Presentation of Waseda university openEHR meeting, with MML-openEHR project and IBIME group developments explained. Most of the presentation (92 slides) is a state of the art about dual model approaches in the world

1. Progress of openEHR Implementation in Spain, Europe and the World Diego Boscá, IBIME Group, Technical University of Valencia, Spain

2. Index (I) Introduction MML-openEHR-HL7 CDA project Europe Sweden UK Denmark epSOS project Spain Other countries 2

3. Index (II) World Brazil Uruguay USA Australia Other world countries Japan Discussion 3

4. Introduction The use of standards that take into account clinical knowledge is gaining focus openEHR ISO13606 HL7 v3 Detailed Clinical Models (DCM) Both openEHR and ISO13606 use archetypes to describe clinical concepts 4

5. openEHR & ISO13606 Two norms, different objectives: openEHR is for EHR system ISO13606 is for the communication of EHR CEN EN13606 adopted the openEHR archetype model. Archetypes part of openEHR is ISO norm (ISO13606-2) 5

6. openEHR & ISO13606 ISO13606 model is a subset of openEHR Also, ISO13606 is more generic ISO13606 not only archetypes: ISO13606-1: Reference model ISO13606-2: Archetype interchange specification ISO13606-3: Reference archetypes and term lists ISO13606-4: Security ISO13606-5: Exchange models http://www.en13606.org/ 6

7. Modelcomparison 7

10. MML concepts as archetypes MML has two kinds of concepts: Common concepts (support) and content modules (clinical concepts). 10

11. MML concepts as archetypes An archetype was created for each concept on common and content modules 9 archetypes for common concepts 12+1 archetypes for content modules The extra archetype is a reused concept Archetypes do not follow openEHR model 11

12. Example Patient information archetype 12

13. Example 13

14. Work Can MML conceptsberepresentedwitharchetypes? Can wegeneratecorrect MML XML fromthe MML archetypes? Can wemap MML tootherstandards? 14

15. Correct MML from archetypes Fordemostration, some MML archetypesweremappedwithconstantvalues and with a sample data source Theexample data instancesweremodified so theyhavejapanesewriting (kanji, hiragana) 15

16. Result Original XML <patientSummary> <extractTime>2010-12-21T12:14:05</extractTime> <id>ID01</id> <demographics> <patientName>被記</patientName> <patientSurname>載者</patientSurname> <dateOfBirth>1974-06-12</dateOfBirth> <gender>M</gender> </demographics> </patientSummary> XQuery Result XML <?xml version="1.0" encoding="UTF-8"?> <mmlNm:Name mmlNm:repCode="A“ mmlNm:tableId="MML0025"> <mmlNm:family>載者</mmlNm:family> <mmlNm:given>被記</mmlNm:given> <mmlNm:fullname>被記, 載者</mmlNm:fullname> </mmlNm:Name>

17. Work Can MML conceptsberepresentedwitharchetypes? Can wegeneratecorrect MML XML fromthe MML archetypes? Can wemap MML tootherstandards? 17

18. Mapping to other standards Only MML clinical modules need to be mapped, support module classes will be inserted on the archetypes before mapping A project was proposed: mapping between openEHR-MML-HL7 CDA Transform data from MML and HL7 CDA into openEHR XML data and store it with opereffa 18

19. Proposed system 19 HL7 CDA openEHR MML Transform Transform Transform Transform Opereffa openEHR

20. Where to start? We have the MML archetypes, we can choose openEHR archetypes to create the transformation from openEHR MML A set of openEHR archetypes was selected from CKM (public online archetype repository) Already existing Japan related openEHR archetypes 20

21. Mapping Few MML concepts have similar scope that openEHR archetypes… MML Diagnosis record ≈ openEHR-EHR-Evaluation.problem-diagnosis MML Progress course ≈ openEHR-EHR-SECTION.soap.v1 But mostly don’t! Missing archetypes Multiple archetypes to represent only one concept Different granularity or internal structure Different codes! 21

22. Missing archetypes Some concepts on MML are not represented yet with openEHR archetypes or information is Japan specific MML Health Insurance module? Japanese names? Subjective archetypes? Create new openEHR archetypes when needed 22

