSEqStL0A) (184 Bytes) [/details] --- ## Post #41 by @thomas.beale There are many things that can be improved in openEHR, no doubt about it. Some comments. First of all, HL7 charges membership fees, meeting attendance fees and purchase fees for the standards; a small company can easily spend $10,000 - $20,000 per annum just on the cash outlay. Larger companies routinely spend $100k per annum when you take into account meeting attendance expenses and opportunity costs. These fees, plus donations by some large companies, fund HL7 marketing efforts. Such an operation does not come for free. If we are to have regional communities, an affiliate model of some kind makes sense. However there is no getting away from some prerequisites: - someone has to pay for the human resource at both local and central levels; 100% volunteer work is just too unreliable - there has to be a way to get all the affiliates established in the first place, which really means creating an association in each country that subscribes to the same common cause - i.e. getting a lot of countries to agree on a common thing. History tells us this is VERY HARD. - the 'common cause' almost certainly has to have some official standards status, or regional affiliates might get lots of interested individuals, but will fail to get MoH/DoH involvement, and hence fail to influence national programmes, and and probably also vendors In sum: the organisation needs a distributed organisational governance structure, and it needs sufficient legitimacy for funding to be provided. Now, the world currently already includes ISO, CEN, HL7, IHE, IHTSDO, OMG, and dozens of other standards bodies, which have a) some governance structure and b) sufficient perceived legitimacy to get some funding. However, there is great fatigue on the user side: most of these organisations compete, don't cooperate properly, don't formally or empirically validate their deliverables, and are not strongly driven by their main stakeholders. For this reason, openEHR has stayed away from creating yet another organisation, overlaid on this crowded scene. In e-health, the exception to the above is IHTSDO, a relative newcomer to the scene, and while not perfect, it is significantly better in all of these areas. It has: - a pretty good governance model, including an explicit member country and affiliate model - direct board membership by key stakeholders of its deliverable, i.e. national e-health programmes - formally defined and relatively well managed specification, software, and terminology deliverables (none of which are anything like perfect today, but the point is that a reasonable process is in place) For this reason, the openEHR Foundation and IHTSDO have been in talks to determine what kind of cooperation could occur in the future, which would a) allow openEHR to work within or alongside the IHTSDO global organisational structure and b) enable IHTSDO to take better advantage of the openEHR knowledge engineering technology, in particular terminology integration. These discussions have not yet completed, but some kind of announcement could be expected in the near future. If some better organisational and funding structure can be created, aligned with an accepted standards body, then I think the whole thing will accelerate very fast. - thomas beale --- ## Post #42 by @pablo Hi Thomas, I didn't mean that we have to follow the HL7 structure and ways of funding. They have good and bad things, as you point. One of the good things is that a set of small regional communities are stronger than a huge central community, because they have common interests, common language, common culture, etc. For example I spend more than 15 mins on writing emails to the lists because of the language, when I spend 3 mins writing to lists in spanish. Reading the english only specs is another thing that discourages people with no formation in the language. But a central community is needed to build guidelines and coordinates the global view, plans and concrete objectives for OpenEHR as a whole. This is a work for the boards, but now I can't see any interest from them (of course, individuals like you are always here, but the boards had no presence here, and we need leadership and vision). > There are many things that can be improved in openEHR, no doubt about it. Some comments. First of all, HL7 charges membership fees, meeting attendance fees and purchase fees for the standards; a small company can easily spend $10,000 - $20,000 per annum just on the cash outlay. Larger companies routinely spend $100k per annum when you take into account meeting attendance expenses and opportunity costs. These fees, plus donations by some large companies, fund HL7 marketing efforts. Such an operation does not come for free. I don't think that a paid membership to local communities will work, as you point, is not the best way to build a community, it's just a way to get enought money to do things. I rather prefer an open model, where people just pay for a service, like courses. There are two types of communities, discution communities and action communities. The first are made of people with a common interest, link "cars" or "travel", you don't have to pay someone for something they want to talk and discuss. We have to encourage people to have interest in OpenEHR. The second, are communities of people that have common problems and try to solve them. We need this type of community to really do things, but we need to start with a common interest. > If we are to have regional communities, an affiliate model of some kind makes sense. However there is no getting away from some prerequisites: > > - someone has to pay for the human resource at both local and central levels; 100% volunteer work is just too unreliable > - there has to be a way to get all the affiliates established in the first place, which really means creating an association in each country that subscribes to the same common cause - i.e. getting a lot of countries to agree on a common thing. History tells us this is VERY HARD. > > - the 'common cause' almost certainly has to have some official standards status, or regional affiliates might get lots of interested individuals, but will fail to get MoH/DoH involvement, and hence fail to influence national programmes, and and probably also vendors > > In sum: the organisation needs a distributed organisational governance structure, and it needs sufficient legitimacy for funding to be provided. Again, I think we can build some money to improve the tools, like making courses, events (like the IHE Connectathon), selling books, t-shirts, coffe cups, etc (donations are always welcome). I'm against a paid membership, it closes a community that claims to be open, this is not a gym :D Just an idea: I think the Service Model is very green yet, but when it go a little more mature, we can make automated tests to test the implementations, and they can have an OpenEHR certificate that the software meets the specification (a paid certificate). > Now, the world currently already includes ISO, CEN, HL7, IHE, IHTSDO, OMG, and dozens of other standards bodies, which have a) some governance structure and b) sufficient perceived legitimacy to get some funding. However, there is great fatigue on the user side: most of these organisations compete, don't cooperate properly, don't formally or empirically validate their deliverables, and are not strongly driven by their main stakeholders. For this reason, openEHR has stayed away from creating yet another organisation, overlaid on this crowded scene. > In e-health, the exception to the above is IHTSDO, a relative newcomer to the scene, and while not perfect, it is significantly better in all of these areas. It has: > > - a pretty good governance model, including an explicit member country and affiliate model > - direct board membership by key stakeholders of its deliverable, i.e. national e-health programmes > - formally defined and relatively well managed specification, software, and terminology deliverables (none of which are anything like perfect today, but the point is that a reasonable process is in place) > > For this reason, the openEHR Foundation and IHTSDO have been in talks to determine what kind of cooperation could occur in the future, which would a) allow openEHR to work within or alongside the IHTSDO global organisational structure and b) enable IHTSDO to take better advantage of the openEHR knowledge engineering technology, in particular terminology integration. That will be great, more tooling and terminology integration are two things to improve in OpenEHR, it's a good oportunity to do so. > These discussions have not yet completed, but some kind of announcement could be expected in the near future. If some better organisational and funding structure can be created, aligned with an accepted standards body, then I think the whole thing will accelerate very fast. > > - thomas beale Kind regards, Pablo Pazos. http://informatica-medica.blogspot.com/ --- ## Post #43 by @thomas.beale > Hi Thomas, > > I didn't mean that we have to follow the HL7 structure and ways of funding. They have good and bad things, as you point. One of the good things