# Open Source EHR at the Americal Academy of Family Physicians ... **Category:** [Technical (archive)](https://discourse.openehr.org/c/technical-archive/156) **Created:** 2003-08-27 16:23 UTC **Views:** 30 **Replies:** 30 **URL:** https://discourse.openehr.org/t/open-source-ehr-at-the-americal-academy-of-family-physicians/14451 --- ## Post #1 by @William_E_Hammond Forgive me for a late comment, but I would like to clear the record at little concerning hL7\. HL7 is an accredited ANSI body, and follows ANSI rules\. Itis an organization that is not funded by any outside group\. As such, the organization deopends on membership for dues to support the organization\. I agree that totally free standards would be the best, and I have argued that position within the HL7 Board\. The best I have been able to do is to get the draft available free\. At the same time, release of a new standard is always accompanied by an increase in membership\. Also, I must point out, that I think it is reasdonable for anyone who will gain advantage from the standard to contribute\. The proce for the standard is just slightly greater than membership dues\. Also, I point out that ISo and ANSI sells standards \- actually for more than HL7\. I hope you all will continue to support HL7 and its work\. I always find it interesting when people talk about HL7 as if it was a them and us\. I hope it is just us, and we struggle to support the tremendous cost of producing the standard\. I think the US may be the only country whose government does not support the creation of standards \- but at the same time, I don't think that is all wrong\. We need the support of all the poeple who understand the value of standards to work together and get the appropriate standards out there while the stars are aligned\. All of you are making important contributions\. Ed H David Forslund <dwf@lanl\.gov>@openehr\.org on 08/20/2003 09:37:41 AM Please respond to David Forslund <dwf@lanl\.gov> Sent by: owner\-openehr\-technical@openehr\.org cc:        Physicians \.\.\. --- ## Post #2 by @David_Forslund Thank you Ed for clearing stating the HL7 position, which has always been clear, in my opinion\. It is understandable, but, as you suggest, it would be desirable that the standards once they are complete be free\. I'm not clear on what the licensing issues are in terms of redistribution of those standards, however\. I also agree that HL7 isn't alone in charging a fee and is probably on the lower end of cost for those who do charge\. There are other models, of course, for handling standards within a non\-profit organization, and it might be useful for HL7 to explore those\. I don't want to suggest that people not support HL7 and its important work because of the fee\. Thanks, Dave --- ## Post #3 by @Shah_Hemant The recent agreement between the Health and Human Services and the College of American Pathologists about integrating SNOMED into UMLS, and making it available for free to everyone in USA, was a landmark. Is there a thought process within HL7 that is exploring such opportunities? If HHS agrees to support HL7 to allow it to make its standards available for free, it will hasten its adoption and development while it serves the goals of the federal government too. There is a need to bring into sync UMLS and HL7 at some level. To my mind Semantic Network and HL7 V3 RIM have to be reconciled. This will facilitate reuse in an object oriented way while retaining semantic validity. We can then have a true unified health information infrastructure. Regards, Hemant --- ## Post #4 by @system > Dear colleagues, --- ## Post #5 by @William_E_Hammond I agree with Gerard that we need to be careful\. However, that does not mean that we go to the lowest denominator\. IF we think SNOMED is the best solution, then we need to spend our time and energy on finding how to make SNOMED available to the rest of the world\. We have a debate in our school system in Durham\. The poorer kids do not have access to the Internet and to laptops\. The debate is whether to prohibit the use of computers and Internet for school work or to try to find methods that will provider laptops and Internet access to the poorer kids\. I think the answer is simple\. However, I do think it is important to make sure that SNOMED is the answer and will be acceptable before we move aggressively\. Ed Hammond --- ## Post #6 by @williamtfgoossen In een bericht met de datum 25-9-2003 15:10:09 West-Europa (zomertijd), schrijft hammo001@mc.duke.edu: > I agree with Gerard that we need to be careful. However, that does not > mean that we go to the lowest denominator. IF we think SNOMED is the best > solution, then we need to spend our time and energy on finding how to make > SNOMED available to the rest of the world. We have a debate in our school > system in Durham. The poorer kids do not have access to the Internet and > to laptops. The debate is whether to prohibit the use of computers and > Internet for school work or to try to find methods that will provider > laptops and Internet access to the poorer kids. I think the answer is > simple. > > However, I do think it is important to make sure that SNOMED is the answer > and will be acceptable before we move aggressively. > > Ed Hammond > > - > If you have any questions about using this list, > please send a message to d.lloyd@openehr.org I agree with Ed in that if we can