# aus health it **Category:** [Clinical (archive)](https://discourse.openehr.org/c/clinical-archive/153) **Created:** 2007-01-21 23:42 UTC **Views:** 6 **Replies:** 38 **URL:** https://discourse.openehr.org/t/aus-health-it/14607 --- ## Post #1 by @Andrew_Patterson Does anyone want to respond to this? http://aushealthit.blogspot.com/2007/01/archetypically-stupid.html David More seems to be going on a bit of a crusade at the moment, firing shots at all current work in Australian e\-health \(NEHTA etc\)\. Some of it is deserved no doubt, but I think he is a bit confused about exactly what the archetype approach is about\. Andrew --- ## Post #2 by @Tim_Churches Andrew Patterson wrote: > Does anyone want to respond to this? > > http://aushealthit.blogspot.com/2007/01/archetypically-stupid.html > > David More seems to be going on a bit of a crusade at the moment, > firing shots at all current work in Australian e\-health \(NEHTA etc\)\. > Some of it is deserved no doubt, but I think he is a bit confused > about exactly what the archetype approach is about\. I agree that David does not have some of the technical details about openEHR archetypes quite right \(note that the qualifier "openEHR" is necessary as there are many other uses of the term "archetypes" out there in information management land, some of which predate openEHR/GEHR work and many which are more widely known\), although the fact that a smart person like David with plenty of time on his hands hasn't grasped everything about archetypes underlines the fact that they are presented in a rather complex and mystifying manner to someone encountering them for the first time\. Not sure how to make it less complex \(a really good professional technical writer might be able to help, but they cost a lot to hire\) \- nevertheless, perceived complexity is the enemy of widespread acceptance, I suspect\. However, I basically agree with David's main tenets that it is premature to be pushing for finalised openEHR standards when there are so few deployed examples of true openEHR systems in production \(not research\) use out there, and when formal \(or even informal\) documented evaluations of such systems \(even of research systems\) are so thin on the ground\. Pilot openEHR implementations funded by the Australian government may or may not have been formally evaluated, but if they have, the reports have not been published to my knowledge\. A Medline/PubMed search for independent peer\-reviewed \(i\.e\. not written by Ocean Informatics or UCL staff\) evaluations, even anecdotal mentions, of any aspect of openEHR informations systems yields, well, exactly zero papers, when I last looked a few months ago\. Have I overlooked something? I suppose what I am saying is that elsewhere in medicine and health care, standards tend to be evidence\-based i\.e\. before a new treatment method or protocol is promulgated as a standard approach, there needs to be a reasonable \(not necessarily extensive\) set of formal evaluations of that method or technique using scientific methods \(typically statistical or epidemiological methods in clinical trials or observational studies for clinical medicine, but that may not be appropriate for evaluation of all aspects of information management systems or methods\)\. That evidence base seems to be lacking for openEHR archetypes\. One could say that it is also lacking for other health information management approaches and techniques, and where these are the subject of final standards, I would level exactly the same criticism at them\. I know that the openEHR/Ocean Informatics/UCL people, and perhaps some other research groups, believe fervently in the adequacy and practicality of the openEHR approach, but modern health care has just about dispensed with fervent belief\. Formal studies in peer\-reviewed journals are needed \- and yes, those takes time \- perhaps a large part of a decade\. But the openEHR project has been going form a decade or so now, and the GEHR project for nearly a decade prior to that\. What's a few more years? I also agree with David that openEHR archetypes will only be a solution \(as opposed to yet another complicated headache, like HL7 already is\) if an adequate national or global "intellectual ecosystem" can be established for the definition, sharing and evolution of openEHR archetype and template definitions\. David comes from the "centralist control freak" era \- I'm an open source person and so am not quite so worried about the ability to impose openEHR Stalinism\. However, some form of co\-ordination and sharing mechanisms are needed, and these do not happen by accident \- they need to be carefully grown and nurtured and even then they may not be sustainable\. Certainly, the business model for openEHR repositories is unclear, as it is not in the interest of the large health system providers \(including the likes of Microsoft and IBM\) to promote such things as true openEHR\-mediated interoperability will mean than vendor lock\-in will be undermined\. Governments should fund such repositories, but will they? Also there are, to my mind, unresolved and rather critical issue with teh way in which openEHR archetypes are licensed\. I have raised these concerns repeatedly with the openEHR developers but am happy to share them on this list if anyone is interested\. perhaps I am needlessly concerned but I think not\. Or have I posted these concerns to this list already? So, my view is: all power and godspeed to the openEHR project, but too soon to be cementing openEHR stuff into final standards\. Not too soon for openEHR standards proposals, that will go through dozens of revisions over the next decade, but definitely too soon to be pushing through final standards for something which for the majority of health professionals and health informatics people is largely unproven in a documented fashion and/or through first\-hand experience\. Tim C --- ## Post #3 by @ognian.pishev The two\-level modelling approach addresses a fundamental concern of information system building: the separation of concerns between knowledge representation \(ontologies\) and information processing\. Archetypes are used to formally represent knowledge structures in machine processable form as applied to electronic health records\. CEN is not an openEHR standard and thus it is not "cementing" it into a standard\. What it does however is quite important: it defines an achievable target that can be implemented on local, regional, international scale, etc\. with the support of the infrastructure and governance needed in all those cases\. CEN standardisation, while taking into account company offerings is not constrained to existing technology and can transcend proprietary limitations\. If industry\-based efforts could produce a similar standard, they would have done it a long time ago\. But as it turns out, industry is not particularly good at defining semantic interoperability\. openEHR is an evolving target that conforms to the well\-known open/closed principle of object\-oriented programming: an architecture should be sufficiently complete \(closed\) in order to produce working systems today but it should also be open to future development\. I am not sure CEN standards achieve this level of flexibility but it is built into the fabric of openEHR which produced the first complete set of implementable specifications about a year ago\. Then it received feedback from multiple projects that implement it in the applications space\. Thus at the end of this cycle, the openEHR specifications will be a lot better\. This iterative mechanism will continue working beyond release 1\.0\.1 but with the added benefit of stability\. The beauty of archetypes is that they transfer the control over clinical modelling to the clinician\. No standard can decree in advance what real practice needs\. The distributed nature of clinical knowledge in society is supported by an archetype infrastructure that will evolve over time and for this to happen we don't need to know all the answers in advance\. In any business information system one needs to have the ability to write business rules and constraints on the business objects that system is dealing with\. The archetype definition language is a formalism specifically design to produce models of concepts that pertain to the clinical domain\. How this formalism will be used depends on the clinical practitioners\. Ogi Pishev Ocean Informatics P\.S\. I am puzzled as to when the author of the blog has discovered that the work that has been going on for 7\-8 years is "archetypically stupid\!" As usual in the case of such categorical statements one wants to find out what the alternatives are and what that authors proposes as a working solution to the issue of semantically interoperable shared record\. Quoting Tim Churches <tchur@optushome\.com\.au>: --- ## Post #4 by @ognian.pishev Thanks, David, It is funny but the title of your blog piece reminded me of Lenin\. He loved using