is that a set of small regional communities are stronger than a huge central community, because they have common interests, common language, common culture, etc. For example I spend more than 15 mins on writing emails to the lists because of the language, when I spend 3 mins writing to lists in spanish. Reading the english only specs is another thing that discourages people with no formation in the language. I certainly appreciate this - I spend time reading specifications in other languages, and it is slow, since I am not perfectly bilingual. We do have some translations of specifications, but not much. Good translations are expensive and they also have to be maintained. For example, the french translation of the ADL spec is excellent, but now out of date, and there is no business model to support its updating. > Again, I think we can build some money to improve the tools, like making courses, events (like the IHE Connectathon), selling books, t-shirts, coffe cups, etc (donations are always welcome). I'm against a paid membership, it closes a community that claims to be open, this is not a gym :D well, its why we never did that. I think your ideas are good, the only concern I have is that I think there still has to be a sufficiently strong central part of the organisation to help organise materials, resources, and run the governance structure; at the moment there is not enough funding to do what would be needed to support local orgs. But I would very much like to see openehr.cl, .br, .uy, etc. > Just an idea: I think the Service Model is very green yet, but when it go a little more mature, we can make automated tests to test the implementations, and they can have an OpenEHR certificate that the software meets the specification (a paid certificate). we can already test with XML schemas. You are right, the service models will be a key basis for conformance testing, but it will take some more time to get the required maturity. - thomas --- ## Post #44 by @Koray_Atalag Hi All, just back from the New Zealand’s national health informatics conference – HINZ. A big thing for a small country – I must say it was as impressive as HIC and Medinfo! Related with the topic I had a chance to present our work – a full-fledged implementation of our openEHR based endoscopy application and it drew significant attention. However compared to the existence of HL7 this was miniscule. I am not going to talk why this is the case but focus on some ideas which might help us to get openEHR better adoption. I have expressed these ideas personally with some of you but here is the full list: - openEHR is not embracing: meaning, apart from a handful of core people fulltime employed to work on this, there is no model of ‘organic engagement’ – it is not tangible by ordinary people. And also a few others, like me, who are lucky enough to get paid to do work on openEHR from academia/research side or like Rong from a super dedicated vendor like Cambio. So how can one folk from company X can be an ‘openEHRer’ ? and why that should be compensated? Commercial organisations usually are reluctant to fund such activities if an employee is not taking some responsibility and that creates some visibility/traction. - In a similar vein, as Shinji pointed out, I fully agree with creating some ‘touch points’ to the openEHR by means of establishing local branches or ‘leads’ so to speak which was in the air some time ago but never started. But this has to be carefully aligned with the bigger openEHR otherwise different messages might start going out. I rather prefer establishing working or interest groups, perhaps facilitated by a more intuitive Web 2.0 tool than these discussion lists – possibly integrated with CKM. Mainly around clinician engagement and requirements capture and doing some ‘bottom-up’ wild-type modelling. I think there is now many of us who could dedicate some time to facilitate these discussions and come up with tangible results - Specs must continue to go with the core group with input from community. But perhaps this input process could be made more effective and all embracing. - I’ve had quite training on HL7, mainly CDA stuff, recently – and I agree with Seref that openEHR is big and difficult but relatively speaking much easier than HL7 v3. We must effectively communicate this and potential cost savings to vendors and programmes – and most importantly prove it! I think we have more than enough evidence now to make this publicly visible. - I personally think the imperfections in tooling is not a barrier to the adoption – they can do 90% of the job initially. I think it’d be too much of a burden on the already overloaded people who are putting so much and going all those extra miles. - I strongly believe (and thus research on) that the main catch of openEHR is on the future-proofness of health information systems as Tom pointed out in his very first paper. So why did we got stuck in this ‘interoperability’ whirlpool? Apart from the national programs and people caring for safety and quality of healthcare (well obviously not too much otherwise we’d be living in a world of health interoperability wouldn’t we?) nobody has incentives to adopt interoperability standards. And national programs do not want to make exclusive commitments. I’ve listened at Medinfo, the Singapore experience, where one of the panelists was HL7 chair I reckon, that it was v3. But I knew they’ve considered and used openEHR models and used Ocean tools and raised this during Q &A. So everybody is trying to be super smart and say the right things but in reality experimenting with other alternatives. At HINZ epSOS we shown as the flagship project for v3 in Europe and so is Swedish national EHR project. Correct me if I am wrong but both should be openEHR/13606 based?? Adopting openEHR is still risky business at the end of the day… - In New Zealand we are going little more smarter and have started a myriad of trials/proof of concept projects before making any commitment on standards, but the overall architecture is inevitably HL7 dominated as there is a strong NZ affiliate working very efficiently. However I am hoping to start a few openEHR based projects and prove that they can work together. I am not sure if this is good or bad from the larger openEHR perspective, through the very open minded and respected NZ chair Dr. David Hay and with very prompt response from Hugh, there’ll be an openEHR stream in the Sydney HL7 WG meeting which is international where I am hoping that the message will be that these are not absolutely mutually exclusive and there are ways of working together. Let’s be practical they don’t have any (real) means to capture clinical requirements and model plus no way to query and we don’t (yet) have something tangible as CDA for persistence and for messaging like v2.x. There might be some opportunity to come up with some new ideas?? Who knows… I think we should really get over the attitude of seeing everything HL7 is doing wrong and conversely they should stop seeing openEHR as an enemy. There is a lot of really good work going on in HL7 and IHE SIG and WGs – especially around getting clinical requirements. I think the chances of wider adoption might be bigger if/when this alienation comes to an end so that vendors can confidently use and see for themselves what is working and not working for them without making any prior commitment. Just my thoughts though – I’ve already proven to be a terrible businessman so read at your own risk! - I’ve also came across a new slogan in the HL7 workshop: SDO consolidation. They’ve mentioned about the current MoUs they have with other SDOs as blockers and want to override them and make them get out of the healthcare scene – such as X12 or ASTM. I think I’ve also heard ISO along the lines ;) This is interesting and very conquering I think and may have some implications for openEHR in future. I personally don’t think the current clinical information representation using v3 RIM methodology will survive for long and this space looks like to be filled pretty good with SNOMED+Archetypes. Perhaps because of this I am clearly witnessing more and more ignorance and even non-promotion of SNOMED / IHTSDO in HL7 rounds ;) So my overall point is, if you want to convince people to adopt openEHR, you need lots of proponents who are armed with knowledge and some form of recognition, to go out and disseminate. In my talks when I introduce myself I usually use the phrase ‘openEHR fan’ rather than member because technically nobody is. I am also a ‘founding member of HL7 Turkish Affiliate’ – and in some occasions when this is announced a crowd of people surround me! Cheers, -koray --- ## Post #45 by @pablo Hi Thomas, I see we agreed in much of the points, I hope to see other's visions. Governance is a good issue to discuss with the community, but I can't see any governance if the OpenEHR boards are distant from the community, and do not understand their real needs. What I was really talking from the begining of this discussion is that people, institutions, and goverments have needs that OpenEHR can satisfy, but at the same time, OpenEHR as a whole is not aware of their needs, or is not taking actions to do something. There are a lots of ways of funding, just yesterday, we had an event here in Uruguay of ICT developments in healthcare (we showed our Open EHR-Gen Framework and people was amazed about the concept), there was a man called Bob Mayes from AMIA, and their are launching a subarea called GHiP to build and support communities that solve problems in healthcare informatics (with funding from Rockefeller and Bill Gates foundations, tehy have a buck or two :D). GHiP may be a good place to find some cash to build a governance program to the regional OpenEHR communities, and to support development and objective acomplishment in those communities. The governance program must have an item on how to spend the funding, and this item must be agreed by the community. **It'd be a good idea if we create some section on the web or the wiki, where we can write some thoughs on the governance subject, also we can put some governance ideas from other communities, discuss them, and see if the community agree them. Again, without the involvement of the boards, this will be a dead-before-born subject.