make this resource available, we need to work on that. I think it is OK that HL7 uses SNOMED as preferred terminology. However, I would be very dissapointed if this would become the only terminology that the current v3 RIM and derivates could handle. I believe also local, or specialty or situation specific terminologies / vocabs etc. should be allowed in messages. But maybe I am overreacting, I did not hear / read that this would not be the case. William Goossen --- ## Post #7 by @William_E_Hammond William, I do not think you are over reacting\. I agree with you\. My only point is that we should be driven by what is best and what is a true solution, and not by the wrong reasons\. I would be most interested in seeing us compile a list of candidates for terminologies that should be considered and a process by which we could blend the terminologies\. I don't know what the best method might be and what organization\(s\) might be best for doing the work and distributing the product\. What is the level of trust for the NLM around the world? Ed --- ## Post #8 by @Tom_Culpepper Hi all, Just wanted to let folks know that at the "Computational Level" the work of the OMG Healthcare Domain Task Force's Lexicon Query Service ([LQS](http://www.omg.org/technology/documents/formal/lexicon_query_service.htm)) address the issue of multiple terminologies and their use in IT settings. This technology is being used today as a mediator between systems that utilize different terminologies which makes it possible to use legacy and new terminologies. The concept is that there will never be 1 terminology system in the world due to human, technological and legacy systems but you can narrow the focus and then utilize technology (LQS) to assist you. The specification was designed and development in an international setting with many of the prominent terminology experts as contributors. As HL7 moves forward at the "Informational Level" maybe they can glean some insights from LQS in terms of working with multiple terminologies. Tom --- ## Post #9 by @lakewood Hi Gerard, Appreciate your post\. It confirms a suspicion of mine that a workable global solution, regardless of topic, is one where compatibility, interoperability and usability are prime concerns, e\.g\., the drive for globalization is modified so that common goals and objectives with workable interfaces are targets\. To justify this recall that in the US we are still on the English system of measurement rather that the metric system simply because a majority of the populace considers metric measurement more difficult and a cheat\. One can purchase a set to tools for the the automobile in English or Metric, and perhaps both\. The various legislatures in the US have backed off many efforts to drive one of the other\. H7 is a good effort\. However, considerable time, effort and resources can be wasted attempting to derive a common standard\. As long as the different systems interface well, why bother\. Our politicians are still attacking those countries, cultures, people, etc that opposed the invasion of Iraq\. Efforts to get the population to accept 'French Fries' are still failing\. Heard a business brief that indicates that sales of these food items are still down from prior levels\. Charge ahead with the European approach and develop good interfaces\. \-Thomas Clark Gerard Freriks wrote: --- ## Post #10 by @lakewood Hi William, A small addition: 1\)It seems unlikely that Practitioners, Patients and associated parties would be UNABLE to effectively communicate without speaking SNOMED\. 2\)It seems likely that a single, dominating system for handling day\-to\-day Healthcare\-related activities it become efficient on a global scale\. 3\)Rigorous testing, including scalability, of SNOMED seems to be sparse: PERFORMANCE; Google search: "SNOMED performance |" http://etbsun2.nlm.nih.gov:8000/publis-ob-offi/pdf/2000-tal-ob-Ft.pdf \(1 hit\) SCALABILITY: Google search: "SNOMED scalability |" \(no hits\) EFFECTIVENESS: Google search: "SNOMED effectiveness |" \(no hits\) RELIABILITY: Google search: "SNOMED reliability |" \(no hits\) AVAILABILITY: Google search: "SNOMED availability |" http://quickstart.clari.net/qs_se/webnews/wed/bx/Bga-mckesson-info-sols.Rn1s_Dl9.html \(1 hit\); DIFFERENT KIND OF 'availability', i\.e\., availabile for use COMPLAINTS: Google search: "SNOMED complaint |" \(no hits\) ERRORS: Google search: "SNOMED error |" \(no hits\) SUSTAINABILITY: Google search: "SNOMED sustain |" \(no hits\) OK\! I give up\! SNOMED, it appears, has never been subjected to any kind of analysis\. It appears to be in the same category as home repair contractors who provide an on\-the\-spot 'tail\-light' warranty\. To roll on this one and push it on the global healthcare community needs some justification I can't provide\. \-Thomas Clark Williamtfgoossen@cs\.com wrote: --- ## Post #11 by @system Ed, I agree with you\. Today I had an discussion with Diane Ashman on this topic\. She is very willing to think along those lines\. But we all must move with caution, think of the many consequences and find the proper balance\. Gerard \-\- <private> \-\- Gerard Freriks, arts Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands \+31 252 544896 \+31 654 792800 --- ## Post #12 by @Tim_Churches Only a tiny percentage of the biomedical literature is accessible to Google \- you need to search PubMed \- see http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed A completely naive search on "SNOMED evaluation" yielded 33 hits, most of which we on topic\. More extensive searches would flush out a lot more papers, I'm sure\. BTW, please talk about "SNOMED CT" which is the original SNOMED classification combined with a clinical terms, including the Read codes\. Personally I think that SNOMED CT is far from perfect \(as has been discussed on this list in the past\), but it is the best show in town for the near and medium future\. The fact that there is a universal license to use it in the US, and some form of NHS\-wide license in the UK, makes it attractive to software developers\. I understand that serious consideration is being given to negotiating a national license for SNOMED CT for Australia, but there is some due process to be gone through first before a decision is made\. Tim C --- ## Post #13 by @lakewood Hi Tim, Pieces of the 33 hits are included below: \-Sarcomatoid carcinoma of the cervix \-An evaluation of the usefulness of two terminology models for integrating nursing diagnosis concepts into SNOMED Clinical Terms \-Improved coding of the primary reason for visit to the emergency department using SNOMED \-Which coding system for therapeutic information in evidence\-based medicine \-Automating SNOMED coding using medical language understanding: a feasibility study \-An evaluation of the utility of the CEN categorical structure for nursing diagnoses as a terminology model for integrating nursing diagnosis concepts into SNOMED \-Semantic features of an enterprise interface terminology for SNOMED RT \-Evaluation of a method that supports pathology report coding \-Evaluation of SNOMED3\.5 in representing concepts in chest radiology reports: integration of a SNOMED mapper with a radiology reporting workstation \-Representation by standard terminologies of health status concepts contained in two health status assessment instruments used in rheumatic disease management \-An evaluation of ICNP intervention axes as terminology model components \-\[Medical data in pathology\-\-evaluation of a large collection\. \(530,000 diagnoses coded in SNOMED II\)\] \-Scalable methodologies for distributed development of logic\-based convergent medical terminology \-The role of peer review in internal quality assurance in cytopathology \-Evaluation of a "lexically assign, logically refine" strategy for semi\-automated integration of overlapping terminologies \-Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity\. CPRI Work Group on Codes and Structures \-The surgical pathologist in a client/server computer network: work support, quality assurance, and the graphical user interface \-Comparison of the reproducibility of the WHO classifications of 1975 and 1994 of endometrial hyperplasia \-Planned NLM/AHCPR large\-scale vocabulary test: using UMLS technology to determine the extent to which controlled vocabularies cover terminology needed for health care and public health \-Mass screening for cervical cancer in Norway: evaluation of the pilot project \-The LBI\-method for automated indexing of diagnoses by using SNOMED\. Part 2\. Evaluation \-Representing HIV clinical terminology with SNOMED \-The LBI\-method for automated indexing of diagnoses by using SNOMED\. Part 1\. Design and realization \-A comparison of four schemes for codification of problem lists \-Can SNOMED International represent patients' perceptions of health\-related problems for the computer\-based patient record? \-Extraction of SNOMED concepts from medical record texts \-Terms used by nurses to describe patient problems: can SNOMED III represent nursing concepts in the patient record? \-\[Descriptive epidemiology from autopsies at the Ospedale Maggiore di Milano from 1986 to 1987\] \-\[Development of a findings and results data system for forensic medicine autopsy cases\] \-Medical linguistics: automated indexing into SNOMED \-Evaluation of the CAP microcomputer\-based SNOMED encoding system \-\[A new microglossary for biopsy pathology\] None of these hits can be related in any significant way to to the implementation and deployment of a system with SNOMED functionality, i\.e\., based wholly on SNOMED or integrating it as a plug\-in or an integral function\. My original posting included some major review topics typically encountered in a software product design \(the focus immaterial\)\. There is an old saying where I come from: Quiting playing with the design and produce something before the competition does\. Design, develop, deploy sustain and upgrade later\. The motivation to charge for SNOMED may well prompt competition to action \. Right now, in my opinion, SNOMED needs relevant Google/developer entries\. Additional comments in your text\. Thanks\! \-Thomas Clark Tim Churches wrote: >> 3\)Rigorous testing, including scalability, of SNOMED seems to be sparse: >> >> PERFORMANCE; Google search: "SNOMED performance |" >> http://etbsun2.nlm.nih.gov:8000/publis-ob-offi/pdf/2000-tal-ob-Ft.pdf >> \(1 hit\) >> >> SCALABILITY: Google search: "SNOMED scalability |" >> \(no hits\) >> >> EFFECTIVENESS: Google search: "SNOMED effectiveness |" >> \(no hits\) >> >> RELIABILITY: Google search: "SNOMED reliability |" >> \(no hits\) >> >> AVAILABILITY: Google search: "SNOMED availability |" >> http://quickstart.clari.net/qs_se/webnews/wed/bx/Bga-mckesson-info-sols.Rn1s_Dl9.html >> \(1 hit\); DIFFERENT KIND OF 'availability', i\.e\., availabile for use >> >> COMPLAINTS: Google search: "SNOMED complaint |" >> \(no hits\) >> >> ERRORS: Google search: "SNOMED error |" >> \(no hits\) >> >> SUSTAINABILITY: Google search: "SNOMED sustain |" >> \(no hits\) >> >> OK\! I give up\! >> >> SNOMED, it appears, has never been subjected to any kind of analysis\. It appears to be in the same category as home repair contractors who provide an on\-the\-spot 'tail\-light' warranty\. >>    > Only a tiny percentage of the biomedical literature is accessible to > Google \- you need to search PubMed \- see > http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed > > A completely naive search on "SNOMED evaluation" yielded 33 hits, most > of which we on topic\. More extensive searches would flush out a lot more > papers, I'm sure\. > > BTW, please talk about "SNOMED CT" which is the original SNOMED > classification combined with a clinical terms, including the Read codes\. > None of the 33 hits listed above refers to SNOMED CT\. This looks like an issue that should be resolved\. > Personally I think that SNOMED CT is far from perfect \(as has been > discussed on this list in the past\), but it is the best show in town for > the near and medium future\. The fact that there is a universal license > to use it in the US, and some form of NHS\-wide license in the UK, makes > it attractive to software developers\. I understand that serious > consideration is being given to negotiating a national license for > SNOMED CT for Australia, but there is some due process to be gone > through first before a decision is made\. > > Tim C > Have the current set of licensees subjected SNOMED CT to an IT WORLD review, analysis and performance/evaluation? If so, did they publish? \-Thomas Clark --- ## Post #14 by @thomas.beale William E Hammond wrote: > However, I do think it is important to make sure that SNOMED is the answer > and will be acceptable before we move aggressively\. > Ed \- how will this happen \- what process can be followed to do this? Do you mean "clincally" acceptable, or acceptable in terms of licencing, $ conditions? I personally have great doubts that any one refernce terminology can be the "one answer" to everything\. All the work going on with archetypes, RMIMs etc at the moment shows quite clearly that the meaning of any term in a specfic context is often \(usually\) not the meaning of the same work in a reference terminiology \(which by definition almost, must have a kind of compromise definition of its meaning\)\. So even if all the licencing and access issues are sorted out to everyone's satisfaction, I don't believe that the final solution has been reached\. This comment is not specific to Smomed of course \- it is a general principle\. \- thomas beale --- ## Post #15 by @thomas.beale Williamtfgoossen@cs\.com wrote: > In een bericht met de datum 25\-9\-2003 15:10:09 West\-Europa \(zomertijd\), schrijft hammo001@mc\.duke\.edu: > > I agree with Ed in that if we can make this resource available, we need to work on that\. > I think it is OK that HL7 uses SNOMED as preferred terminology\. > > However, I would be very dissapointed if this would become the only terminology that the current v3 RIM and derivates could handle\. I believe also local, or specialty or situation specific terminologies / vocabs etc\. should be allowed in messages\. I agree \- I would state even more strongly \- I don't think it can be any other way\. Recently, Sam did a review of our models of "Apgar result" \(your favourite;\-\) and discovered that the terms used for various things on US and UK websites were different \(e\.g\. the terms used for the 0,1,2 values for each of the 5 input variables\)\. No single global terminology can deal with this problem \- only capsule terminologies which are strongly bound to particular concepts can\. \- thomas beale --- ## Post #16 by @thomas.beale William E Hammond wrote: > William, > > I do not think you are over reacting\. I agree with you\. My only point is > that we should be driven by what is best and what is a true solution, and > not by the wrong reasons\. I would be most interested in seeing us compile > a list of candidates for terminologies that should be considered and a > process by which we could blend the terminologies\. > > I don't know what the best method might be and what organization\(s\) might > be best for doing the work and distributing the product\. What is the level > of trust for the NLM around the world? > Peter Elkin \(Mayo\) claims to have identified about 40 or so candidate terminologies for use in an open terminology system, according to his paper in MIE 2003\. But I don't believe the correct methodology in this area has yet surfaced\. It will start to when small, targetted knowledge models start being used more widely, and terminologists start to see that there is no solution based on the idea of a "single , perfect holy grail terminology"\. It just doesn't work like that\. There are capsules of meaning everywhere which link back into ontologies, and I think that a theory and methodology based on this idea will begin to surface in the next few years\. Snomed\-ct will be then seen as a best effort without this theory, and may end up being the biggest single resource for re\-enginering into a new typology of terminologies / ontologies / small knowledge models \(archytpes, HL7 models, guidelines etc\)\. Right now I really think people need to understand that there is still a lot of intellectual work ot go in this area, and that finalising licencing situations will not particularly change things\. \- thomas beale --- ## Post #17 by @William_E_Hammond I basically agree\. I think I mean both clinical and economical\. What I am hoping for is that we can create a single process in which all the appropriate terminologies can be blended, overlaps and mapping, and distribution made common\. Do it once not each institution or even each country\. I would like to establish a core terminology group that is international that works toward this goal\. Ed --- ## Post #18 by @Tim_Churches And theoretical health informaticists need to understand that the absence of a widely available termonology/classification is badly hurting real\-life efforts to improve and protect health, right now\. I don't particularly like SNOMED CT \- its bulky and inelegant \(although fairly comprehensive\), and as Thomas points out, uses way too much pre\-coordination\. But from where I sit, as a practicing epidemiologist who works with practicing clinicians, we need a terminology now\. As I said, SNOMED CT seems to be the best bet, at least for English\-speaking countries, and the license costs at the national level \- US$32 million for the whole US for 5 years, presumably rather less for, say, all of Australia \- are not unsustainable, and at least SNOMED is essentially a non\-profit organisation, not a rapacious multinational corporation\. But efforts on open terminologies, both niche and global, should definitely continue\. Hopefully SNOMED CT can then be replaced in a decade or so with a free, global alternative\. --- ## Post #19 by @Beatriz_de_Faria_Lea Dear Ed, I fully agree with you\. We do need an international vocabulary\. We need to make translations to other languages and it is no so easy to convince the ones who pay the bill that to translate SNOMED \( for example\) to Portuguese should be done\. If this is an international effort with many other countries aligning maybe we can try to find funds together\. The sooner the better\. At the moment we are defining a new vocabulary for health procedures \- sort of Brazilian CPT\.\.\. Best regards, Beatriz --- ## Post #20 by @Ahmad_Risk1 Tim > But efforts on open terminologies, both niche and global, > should definitely continue\. Hopefully SNOMED CT can then be > replaced in a decade or so with a free, global alternative\. We shouldn't wait for a decade or so\. We need it now\. In the UK, SNOMED\-CT is a done deal, and it is the door opener to Europe\. These things have their own momentum, and before we know it, the SNOMED juggernaut will roll over everywhere, and the not\-for\-profit \(who said it was?\) organisation will become just as dominating as any other 'globlaisation\-embracing' full blooded organisation\. We need this open terminology now\. What Gerard descibed many years ago as "MedSpeak"\. Ahmad Risk http://hi-europe.info --- ## Post #21 by @Tim_Churches Yes, I agree we need a global, open terminology now, but realistically it will take a decade of work to produce such a thing\. In the meantime, we need a usable, albeit imperfect terminology, at least the national level\. AFAIK, SNOMED is owned by ACOP \(American College of Pathologists\), which is a non\-profit organisation\. --- ## Post #22 by @Christopher_Feahr My understanding is that the US open\-licence period for SNOMED CT begins Jan 1, 04\. I have also been told that Centers for Medicare and Medicaid Services are planning a number of "demonstration projects" early in 2004, involving EHR systems and SNOMED CT terms\. Therefore, I would agree with Ed and others who seem to be suggesting that we move forward with whatever steps are necessary to get SNOMED CT into production systems\. In the context of a reasonably homogenous terminology space like the U\.S\., what would you see as the main problems with SNOMED that would have to be "fixed"? Pre\-coordination issues have been mentioned along with some even more fundamental \(??\) issues that Thomas Beale suggests will take several years or possibly a decade to straighten out\. Of course, from my point of view, my biggest problem will likely be scarcity of special vision care concepts/terms\. So, what would we have to do exactly? And which standards organization would coordinate such a project\.\.\. HL7? \-Chris Christopher J\. Feahr, O\.D\. Optiserv Consulting \(Vision Industry\) http://Optiserv.com http://VisionDataStandard.org Office \(707\) 579\-4984 Cell \(707\) 529\-2268 --- ## Post #23 by @thomas.beale Christopher Feahr wrote: > My understanding is that the US open\-licence period for SNOMED CT begins Jan 1, 04\. I have also been told that Centers for Medicare and Medicaid Services are planning a number of "demonstration projects" early in 2004, involving EHR systems and SNOMED CT terms\. Therefore, I would agree with Ed and others who seem to be suggesting that we move forward with whatever steps are necessary to get SNOMED CT into production systems\. > > In the context of a reasonably homogenous terminology space like the U\.S\., what would you see as the main problems with SNOMED that would have to be "fixed"? Pre\-coordination issues have been mentioned along with some even more fundamental \(??