The following questions may be US centric but my general intent is the general healthcare topic of interoperability:
What is the difference between WorldVistA and OpenEHR? I know VistA is written in Mumps which claims a superior organization of vast numbers of dependencies.
If HL7 (FHIR being developed: http://www.hl7.org/FHIR) is the standard in data protocol between all healthcare software vendors, doesn’t that mean that any system that can use that protocol solve the interoperability problem?
I’d really appreciate hearing the facts and then separating those from the different point of views.
I didn’t know about the existence of WordVistA, but by the looks of it seems to be a software, is it right? openEHR is a set of open specifications to build future-proof health information systems. There are some reference implementations in different programing languages and technologies.
I don’t think anyone would say that a single standard solves interoperability problem. I assume that FHIR would be perfect if your requirements align with the original purpose of each Resource. However, I think there is still work to do with the profiling of FHIR resources. I believe that just to know if the profile of the server and the client are “compatible” is still an open problem, and without that you end with one-to-one agreements which I find difficult to call interoperability. I think this part is better solved with the dual model approach. To make an analogy, the archetype approach is similar to FHIR profiling, but everything would come as profiles of FHIR Composition Resource. Instead of a 80-20 philosophy, archetypes follow a maximal approach, which can be specialized or templated for your use case. This assures that specialized archetypes follow both the original archetype and the reference model. You can see examples of archetypes in http://www.openehr.org/ckm
PS: ISO13606 is an archetype based ISO standard for the semantic interoperability of EHR data, and has been a standard for some years now. FHIR is still a DSTU. I think that your second question could be rewritten with any other healthcare standard
WorldVista is the group but yes it seems to be a software too. There is also a software called openVista. The origination of Vista came from the Veterans affairs in the US. It was written in MUMPS programming language with is also the database. From my understanding, GT.M is the mumps database but mumps is also the language. The database is indexed so I think that is noSQL. How is openEHR different? Which implementations have been successful and do they talk to each other?
Wow, this is confusing to me. Can you please elaborate? Please explain like I am a two year old. I am a clinician by training and new to programming. Archetypes? I found this: http://www.cise.ufl.edu/research/ParallelPatterns/CITarchetypes/archetypes.html. Also can you explain how interoperability is still a problem if there is a standard like HL7/ISO13606? ISO13606 mentions something about identifiable information.
I’d like to hear some of the reasons both technical and not why other options instead of Vista are being used. I do not sell any of this stuff, I just want to learn about the differences and thought process of for all the systems. At the end of the day, I’m interested in how this will be received by users, specifically patient consumers.
I encourage you to visit the wiki. Archetypes are aimed to clinicians so you will have no problems with that. I’ll also send this mail to the clinical discussions list, from which you will get responses suited for you.
The use of standards in healthcare is not the as widespread as it is in other domains, and not all factors are ‘solvable’ (i.e. political factors)
Essentially; #VistA is a successful EHR from the VA, which needs refactoring to bring it into the 21st Century. Its architecture is complex + and it could do with improvements along the lines of openEHR imho. openehr offers the technical specifications & architecture that many of us feel is well suited to 21st Century healthcare platform, esp the two level modelling elements (aka archetypes and templates) to build scalable healthcare applications. openEHR can be implemented in several flavours with languages from .net to java and databases from SQL to NoSQL in active use.
That first article was to suggest these 2 camps could learn from each other..
ie VistA could learn from openEHR and openEHR could learn from the NoSQL properties of M.
Much of the standards efforts in healthcare to date has been about standardising the messages between system eg HL7 , FHIR etc, which doesn’t get to the heart of the 21st C challenge. openEHR goes deeper than that to standardise the architecture of healthcare applications via a platform approach, (which by the way can help with message standardisation as a by-product).
Re: greetings and 2 questions
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Sorry for the confusion, I assumed you had a background in FHIR
I think what archetypes are is well explained here: https://openehr.atlassian.net/wiki/display/healthmod/Introduction+to+Archetypes+and+Archetype+classes
I encourage you to visit the wiki. Archetypes are aimed to clinicians so you will have no problems with that. I’ll also send this mail to the clinical discussions list, from which you will get responses suited for you.
The use of standards in healthcare is not the as widespread as it is in other domains, and not all factors are ‘solvable’ (i.e. political factors)
WorldVista is the group but yes it seems to be a software too. There is also a software called openVista. The origination of Vista came from the Veterans affairs in the US. It was written in MUMPS programming language with is also the database. >From my understanding, GT.M is the mumps database but mumps is also the language. The database is indexed so I think that is noSQL. How is openEHR different? Which implementations have been successful and do they talk to each other?