arch, archi as a prefix\. I believe that archetypes and the two\-level method are universally applicable across industries\. Their first implementation was actually at AMP back in 1999\. They work quite well but the larger the system, the harder the coordination issues\. I agree in general that it might be better to focus on simpler task\. However you can't solve problems at the level where they have been created\. Turning ontology business modelling into a primary concern is a major accomplishment\. We've got to get knowledge representation right, otherwise we'll end up where Artificial Intelligence ended 20 years ago with the hyped idea of "knowledge engineering without the engineer\." Ogi Quoting David More <davidgm@optusnet\.com\.au>: --- ## Post #5 by @thomas.beale Tim Churches wrote: > I know that the openEHR/Ocean Informatics/UCL people, and perhaps some > other research groups, believe fervently in the adequacy and > practicality of the openEHR approach, but modern health care has just > about dispensed with fervent belief\. Formal studies in peer\-reviewed > journals are needed \- and yes, those takes time \- perhaps a large part > of a decade\. But the openEHR project has been going form a decade or so > now, and the GEHR project for nearly a decade prior to that\. What's a > few more years? >   well, actually, openEHR was only created in 1999, so that's 8 years\. As for archetypes \- while Sam and I conceived of the solution which is the core of today's archetypes in 1997, it was not until about 2001 that we managed to turn it into anything explainable or formal \(this is the year of my original web paper explaining it\)\. So that's\.\.\.5 years\. And it is as far as I know a new idea\. I found afterwards Michael Kifer's F\-logic paper \(due to being pointed in the right direction by Alberto Maldondo and his team in Valencia polytechnic \- far better researchers than I will ever be\)\. In this there is the barest outline of F\-logic queries, but if you know how to read it, it is the formal idea of the definition part of an archetype\. But no connection to terminologies\.\.\.\.or multiple natural languages\. We built the current formalism based on our ideas from 1997 and with all kinds of other people's thinking along the way \(see the revision history of the documents; CEN meeting minutes, work done at UCL, DSTC etc\), and particularly from a post Peter Elkin once made on an HL7 list about what was needed: flexible integration with languages and terminologies\. Today it does these things, as shown by the tools\. So that is about 6 years' work\. Papers and PhDs have been appearing so fast in the last 3 years that I have lost count, and I admit we must make a better effort to get more references posted on openEHR's website\. \[paper authors please help\.\.\.\.\] But your really shouldn't accuse people of using 'fervant belief' when they are using scientific methods\. All of the progress made so far is based on evidence and testing\. That's why we have tools that work and archetypes that actually do model what clinicians want\. That's why templates were easy to define and implement \(specifications are close to being publishable, but we are still looking at the evidence;\-\)\. And why it was possible to actually build EHR repositories using them, e\.g\. http://demo.oceanehr.com/EhrViewDemo \(this is an online demonstration of archetyped openEHR EHRs\)\. > I also agree with David that openEHR archetypes will only be a solution > \(as opposed to yet another complicated headache, like HL7 already is\) if > an adequate national or global "intellectual ecosystem" can be > established for the definition, sharing and evolution of openEHR > archetype and template definitions\. David comes from the "centralist > control freak" era \- I'm an open source person and so am not quite so > worried about the ability to impose openEHR Stalinism\. \.\.\. >   there is no doubt that this is true\. And it is also happening\. But you have to realise that not everything happens in public\. Various e\-health authorities are working on this issue\. The requirements in this area are still being researched, with some initial technical solutions, such as this ontology\-driven repository: http://www.archetypes.com.au/archetypefinder/archetypefinder \. But the main issue here is this: if agreeing on anything at all were predicated not only on formalisms, tools, etc but also on having government buy\-in and requirements for large\-scale governance of archetypes, terminology and so on, we really will be waiting 10 years before we can build the first blood pressure archetype\. That's just not practical\. Electronics engineers did not wait for the Pentium or VLSI technology before standardising resistor and capacitor values or building the first transistor radio\. I don't believe the approach to governance will be greatly dependent on the details of archetypes or other alternatives, so allowing it to be dealt with independently seems reasonable\. With respect to David More's points, I am fine with sceptical commentary and critique \- it is necessary for progress\. But, please, make sure the criticism is based on facts, and offer some alternatives if you don't like what you see\. What is here is the best analysis of a growing group of people who know the challenges of this area very well\. I also don't think that titles like "archetypically stupid" help your case to be taken seriously\. \- thomas beale --- ## Post #6 by @Dipak_Kalra Dear All, Rather than respond to this list, I felt it better to reply directly to David's blog site, since this is where his readers will go to follow the discussion\. He has kindly now authorised it to be posted, so you can go and read it if you wish\! http://aushealthit.blogspot.com/2007/01/archetypically-stupid.html It may be helpful for us to nominate one location to continue this thread of discussion, rather than this list and his blog site\. I should like also to point out that the breadth of work that underpins where we are today on archetypes and what can can consider as its evidence base is broader even than those items listed in Tom's mail \(and would be longer than any sensible e\-mail to contain\!\)\. With best wishes, Dipak --- ## Post #7 by @Tim_Churches Thomas Beale wrote: > Tim Churches wrote: >> I know that the openEHR/Ocean Informatics/UCL people, and perhaps some >> other research groups, believe fervently in the adequacy and >> practicality of the openEHR approach, but modern health care has just >> about dispensed with fervent belief\. Formal studies in peer\-reviewed >> journals are needed \- and yes, those takes time \- perhaps a large part >> of a decade\. But the openEHR project has been going form a decade or so >> now, and the GEHR project for nearly a decade prior to that\. What's a >> few more years? >>   > > well, actually, openEHR was only created in 1999, so that's 8 years\. OK, I stand corrected\. > But your really shouldn't accuse people of using 'fervant belief' when > they are using scientific methods\. All of the progress made so far is > based on evidence and testing\. Where can I read about that evidence and the results of that testing, Thomas? That was my point\. Perhaps I am looking in the wrong places? I can find some papers, and lots of technical reports published by Ocean Informatics and openEHR and a few others describing the underlying ideas and implementation details of openEHR, but no documents which describe how well it actually works in practice \- any aspect of "how well it works", from speed and capacity with large data volumes and many users, to the adequacy of concept representation when using currently published archetype definitions in the field, to the ability to seemlessly exchange openEHR data between heterogenous openEHR clinical information systems without information loss or degradation or misinterpretation\. I'd be very grateful if you could point out these papers and reports\. But only if they are publicly available\. No\-one is interested in unpublished, unavailable reports\. Yet\-to\-be published manuscripts, yes\. Research degree dissertations, if available in electronic form, yes\. Of course, I should do a fresh PubMed and Google Scholar search on openEHR\. I last did one about 10 or 11 months ago and could not find any evaluations of how well openEHR works in practice, only descriptions of it\. Tim C --- ## Post #8 by @thomas.beale Tim Churches wrote: > > Where can I read about that evidence and the results of that testing, > Thomas? That was my point\. Perhaps I am looking in the wrong places? I >   Tim, you are asking for papers about systems that have been fully engineered, deployed, and run long enough to gather statistics on\. Given that the effort started \(in earnest\) about 5 years ago, these clearly won't be available just yet, although I expect to see independent validations of performance and volume in actual deployment this calendar year\. \(actually, I would like to see similar papers about similar / competing systems \.