\) issues that Thomas Beale suggests will take several years or possibly a decade to straighten out\. Of course, from my point of view, my biggest problem will likely be scarcity of special vision care concepts/terms\. > > So, what would we have to do exactly? And which standards organization would coordinate such a project\.\.\. HL7? my feeling \(with apologies to those who have been working for years in terminology and I realise know the semantic space much better than I do\) is that a new process could emerge: a\) some people develop some archetypes , e\.g\. American College of Opthalmologists \(not sure what the proper title is\) b\) these archetypes will have local vocabulary which defines meanings for exactly what terms need to mean in the exact context of the archetypes\. c\) The mundane task of mappings to ICD or similar classifiers needed for reimbursement and various population & efficiency studies is easy\. This will take care of the practical need for these codes\. d\) mappings to ontologies are more challenging, and it may well be that local archetype terms form "capsule vocabularies" that could be the basis of change requests to developers of ontologies\. Snomed is probably more in this space than pure terminology, so it may be that we send change requests of some kind to them, based on archetyps\. e\) due to d\), ontologies may change over time in such a way that more direct mappings from archetypes become possible\. \- thomas beale --- ## Post #24 by @williamtfgoossen Dear all, Thomas in particular to remind me to send the message to all, instead only to him :-) Some possible additions to Thomas procedure: > a) some people develop some archetypes , e.g. American College of > Opthalmologists (not sure what the proper title is) Yes, any professional organisation, or multidisciplinary group, or even patient organisations develop such things. b > ) these archetypes will have local vocabulary which defines meanings > for exactly what terms need to mean in the exact context of the archetypes. Yes, but, if this is going to be constructed, it is wise to already look at well defined terminology and proceed as follows: - if a scientifically validated and reliable scale (mini ontology?) is available and meets the clinical need then choose that. if this scales are not available, then use some kind of standardized terminology like LOINC, SNOMED, ICF, NANDA or whatever. if that is not available to fullfil the needs for the subject, then choose your own wording that defines best the meanings for the clinical area. c > ) The mundane task of mappings to ICD or similar classifiers needed for > reimbursement and various population & efficiency studies is easy. This > will take care of the practical need for these codes. Given the earlier suggestion to already use such terms, a part of the coding has been done. Otherwise, depending on purpose (clinical trial is different from international prevalence study) map from scale / local term to classification. d > ) mappings to ontologies are more challenging, and it may well be that > local archetype terms form "capsule vocabularies" that could be the > basis of change requests to developers of ontologies. Yes, a validated scale on a particular issue around human functioning could be part of an ontology, but perhaps not always. The Barthel index or the APGAR score e.g. have distinct and different variables that probably would not stand beside each other in an ontology. Or, it would be an ontology with many to many parent - child relationships. Snomed is probably > more in this space than pure terminology, so it may be that we send > change requests of some kind to them, based on archetyps. Yes, the process would become interactively with knowledge determiners (ontology, scales) terminology developers (semantics) and information modellers (archetypes as constraining mechanisms for what a record system / messaging system must do with this particular grouping of patient data. e > ) due to d), ontologies may change over time in such a way that more > direct mappings from archetypes become possible. Yes, that might work two ways from archetype to ontology, but reverse to via including from ontology into archetypes. Hope this helps, Sincerely yours, Dr. William T.F. Goossen Senior Researcher and Consultant Health and Nursing Informatics Acquest Research and Development, Koudekerk aan den Rijn, the Netherlands [http://www.acquest.nl/](http://www.acquest.nl/) & Adjunct Associate Professor in the College of Nursing, faculty in the Organizations, Systems and Community Health Area of Study, the University of IOWA, Iowa City, Iowa, USA. www.nursing.uiowa.edu/NI & Country Representative for the Netherlands in the Special Interest Group Nursing Informatics, IMIA. http://www.infocom.cqu.edu.au/imia-ni/ & Member Evaluation Committee International Classification for Nursing Practice, Geneva, ICN. [International Council of Nurses http://www.icn.ch/](http://www.icn.ch/) and http://www.icn.ch/icnp.htm & Associate Professor, Adjunct on the faculty of the School of Nursing, University of Colorado Health Sciences Center, Denver, USA. & Bestuurslid Vereniging voor Medische en Biologische Informatieverwerking [http://www.vmbi.nl/](http://www.vmbi.nl/) & Fellow of the Centre for Health Informatics Research and Development (CHIRAD), School of Social Sciences, Kings Alfred's, Winchester [www.chirad.org.u](http://www.chirad.org.uk/)k --- ## Post #25 by @Philippe_AMELINE1 Hi to all, > b >> \) these archetypes will have local vocabulary which defines meanings >> for exactly what terms need to mean in the exact context of the archetypes\. > > Yes, but, if this is going to be constructed, it is wise to already look at well defined terminology and proceed as follows: > > \- if a scientifically validated and reliable scale \(mini ontology?