Wow, this is confusing to me. Can you please elaborate? Please explain like I am a two year old. I am a clinician by training and new to programming. Archetypes? I found this: http://www.cise.ufl.edu/research/ParallelPatterns/CITarchetypes/archetypes.html. Also can you explain how interoperability is still a problem if there is a standard like HL7/ISO13606? ISO13606 mentions something about identifiable information.
Are you saying that health is on the same political level as war?
The link you sent about archtypes is great! However, the Demo of observation has holes in the sense that it doesn’t link clinical data with engineering data frameworks clearly.
I think an approach that would both serve clinicians and engineers simultaneously would be to have a complete SOAP(subjective, objective, assessment, and plan) in a “fake” visit that encompasses all types and subtype of archetypes in a typical visit/encounter. The visit would need to be exaggerated where the patient consumer generates all of the types of data then circle the types of “data” be generated and label it like so in the demo document. That would be a great starting point to either refute or accept what kind of “archetype” of data both from a clinical perspective as well as a engineering perspective.
Heather: I think my approach to combine the clinical and engineering data mentioned above begins to address the archetype editor and template design you mention in your blog. After the relationships become more solidified, then there can be a more intelligent assignment of how the data can be dropped in their respective buckets: xml, json, or images. I think it basically breaks down to text (including alpha numeric) or images (MRI, CT scans, x-rays blah blah).
Tony: I’ve heard good things about VistA. Here is the relationship tree that I thought was interested but didn’t know how it related to interoperability: http://code.osehra.org/vivian/. Tom Munnecke and company who built the original kernel for Vista had the vision of creating a program that would allow users (clinicians) to modify it. I think the unintended consequence was that there was no standard on how data would be put in buckets so other computers could talk to it. I want to know how the “vivian” vista framework this relates to openEHR in regards to archetype and template modeling?
Danny
The vivian tree doesnt relate to interoperability, more a mindmap of the current VistA architecture.
The vivian tree doesnt directly relate to openEHR archetypes or templates either, as VistA essentially misses/lacks the 2 level modelling openEHR offers.
Suggest you need to read more about the 2 level modelling that openEHR offers.. then come back with further informed questions.
Heathers has sent 2 useful related articles
Tony
I’m looking at the clinical knowledge manager and I just get more confused. An EHR should not be owned by anyone and money should be made on the services (care) rendered to the patient consumer with them choosing, not on how the data is stored.
This is in dire need to be simplified. What are the shortcomings of archetypes and why does there need to be templates? I understand that clinicians need an agile platform but why would you need to to have such a vast library. At the end of the day, humans have genetic code that gets translated to proteins then to there the “human organism” then there are events by the environment, including other organisms.
Vitals are important but I don’t see why you need so many ways to store a vital whether it’s by a clinician, patient, or medical device/wearable. Regulations on what is a “legitimate” vital is arguable. A vital sign is a vital sign whether you measure it with a sphygmomanometer or your two fingers on your wrist. Clinicians already do this. Trauma is trauma, whether it’s by a turtle or a pencil. Now onto billing, value based cased is important but having 18,000 ICD-10 codes starting October 1, 2015 is absurd. Even when you’re looking at the electronic BP monitors in hospitals, each one has different algorithm determined by the vendor. The point is standardization starting at the fundamentals, working from principles.
In medicine and healthcare, there are people, products, and services. Healthcare should not be any different unless we are selling immortality. That will eventually be a service if super AI can produce it with genetic modification and regeneration of telomeres and recomposition of atoms. But I digress. Why is healthcare so complicated that new names for things constantly need to be made and then accounted for in data classification??? Back to the fundamentals. People, product, services. Is there something inherently different about health as a service?
I’m really curious on what others in the group think.
Danny
You need to do some more reading.
Healthcare is not just complicated, its complex.
Complex Adaptive Systems such as healthcare exhibit vast diversity, yet common patterns are seen within, which is where you are trying to navigate.
Read up more here http://frectal.com/book/chaos-complex-complicated-simple-and-cynefin/
Okay. You tell me what your approach and how you would solve the problem besides open sourcing everything? Looking at your Leeds initiative, I don’t see how increasing the barrier in a day an age where you can easily click a button to opt out of sharing your information (taking into account back doors) makes any sense: http://www.leedscarerecord.org/faqs/. In addition, patients have the right to their own data and privacy which means they can do whatever they want with it. Just because clinicians have taken the hippocratic oath to save the world doesn’t mean people can’t do whatever they want with their data. Elon musk can break down rocket science and solar energy in a pretty simple way. Why can’t the same be done with healthcare?
