9 posts were split to a new topic: Archetype specialisation and tooling issues
Many countries, Norway included, are going in to a new stage with Covid-19.
Going from outbreak to epidemic and now WHO has declared a pandemic situation. Lots of patient will/may need specialised healthcare services provided by the hospitals. There might be limited resources and the healthcare providers have to monitor the patients regarding the need for intensive care treatment.
I have an idea going in the direction of some scoring to evaluate the overall health state of a patient admittet to the hospital. My competence and expertice on this area is low, being a trained physiotherapist and later a technical guy. But I think there are some openEHR knowledge and archetypes in this domain.
So far I have found some possible archetypes/concepts:
- ASA physical status classification
- ECOG performance status
A scale used by clinicians to assess the functional performance status of a patient with a diagnosis of cancer. Also known as the WHO performance status or Zubrod performance status. - WHO Performance status.
- NEMS Score
Nine Equivalents of Nursing Manpower Use Score (NEMS) is a therapeutic index to measure nursing workload at the ICU level. NEMS is a suitable therapeutic index to measure nursing workload at the ICU level. - CRB-65
CRB-65 for the assessment of pneumonia severity: who could ask for more?
And then we have the score systems based mostly on vital signs:
- NEWS (National Early Warning Score) is a simple score used to provide an objective indication of a patient’s degree of clinical deterioration. This version follows guidance issued by the UK Royal College of Physicians
- qSOFA score
Quick Sepsis-related Organ Failure Assessment (qSOFA) is a simplified version of the SOFA score, which is used outside intensive care units to quickly assess sepsis risk in adults.
UPDATE:
Found a Lancet article Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, with the following interpretation:
The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future.
I am working on this to see if we are to create some templates for the follow up and risk management for patients admitted to the ward. Appreciate any feedback and experiences on this topic.
Update 2: @shnj.kobayashi shared this article on Facebook : https://www.nejm.org/doi/full/10.1056/NEJMp2003539?query=TOC#.XmrhVJvyZjc.facebook
Update 3: I am working on a template to cover the health state assessment based on vital signs and some health state scores. It’s found in the Covfefe reposistory “DIPS-Covfefe” and named: 2019-nCoV-health-state-assessment
Note: it is work in progress - working on an idea.
I’ve modelled a representation of this AU screening document and uploaded it to CKM - Template: AU COVID-19 Likelihood Assessment [openEHR Clinical Knowledge Manager]
Silje and I worked up the ‘Travel event’ archetype yesterday, deriving content from the Travel summary EVAL which has been evolving gradually for some time and had been uploaded to CKM as a proposal.
I’ve included an OBSERVATION for Screening for symptoms and signs as we do this so frequently in screening and systematic questioning, and sometimes it is just too hard to explain how to use the CLUSTER.symptom. So this creates some distance between the two for different purpose but if a symptom/sign is deemed present in the screening OBSERVATION, then the details can be further recorded in the CLUSTER as part of the formal health record.
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Covid-19 in Norway
It’s Friday evening after a week where the Norwegian society has been impacted in dramatic ways because of a extremely small organism with a huge apetitt for growth.
Yesterday all schools where closed. People who can work at home does so. And the healthcare services prepare for a huge amount of sick people. In Norway, as elsewhere, intensive beds are a limited resource. The hospitals has to prepare for lots of patients. As part of this the interest for the Covid-19 application has raised.
Current status for the deployment:
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One hospital, Diakonhjemmet Hospital, registered the first patients on Wednesday. It was used at a ward for risk assessment of admitted patients. They are also planning to use the application at the acute ward.
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The northern and western region are installing the application in test. They set up the application and prepare it as a readiness for the days to come. In total they are evaluating if they will use the application at 8 hospitals. We all know how much effort it will take to introduce a new application into a workflow with hundreds of employees, and at the same time reorganizing the wards and personell to prepare for the pandemic.
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The biggest health region in Norway, Helse Sør-Øst, is currently using our openEHR platform at one hospital, Oslo University Hospital. They want to test the application and I assume they will install in test early next week.
A very interesting story is the following:
Our company owns a system called FastTrak. It’s a great software used in some of the municipalities, for some quality registries at the hospitals and some national registries. I have admired their work for many years though it’s not based on openEHR.
What we did the last week was to adopt the openEHR clinical models we developed and apply them into FastTrak. At Wednesday we did a coordinated demonstration of our openEHR solution and FastTrak. We are currently deploying both systems to all our customers in secondary care.
I find it so appealing to see the knowledge and competence from our openEHR community being applied into other systems and speeding up the development and deployment process.