\) is available and meets the clinical need then choose that\. > if this scales are not available, then use some kind of standardized terminology like LOINC, SNOMED, ICF, NANDA or whatever\. > if that is not available to fullfil the needs for the subject, then choose your own wording that defines best the meanings for the clinical area\. It certainly makes sense\. From what I personnaly experienced, if you don't make the "semantisation" work at the very first stages, you will have a hard time doing it afterward because an ontology is an accurate but restricted langage ; thus you end up translating from natural langage to a more restricted langage \- or worse from classification terms, triyng to give a meaning to terms that where only created for "patient grouping"\. Making "semantic Archetypes" is a job that involves a doctor and a knowledge manager \- this one translates between "doctor langage" and "ontological langage", but also asks for the proper level of accuracy in the concepts representation\. Very hard to do lately\. > Given the earlier suggestion to already use such terms, a part of the coding has been done\. Otherwise, depending on purpose \(clinical trial is different from international prevalence study\) map from scale / local term to classification\. We are currently experiencing such things ; it is not easy to have people understand the difference between description \(As accurate as possible\), local study \(question 5 can be answered 5\.1, 5\.2\.\.\.\) and studies using classifications such as ICD or ICPC where you just can use concepts inside the classification \(and it is sometimes complicated since, for example, "send to the hospital" as no entry inside ICPC\)\. I don't think you can expect adressing all these issues through Archetypes > Yes, a validated scale on a particular issue around human functioning could be part of an ontology, but perhaps not always\. The Barthel index or the APGAR score e\.g\. have distinct and different variables that probably would not stand beside each other in an ontology\. Or, it would be an ontology with many to many parent \- child relationships\. The way we solve this kind of problem is that we incorporated inside the ontology concepts as "ICD10 code", "ICPC code" and so on\. These ontology concepts are given the code as a "value" in the same way "patient size \(cm\)" would be given 180 as a value\. --- ## Post #26 by @thomas.beale Philippe AMELINE wrote: > Hi to all, > > We are currently experiencing such things ; it is not easy to have people understand the difference between description \(As accurate as possible\), local study \(question 5 can be answered 5\.1, 5\.2\.\.\.\) and studies using classifications such as ICD or ICPC where you just can use concepts inside the classification \(and it is sometimes complicated since, for example, "send to the hospital" as no entry inside ICPC\)\. > > I don't think you can expect adressing all these issues through Archetypes I would not either\.\.\.we just need some good oontologies\.\.\. > Yes, a validated scale on a particular issue around human functioning could be part of an ontology, but perhaps not always\. The Barthel index or the APGAR score e\.g\. have distinct and different variables that probably would not stand beside each other in an ontology\. Or, it would be an ontology with many to many parent \- child relationships\. > > The way we solve this kind of problem is that we incorporated inside the ontology concepts as "ICD10 code", "ICPC code" and so on\. These ontology concepts are given the code as a "value" in the same way "patient size \(cm\)" would be given 180 as a value\. the ADL supports this more or less as well\.\.\. \- thomas beale --- ## Post #27 by @Christopher_Feahr Thomas, Thank you\.\.\. this is getting clearer\. I know that there are several hundred coded terms and answer lists relating to eyeglass and contact lens products already in LOINC, and there may well be some eyeglass terms in SNOMED CT\. Many of these LOINC terms, however, have incomplete/ambiguous definitions or do not fully support business messages like eyeglass purchase orders and insurance claims\. So it seems that a vision industry committee could start fresh by creating ontology models \(UML\) for "eyeglass" and "contact lens" products, from which archetypes can be defined with ADL\. It would only seem necessary to map these archetypes to LOINC and/or SNOMED CT if there were business applications already using those terminology systems\.\.\. and we wanted the old LOINC\-based systems to be interoperable with the new archetype\-based systems\.\.\. right? Finally, if a vision industry committee did successfully create 100 new archetypes to support doctors ordering eyeglasses from labs, would our committee be able to simply distribute the archetype\-definition\-list to the industry as one, big XML document? I guess, the other implied question is whether it would be necessary to set up one or more terminology servers\.