\.\.\) \- thomas --- ## Post #9 by @Tim_Churches Thomas Beale wrote: > Tim Churches wrote: >> Where can I read about that evidence and the results of that testing, >> Thomas? That was my point\. Perhaps I am looking in the wrong places? I >>   > > Tim, > > you are asking for papers about systems that have been fully engineered, > deployed, and run long enough to gather statistics on\. Given that the > effort started \(in earnest\) about 5 years ago, these clearly won't be > available just yet, although I expect to see independent validations of > performance and volume in actual deployment this calendar year\. OK, that's fair enough, and I wasn't intending any criticism of the pace \- these things do indeed take time\. I was merely pointing out \(or rather agreeing with David More's point\) that a push for finalised ISO and other standards for openEHR implementations does seem a bit premature in the absence of such documented real\-world experience of successful use\. Or am I just being overly pernickety? > \(actually, I would like to see similar papers about similar / competing > systems \.\.\.\) Yes indeed\. But two \(or more\) wrongs \(or absences of evidence\) don't make a right\. My view is that the practice of health informatics needs, desperately, to become evidence\-based, otherwise we will continue to see hundreds of millions or billions of dollars being poured into the deployment of health information systems based on what is in the sales brochure, or based on tender responses, which tend to be just more elaborate versions of the sales brochures\. No government would ever dream of subsidising the cost of a new pharmaceutical unless there was good evidence that the drug offered real\-world benefits over existing drugs of the same type\. \(Actually they would, but I am sure you get my point\)\. Tim C --- ## Post #10 by @pablo Hi, I think the results of testing openEHR for developing systems may come out when those systems where finished or prototyped\. Where are developing a system based on openEHR java core implementation \(thanks Rong\!\) and a "restricted" openEHR reference model, and we have learning and testing many aspects of openEHR over six months, and all work fine, the idea, the reference model, the archetypes, the persistence system based on their proposal, etc, etc\. Yes, it works\. I know that is not a serious evaluation of the openEHR idea, but we dont have enough time to do so, I think that today there is not much information about openEHR and not formal studies \(your point is correct\), may be in a while, when there where more systems o prototypes of systems finished \(that use openEHR\) will be more time to create "Formal Papers" testing openEHR, so I think you have to wait a bit ;\-\) Ragards, Pablo Pazos SICTI Project \- NIB --- ## Post #11 by @Koray_Atalag Hi, I want to express a few thoughts here\.\.\.I am doing Ph\.D\. study on modeling of a medical domain \(endoscopy\) with openEHR and alternative methods \(such as UML, Protege, openSDE, HL7 and so on\) and evaluation of the methodology\. I asked exactly the same question to leading openEHR people: where in heavens I can find formal papers that I can cite and put in my references list of my papers and use in academic work\. Because I needed them badly to convince my professors that I am doing something sensible and acceptable\. I had started my research in 2000, it is only now that things got mature for me to finalize my work\. In the beginning phase \(1\-2 years\) I discovered that even my advisor, not to mention other faculty, did really not give good credit for my work just because I could not show many references in reputable journals\. After that phase, after insisting on this topic and changing my advisor\(\!\), they became more neutral\. And now after 6\-7 years, they do not ask many questions about other studies but look at the advance and impact of my study\. So what's the catch? There is clearly a real "paradigm\-shift" here in design, development, deployment and most important maintenance of HISs\. So it is only natural that formal papers and academic work start evaluating these\. > I'd be very grateful if you could point out these papers and reports\. > But only if they are publicly available\. No\-one is interested in > unpublished, unavailable reports\. Yet\-to\-be published manuscripts, yes\. > Research degree dissertations, if available in electronic form, yes\. >   I would also love to learn about other material; I guess a page exists at openEHR website to put the docs and links which can be used\. I always think other examples in history like Watson & Crick's discovery of DNA double helix, or Information Theory in 1968 which was published in Bell Laboratories Record \(which is not a classical "peer\-reviewed" journal\), or Three Amigo's initial writings about OO methodologies and UML\.\.\.How many references were there in their original article? I guess quite few\. As far as I know, they did not start as some academic exercise and then jumped into market and get commercialized\.\.\.They rooted from the very problem domain and done by very committed and ambitious \(and I guess smart\) people after a long time of study\. I personally put openEHR into this class of research, it is a "paradigm\-shift" and should be treated as such\. Another point is that, probably I am not in a position to say so due to my relatively short experience in academia, but I will say it :\) I have really seen many examples of directed research \(i\.e\. by a pharmaceutical or medical device maker\) published in high impact journals\. I am sure many of you have realized the importance of knowing editor or having a good network with key people in a domain to get your stuff published\. So reliability is still an issue here\. Also discussion lists and other sorts of electronic collaboration tools when controlled \(and sometimes moderated\) provide more useful and timely information than classical ways of disseminating knowledge and information\. So I trust openEHR lists and personal communications more than journal papers in most situations\. Of course these are my own thoughts\.\.\. Best regards, Koray Atalag, M\.D\. --- ## Post #12 by @thomas.beale Tim Churches wrote: > ``` > Thomas Beale wrote: > > ``` > > > ``` > > formance and volume in actual deployment this calendar year. > > > > ``` > > ``` > > OK, that's fair enough, and I wasn't intending any criticism of the pace > - these things do indeed take time. I was merely pointing out (or > rather agreeing with David More's point) that a push for finalised ISO > and other standards for openEHR implementations does seem a bit > premature in the absence of such documented real-world experience of > successful use. > > Or am I just being overly pernickety? > > ``` to be honest I don't know when is the right point for an ISO standard. All I can say is that it is the wrong point if no software had been done, no archetypes had been built, no clinicians had been involved and no data have been built with the archetypes etc...but all this has been achieved and demonstrated. Obviously more has to be achieved, but on the other hand this is a lot better than a lot of standards that have no implementations at all. And if it isn't useful, it won't get used - something better will come along and replace it. > ``` > > ``` > > > ``` > > (actually, I would like to see similar papers about similar / competing > > systems ...) > > > > ``` > > ``` > > Yes indeed. But two (or more) wrongs (or absences of evidence) don't > make a right. My view is that the practice of health informatics needs, > desperately, to become evidence-based, otherwise we will continue to see > hundreds of millions or billions of dollars being poured into the > deployment of health information systems based on what is in the sales > brochure, or based on tender responses, which tend to be just more > elaborate versions of the sales brochures. > > ``` well, I can't disagree. We are working as fast as possible on such outcomes. > ``` > No government would ever dream of subsidising the cost of a new > pharmaceutical unless there was good evidence that the drug offered > real-world benefits over existing drugs of the same type. (Actually they > would, but I am sure you get my point). > > ``` it is not so clear cut in my mind. On the road to "a new pharmaceutical" are all kinds of intermediate steps, often occurring in university labs, teaching hospitals and elsewhere. To have the level of teaching and basic research framework to allow someone to get close to making a new drug necessarily implies some level of social funding (unless we want a user-pays-for-every-little-thing kind of society); so while the drug itself should not be funded unless it is safe etc, the other 90% of the iceberg must have already been funded somehow to even have a society with organisations and people who could make such a drug... - thomas beale --- ## Post #13 by @ognian.pishev The first question to ask ourselves is: Does openEHR have to be an ISO standard? If yes, this entails all the procedural handicaps that we have been avoiding so far\. The current model allows us to tightly manage an evolving architecture\. Its acceptance is neither mandated nor enforced\. If it doesn't work for David More, W\. Goossens, and others, they don't have to adopt openEHR \(but then they'll have to come up with a credible alternative\)\. On the other hand, if it offers competitive advantages to multiple vendors that are developing solutions requiring scalability and semantic interoperability, it is up to them to define the limits \(or limitations\) of its applicability\. Since openEHR is neither Microsoft nor the EU, it can only proceed through consensus community building\. Critical voices inside the community contribute to the evolution of openEHR\. Sweeping criticisms from without don't seem to contribute much\. Every company needs to find the business model that works for it\. In the case of Ocean Informatics it seems that demand for its tools and components is rapidly increasing and there exist a growing number of partners willing to pay for developer licenses and also to commit sufficient in\-house resources to testing and deploying openEHR\-based solutions\. Does it pay to have more articles and studies published? Probably it does\. Is it a good use of scarce resources to engage in a "my PowerPoint against your PowerPoint" competition? I guess not\. As general San Martin said "Con dias y ollas venceremos\." Ogi Pishev Ocean Informatics Quoting Thomas Beale <Thomas\.Beale@OceanInformatics\.biz>: --- ## Post #14 by @Hugh_Grady Or, as Google translator puts it, "With day and pots we will win" Que? Hugh Grady --- ## Post #15 by @ognian.pishev During the wars of independence of Latin America \(1810\-1817\), General San Martin laid siege on Lima, Peru\. His lieutenants wanted to attack but he had a fifth column \(a nice mix of latter day metaphors with historic facts\) in the city and received information on the mood in the besieged city in pots with false bottoms\. Hence \- "con dias\.\.\." \- with every single day the mood was changing\.\.\. "y ollas" \- more information received\. And finally after a while, the city opened its gates and capitulated without fighting\.\.\. Ogi Quoting Hugh Grady <hugh\.grady@oceaninformatics\.biz>: --- ## Post #16 by @David_More Tom and All, This is all starting to drift off my main topic. My simple point was that deployment of archetypes had not been brought to the stage of development required to be incorporated into an ISO standard..and that is that. I am still of the view that to do this is "stupid" - allowing a little journalistic licence to catch attention and have people read what it pretty dry stuff. I will persist in my view you create Standards after something has established its utility, viability and applicability - not after! I am also of the view that some of the smartest people working in the area are involved with all this and have a feeling they would make more impact attacking more tractable problems..but obviously it is their call. If you have browsed my blog you will be aware I have been suggesting for a while that a focus on solving those problems we can get our heads around before addressing "life the universe and everything" is more likely to be a successful way forward. I am sure others will have a different view - that's life! An example of my view is that I think semantic inter-operability is a much less important problem that getting systems which provide quality decision support into the hands of clinical users. Doing this would save more lives in the next decade in my view. You can all disagree or agree, but given I am not able to post on the list this will be my last comment. Cheers David. --- ## Post #17 by @Tim_Churches1 > > During the wars of independence of Latin America \(1810\-1817\), General > San Martin > laid siege on Lima, Peru\. His lieutenants wanted to attack but he had a > fifth > column \(a nice mix of latter day metaphors with historic facts\) in the > city and > received information on the mood in the besieged city in pots with false > bottoms\. Hence \- "con dias\.\.\." \- with every single day the mood was > changing\.\.\. > "y ollas" \- more information received\. > And finally after a while, the city opened its gates and capitulated > without fighting\.\.\. I think that pots of money might help openEHR succeed\. Tim C --- ## Post #18 by @Tim_Churches1 > I will persist in my view you create Standards after something has > established its utility, viability and applicability \- not after\! I presume you meant "not before", in which case I agree completely, particularly for something like an ISO standard\. Thomas and others on this list probably also agree with this position\. The difference is over whether the utility, viability and applicability of openEHR has already been established\. For Thomas and others, it seems that it has\. For me, it hasn't adequately been established\. Perhaps it is just a matter of time\. > If you have browsed my blog you will be aware I have been suggesting for > a while that a > focus on solving those problems we can get our heads around before > addressing "life the > universe and everything" is more likely to be a successful way forward\. > I am sure others > will have a different view \- that's life\! An example of my view is that > I think semantic > inter\-operability is a much less important problem that getting systems > which provide > quality decision support into the hands of clinical users\. Doing this > would save more > lives in the next decade in my view\. I'll have to disagree with this\. I think it is good that Thomas and others are working on solving "life, the universe and everything" \(Douglas Adams, you are much missed\), although as I have said, claims of success in such a large endeavour do, I feel, need to be backed by reasonably good levels of published evidence which can be verified and reproduced by others\. I also think that semantic precision and, related to that, semanic interoperabilty is a sine qua non for a generalised clinical decision support system infrastructure or ecosystem \- otherwise we are doomed to forever creating one\-off, specific decision support systems which only work with specific health information system installations\. But whether openEHR is the answer, or a sufficient answer, to the problem of semantic interoperability remains to be demonstrated, from my perspective\. It looks promising, but more experience with it in real\-life and pilot situations on a wider range of clinical problems is needed, and that experience needs to be formally assessed and evaluated and reported if at all possible\. Again, perhaps it is just a matter of time\. Tim C --- ## Post #19 by @David_More Hi Tim, Yes I meant before - not "not after" . On the second point - I agree its good for people to be working on this stuff (but worry when it seems to become akin to religion and possibly as potentially divisive) - but I think more lives will be saved by e-health applications in my life time if the focus was more practical and clinical outcome focussed. (Its part of my walk before running view - but I do see your ecosystem point) That is why I got into this long ago - hoping it would be a point of leverage to make a difference. There is a idea I have yet to show to be valid! (Oh well) Anyway I said I would shut up - so I better do so. Cheers David --- ## Post #20 by @system The question raised is: can we trust it. Some are of the opinion that when it is not published in a peer reviewed journal it can not be trusted. Application of the rule that **only** published academic articles contain truths that can be trusted, is false. It is the review process by a few selected people before publishing that provides **some** trust. With EU R&D projects it must be clear that these consortia consists many times of nice collections of the best and the brightest that are in continuous interaction for three years. With the standardisation process of CEN and ISO it is clear (in Europe) that many times people that are active in R&D as well take part in an very interactive process in the technical committees. Results of which are discussed in the many member states is local committees. OpenEHR is based on European and Australian R&D CEN/tc251 EN13606 (and other standards) are based on sometimes 20 years of European R&D (plus demonstrators) and standardisation. OpenEHR is an open source community that produced implementable specs and working software. It is on the basis of these observations that I think that work by OpenEHR, CEN/tc251 and ISO/tc215 is much more peer reviewed than any article in a journal. Therefor I have much more trust in the knowledge contained in documents from OpenEHR, CEN and ISO than articles in good (academic) journals. Gerard Freriks former convenor of CEN/tc251 