** --- ## Post #46 by @SIMPA_DANIA1 Just my own experience. I had been in talks with the National Cancer Institute, they are looking at developing some ehr system for telepathology as well has having a system that can fit conveniently (sematic interoperability) with caBIG and I talked about the openehr specification/work and gave a couple of contacts. here is the feedback and I really do not know how to answer it. --- ## Post #47 by @thomas.beale Hi All, just back from the New Zealand’s national health informatics conference – HINZ. A big thing for a small country – I must say it was as impressive as HIC and Medinfo! Related with the topic I had a chance to present our work – a full-fledged implementation of our openEHR based endoscopy application and it drew significant attention. However compared to the existence of HL7 this was miniscule. I am not going to talk why this is the case but focus on some ideas which might help us to get openEHR better adoption. I have expressed these ideas personally with some of you but here is the full list: - openEHR is not embracing: meaning, apart from a handful of core people fulltime employed to work on this, there is no model of ‘organic engagement’ – it is not tangible by ordinary people. And also a few others, like me, who are lucky enough to get paid to do work on openEHR from academia/research side or like Rong from a super dedicated vendor like Cambio. So how can one folk from company X can be an ‘openEHRer’ ? and why that should be compensated? Commercial organisations usually are reluctant to fund such activities if an employee is not taking some responsibility and that creates some visibility/traction. --- ## Post #48 by @Segun_Odujebe Hello All, It has been quite interesting following this string of discussion\. A lot of passion is coming out which indicates a mixture of frustration and hope\. But let me say OpenEHR is a wonderful idea\.Yes the initial intent was future proofing but we can't wish away interoperability as a major deliverable\! As far as standards go, it is not always the best that gets wide adoption\! The key to ubiquity is reaching critical mass quickly and that depends on utility: utility in the wild, not in the research lab\. There must be some well\-scoped demonstrable platform that everybody can work toward delivering\-that will be supported by the community\. Not just siloed implementations\. This platform will stand the best chance if it is open\-sourced\.Then it can be a trigger for adoption\. I don't think clinicians have time to wonder what standards are running their EHRs\.They just want them to work\. As hard as HL7 seems, it has utility\! Like the adage goes if you are winking in the dark, only you know it\. To overtake other standards, the openEHR community must learn from the Apache Foundation or OSGi for instance\. The route to viral adoption is open\-sourcing of an implementation\. Cambio most likely may lead in this since theirs is based on Java\. May Ocean should\! The other thing is the Service Model which can be used not only for testing but for serving instances of implementations\. I hope my ramble made some sense\. Dr Olusegun Odujebe Lagos, Nigeria --- ## Post #49 by @Stefan_Sauermann Hello\! Just an idea: The Swedish national EHR implementation is to my knowledge one of the largest one using archetypes, and it is based in large parts on industry components\. May this serve as a kind of "landmark" project to carry the news to others? I hear that this runs quite well in practice? If I remember they have a workshop in Sweden about this in January, will this discuss possible communication activities? Greetings from Vienna, Stefan Sauermann Acting Program Director Biomedical Engineering Sciences \(Master\) University of Applied Sciences Technikum Wien Hoechstaedtplatz 5, 1200 Vienna, Austria P: \+43 1 333 40 77 \- 988 M: \+43 664 6192555 E: stefan\.sauermann@technikum\-wien\.at I: www\.technikum\-wien\.at/mbe I: www\.healthy\-interoperability\.at segunodujebe@yahoo\.com schrieb: --- ## Post #50 by @Peter_Gummer1 segunodujebe@yahoo\.com wrote: > The route to viral adoption is open\-sourcing of an implementation\. > > Cambio most likely may lead in this since theirs is based on Java\. > May Ocean should\! Not sure what you mean there\. ADL Workbench and the Archetype Editor have both always been open source\. http://www.openehr.org/svn/ref_impl_eiffel http://www.openehr.org/svn/knowledge_tools_dotnet/TRUNK/ArchetypeEditor \- Peter --- ## Post #51 by @Dr_Carola_Hullin_Luc Dear all, I have been reading this topic with lots of interest. the example given bellow, should a great motivation to achieve efficencies in our health systems. Cheers Carol __**Dra Carola Hullin Lucay Cossio**__ __**Presidente of IMIA-LAC**__ __**PhD Health Informatics**__ __**www.imia-lac.net**__ **+5628979701 Chile** --- ## Post #52 by @Dr_Carola_Hullin_Luc Dear all, I have been reading this topic with lots of interest. the example given bellow, should a great motivation to achieve efficencies in our health systems. Cheers Carol __**Dra Carola Hullin Lucay Cossio**__ __**Presidente of IMIA-LAC**__ __**PhD Health Informatics**__ __**www.imia-lac.net**__ **+5628979701 Chile** --- ## Post #53 by @Dr_Carola_Hullin_Luc Dear all, I have been reading this topic with lots of interest. the example given bellow, should a great motivation to achieve efficencies in our health systems. Cheers Carol __**Dra Carola Hullin Lucay Cossio**__ __**Presidente of IMIA-LAC**__ __**PhD Health Informatics**__ __**www.imia-lac.net**__ **+5628979701 Chile** --- ## Post #54 by @Segun_Odujebe Hello Peter, The ADL is open\.\.\. We have not even agreed on what kind of licence should govern it\. The Editor is free software, I am not sure if it qualifies as open source\.Then it is a development tool\. Like I said in tooling and platforms, OSGi and Apache Foundation are good examples\. I was hoping to take the discussion from the academic to the pragmatic level\. We build archetypes as foundations\.Yes\. What happens if they are not deployed widely? Our dream of 'making health compute' becomes a pipe\-dream\! Thank you\. Dr Olusegun Odujebe Lagos, Nigeria --- ## Post #55 by @Segun_Odujebe Hello Stefan, Now that will be a pragmatic step in the right direction\! That can really be a 'reference'\. Would they be willing to open the hood? Olusegun --- ## Post #56 by @Peter_Gummer1 segunodujebe@yahoo\.com wrote: > The Editor is free software, I am not sure if it qualifies as open > source\. Yes, the Archetype Editor is definitely open source\. I gave the link to its source in my earlier reply: http://www.openehr.org/svn/knowledge_tools_dotnet/TRUNK/ArchetypeEditor \- Peter --- ## Post #57 by @thomas.beale Here is a wiki page for governance discussion - [http://www.openehr.org/wiki/display/oecom/Community+Governance](http://www.openehr.org/wiki/display/oecom/Community+Governance) Bob Mayes is a great guy by the way, he worked for many years in Zimbabwe. - thomas [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #58 by @pablo Great Thomas, I'll put there some ideas to discuss with the community. [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #59 by @pablo Hi All, yesterday I've written some random ideas to create an OpenEHR governance program, to help the creation and development of regional OpenEHR communities, and coordination with those communities. It would be nice if you can take a look at the ideas and make comments about them, or add your own ideas if you note something is missing. [http://www.openehr.org/wiki/display/oecom/Community+Governance](http://www.openehr.org/wiki/display/oecom/Community+Governance) [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #60 by @Ann_Wrightson_NWIS_E Just to set the record straight, HL7 membership includes access to the standards IP, there are no additional access or purchase fees. Country affiliate level participation in HL7 carries all IP benefits and for HL7 UK costs £650 +VAT for organization membership. Having said that, I agree with Thomas's overall point regarding needing resource to work effectively. Regards, Ann W. Ann M Wrightson Pensaer TG | Technical Architect Gwasanaeth Gwybodeg GIG Cymru | NHS Wales Informatics Service Symudol/Mobile: 07535 481797 Llanelwy | St Asaph: WHTN: 1815 8232 Ffôn/Tel : 01745 448232 Pencoed: WHTN: 1808 8930 Ffôn/Tel: 01656 778940 --- ## Post #61 by @tonyshannon Thanks for a very timely and provocative debate\. I think the original question came from Dereks reply to my earlier blog posting\. The reasons for slow adoption have been discussed here already and recent discussions on the technical lists highlight the challenges in aligning the health IT standards community in any one direction\. My own perspectives on the challenges include; Complexity\.