23. Multiplearchetypestorepresentone concept Forthepatientidentification, 10 archetypeswherechosen. 8 fromtheopenEHRrepository: openEHR-DEMOGRAPHIC-PERSON.person.v1 openEHR-DEMOGRAPHIC-PARTY_IDENTITY.person_name.v1 openEHR-DEMOGRAPHIC-ADDRESS.address.v1 openEHR-DEMOGRAPHIC-CLUSTER.person_additional_data_iso.v1 openEHR-DEMOGRAPHIC-CLUSTER.person_identifier_iso.v1 openEHR-DEMOGRAPHIC-CLUSTER.person_death_data_iso.v1 openEHR-DEMOGRAPHIC-CLUSTER.person_birth_data_iso.v1 openEHR-DEMOGRAPHIC-CLUSTER.biometric_identifier_iso.v1 2 providedbyKobayashiShinji: openEHR-EHR-CLUSTER.person_name-japan.v1 openEHR-EHR-CLUSTER.address-japan.v1 23

24. Different granularity 24 Join or split fields on the mapping process… …but also, suggest improvements to current openEHR archetypes!

25. Different codes Both MML and openEHR archetypes rely on internal terminologies Valid status Valid texts or codes Make table mappings between them E.g. sex 25

26. DEMO 26

27. Work to be done Create the mappings between the openEHR archetypes and the remaining MML archetypes Finish and check the validity of the openEHR to MML transformation Generate valid instances from openEHR archetypes for testing MML to openEHR archetypes. Usually, several openEHR archetypes were mapped to only one MML concept… …so one MML concept can be mapped to different openEHR archetypes 27

28. openEHR use:Europe

29. Sweden Sweden National Project Business: CAMBIO Transforming openEHR archetypes & templates to Cambio templates Academia Linköping University 29

30. SwedenNational Project Long term project Use both openEHR and ISO13606 at different stages of the national project Their own CKM version SKL (Sweden version of CKM) http://sllocean.karolinska.se/ckm/ 30

31. SwedenNational Project 31 © IngerWejerfelt

32. SwedenNational Project Level 1: NPÖ (National Patient Summary) Create a 13606 archetype and generate the NPÖ from current systems Level 2: Pilot : two healthcare organizations, one quality register Use archetypes to capture information and send to quality register Use of SNOMED Level 3: Full openEHR system 32

33. Linköping University LiU EEE (Educational EHR Environment) Based on openEHR & REST Modular Open source XML database for storage Support for AQL 33

34. UK NHS Sintero: Wellcome-fundedresearch datarepository (diabetes) UCL Opereffa(openEHRREFerence Framework and Application) 34

35. NHS Connecting for Health Developed nearly 1000 openEHR archetypes and 60+ templates https://svn.connectingforhealth.nhs.uk/svn/public/nhscontentmodels/ Using a profile of EN13606 (together with CDA) as part of the Logical Record Architecture How to link SNOMED-CT with archetypes 35

36. UCL Opereffa Open source DevelopclinicalapplicationsbasedonopenEHRarchetypes BasedontheopenEHR Java implementation Additionalfunctionality GUI generation Persistence Demo: http://opereffa.chime.ucl.ac.uk/MainContainer2.jsf 36

37. 37

38. Denmark Proof-of-concept project: Observation archetypes were easilyadopted by vendors Non-observation archetypes, not so direct Vendors believe on archetyping to import semantically rich data on their systems Vendors not willing to implement non accepted parts of openEHR, like templates or export Governance is a big challenge 38

40. epSOS Project Methodology: Clinical specifications were developed by a clinicians A set of terminologies was selected, from international sources or as an own development. Technical specifications in HL7 CDA and ISO 13606 were defined following the clinical specifications. Pilot tests are being implemented. © David Moner 41

41. Spain Not adopted by the government (yet) But with presence in hospitals and the academic world. 100+ professionals formed on ISO13606 standard 42

42. Spain 43 Academia Alcalá University ArchOnt Framework Carlos III Institute Archetype instance server Murcia University openEHR↔ ISO13606 converter Archforms

43. Spain 44 Academia Vasque Country University EHROnt Valencia Technical University Archetype based legacy data integration Business Veratech

44. Alcalá University ArchOnt Framework 45 Inference SNOMED Reference Model Archetype Ontologizer 3 1 ADL Archetype 2 Instance Mapper Patient data Risk data

45. Carlos III Institute Archetype Instance Server Based on ISO13606 Instance repository Instance validator Use of ISO21090 for data types profiling 46

46. Murcia University openEHR↔ ISO13606 converter Transform between openEHR and ISO13606 archetypes via OWL http://miuras.inf.um.es:9080/PoseacleConverter/ Web service Archforms Generate graphical interfaces from the reference model semantic model 47

47. 48

48. Vasque Country University EHROnt Framework for translation between standards EHR classes described in OWL Mappings as SWRL rules For the moment works with ‘observations’ More classes will be supported in the future 49