The last days I have also seen tweets with screenshots from other applications who build on the models developed by @ian.mcnicoll and the community. It so nice.
The guidelines changes somehow from day to day. We still think the inital design and architecture covers the needs. We deliver a flexible application with three forms and dataelements to display the status of the processes. Those artifacts can be used in different ways at our customers depending on the needs. Some use-cases so far discovered are:
- Risk assessment in the acute ward
- Daily risk assessment based on symptoms at a ordinary ward
- Contact tracing performed by infection team. The data recorded as part of the contact tracing might be sensitive. Our customers tend to set this up in an “access-group” for only a small number of personells.
- Retrospective follow up on outpatient stays. This use-case is not so common anymore since hospitals cut down on all their elective activity.
The next days and weeks will be very interesting. We want to find out if the measures implemented by the authorities work. The situation might change for better or worse. We, as a e-health community, will have to adapt to the changes and try our best to provide the best possible systems for our beloved health care workers.
Wash your hands and keep up the good work!!!
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That’s a great summary of the amazing progress made but much more importantly validation that this work was worthwhile. As you know, whilst the idea of an inpatient admission triage seemed sensible, we were all a little anxious that it might not turn out to have real value but simply add to the documentation burden of already hard pressed staff. I’m delighted therefore that your hunch was correct and this will have a very positive effect on others who not unreasonably did wonder about the value.
I will work further on a new version of the screening template to reflect changes in UK advice, some good ideas from the Australian screening form and possibly some more snomed coding.
It woukd be great to hear an update from anyone else developing apps based on the template even if they have made local adjustments.
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There probably is something here worth doing but it is going to be tricky to identify a core set of measures that can be agreed and do not collide too much with an existing EPR.
One approach might be to modularise things such that small parts (embedded templates) can be reused by multiple implementers but with something more like an exemplar template which is itself less likely to be actually deployed other than in clean-room scenarios.
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Hi all,
You may have noticed that in the last couple of hours @siljelb and I, as co-leads for the clinical modelling program and responsible for the governance of the CKM, have created a COVID-19 project (https://ckm.openehr.org/ckm/projects/1013.30.81) to complement the existing COVID-19 incubator (https://ckm.openehr.org/ckm/incubators/1013.30.80).
Please note: the existing incubator was previously named ‘COVID-19 project’ which may have been somewhat ambiguous and confusing.
This is to facilitate appropriate governance for the archetypes and templates as we respond to the COVID-19 crisis, as well as to provide some useful insight into data models contained within each.
For those of you not aware, the incubators operate as development and collaboration ‘sandpits’. Owners and members operate autonomously and can upload, modify and delete to suit their purposes.
On the other hand projects are tightly governed, meaning that only archetypes and templates that are have the potential (as determined by Editors and the Clinical Knowledge Administrators) to go through a peer review process and be published are uploaded to a project. Of course, in the review process there may always be situations where major changes are required or the draft archetypes may be deemed totally unsuitable and be rejected, but the intent in archetype design within projects is to create a model/pattern that will be broadly reusable beyond a single use case or data set.
In this specific case, we are acutely aware of the agile processes that were involved in the initiation of the COVID-19 work. Some initial work has been deliberately pragmatically ‘quick and dirty’ in order to get initial drafts kicked off - this was absolutely necessary at the time and invaluable as the foundation for further work to build upon. However, as time has progressed and a broader variety of use cases become evident, we have also been able to identify some reusable patterns that were not obvious in the first or second requirement documents/packages.
In the spirit of CKM transparency, location of an archetype or template within an incubator or project will provide some insight to system developers and implementers about the design intent by the model author. Of course, as incubator models become more refined and mature, then they can always be ‘promoted’ by Editors transferring them into a governed project. Similarly a whole incubator may be ‘promoted’ to a governed project.
However, critically, implementers also need to understand that being an ‘early implementer’ of data set from an incubator may be a two-edged sword with the risk of inherent technical debt. Just as any artefact within CKM with a draft status may evolve and be refined through the review process, incubator assets may also be totally incompatible with the CKM priority of creating a coherent international ecosystem of archetypes and may never have a forward path into the governed projects.
I hope this provides some clarity about the reasoning for both the COVID-19 project and incubator. It is our hope that we can continue to refine most of the work contained in the incubator and promote it to the project over time, but there are no guarantees, especially at this early stage.
@siljelb and I will do all we can to support this international effort from a governance point of view, and to complement the innovation and global leadership being demonstrated by our CKM community.