\. we are dealing with a very complex system in healthcare\. This is an ecosystem not a machine so none of us has complete control or understanding of the space\. http://frectal.com/book/chaos-complex-complicated-simple-and-cynefin/ Change requires; \-People\.\.people have different backgrounds, agendas, goals etc in this field\. They can really struggle for a common language at times \(eg datatypes dare i say\!\)\. Its easy to say the other guy doesn't quite understand my world\. Rather we all need to make an effort to the whole that makes life that little bit easier for everyone else\. Politics is the tricky "process by which groups of people make collective decisions"\. It seems clear that there are too many SDOs/standards bodies in eHealth with overlapping but unaligned efforts\. We need to address that\. As Tom mentions the openEHR is in discussion with IHTSDO toward that end\. I have invited comments/thoughts on that in recent months\.\. \-Process\.\. again many folk work differently so joining efforts up is a challenge \(again back to joint working needed \+ more on process anon, w\.r\.t\. progressive developments in Sweden\.\.\) \-IT\- I agree with many others that we particularly need better tools, shared tools, particularly those that help join the clinical frontline with the international health IT standards space\. \(See this story as to where my own efforts in the NHS got stuck\.\.\) http://frectal.com/book/healthcare-change-the-way-forward/healthcare-change-why-%E2%80%9Copen-source%E2%80%9D-is-part-of-the-recipe/ As has been highlighted we need a means to resource that tooling development, which the health community can both contribute to and benefit from\. \-Value\.\. we need to aim to offer value right at the clinical frontline\.\. that must prove their utility in the wild as Olusegun put it\. As indicated, we await progress on a funding an approach to tackling these key challenges with IHTSDO\.\.\.\. meanwhile please keep up the provocative debate\. Regards, Tony Dr Tony Shannon Consultant in Emergency Medicine, Leeds Teaching Hospitals Clinical Lead for Informatics, Leeds Teaching Hospitals Chair, Clinical Review Board, openEHR Foundation tony\.shannon@nhs\.net \+44\.789\.988\.5068 --- ## Post #62 by @system Hi\! > there are zero paid openEHR people, full\-time or part\-time\. That is not such a useful way of looking at openEHR funding\. There are a lot of people working with openEHR on paid time during working hours\. They are just not funded by the openEHR foundation\. This situation is the same for many open source projects etc\. If you define "openEHR people" as people funded by the foundation you are automatically excluding most of the community from being "openEHR people"\. That might not be the smartest thing to do\. Too often I hear "openEHR needs funding" with the accompanying thought that the foundation itself needs a lot of money\. Yes the foundation might need a little money for server & maintenance costs \(if we don't want to use "free" services\) and for trademark registrations etc\. But the real need is working hours, not money\. Certain organisational behaviours make people and companies donate working time, while other behaviours do the opposite\. Some behaviours get the time donations ending up within the original project, other behaviours result in related projects more using and indirectly contributing to the project via related but organisationally independent projects\. Many other volunteer organisations understand this difference better than what the openEHR foundation seems to do, at least judging from the few signals one can receive from the not\-so\-community\-present foundation board that has nobody to formally answer to but themselves\. In a volunteer project it can be quite OK with natural self appointed leaders, often the founders, but it then has to be matched with other attitudes or safeguards such as\.\.\. \- being very good at communicating and willing to actively explain and discuss decisions \- the ability for any participant to branch of and take \(a copy\) of invested time \(work\) with them, if the leadership becomes poor \.\.\.and so on\. > The people who > currently put some effort into openEHR, such as myself, are working on > exactly the same basis as anyone else in the community\. We are just crazy > enough to spend more time on it;\-\) There are a lot of completely sane reasons for investing time in openEHR\. I for example believe Ocean Informatics would not at all have been getting assignments all around the globe if it had not chosen to invest time in open specifications\. Very few would have heard of that little Australian company\. \(On the other hand, it could probably have been an even bigger company if everybody, not just a few, within that company understood open source business models better\.\) To get back to the real issue of "slow" openEHR adoption, I believe Seref is closest to the problem: a system trying to do everything openEHR tries to in a well engineered way, really becomes an "elephant"\. It takes time to properly implement an elephant from scratch, especially including all supporting systems\. The two organisations that could have provided a real working open implementation of that elephant first would probably have been UCL and Ocean Informatics\. Now, instead of joining forces on that, they have both been running their own competing commercial closed source implementation projects \(OK UCLs were probably more 13606 than openEHR, but you get the point\)\. They are of course both fully entitled to do so, and it's great that the specifications themselves are open, but I believe it has delayed the arrival of an open demonstrator platform that people can use to try openEHR ideas on and are willing to invest time in\. On the other hand it has left the field completely open for both competing commercial and open source efforts, which in the long run, after this delay, might show to be beneficial for the world at large \(but probably less beneficial for Ocean and UCL than it could have been\)\. UCL by the help of Seref and whoever supports him, now seem to be getting the point of an open demonstrator, so things seem to be changing there\. One should not deny that there might be a similar competition between open source efforts, but I believe cross\-pollination of ideas between such projects can be pretty fruitful and efficient \(look at Archetype editors for example\), and thus less effort might be wasted than in commercial competition\. \(To add to the open source confusion some of us are thinking of alternative ways \(http REST\) to slice the elephant implementation and let smaller parts cooperate \(or compete if you wish\) in implementations \- but that should be a separate post later\.\) I hope this mail did not sound too complaining, I more aimed at explaining \(from my particular point of view\)\. I like both UCL\- and Ocean\-people, that's one reason to try and be honest with them\. :\-\) Best regards, Erik Sundvall erik\.sundvall@liu\.se http://www.imt.liu.se/~erisu/ Tel: \+46\-13\-286733 --- ## Post #63 by @pablo Hi Erik, > Hi! > > > there are zero paid openEHR people, full-time or part-time. > > That is not such a useful way of looking at openEHR funding. There are > a lot of people working with openEHR on paid time during working > hours. They are just not funded by the openEHR foundation. This > situation is the same for many open source projects etc. Also, there are a lot of people working with openEHR with no payment at all, and the difficulties of having to study the specs, and little tooling and open projects that are not updated with some frequency. That was the whole point of the discution. There were a lot of people that start working with openEHR, but the cost of understand the specifications, trying software (incomplete or not updated), and the complexity of building something based on openEHR that realy works, just discourages people. And we need to do something to change this reality (if we want openEHR be widely adopted). > > If you define "openEHR people" as people funded by the foundation you > are automatically excluding most of the community from being "openEHR > people". That might not be the smartest thing to do. Is just people (like us) that works with openEHR. > > Too often I hear "openEHR needs funding" with the accompanying thought > that the foundation itself needs a lot of money. Yes the foundation > might need a little money for server & maintenance costs (if we don't > want to use "free" services) and for trademark registrations etc. But > the real need is working hours, not money. We need people that update the tools and software projects with some regularity. Yes, it's working hours, that must be payed some way... not everyone works on a university that pays people to investigate on openEHR. > > Certain organisational behaviours make people and companies donate > working time, while other behaviours do the opposite. Some behaviours > get the time donations ending up within the original project, other > behaviours result in related projects more using and indirectly > contributing to the project via related but organisationally > independent projects. Not every organization can do this. The reality in here in South America is very diferent to the one you mention. There are things that simply cannot be made without funding, in the other hand, we can't wait to see when openEHR is got to be widely adopted, so I start this discution to see: 1. where are we going? 