49. IBIME Group (UPV) Leaded by PhD. Prof. Montserrat Robles Ten years of experience in the field of Biomedical Informatics ≈ 20 members Funded by Regional, National and European R&D projects and technology transfer http://www.ibime.upv.es 50

50. IBIME Group (UPV) LinkEHR Archetype Editor Archetype edition Reference model independent Open Source LinkEHR Integration Archetype Editor Legacy data source mapping XQuery scripts automatic generation EHRFlex (EHR Viewer) Archetype based EMR system Open source 51

51. LinkEHRArchetype Editor Any model can be imported Tested models: openEHR, ISO 13606, HL7 CDA, ASTM CCR and CDISC ODM. Therefore, it is possible to define archetypes based on these models. Archetype creation driven by the reference model Includes a syntactic and semantic validator. Connection with CKM 52

52. LinkEHRIntegrationArchetype Editor To generate XML documents conforming to the reference model is necessary to define how archetypes sources of data are related: mappings or correspondences. The user must specify how to calculate from one or several values of the data source the value of an attribute of the archetype. The data sources can be relational,XML or archetypes 53

53. Data source: demographics Archetype Patient Full Name concat Age Gender Standardization Process with LinkEHR-Ed

54. EHR Viewer (EHRflex) EHRflex is an archetype-based Electronic Medical Records system. Independent of the reference model. Uses web technologies (Google Web Toolkit). Automatic generation of archetype-based interfaces for view and edit clinical data. Open source project.

55. EHR Viewer (EHRflex)

56. EHR Viewer (EHRflex) Open source project: http://ehrflex.sourceforge.net/

57. Real Experiences Hospital General Universitario de Valencia Pangea-LE implementation for over 5 years Integration of distributed data sources (more than 25 databases). Virtual Federated EHR viewer. Full migration to ISO13606 EHR Extracts in development.

58. Real experiences

59. EHR petition LinkEHR-Ed Pangea-LE Map XML Archetype Standardization Integration Legacy data sources Proprietary XML Standardized XML Other uses EHR communication EHR viewer Sistema LinkEHR 60 Real Experiences

60. Real Experiences Hospital de Fuenlabrada (Madrid) Use of openEHR and ISO13606 archetypes for pressure ulcer nursing control. The archetype creation methodology was evaluated. Both reference models were compared and tested.

61. Real Experiences Hospital de Fuenlabrada (Madrid) Use of EN13606 for medication conciliation between primary and specialised care. Agreed definition of a primary-care summary archetype. Communication of normalised legacy data to support patient transitions between primary care and the hospital.

62. Real Experiences The semantic interoperability of the Patient Summary is being tested between the Hospital General Universitario in Valencia (HGUV) and the Hospital de Fuenlabrada in Madrid. Based both on the Spanish and epSOS definition of the contents of the Patient Summary. The information is communicated using the CEN EN13606 norm.

63. Real Experiences Hospital de Fuenlabrada Madrid Communication of standardized EN13606 information EHR Server EHR Server Hospital General Universitario Valencia

64. Methodology 1. Agree a concept definition and define the archetype We have used two different definitions Spanish National Patient Summary epSOS Patient Summary final dataset They can be easily edited or modified with open source archetype editors like LinkEHR-Ed http://www.linkehr.com

65. Methodology 2. Map the archetype to original/legacy data With these mappings we can automatically generate transformation programs for the EHR system. Existing EHR systems XML

66. Methodology 3. Deploy the transformation program in the EHR server Set up a standard EN13606 extract server in both hospitals to generate and communicate the standardized information Transformation is applied on demand Web-service based Includes a standard EN13606 web viewer Mapped Archetype Mapped Archetype EN13606 Standard Information XML CHGUV HIS HF HIS EHR Server EHR Server

68. Real Experiences Virgen del Rocío Hospital HL7 CDA can be archetyped. Archetypes can be used as templates for HL7. HL7 CDA has some characteristics that do not follow Object Oriented Modeling, but are XML Schema specifications. Archetypes are only applicable to OO models, so some tweaks had to be implemented. LinkEHR can use CDA archetypes to generate valid CDA instances of existing data. 69

69. Other Countries Slovakia: National eHealth program based on openEHR Portugal: Integrating legacy data (National system) with openEHR archetypes and templates Russia: Interest in openEHR Netherlands: ZorgGemak. Health record based on openEHR Austria: University of Vienna. Archetype repository Germany:Helmholtz Center München. CCR equivalence in ISO13606 Romania: ISO13606 compatibility with Romanian healthcare system 70