Thanks+++ to all who are actively involved, and we wish you and your families good health and safety during these difficult days. You are making an important difference 
Kind regards
Heather
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If anyone wonders what openEHR template development looks like you might want to dip into this video of me and @heidi.koikkalainen hothousing a new template based on a prototype developed by NDS Scotland.
This is to help people express their wishes about what they wish to happen should they get very sick. Was work in process but sadly being ‘hurried up’ .
The template is now at https://ckm.apperta.org/ckm/templates/1051.57.233 with the .opt at https://ckm.apperta.org/ckm/templates/1051.57.233/opt
From 45 mins, we show how the template can be used to build a simple form, save some data then query it back using the Better Ehr Explorer.
From Balsamiq prototype to simple app based on fully structured, queryable data, based almost completely on shared international archetypes in 1hr 15 minutes.
This may never get used ‘as-is’ but it shows the power of openEHR.
It was done ‘live’ with no preparation, and with a deadline of the ‘client’ teleconference 1 minute after we finished, so apologies if not exactly slick!!
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Here’s the Seattle Intensivist’s one-pager on COVID-19 - might supply a few extra data points:
https://www.onepagericu.com
And from the same site, a bunch of nice professional clinical resources.
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Details of this international project were circulated to me yesterday and may be of interest to members here. Ian has suggested I post information from the email and I have cut and pasted it here.
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I am pleased to say that KI have agreed to lead the COVID-19 Helix. Martin has set up a webpage (still not public) but you can see it here https://network.crowdhelix.com/covid-19
We have also set up a COVID-19 Helix on the platform for researchers to join as there seems to be a lot of activity on the platform and also funding available. Basically we will be collating a list of all of the collaborative funding that gets announced, and providing a new helix to foster collaborations for it - we will set up covid19@crowdhelix.com email address, and anyone with expertise in relevant fields (e.g. virology, behavioural science, epidemiology) can sign up for an individual account for FREE once we’ve checked their credentials. We wish to promote this globally.
We are also speaking with Science Business to see if we can have their news items related to COVID-19 funding and other items on to the page above. They have also said they would promote the platform across their network and contacts.
In addition to the information above, you can help in the following ways:
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Ask researchers working on COVID-19 to join the platform and recommend it to colleagues they know globally. Access will be free if we can verify the person registering is genuine.
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Recommend the COVID-19 portal (web page above) to colleagues in your network - globally
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Ask your communications department to help us disseminate this as wide as possible.
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We would be very happy to receive a quote from our Ambassadors supporting this initiative and we can publish this on the page. This will give us the credibility required and get above all the noise that is happening over the internet on this topic.
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We would also like to add the logos from your organisation/institution to this page - please let us know if this is ok.
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Covid-19 Citizen Screening
In Norway we are working on the idea to provide citizen screening. DIPS and a few other vendors will meet tomorrow (Friday, 20. March) to discuss if we can share some information models.
The source code for the models is here: https://github.com/DIPSAS/covid-19-citizen-screening
I will update on the status tomorrow evening.
Wash your hands, take care and keep up the good work!!
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Here is a link to a shared folder I have set up with two very good short videos explaining the medical science and health service implications of the current viral epidemic. They’ve been circulated within my local Neighbours’ WhatsApp Support Group.
Also, The Times in the UK has started publishing a daily and freely available email news summary of the epidemic . You can sign up to receive this at:
Thought these resources might be useful. Best wishes to all.
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I have made an illustration to clear my thoughts on the symptom/disease state, the isolation procedure and the outcomes.
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Update from Norway
Last week was really absurd in so many ways. Norway was locked-down to face the pandemic situation. Schools are closed. People who can work at home does so. And people buy as much toilet paper as they can carry. We have no idea why they do so, but we assume it is important to have a shiny ass when facing a pandemic situation…
Our customers prepare for lots of patients in the hospitals. The health regions had working groups to decide what solution to choose. Current state is:
- Northern and western region deploy DIPS Arena “on track of Covid-19”
- South-east region deploy DIPS FastTrak “on track of Covid-19” (this is not native openEHR but developed based on the clinical models we made)
On Friday there was a meeting among Norwegian vendors and the Directory of e-health. The intention from the vendors was to agree on some clinical models. An outcome from this was that @siljelb takes the lead to organize and develop the shared clinical models and terminologies to be used. This is really good news. The Norwegian vendors will adapt these models. In turn this makes data inter-operable and the applications will be portable.
I find it really satisfying to experience that the principles of an open platform is what really works when it really matters.
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