2. is it worth to invest my free time in this standard or I have to look elsewhere? > > Many other volunteer organisations understand this difference better > than what the openEHR foundation seems to do, at least judging from > the few signals one can receive from the not-so-community-present > foundation board that has nobody to formally answer to but themselves. > In a volunteer project it can be quite OK with natural self appointed > leaders, often the founders, but it then has to be matched with other > attitudes or safeguards such as... > - being very good at communicating and willing to actively explain and > discuss decisions > - the ability for any participant to branch of and take (a copy) of > invested time (work) with them, if the leadership becomes poor > ...and so on. > I agree. > > The people who > > currently put some effort into openEHR, such as myself, are working on > > exactly the same basis as anyone else in the community. We are just crazy > > enough to spend more time on it;-) > > There are a lot of completely sane reasons for investing time in > openEHR. I for example believe Ocean Informatics would not at all have > been getting assignments all around the globe if it had not chosen to > invest time in open specifications. Very few would have heard of that > little Australian company. (On the other hand, it could probably have > been an even bigger company if everybody, not just a few, within that > company understood open source business models better.) > Not everyone that is investing free time on openER works in a company that can made some kind of profit. --- ## Post #64 by @thomas.beale Erik, a few points informally (I am not on any boards of any organisations, so these are my own thoughts): - any organisation like openEHR needs some core paid people to execute key functions, and to maintain continuity. There is an 'officers' level, which runs any organisations, including admin and other support staff, and there is an operational level. - for the operational level, there are typically posts like CTO, CMO, infrastructure management, project coordination, and so on. If the organisation is to do properly what its members want - typically 2 things: a) manage specifications/standards, including member involvement in this, and b) manage open source projects, potentially largely staffed by volunteers - then it has to have a few dedicated posts. Otherwise it becomes no-one's responsibility to actually coordinate things, keep infrastructure running etc. - currently openEHR Foundation pays no-one. Therefore, all attempts at the above work are performed by people on the payrolls of other organisations, each having their own raison d'être and agenda. Compare this with IHTSDO, HL7, CEN, OASIS, Linux.org, Apache.org etc - they all have core paid posts to enable the organisation to do its work. - if we say that openEHR (for some odd reason) should not try to get funding for such posts, but it would be ok to get time instead, then all we are saying is that some other organisation(s) should essentially loan people to the Foundation to do this work and pick up the cost. This is equivalent to them just paying that amount of money into the organisation. There may be tax benefits, but otherwise the basic argument does not change. - If on the other hand, other orgs provide some of their people, some of the time, for limited periods, to do specific tasks on projects, this is inevitably because it is in that organisation's interest to do so. Many orgs, like the NHS, VHA, as well as universities, do this already. But these people aren't performing core Foundation work, they are trying to execute some project on their own agenda. So this doesn't actually help the Foundation get more organised. - as far as I can see, the wide experience in non-profit orgs of any kind shows that core paid posts (whether by direct funding or other means) are essential for good functioning. The only thing to understand about Ocean is that (10 years ago) it didn't decide to work in the Java space, which is the natural environment of open source these days. In the ICT industry today, there might be 1/3 of all companies oriented to Java (1/3 .Net, 1/3 everything else), and of that fraction, maybe 10-20% making their source code openly available. Ocean doesn't happen to be in that demographic, along with probably 80% of all companies in ICT (and health ICT). Ocean's mission is therefore not to build open source Java implementations of anything. Nevertheless, Ocean has donated significant time to openEHR specification projects, open sourced/ing its subsequent specification work, and open sourced 2 key tools (which incidentally attract no external coder activity, proving the point that if it isn't Java, PHP, Python etc, it is not seen as open source). I don't think there are any commercial archetype editors at all. If we look at where the main implementation work that has been done open source, and in Java, the bulk came from Rong's original (small!) company A-code, and since then Cambio has financed his further efforts. This work, like the specification work, was significant, and as far as I know, never reimbursed - it was done because the relevant people thought it was a useful thing to do. Significant additions have since been done to the EHR Java code base, including by Zilics, a Brazilian company with a commercial openEHR implementation, other Brazilian companies, Ocean, as well as many universities, including CHIME, Linköping, and many others (the proper list visible on SVN of course). Likewise to the Java tool base, including Linköping's archetype editor, no longer currently maintained. I can't answer for CHIME specifically, but universities are of course 100% welcome to put as much time as they want in some openEHR-related activity, and that is certainly happening. The CHIME Opereffa project is specifically an open source reference implementation built on Rong's earlier platform. With more resources, this project could certainly make faster progress. But with everyone working on their own main job (PhD, company project, lecturing etc), today it is done just with little pieces of time as they are available. There is really no avoiding the problem of funding here: no matter whether it is done on the openEHR side, or by some other organisation, it just costs money for dedicated analyst/architect/developer time. The blockers are, in my view: the unfunded central posts (preventing efficient organisation, management and maintenance), and the dire e-health standards situation, where none of the official standards adequately address the EHR space, but adopters in general feel unable to easily embrace non de jure work like openEHR (preventing more widespread 'customer' uptake). The openEHR/IHTSDO dialogue is partly to address these questions. We can hope that it produces a result, since it is clear that the industry is not happy with the status quo. - thomas [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #65 by @thomas.beale One further point I omitted \- a key activity that has to be done by orgs like openEHR is education, dissemination and communication\. This is also normally related to one or more paid posts in such organisations, because it is so critical\. \- thomas --- ## Post #66 by @system Hi All The adoption of all health standards is very slow; and it is universally so\. Government eHealth programs have embraced HL7v3 or CDA or openEHR or 13606 \- at great cost\. Still things go slowly\. The fact is that until people want a shared logical model of the actual EHR \(rather than a message or a document\) openEHR will not be centre stage\. Why have openEHR at the centre of a national program? There are a number of reasons that are potentially persuasive\. 1\. The core platform as implemented does not describe clinical information\. This allows changes to clinical information to take place in the world of archetypes \(the 99% of standardisation that is yet to be carried out\!\)\. The corollary is that only when there are enough high quality archetypes freely available does the argument for this separation is compelling\. There are close to 300 archetypes of good quality now available and we are going to see a rush of validation coming soon\. 