wg1 -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #21 by @williamtfgoossen Of course it is bad news in this community if the same principles of 13606 / Open EHR are applied in HL7 v3 Patient Care and that it works. I think the debate of either or standard is the scientific debate of last century. The work of this century is to standardise clinical content in small discrete archetypes to be used in any IT solution. Lot of work goes in sorting out the clinical stuff and an appropriate binding to vocabulary and determination of appropriate datatypes. See earlier points made by Cecil Lynch Then an agnostic modeling serves very well to facilitate implementation in several technical systems, either EHR or message. Breakthrugh work in this sence is the linkage of HL7 v2 messages and OpenEHR archetype identifiers in the message that specify the clinical content. This methodology can be used in HL7 v3 messages in a similar way (refer in the XML tags to the appropriate archetype / template). Tooling is underway. Transformation form standard A to B or B to A a piece of cake if all hard clinical consensusbuilding and specification has been done. Since we have so many ( I envision in the tenth of thousands, even up to hundreds of thousands discrete and small molecular archetypes, given experiences in about a dozen of projects involving clinicians, having dealt with about 10.000 discrite variables, organised in every possible grouping), the most dramatic problem to be solved is the repository of these things called GPICs, CMETs, archetypes, R-MIM, care information models, detailed clinical models, templates. It is nice to have a big book of all kinds of requirements for archetypes specification such as the Iso 13606-2 archetype language, but if nobody worries about the content itself it is waste of time and effort of 10 years of research in both CEN / OpenEHR and HL7 v.3 Finding a way to organise, maintain and update archetypes/templates/care information models is the real challenge. So I think this community should re-read the blog by David More carefully and see similar worries that I have given 3 years of submitting content to both standards organisations, all acknowledging that it is important and all asap ignoring it. So what we need is a repository of clinical templates, maintained well, that basically ignores the specific technical implementation in either OpenEHR or HL7 CDA or v3 messages. We can apply similar systems as the ISO OID registry to identify sources and content. William Goossen --- ## Post #22 by @Koray_Atalag Tim Churches wrote: >> Yes indeed\. But two \(or more\) wrongs \(or absences of evidence\) don't >> make a right\. My view is that the practice of health informatics needs, >> desperately, to become evidence\-based, otherwise we will continue to see >> hundreds of millions or billions of dollars being poured into the >> deployment of health information systems based on what is in the sales >> brochure, or based on tender responses, which tend to be just more >> elaborate versions of the sales brochures\. >>   I want to point out a more unfortunate situation still happening in Medicine: Not even in such an established and trusted profession has truly embraced so called Evidence Based Medicine \(EBM\) or even Problem Based Learning in their medical education curricula\! I had been taught that the facts \(Science of Medicine\) in some thousand page terrifying textbooks/boring journals or the "Art of Medicine" as taught in clinical wards by word of mouth or mostly stored in brains of older clinicians\. I strongly disagree that Medicine is an "artistic" profession in essence; I hope that it is truly "Scientific"\. This is some philosophic part of my research but shortly I found out that there are two sources of knowledge in Medicine: Research LABs and Clinical Wards\. And most of this knowledge is generated in the latter by digesting and discovering new knowledge from years of accumulated information from patient encounters\. Why it is kept unstructured? Mainly because they don't really materialize these and they become "insights"\. Or not infrequently of course most do not need to formalize and disseminate it as it professionally brings him some strategic advantage\. Maybe write some papers giving pinpoint part of it but never expressing the "whole picture" as needed\. And believe me these are not bad people at all; it is how they are trained\. Well I guess an extensive IS capturing structured and sharable data from these wards will make most of this information available for processing and this will yield vast amount of new knowledge I very much hope\. Apart from pratical purposes of sharing health data, I am much more interested in this aspect\. Although I agree with the idea of evidence based health informatics, I feel sorry that my life span won't be good to see that :\( However a realistic and medium term solution might be first having of course the "essential" standardization work finalized, digested and implemented\. But more important is making sure that people/industry "obey" these\. And this can only happen \(by free\-will of course\) if health informatics becomes a "real" profession by implying some sort of control over practice and education\. Hehe very practically, even though I am in love with what I do, I have hard time to explain to my Mom or other "normal/ordinary" people what I do :D She keeps on saying: Oh my son you have studied medicine and now this computer thing, what are you waiting to be a real successful \(moneywise\) man?? Funny ha\.\.\. One criticism I want to make for long time is that, for openEHR and possibly other innovations in the open source domain, it shouln't take sooo much time to see "real" reference implementations publicly accessible somewhere\. As time goes by, this is unfortunately the case for cutting\-edge R&D that they start "loosing\-blood" because there are many other sharks out there\.\.\.I guess the patient has not died, or even near to that but I know that it will take much longer now to fully recover\. Also one important warning is that, being open source/spec is not a complete protection as in many cases of FOSS products, propriety products are still preferred for mainly three reasons: 1\) There is a switching\-cost, 2\) Integration issues with other apps around 3\) In most cases total cost of ownership is lower in propriety products in short to medium term\. Of course these are my ideas again\. As a last comment and a wish, I really think the main body of industry will jump into openEHR based products after seeing for themselves some big reference implementations; not just R&D projects\. I don't think the end\-users or buying organizations will have much influence on their decision\. Because an openEHR based system is expected to do "at least" what is currently being done and "plus" more\.\.\.And this plus will take some time to materialize in people's mind\. So the users will not see much change when using their Hospital IS\. An important "buying point" is that I am sure openEHR will let most of these vendors do these things more consistently and cheaper and also offer totally new features \(such as on the fly translation, or provide context sensitive decision assistance\) So to cut short: High impact industrial "reference" implementations are needed\. Well I hope I did not bore you all\.\.\.\. Best regards, Koray Atalag, M\.D\. --- ## Post #23 by @thomas.beale David, I won't argue about the standards thing. The openEHR Foundation is not a standards body, and does not offer its specifications to standards bodies. If anything is heading towards ISO, it is because people in CEN and ISO groups decided that it would be a good idea - it's not in any way an outcome of openEHR processes. The question of relative utility of decision support versus interoperability is an interesting one. I am far from competent to answer properly (not being a clinical professional), but my experience over the last 13 years of being involved in this area is this: - proper decision support is almost non-existent - this is because there are almost no longitudinal patient-centred records available for inspection - which most medical decision support needs to make any kind of safe inferences - the key to getting longitudinal patient-centric records (or constructed views that have the same effect) is interoperability - being able to share, convert, integrate data, or to be able to computationally construct views from heterogeous data that has the equivalent effect - interoperability that is not "semantic intoperability" is of no use to computers, only to humans, and therefore cannot support decision support So interoperability doesn't just serve the needs of shared care, but is crucial for decision support. In recent years it has become clear that health authorities would like something else before they get decision support - they would like patient workflow, i.e. care pathways to be managed by the IT. This