\.\. or could each lab management system and practice management system simply be shipped with a local copy of the current archetype list? \.\.\. with the ability to import newer versions \(simple XML documents\) later on? Thanks, \-Chris --- ## Post #28 by @Sam Dear All This area is difficult and we must learn as we go\. There are a few conclusions I have come to from an EHR system point of view\.\. 1\. The data structures and term sets that are required for clinical care and communication must be able to be instituted both prior to and after the standardisation processes have been published\. 2\. Special requirements that are not contrary to agreed standards should be able to be implemented without difficulty \- this is the norm rather than the exception\. 3\. Where terminologies required in archetypes are small and generally agreed, these should be primarily expressed in the archetype itself \- not to do so is to add to the unrealistic demands on external terminologies\. 4\. Translations will be safest inside archetypes where the meaning is clear \- the context is highly specified\. This is a reason to extend the role of internal terminologies of archetypes\. So, the new statements I would make are: 1\. Archetypes should have no language or terminology primacy \- and these should be able to be added post\-hoc\. 2\. Terminologies internal to the archetype will always be safer to translate and provide synonyms and specialisations\. Despite the feeling of some in the business, this does not really diminish the need for external terminologies\. I am also aware that the comprehensive approach of Philippe and the Odyssey Project and the text processing of Peter Elkin\. I believe these efforts will remain as relevant, but more focussed within an archetype driven information model\. Cheers, Sam Heard --- ## Post #29 by @Bhupinder_Singh Thomas had indicated that you were going to respond to the issues and clarify the stand being evolved in this respect by EHR\. Shall welcome your comments\. Dr Grewal --- ## Post #30 by @Sam Dr Grewal Can you please outline the issues as the included email is from me\.\.\.Sam --- ## Post #31 by @Christopher_Feahr Thomas and Ed, I just noticed this unsent message to you from 9-26 (included below) and I'd like to add an update. The vision care industry has launched a project in Open Applications Group called Vision Markup Language or VisionML. [http://www.openapplications.org/projects/VisionML.htm](http://www.openapplications.org/projects/VisionML.htm) describes our core mission and there is a short .ppt presentation on that same page under the Project Status from last update link. Anand Kumar and others will be assisting us with the ontology/terminology issues that I outline in the .ppt. While VisionML is focused on the needs of the vision care industry, the public comment, vetting, and formal voting model that we propose, as well as OAGi's basic development model will also be applicable to other specialty care domains. I believe that the logistics involved with bringing doctor-minds to bear on this problem are more challenging in some ways than the technical ontology modeling work. For this reason, we are also positioning VisionML as a demonstration project for providers in the ~30 other healthcare specialty domains. OAGi and Oracle Cporporation are co-sponsoring our webcast on Dec. 9th to inform key vision industry stakeholders of the project and to make a pitch for sponsorship of VisionML through OAGi membership. Ed, I heard and agree with your comments at the IOM briefing last Thurs. regarding patient safety. I also agree with IOM that data standards and a common vocabulary are of utmost importance and that the work must be at least partially funded by the federal government. We hope to obtain CMS/HHS funding for the VisionML project early in 2004. I would invite everyone on this email distribution list to register for our webcast at [http://www.openapplications.org/webcast/VisionML/VisionML.htm](http://www.openapplications.org/webcast/VisionML/VisionML.htm) Best regards, -C Christopher J. Feahr, O.D. Optiserv Consulting VisionML Project Lead Open Applications Group, Inc. http://www.openapplications.org Office (707) 579-4984 Cell (707) 529-2268 (9-26-03 unsent message) Thomas, I am inclined to agree with Ed (and others) who are suggesting that we at least attempt to develop a robust and nearly universal medical terminology for healthcare. Many believe that SNOMED and possibly UMLS are good places to start. CPT and ICD-type codes are barely adequate even for insurance transactions and completely inadequate for most health care processes. As long as perfection is not our immediate goal, I think we should move forward immediately into addressing the terminology component. The most expensive part of this undertaking will be the vetting with a credible representation of the provider community. An efficient mechanism for managing the vetting will have to be designed and implemented first. I would be glad to discuss some infrastructure ideas if there is interest in this. Regards, -Chris --- **Canonical:** https://discourse.openehr.org/t/open-source-ehr-at-the-americal-academy-of-family-physicians/14451 **Original content:** https://discourse.openehr.org/t/open-source-ehr-at-the-americal-academy-of-family-physicians/14451