2\. Adopting an EHR service allows applications to come and go without losing/changing/adapting the health records\. For patients, hospitals and major providers this is a massive benefit \- you can keep your health records for a lifetime\. It does, on the other hand, require enough high quality applications to be available to provide solutions for providers\. There is a growing number \- nursing, paediatric hospital, field hospital, infection control, cancer research \- but there is still some way to go\. 3\. The recording model in openEHR fits with the business process of healthcare\. A lot of things work out of the box from a medico\-legal perspective in a distributed environment\. The coherent management of workflow over a range of applications and services is the next step in this process and the one that Ocean is concentrating on\. Even if the first argument is only accepted as a logical model for EHR services, the tooling available now makes it possible to produce different artefacts for different systems\. On this basis people are becoming more willing to invest resources in developing archetypes through open collaboration on the internet\. The second and third arguments are bringing some institutions and software vendors along\. Seref is doing a wonderful job and Ocean has some experience in real implementations to which Seref is party \- so he does not make the same mistakes\! Where simplification is beneficial let's do it\. The reality is that openEHR proposes a massive shift in emphasis \- from the message to the EHR\. More than 7000 vendors in the USA have invested in their own data model \- which they maintain\. Until it is quicker, cheaper and easier to build a system using openEHR, uptake will be slow\. But I guarantee you, the alternatives will get slower and more expensive by the day\. That is why we should continue: health information is highly complex AND 'you ain't seen nothing yet'\. Cheers, Sam --- ## Post #67 by @Tim_Cook2 Hi Tom, > a few points informally \(I am not on any boards of any organisations, > so these are my own thoughts\): >       \* any organisation like openEHR needs some core paid people to >         execute key functions, and to maintain continuity\. There is an >         'officers' level, which runs any organisations, including >         admin and other support staff, and there is an operational >         level\. >       \* for the operational level, there are typically posts like CTO, >         CMO, infrastructure management, project coordination, and so >         on\. If the organisation is to do properly what its members >         want \- typically 2 things: a\) manage specifications/standards, >         including member involvement in this, and b\) manage open >         source projects, potentially largely staffed by volunteers \- >         then it has to have a few dedicated posts\. Otherwise it >         becomes no\-one's responsibility to actually coordinate things, >         keep infrastructure running etc\. If these are the thoughts of, whom I consider to be, the most open source/content aware person within the openEHR Foundation\. Then I \*highly\* recommend: Hippel, Eric von\. Democratizing innovation / Eric von Hippel\. ISBN 0\-262\-00274\-4 \(available in PDF via a CC license; btw\) Also, you may want to re\-visit your comments about Linux\.org and Apache\.org\. The history of how they became organizations is more important than the fact that they exist today\. I hope you find this useful\. Regards, Tim --- ## Post #68 by @Seref Greetings, I can see a specific pattern emerging in the recent mails of this thread, to which I'd like to response, and contribute. I will repeat my point I've made some time ago in this discussion, and by doing so I will insist on it. To deliver what openEHR is capable of, there is a significant requirement for time and money. Therefore I agree with Tom's points about posts and funding, and disagree with Erik and Tim, if I'm getting what they've been saying right. There is a consensus one can identify, about what is actually demanded from the openEHR standard. All the names heavily involved in this domain have discussed these requirements in time, some seeing a larger set of requirements than the others. At a very simplistic level, hours is what we need indeed. But there is a threshold for the amount of hours me, you, or anybody else needs to put into openEHR to deliver what is clearly demanded. With such a complex problem, we need lots and lots of hours, and the threshold which turns the required work into a full time position is reached very quickly with openEHR. The perception of this cost is different for everyone. Going back to the anology I've used, everyone is asking for what they need, which is way smaller than the total demand, and this is mostly likely to be the reason for people to say "how hard can it be?, I'm just asking for XYZ!" Delivering what a party asks for, without breaking the consistency of the solution (which makes it a solution in the first place), requires a lot of work and coordination. As in many things in life, people (including me) are only interested in what they're looking for, and if it is not there, than it does not matter to them if there is huge amount of work and promise out there. I do the very same thing every day. But there is also another side to this fact: when you contribute, your contribution does not necessarily solve a lot of others' problems. You may think that individuals each committing a limited amount of time into the solution may develop what we all ask for, but you simply can not. You need to set priorities of tasks, based on the actual impact of the outcome of the tasks, and unless everybody who puts input in any way knows absolutely everything about everybody else's requirement, you can not do this. So often I see this necessity either neglected, or its very existence not accepted. Many of the other works so often referred to are similar in one way or another to our project(s) here, but in my opinion that similarity is not strong enough to suggest that what has worked in other foundations, projects would also work with openEHR. Size and scope of the task at hand, the problem domain, the commercial space around the domain all matter in success or failure of initiatives like openEHR, and just looking at outcomes and only including one or two of the factors which led to those outcomes do not produce meaningful examples. Just like many other groups out there, openEHR is suffering from an asymetry. The input regarding the requirements and what should exist is gigantic, compared to input to deliver the results. Also, the cost of making a request is much lower than actually responding to that request.. This is not a bad thing, not a complain or rant, this is just a fact of this kind of organization. It is just that you need to acknowledge this situation to solve the problem, and develop a way to solve the problem with this picture in mind. Whereever we are with openEHR, this is where we are now. This is the solution we have in our hands, which reached this point as a result of whatever happened in the past, which will never ever change. openEHR was born in its own way, grew its own way, and due to million things effecting its domain, ended up where it is now. Looking at the history of other works won't change this. Their evolution brought them to where they are, better or worse, and openEHR's brought us here. Let me specialize Tom's argument: as far as I know, no member of the openEHR community who is putting his/her work out there for others to used freely, is getting paid just for doing so. To tackle the tasks I've outlined above, there should be people who are funded to perform these tasks. People's work on openEHR in their own companies, environments are not relevant unless they end up being available to the rest of the community, and there are very few instututions who let their intangible assets go into public domain. We need to do a huge amount of work, and I personally don't see this work being done in any other way than a properly funded, planned, and managed approach. You can't break down all tasks and diffuse it into some good intention based completely democratic virtual work force. openEHR has lots of tasks with this nature at hand, and many things which has worked in other scenarios won't work here because of this. Best Regards Seref --- ## Post #69 by @thomas.beale Tim, this is an interesting looking book, I downloaded it. However, as I and I imagine others won't get through 220 pages instantly, do you want to summarise what you see as the lessons from it, while this discussion is still warm? - thomas [details="(attachments)"] ![OceanInformaticsl.JPG|183x82](upload://2lcnRHcC3QqDv6AeaDZuo8M9Qlv.jpeg) [/details] --- ## Post #70 by @Tim_Cook2 Hi Tom, > Tim, > > this is an interesting looking book, I downloaded it\. However, as I > and I imagine others won't get through 220 pages instantly, Well, that is all a matter of personal cost/benefit; isn't? :\-\) > do you want to summarise what you see as the lessons from it, while > this discussion is still warm? Nope, not on my todo list nor in a consulting contract\. I only offered the information there for those that think it might be helpful\. Reading a book is a context sensitive thing anyway\. Cheers, Tim --- ## Post #71 by @system > Let me specialize Tom's argument: as far as I know, no member of the openEHR > community who is putting his/her work out there for others to used freely, > is getting paid just for doing so\. We don't get any extra up front payment for putting things out freely, but certainly many of us \(probably including you and Tom\) have had some kind funding that at times allows us to do openEHR related stuff on paid time\. It's actually easier to get certain kinds of funding if you let your work out freely, sometimes it's more or less a requirement\. \(I don't say that it's easier to get \_private\_ investor money for open source, but enough of the big openEHR end users will be governments and public health care providers in the long run\.