Current laws in all 50 US states only mandate organizations to hold onto health care records for 3-7 years. Explain that because it makes no sense to me. Labs can only be ordered after a diagnosis code to bill to insurance. What about preventative medicine and getting work on your blood whenever you want? http://truecostofhealthcare.org/. Emergency hospital visits occur and patients have no idea how much it costs until a bill is sent to their house which is nothing near what hospitals are reimbursed for (around 25%). There is the classical paternalistic culture in medicine because of all this “formal schooling”. The asymmetry in information between clinicians, insurance, pharmaceutical, hospitals and the patient consumers are vast. That’s when checks and balances break down. Medicine is not that difficult. Complicated and complex because of the science or the other moving parts? Elon Musk is working on a spaceship to Mars.
I’d really like to hear “non-clinical” people chime in because they have more perspective on the problem since they are the end users/ “patient consumers” in my eyes. I still haven’t heard many pros or cons about the necessity for the archetype AND the template methodology.
FOIA VistA Freedom of Information VistA very raw from the government. Should probably avoid.2) WorldVistA sponsored by 501c3 organization WorldVistA derivative of FOIA that has been worked on for many years to make it usable in the private sector.
Astronaut VistA (my company Astronaut, LLC) worked on for many years easy to install yum and apt-get based WorldVistA with lots of necessary clinical space refactors, modifications and enhancements that WorldVistA doesn’t have.
OpenVistA sponsored by Medsphere corporation, derivative of FOIA
vxVistA sponsored by DSS corporation derivative of FOIA.
OSEHRA VistA public-private VistA corporation derivative of FOIA supposed to be education only oriented.
I echo most of Tony's comments... to me openEHR is focused on getting
the DNA right so that interoperability comes naturally... while VistA is
a public domain and open source EHR solution that could benefit from
some degree of genetic re-engineering. So could every other EHR and
health care solution for that matter. To Tony's point on refactoring
etc. the VA is investing close to $200 M upgrading VistA levarging
technology like java script, node.js etc.
WorldVistA is a charitable, non-profit, incorporated in 2002, which
established the open source community for VistA, ported VistA to a full
open source stack, and is the steward of WorldVistA EHR which is the
dominant version of VistA used outside the US (e.g. Jordan's national
health system, Mexico IMSS and 12+ hospitals in India) The Hardhats
forum is the place to explore VistA if anyone interested in learning
more about VistA:
The takeaway in this thread for me is what and how can communities learn
from each other without requiring complete religious conversion? I know
we are all extremely busy, but it's remarkable how little
cross-pollination is taking place the open source world.
Cheers,
Joseph
Joseph Dal Molin
President, E-cology Corp.
Chairman, WorldVistA
Tel: +1.416.232.1206
Skype: dalmolin
200 Million dollar for a software upgrade?
Let’s say, 2000 high quality programmer years?
It does not occur to me as a healthy situation. Is the system so much behind? What is the vision, can’t just be implementing some new technologies. It must be a whole new vision, and a new product coming out of that which has nothing much more then backwards compatibility to remind of the old system.
I think with 400 high quality programmers in 5 years they should be able to wipe out all the closed source vendors, especially if the product will be developed on non profit base. It looks like a war against the healthcare software industries.
I agree it's not a healthy situation...the amount of money has little to
do with the software...VistA is consistently rated by doctors and nurses
as better than Epic, Cerner etc. The cost has more to do with
procurement and software development practices in the US federal system
and EU, Canada, Australia etc. for that matter... plus the size and
complexity of the VA itself. There are many examples of how improvement
can be made faster and at a reasonable cost... Tony Shannon and Rob
Tweed contributed good examples recently.
Having said that .... this is way off topic for this list... happy to
discuss offline or suggest going to HardHats.
I see that Veteran Affairs is a government organization.
In Europe it would not be allowed that a government organization would undertake a 200 million dollar attack paid by tax-money on a vivid market.
One would not expect such an attack on legal and healthy market partners in the USA.
This action must scare away investors and slowdown innovation
I am very interested in seeing the source of this rumor. I just find it hard to believe.
I wouldn’t say that generally (many innovations can only be done by huge companies), but besides that. If the government wipes out the market by dumping a massive amount of tax-money to a single party, innovation on the market will be dead, because the market will be gone. These are very basic economics. It would kill competition, and what innovation is, it would also foster corruption, because suddenly you would need some very specific friends. Anyway, I was wondering about the source of this rumor, because I cannot believe that parties on the market find this acceptable. In Europe (maybe except NHS) this would nowhere be possible. In the USA I believe they have similar regulations. Thanks Bert