means being able to managed distributed, heterogeneous data in such a way that the software knows where the patient is, what the last medications were, and what the next scheduled steps are. This all requires an interoperability basis as well. I can't argue about the relative importance of clinical decision support (you may well be right), but I can say this: it won't happen without interoperable systems - to put it concretely, if my CDS software can't read the blood pressures in the EHR in a standardised way, how is it going to be able to infer hypertension? - thomas David More wrote: --- ## Post #24 by @thomas.beale Tim Churches wrote: > ``` > I also think that semantic precision and, related to that, semanic interoperabilty is a sine qua non for a generalised clinical decision support system infrastructure or ecosystem - otherwise we are doomed to forever creating one-off, specific decision support systems which only work with specific health information system installations. But whether openEHR is the answer, or a sufficient answer, to the problem of semantic interoperability remains to be demonstrated, from my perspective. It looks promising, but more experience with it in real-life and pilot situations on a wider range of clinical problems is needed, and that experience needs to be formally assessed and evaluated and reported if at all possible. Again, perhaps it is just a matter of time. > > Tim C > > > ``` for those interested at a technical level, making CDS work requires two things: a) interoperable systems, so as to get a standardised view of the data b) a way of querying the data. In openEHR, we have done something called archetypes + templates to help the first.Ocean Informatics has also developed a query language based on SQL + archetype paths to intelligently query the data. This will be published in MedInfo 2007, and will be offered to openEHR as a candidate for an openEHR query language. Other approaches to solving the problem exist at UCL and elsewhere, and choosing among proposed solutions we hope will be done in a similar process to OMG. - thomas --- ## Post #25 by @Dipak_Kalra Dear Colleagues, It has been suggested that I should cross\-cost my long reply to David More on this list, so here it is\. There has been a little further correspondence between us on the blog site since\. Dear David, Thank you for setting up this blog as a window through which to air your concerns\. As the primary author of the section of prEN13606\-2 that you quote, I am surprised and a little disappointed to find that you are so critical of something which rather transparently admits its limitations and points to the wider challenge of which it is a part\. The goal of defining data structures to represent key clinical information in systematic ways is an old one, going back decades, and is vigorously being accelerated now in many national eHealth programmes such as yours \(Data Groups etc\.\)\. These bodies are finding many of the challenges you describe: how to contain the number of data structures whilst catering for as much of real clinical diversity as is wise, how to bind record structures with new\- generation large terminology such as SNOMED\-CT, how to define editorial and governance policies and publishing infrastructures for these data structures and data sets, how to maintain them in the light of evolving practice, and how to deliver a coherent set of distributed knowledge services to support authorship and EHR systems\. Despite these many challenges, it is recognised that this kind of approach is necessary if we are to aspire towards even modest semantic interoperability of health records\. One key problem is that all such sets of defintions internationally use rather ad hoc representation formalisms\. Part 2 of 13606 is therefore an important stepping\-stone contribution towards harmonisation in this area, drawing as it does on the openEHR Archetype approach\. The ability to foster an international standard for how such data structures can be represented and shared has been widely supported by many of the nations who are already building up such data structure libraries \(including the UK and Australia, voting positively for 13606\-2 in historic ballots\)\. It is recognised that the challenge of building up content needs to be internationally shared, and that vendors \(often being global\) wishing to exploit such knowledge artefacts would in general prefer a single standarised representation\. The truth is that this is an area in which research, standardisation and productisation need to proceed hand in hand\. The solutions cannot be found by waiting for research alone to finish, because research needs to learn from wide scale practical experience and vice versa\. You will know, I am sure, that 13606 Part 1 does not require the use of archetypes i\.e\. it is recognised that much useful EHR sharing can and will take place before archetypes become widely used\. Part 2 is seeking to standardise that part of the archetype approach that is reasonably well established \(a comprehensive representation of what needs to be specified when a data structure is defined\)\. Future standards will be able to address most of the other areas you raise, but we are not yet at a point where best practice is established for those areas\. The openEHR Foundation and its Clinical Review Board, and a new Detailed Clincial Models Collaborative of openEHR plus HL7, are seeking to build up an understanding of best practice in these other areas\. There are also many running systems \(some research and some commercial products\) that have adopted an archetype\-like approach from which we can learn\. And there are substantial national efforts, such as the Dutch work that William refers to, which are identifying important issues and solutions\. I hope therefore that you can use your efforts, given that you have taken the trouble to study the field, to help contribute to the future learning we still need to make\. If you do have specific rewordings to propose to 13606 Part 2 I am very happy to receive them, and to put them into the consensus standardisation process for consideration\. I hope that you and your readers can recognise that the various organisations, be it a national effort like the Australian or Dutch, a standard like 13606 or HL7 Templates, or research like openEHR's or our own at UCL, are all working rather unusually closely and harmoniously towards tackling these difficult challenges\. I hope you will also find that, as a community, we are open to constructive critique and to fresh inputs from others\. I look forward to your reply\. With best wishes, Dipak --- ## Post #26 by @Nandalal_Gunaratne Indeed Semantic interoperability is crucial to develop really useful IT based systems\. It is not possible to make safe healthcare IT systems unless we work in a way that computers work and make use of that ability\. Computers are far more accurate than our brain and is not affected by extraneous factors, does not lie and does not tire etc\. Therfore they have a place in safe medicine\. Decision support is never going to be simple as it is based on EBM and CPG \(Clinical Practice Guidelines\) and will have multiple algorithms even for the same conditions\. Their integration into the system of care can only be attained if there is semantic interoperability\. The process of the audit cycle will also depend on the above and patient care pathways and again, needs interoperability to work \- audit should show if we are following clinical practice guidelines, and if not, put this information into processing to be researched into depending on patient outcomes by comparison of the deviated practice as opposed to the evidece\-based pathway\. OpenEMR archetypes is the only way I can see that will make the above possible\. Theories are always incomplete and need to be tested and improved and the OpenEMR allows for this\. The work is tedious and long drawn, but not stupid and impractical\. It is best to use it now and improve it until we get what we want from it, rather than wait until somebody uses it and proves it is impractical or brilliant\! I too have studied it but not used it, yet\. Therefore I am not qualified to call it stupid or anything\. But i have some faith in the underlying reasons for its development\. Nandalal Nandalal Gunaratne MS FRCS\(Eng\.\) MRACS\(Aus\.