\) In cases when openEHR work is funded by taxpayer money \(like EU\- and national projects\) then I personally think it's bad manners not giving results away for free, but I know others that probably will disagree\. > People's work > on openEHR in their own companies, environments are not relevant unless they > end up being available to the rest of the community, True\. I tried to use similar thoughts as an explanation of how things go a bit slower when that road is taken\. Any wider dissemination of implementation experiences will then depend on the goodwill and available time of the people in such companies\. Even if the goodwill is there, then there is still a dissemination bandwidth problem when doing research and development primarily in closed instead of open environments\. We all understand that there are other more pressing needs in a company, needs that must be prioritized over documenting and sharing your implementation findings with the general public\. That is a reason to aim for shared open research and development if speed is an issue and if any good business model allows it\. > and there are very few > instututions who let their intangible assets go into public domain\. Not true\. http://developers.facebook.com/opensource/ http://developer.yahoo.com/hadoop/ http://code.google.com/hosting/search?q=label:google http://code.google.com/webtoolkit/overview.html http://developer.apple.com/opensource/ \(e\.g\. http://webkit.org/) http://oss.oracle.com/ http://www.ibm.com/developerworks/opensource/newto/#9 \(While at IBM, some might like the heading "Open Standards Are Not Born; They Evolve" at http://www.ibm.com/ibm/governmentalprograms/ipos.html \) Why do you think these giants often cooperate in open projects? One reason is that open source is a very clever way to share risks and talent\. Would it really be better for the Yahoo and Facebook brainshare in e\.g\. the hadoop project to just fund the Apache foundation to employ some hadoop developers and maintainers rather than having their own Yahoo and Facebook employed engineers actively contribute? Yahoo and Facebook surely do sponsor the Apache foundation in general, but the invested time is a lot bigger sponsoring\. See who sponsors\.\.\. http://www.apache.org/foundation/thanks.html \.\.\.plus the amounts, \_and what the money is used for\_\.\.\. http://www.apache.org/foundation/sponsorship.html \.\.\.it isn't really for research and development costs is it? > We need to do a huge amount of work, and I personally don't see this work > being done in any other way than a properly funded, planned, and managed > approach\. One of the best things that can happen to open source projects \(and probably also to open specification projects\) is that a big financially strong users \(preferably more than one\) start using it and invest time and engagement\.\(See e\.g\. the Hadoop story at http://cutting.wordpress.com/2009/08/10/joining-cloudera/ \) In the case of openEHR such users could be national health IT\-programs and local health care providers with their own IT staff\. Probably openEHR interest will remain a bit low until there are more and better free demo systems though, and until then risks are that funding will be at the same low levels as now\. \(I hope to be proven wrong about the difficulty in getting monetary funding directly to the foundation in it's current form\.\) So perhaps I really should try to shut up and code\+publish instead to speed up my part of demo development\. Just one more try with the most urgent openEHR problem before I stop: > \[\.\.\.\] the world of > archetypes \(the 99% of standardisation that is yet to be carried out\!\)\. The > corollary is that only when there are enough high quality archetypes freely > available does the argument for this separation is compelling\. I agree with Sam that most of the interoperability work, the archetype development, is still left to do \(and agree with most other things said in that well formulated mail\)\. That's why I and many others \(e\.g\. Thomas Beale, Andrew Patterson, Martin van der Meer\) have tried to be very clear on the risks of not opening up the licence of the archetypes to CC\-BY rather than the current infectious CC\-BY\-SA\. See: http://www.openehr.org/wiki/display/oecom/openEHR+IP+License+Revision+Proposal With CC\-BY the big players \(NHS et al\) can let their clinicians cooperate in global archetype development on paid time, and they won't have to even bother about the potential risk that the hard to grip openEHR\-foundation central decision process does anything stupid to lock in their invested work\. They can leave whenever they please and take a copy of their invested work with them\. That freedom then becomes a reason to actually stay\. \(Even Google knows this, see http://www.dataliberation.org/ \) I think the openEHR foundation board still has miserably failed to communicate their reasons for stopping or delaying a licence change of openEHR hosted archetypes from CC\-BY\-SA to CC\-BY\. Some of us have seriously started discussing archetyping of data sent from medical devices, including proprietary ones\. Should device people come begging the foundation to liberate certain archetypes from the SA bondage every time they find use for one \(and how long would that take\) or would they be forced to go the anti\-interoperable way and start archetyping such things from scratch in a track separate from the openEHR CKM archetypes? I have even heard people say that copyright issues is a potential reason not to use international openEHR hosted archetypes as a basis for national eHealth work\. Why not simply eliminate such an argument with CC\-BY? Couldn't somebody else than Sam from the foundation board try to explain their reasoning this time to see if they can explain better? Best regards, Erik Sundvall erik\.sundvall@liu\.se http://www.imt.liu.se/~erisu/ Tel: \+46\-13\-286733 --- ## Post #72 by @Seref Hi Erik, This bit: > and there are very few > instututions who let their intangible assets go into public domain. is written in the context of openEHR. openEHR may end up in a relationship with big vendors, similar to some of the examples you have provided. For this to happen, what we have out there has to pass a certain threshold, and this is where we are having the trouble. In order to convince strong supporters, we have to provide actual working software, which proves at least our key points, and with openEHR this is a big task. This is where we absolutely agree: we need implementations freely available, and we are pushing for that as hard as we can. As you can see from the comments, this is not enough, and even with lots of effort, we are facing a chicken and egg problem here. Here is how it goes: Capable, open source demonstrator is required to gather interest and support, but this is a big work item, so we fail to develop it to the extend it would help us prove the point, people say it is not there yet, and we go back to starting position. At CHIME, we are trying to break this with the incremental approach, and I'd say it works quite good, but still not good enough to demonstrate every key capability the specs provide. I personally see this big bootstrapping requirement as a unique problem of this domain, and that's why I've been suggesting the things I've been writing. I know that there are many paths an open source initiative and business model can take, but I'd like to have that discussion with clear suggestions/list for work items, and people who will be responsible with it. Best Regards Seref --- ## Post #73 by @Tim_Cook2 Compared to creating your own world class web server in the mid 1990's? RE: http://www.apache.org/foundation/how-it-works.html --- ## Post #74 by @thomas.beale Tim, a few points by way of response: 1. the NCSA web server (which I used to administer in one company) was built by normal paid engineers in jobs where they were directed to build that tool - i.e. dedicated paid time. 2. there has been no barrier that I am aware of to people wanting to come and work on any openEHR project, indeed it is and has always been highly encouraged. If you think there is some barrier, please let us know. 3. with respect to Sam, you are doing him a disservice. Sam is a medical doctor, and people technical here sometimes forget that the main game in the real world for doctors is giving care: seeing patients individually; improving methods of care; sometimes working at policy level to change health care systems. From that point of view, the ideology of software is pretty uninteresting; people in this position are heavily oriented toward *solving the problem*. As a GP familiar with computers, Sam was using Windows to built desk-top tools 20 years ago, and even 10 years ago, it was the only realistic way to built desktop applications. There was no way for small companies to easily build a desktop app out of C++ or other such engineering languages. So the choice of using (today) .Net has nothing to do with the ideology of open source or otherwise; it was just about using tools that were available to solve the problem. As it happens, Sam is very interested in open source, and the Archetype Editor was open source since day 1. It turns out that the world at large is not interested in helping write even this tool. It may be that unless something is written in Java, Python, PHP etc, it is not seen as open source. For the other tools built by Ocean, the priority was always to build something economically that solved the problem most efficiently. 