70. openEHR use:World

71. Brazil openEHR and archetypes for the shareable EHR at three levels of government - federal, state and municipal. Minas Gerais 13606 project Business Zilics: eZ-EHR P2Z: ProntuárioUniversal P2D 72

72. BrazilianNational Project Defined the standards going to be used on the National Brazilian Project EHR information model: openEHR clinical reference terminology: SNOMED CT clinical documents: HL7 CDA record location: IHE PIX (Patient Identifier Cross-Referencing) and PDQ (Patients Demographics Query) Not much more information yet 73

73. Minas Gerais Project Largest Brazilian state 853 cities Over 5000 health units Store every citizen patient summary and demographic data using 13606 archetypes Duration: from 2009 to 2015 Developed archetypes availabe at: http://sres.saude.mg.gov.br/arquetipo/listar 74

74. Uruguay Open EHR-Gen Framework: Automatic generation of GUI Data validation Data persistence Generation of CDA Open source (apache license) https://code.google.com/p/open-ehr-gen-framework/ 75

75. Open EHR-Gen Framework 76

76. Open EHR-Gen Framework 77

77. USA Ethidium Evolution EMR: small to medium sizedfacilities EMR openEHR based system PatientOS open source Complete HIS based on openEHR archetypes American College of Rheumatologists Designing EHR content using openEHR 78

78. Australia Bussiness Ocean Informatics Medical Objects Extensia Meridian Health Informatics Projects GastrOS 79

79. OceanInformatics Archetype editor (Free) Template designer (Licensed) Ocean EHRBank (Licensed) Ocean Clinical Knowledge Manager (CKM): Archetype Repository (Licensed) Archetype Workbench (open source, Eiffel) Terminology Server Query builder 80

80. GastrOS Endoscopic reporting application Based on openEHR and MST (Minimal Standard Terminology for Digestive Endoscopy) Open source (C# and .NET) Annotations on templates show how GUI is displayed http://gastros.codeplex.com/ 81

81. GastrOS 82

82. Australia Queensland Health: openEHR repository for dischargesummary management Cancer Council of Victoria: openEHR to aggregate current data in the repository NEHTA openEHR – HL7 relationship 83

83. NEHTA Adopted openEHR archetypes to represent clinical concepts Created their own CKM repository http://dcm.nehta.org.au/ckm/ Involving the Australian clinicians in the concept creation process The archetypes will be transformed into platform and reference model agnostic models (based upon ISO 11179) 84

84. openEHR – HL7 relationship People from openEHR and HL7 meet on the last HL7 WGM on Sydney openEHR archetypes ≈ DCM ≈ HL7 templates There is an intersection! Create a technical document with the differences and similarities A HL7 DCM is an archetype, but not a openEHR archetype! 85

85. Japan Kano Laboratory Virtual EHR editor openEHRApp Ehime University/Kyoto University Intractable disease surveillance program Yoshihara Laboratory MML ↔ openEHR transformation 86

86. KanoLaboratory Virtual EHR editor EHR application Open source openEHRApp Generic EHR processing platform Open source In use on different projects: For emergency medical service in Jakarta, Indonesia For tuberculosis data collection in Cambodia For maternal and child care 87

87. KanoLaboratory 88 Virtual EHR Editor User Interface Back-end Generic EHR processing platform 1. Available openEHR service model (EHR Service, Demographic Service, etc.) 2. REST web service communication 3. Available openEHR API (openEHR Java Reference Implementation) 4. Available Wrapper technique (http://www.openehr.org/projects/opereffa.html) 5. Javaobject-oriented database (db4o, open source) ©Kong Saran

88. Intractable Disease Surveillance Program Distributed data bases with more than 600k patients Model clinical research forms using openEHR archetypes and templates Translation & adaptation of archetypes Demographic, Insurance Implementation of a server and a registry 89

89. Other world countries Chile: National program South Africa: Two companies working to provide a national solution Canada: pilot New Zealand: Shared Health Information Platform (SHIP) Kazakhstan 90

90. Discussion Dual model approaches are on the focus of governments, enterprises and universities A lot of open source approaches CKM Archetypes have creative commons license 4 working archetype repositories + several archetype repositories on the works New openEHR specifications in the works 91

91. Discussion Archetypes can be used to describe clinical knowledge, even outside openEHR and ISO13606 Transforming archetypes (concepts) between standards will be very important in the future… and now! 92

92. 93 おわり Diego Boscá diebosto@upv.es