\) Urological Surgeon Sri Lanka \-\-\- Thomas Beale <Thomas\.Beale@OceanInformatics\.biz> wrote: --- ## Post #27 by @system Dear William, You write: > Interesting view Gerard, > .... > My point is: again: we are arguing the wrong case, namely that of the 'best' standard. None is the best, both work depending on the goal. My reaction: We are having the wrong discussion. I'm NOT talking about the 'best' standard. My argument was/is that standards are much more peer-reviewed than many papers in journals. And in the case of OpenEHR implementable specifications have been produced and peer-reviewed, including working software that ism published. So what more proof can you get. That was my argument. The discussion of what is the best standard and standardisation process, is futile. We both know our own answers and will not change opinions. So be it. That is a discussion I'm not interested in. With regards, Gerard -- -- Gerard Freriks, MD Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands T: +31 252544896 M: +31 620347088 E: [gfrer@luna.nl](mailto:gfrer@luna.nl) Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety. Benjamin Franklin 11 Nov 1755 --- ## Post #28 by @David_More Hi Tom, My quoting seems to misbehave, so I will put comments in the text. See below Cheers David --- ## Post #29 by @thomas.beale David More wrote: > > - this is because there are almost no longitudinal patient-centred records available for inspection - which most medical decision support needs to make any > > kind of safe inferences > > - the key to getting longitudinal patient-centric records (or constructed views that have the same effect) is interoperability - being able to share, > > convert, integrate data, or to be able to computationally construct views from heterogeous data that has the equivalent effect > > - interoperability that is not "semantic intoperability" is of no use to computers, only to humans, and therefore cannot support decision support > > This is where I part company - taking a purist view you are dead right..but there are a set of middle steps that can be taken that can make a substantial difference. (e.g. within one well designed client providing effective basic prescribing decision support based on some basic information and a little history etc). well, that is more or less what products like Prodigy do. Prodigy only works because a) it knows that the target system is EMIS (a heavily used GP system in the UK), and b) that READ2 coding is used throughout. This is an example where sufficient (defacto) standardisation and longitudinal data exist to support safe-ish inferencing. And in the UK, this situation only exists because a) the government was smart enough to financially encourage MDs to get computerised b) the solution providers like EMIS actually build pretty good systems, and c) patients have to stick to one GP here in the UK. Elsewhere, in general, none of these factors hold. You couldn't run Prodigy with Medical Director in Australia for example because the notes are not coded, mostly narrative, not structured, and in general are too arbitrary to do computing with. And that's assuming the GP uses MD to write her notes anyway. And then there is the problem that any person in Australia (like many other countries) has fragmentary clinical records in multiple GP sites (not to mention hospital records). One thing that could be achieved fairly soon is medication decision support based on a current medications list. But just obtaining that is hard in many places. So what we are doing in openEHR is making it possible for this sort of information to be standardised and shared. We are not trying to do this kind of decision support - there is nothing standing in the way of it being done, assuming the data can be obtained. That is for other people, products etc. We see our job as making the data available. > I believe your completed solutions are a good few years off and I see it as being worthwhile to take some small interim pragmatic steps and get some basics going. well, actually, deployments are a good deal closer than you realise... > Trying to "boil the ocean" has typically proved both slow and ultimately maybe impossible - but we could make a difference to ordinary practice with simpler approaches I believe. It is undoubtedly true that some tools not being used today could be used in today's practices. E.g. medication checking could probably be used now with applications like Medical Director - we are not preventing that at all. But it is a lot harder than you think. Just consider the obstacles to making a hypertension evaluatable against Medical Director data... > > So interoperability doesn't just serve the needs of shared care, but is crucial for decision support. In recent years it has become clear that health > > authorities would like something else before they get decision support - they would like patient workflow, i.e. care pathways to be managed by the IT. This > > means being able to managed distributed, heterogeneous data in such a way that the software knows where the patient is, what the last medications were, and > > what the next scheduled steps are. This all requires an interoperability basis as well. > > We could start using things like the CCR (ASTM) and then, having learned, do more. CCR is a kind of mega-template for everything that could go in an encounter note. We have already modelled much of this in archetypes, and in fact the entirety of the CCR can be done in archetypes. The reason to do this is that while the CCR is a reasonable clinical statement of information to be captured, it is not in a useful deployment form (single XLM schema). This provides little or no componentisation, ability to mix and match various pieces of information captured in different settings, ability to dynamically include items not currently in the CCR, ability to use the same definitions as the basis for GUI forms and query expressions and many other things. XML-schema also doesn't allow the kinds of rich constraints to be expressed that can be done in archetypes. > > > > I can't argue about the relative importance of clinical decision support (you may well be right), but I can say this: it won't happen without interoperable > > systems - to put it concretely, if my CDS software can't read the blood pressures in the EHR in a standardised way, how is it going to be able to infer > > hypertension? > > See above...we can get along the way by basic information capture within a simple system and a simple rules based system and then improving incrementally. We can save lots of lives before we reach the point of true incompatible system interoperation I believe David, we have been doing "basic information capture" within "simple systems" for 40 years now. What we can do with today's data is minimal. That's because none of the content has a semantic definition or common record model. If this weren't the case, you would see working decision support systems all through clinical practice. - thomas --- ## Post #30 by @Tim_Churches Thomas Beale wrote: > David More wrote: >> See above\.\.\.we can get along the way by basic information capture within a >> simple system and a simple rules based system and then improving >> incrementally\. We can save lots of lives before we reach the point of true >> incompatible system interoperation I believe > > David, we have been doing "basic information capture" within "simple systems" > for 40 years now\. What we can do with today's data is minimal\. Well, what computers can do automatically with today's \("computerised"/electronic\) health data is minimal\. Humans can do a lot with it, but then humans are very good at resolving semantic ambiguities and imprecision and incompatibilties, on\-the\-fly, without even having to think about it most of the time\. Also, computers can do things automatically with existing data, but they need to have their semantic hands held by a human on a case\-by\-case basis\. This is waht happens when, say, a researcher analyses clinical data collected from heterogenous \(or even one\) health information systems \- the human needs to put in a lot of effort to resolve and smooth over the semantic problems in the parts of the data in which they are interested for their analysis\. > That's because > none of the content has a semantic definition or common record model\. If this > weren't the case, you would see working decision support systems all through > clinical practice\. I think the problem is that building good, safe and sufficiently capable clinical decision support systems is very hard and needs a lot of input and effort from a lot of parties, and thus is expensive\. Much of the effort will be in resolving semantic problems within each system, on a one\-off and specific basis\. This means that small\-to\-medium\-sized vendors/developers of health information systems never have enough resources to build good DSS for \*their\* particular product\. And of course the large health system vendors typically don't sell a single system, rather they sell frameworks on which customised systems can be built or configured\. If you look at how data is captured and represented in two different, say, CERNER systems in two different countries, or even two different states of Australia, you will find significant differences in how data is captured and represented\. So again, it is difficult to achieve the necessary economies of scale to enable good DSS to be developed\. openEHR archetypes provide a promising technical basis for achieving shared semantic definition and common record models, but as everyone