4. There is nothing stopping other companies being particularly open source oriented. Indeed, Zilics did it some years ago, building on Rong's original Java openEHR code. This also didn't magically make hoards of programmers come on board (in fact only the programmers from their company worked on it). The same thing can be said about the CHIME Opereffa project. As Seref said, this is largely because any such project that actually is open sourced, is not perceived to be sufficiently relevant to other parties in solving their problems that they should start work on it. So they don't, the write some other software of their own. This in my view is an indicator not of the bloody-mindedness of people, but of the massive complexity and diversity of the field. Its needs just can be solved by building a single tool like an Apache server. 5. One key difference between the kind of solutions being built in this domain and Apache is that Apache is ubiquitously useful - to everyone. It's like running water - everyone wants it. So of course it is easy to get bazaar-style open source taking off in that situation. Same with Linux. In the e-health area, it is much much harder, and that's what history shows. The various attempts to set up and run communities, cannot be said to have succeeded - even with hundreds of individuals available and apparently motivated to make something happen. Yet, no real open source EHR solution has appeared. I suggest that this is because: - it is intellectually hard, and is not a problem that can be solved by jumping into code before doing some serious design work - many people have different, incompatible ideas of what an EHR is, and therefore don't agree on what to build anyway - it requires interoperability as a key feature, and interoperability requires agreement. It is extremely hard to get meaningful agreement on technical standards for e-health, and the poor results of the official bodies (using completely the wrong algorithm and business model) are evidence of this. Open source, as a movement, has made practically no useful contribution to interoperability, so clearly, it is a problem that has to be solved elsewhere - in my view, as you know, by a dedicated engineering/development group. In hindsight, what was probably needed was an IBM to spend $30m developing an EHR stack and then giving it away through Eclipse or so. Nevertheless, progress is happening, and it will not be long before more open source tools are available. - thomas --- ## Post #75 by @system Hi\! > Democratizing innovation / Eric von Hippel\. ISBN 0\-262\-00274\-4 > this is an interesting looking book, I downloaded it\. > However, as I and I imagine others won't get through 220 pages instantly, > do you want to summarise what you see as the lessons from it, > while this discussion is still warm? The first chapter, 17 pages of easily\-read book text, actually seems to be a summary of the book, offered by the author\. Chapter 1 pdf: http://web.mit.edu/evhippel/www/books/DI/Chapter1.pdf Under the title "Users’ Innovate\-or\-Buy Decisions" on page 6 in the chapter\-pdf above one gets some hints regarding "agent costs" that might explain why most apache\-hosted project contributors are working at real "user"\-companies and are not agents for the end users funded by the foundation\. Regarding the need for funded development, I think there is a misunderstanding in this list discussion \- I don't think anybody has said that developers don't need funding for a project at the scale of openEHR, neither has anybody said that full\-time position for developers would be bad\. The underlying issue is rather future\-proofing the role of a foundation in this puzzle in order to allow larger entities to trust it and a proper community thinking to evolve\. I won't go into details over again but you can probably get some hints by re\-reading the discussion and the links with this in mind\. > I personally see this big bootstrapping requirement as a unique problem of > this domain \[\.\.\.\] Seref, calling it a "bootstrapping" problem was a good way to put it, I think it \(for techies at least\) describes the present openEHR situation in an excellent way\. If e\.g\. IHTSDO now has seen this problem and wants to help out with the initial bootstrapping, then perhaps they can temporarily themselves employ people like Tom for a while to work on open source tooling and documentation according to IHTSDOs requirements and at the same time inspire the foundation to transition into a more open and sustainable form in order to survive the changed requirements that will likely become even more apparent when the bootstrapping phase is over\. I don't know if that's what the openEHR\-IHTSDO talks are about, they seem to be pretty secret and cut of from any community discussion\. Back to the book, links to all chapters and the entire book: http://web.mit.edu/evhippel/www/democ1.htm What I have read so far is very interesting, and it seems to avoid becoming yet another political pamphlet, rather it seems to be a theoretical framework based on empirical findings, so thanks for the book recommendation\. I think the openEHR approach in the long run can inspire and allow a lot of end user innovation \(as described in the book\) without loosing interoperability and transcending into total chaos\. Best regards, Erik Sundvall erik\.sundvall@liu\.se http://www.imt.liu.se/~erisu/ Tel: \+46\-13\-286733 --- ## Post #76 by @thomas.beale I should have added earlier that the openEHR Java project is a pretty good example of the meritocracy Tim wants to see. It has 16 committers, and the list remains as active as ever, with a large number of subscribers. Although currently under-resourced, it works in exactly the way it should, not only that, its history is typical. The original core of code was written by Rong Chen and his small company, as part of a system to deploy at Karolinska Institute in Stockholm. Like everything else, the core initial code needed to be built by a very small number of people, with a very clear and complete idea of openEHR, and what they wanted to build. Large additions have been done by the people at Zilics, Seref at UCL, and various others. Many other programmers are using the code and constantly improving it. None of them do so unless it aids them in solving a problem they are working on. There is nothing stopping more people joining either. The limitation that I would say this project has is not lack of volunteers or enthusiasm, it is dedicated paid time to: - do proper architecting of large changes / enhancements - do better project management (admittedly, this could be improved today for free by making better use of the openEHR Jira issue tracking system) - get together physically and meet. It is hard to do some of this stuff well with no financial sponsors. Nevertheless what has been achieved is an excellent piece of work, and it continues to grow. One day I believe it will be as indispensable as Apache to those that need an EHR. - thomas --- ## Post #77 by @Paria_Kashfi Hi Seref, Have you published this interesting document somewhere except your weblog? I want to cite this in an article. Best Regards Pariya MSc; PhD Candidate Department of Computing Science and Engineering Chalmers University of Technology [http://www.chalmers.se/cse/EN/people/kashfi-hajar](http://www.chalmers.se/cse/EN/people/kashfi-hajar) --- ## Post #78 by @Seref No I did not. Honestly, it requires corrections and even after that, it would probably only go under wiki. I'm not sure if this could be a publication :) Best Regards Seref --- **Canonical:** https://discourse.openehr.org/t/articles-on-healthcare-complexity-change-process-it-and-the-role-of-openehr-etc/15024 **Original content:** https://discourse.openehr.org/t/articles-on-healthcare-complexity-change-process-it-and-the-role-of-openehr-etc/15024