agrees, only if a viable and sustainable mechanism for maintaining a unified set of archetypes definitions \(including the terminologies to which they are bound\), can be achieved\. It must also allow for the necessary specialisation of archetypes for local needs\. Building such a mechanism is a politico\-sociological endeavour far more than a technological one\. It is achievable, I think, but won't be easy and will never be as neat and clean as anyone would like\. That's life, and is not a reason not to try\. But I feel that far more evidence that openEHR is the best technical vehicle for this endeavour is needed before large scale engagement by lots of parties will occur\. Tim C --- ## Post #31 by @Tim_Churches Tim Churches wrote: > Also, computers can do things automatically with existing data, but they > need to have their semantic hands held by a human on a case\-by\-case > basis\. Sorry, that should have read: Also, computers can do things with existing data, but they need to have their semantic hands held by a human on a case\-by\-case basis\. Tim C --- ## Post #32 by @David_More All, Just a few points. Regarding doing some simple things before moving on...the evidence from Australia is (from MJA this year) that only 21% or practitioners are properly using the fully electronic capabilities of existing software. Getting this up to some much higher figure would be a good first step. Generic point is to get what we can do now fully deployed will make a substantial difference. Also I wonder how many reading here have fully reviewed CERNER's more advanced capabilities. They do have a pretty decent (flat I know) data model that does allow for quite useful rule based decision support based on clinical information held on the individual patient in the repository. Using this fully could also make a difference while waiting for the advanced system to arrive. I agree with Tim's points and while waiting for the enormous change he recognises is needed for practical archetype implementation there is useful stuff we can do today. A dual track approach (do what we can fully while developing the next generation) seems smarter and lower risk to me. Cheers David --- ## Post #33 by @Tim_Churches David More wrote: > All, > > Just a few points\. > > Regarding doing some simple things before moving on\.\.\.the evidence from Australia is \(from > MJA this year\) that only 21% or practitioners are properly using the fully electronic > capabilities of existing software\. Getting this up to some much higher figure would be a > good first step\. > > Generic point is to get what we can do now fully deployed will make a substantial > difference\. > > Also I wonder how many reading here have fully reviewed CERNER's more advanced > capabilities\. They do have a pretty decent \(flat I know\) data model that does allow for > quite useful rule based decision support based on clinical information held on the > individual patient in the repository\. Using this fully could also make a difference while > waiting for the advanced system to arrive\. Where can one review the CERNER data model, David? Especially if one is not a CERNER customer? Or even if one works for a large organisation which is a CERNER customer? Where do we look or whom does one need to approach to get access to what you describe? > I agree with Tim's points and while waiting for the enormous change he recognises is > needed for practical archetype implementation there is useful stuff we can do today\. A > dual track approach \(do what we can fully while developing the next generation\) seems > smarter and lower risk to me\. Yes, and a multi\-pronged approach is exactly what will happen because we are not discussing a centrally\-planned\-and\-commanded economy here, nor a single corporate entity\. Each R&D group will basically do what they think best and/or what they can get funds to do\. Thus people working on and promoting openEHR should and will continue to do so, and yes, others should and will work on more simple\-minded short terms stuff\. Tim C --- ## Post #34 by @David_More Hi Tim and all My exposure to the Cerner Data Model has been via 2 evaluations for various international and local clients where I have had it shown to me in the sense of how it is used to build their system during imlementation and how data-elements are found to be incorporated in decision support rules - using their Arden Syntax Engine. I believe it is available to all those involved in building the various applications Cerner provides in a particular implementation and is, as you would appreciate the key to their application integration. It is designed to be provided as a stable core of "data concepts" and there is capability to add specific data elements locally and while customising for different countries etc. While I don't have a copy to walk away with or give you (I am pretty sure Cerner sees it as a core part of their IP - the design especially) I am sure any of the major sites in NSW Health would be able to tell you a great deal more and indeed show you how it is used. Cheers David. --- ## Post #35 by @thomas.beale David More wrote: > All, > > Also I wonder how many reading here have fully reviewed CERNER's more advanced capabilities. They do have a pretty decent (flat I know) data model that does allow for quite useful rule based decision support based on clinical information held on the individual patient in the repository. Using this fully could also make a difference while waiting for the advanced system to arrive. Hmmm. How many GP surgeries will be getting Cerner soon I wonder... - thomas --- ## Post #36 by @David_More Hi Tom, > Hmmm. How many GP surgeries will be getting Cerner soon I wonder... > > - thomas That is hardly the point - not that it is not being used in a range of ambulatory care environments and that Cerner does not have a GP offering. The point is this actually exists today, works and has literature evaluating it (albiet with a variety or outcomes). The consensus view is that CPOE can save lives and improve quality and has been shown to do so in Hospitals - trouble is only 3-4% currently have it, its is not cheap and hard to implement - due in part to clinician resistance. Get that figure up and we would also save more lives. Cheers David --- ## Post #37 by @Tim_Churches David More wrote: > Hi Tim and all > > My exposure to the Cerner Data Model has been via 2 evaluations for various international > and local clients where I have had it shown to me in the sense of how it is used to build > their system during imlementation and how data\-elements are found to be incorporated in > decision support rules \- using their Arden Syntax Engine\. > > I believe it is available to all those involved in building the various applications > Cerner provides in a particular implementation and is, as you would appreciate the key to > their application integration\. It is designed to be provided as a stable core of "data > concepts" and there is capability to add specific data elements locally and while > customising for different countries etc\. Perhaps this is a bit off\-topic, but what David describes in CERNER sounds somewhat akin to the "concept dictionary" which is implemented in OpenMRS \(see http://openmrs.org/wiki/OpenMRS and http://openmrs.org/wiki/Data_Model and http://openmrs.org/wiki/Concept_dictionary and http://openmrs.org/wiki/Dictionary_101 \), which I believe is based on the Regenstrief Clinic data model which has been used in their systems for several decades\. At its core it uses an EAV \(entity\-attribute\-value\) type of representation, where entities are patients etc, and "attributes" defined in the second, "soft\-coded" level of the data model have "concept" metadata and constraints associated with them\. Thus it is a typical two\-level model\. Not nearly as sophisticated as openEHR, but it has been in the field at Regenstrief for decades and is now in the field in Africa in several OpenMRS implementations\. I know that Regenstrief has several decision support systems built on top of this, and there are plans to do the same with OpenMRS\. My view is that openEHR is an attempt at the next generation of Regenstrief/OpenMRS\-style two\-level information systems \(or meta\-systems, or system frameworks\)\. Tim C --- ## Post #38 by @Ole_Jorgen_Anfindsen Where can I get an electronic copy of *Health informatics — Electronic health record communication — Part 2: Part 2: Archetype interchange specification*? I have searched for it, but thus far with no luck. - Ole Jørgen Anfindsen Andrew Patterson wrote: --- ## Post #39 by @Dipak_Kalra Dear Ole, You can download the latest version of all 13606 drafts here: http://www.chime.ucl.ac.uk/~rmhidxk/13606/13606_2006_Drafts.zip This zip file contains all the parts, and a Readme\. With best wishes, Dr Dipak Kalra CHIME, UCL --- **Canonical:** https://discourse.openehr.org/t/aus-health-it/14607 **Original content:** https://discourse.openehr.org/t/aus-health-it/14607