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eHealth Foundations: Can openEHR Provide One Layer?


Published on

Presented by Sam Heard
Chair, International HL7 EHR Technical Committee
Chairman, openEHR Foundation

Published in: Health & Medicine, Business

eHealth Foundations: Can openEHR Provide One Layer?

  1. 1. eHealth Foundations: Can openEHR provide one layer? Sam Heard Chair, openEHR Foundation Practicing Family Physician Bill Aylward, OpenEYEs, Rong Chen Cambio, Ian McNicoll Ocean
  2. 2. Declarations of interest A clinician who wants a genuine electronic health record that can be utilised at the point of care wherever a person interacts with the health service. This record should not have to be complete or unitary. The technology should not dictate the information flow. I want to see it in my lifetime. HL7Rim RIM HL7 I am chairperson of the openEHR Foundation, Ocean Informatics and Northern Territory General Practice Education. I earn money seeing patients and some consulting with Ocean Informatics who were awarded as a Microsoft Health Partner of the Year for 2013. RIM Free Zone
  3. 3. People Discourse in eHealth Health Portal, A pps Consultation TeleHlth Multiple barriers to communications: • Languages and behaviour • Clinical language and behaviour • Technical language and behaviour IT Clinicians Developer Clinical Software
  4. 4. Balance • ―If it doesn‘t work for the clinicians then it isn‘t a health record‖ • Ownership not a useful concept, Access is. • Masking information can rarely be done safely without referral or a new point of care • • Other information available gives diagnosis (e.g. medication, test results) Documents are statements for which clinicians are medico-legally accountable
  5. 5. Some facts are unpalatable • Breast self examination does harm - sacking of the UK NHS Chief Medical Officer • A CT of your brain is more likely to cause a brain tumour than detect one • PSA‘s do harm – but are widely promoted by Urologists direct to consumers • PAP Tests under 25 do harm
  6. 6. Domains of Standardisation in Health • Evidence-based practice • • Quality and Safety • • Synthesis of the latest research generates best practice recommendations Performance indicators flag when processes are suboptimal Technical operations • • For interoperability Safe operation
  7. 7. Why does standardisation fail? • The standard fails to get started • The standards group fails to achieve consensus and overcome deadlocks • The standard suffers from ‘feature creep’ and misses the market opportunity • The standard is finished but ignored by the market • The standard is finished and implementations are incompatible • The standard is accepted and is used to manage the market Carl F Cargill:
  8. 8. Why does standardisation fail? • CEN: New Work • • Title: Service Excellence Systems – requirements and guidelines for service excellence systems in order to achieve customer delight Scope: This Technical Specification specifies requirements and guidelines for service excellence systems in order to achieve customer delight. This Technical Specification applies to all organizations delivering services like commercial service providers, public services and service departments of manufacturers.
  9. 9. Standards Domain Experts Clinicians, Consumers, Research, Administration
  10. 10. Interoperability is not a tech problem • Interoperability is a clinical problem • Diverse recording practice (sometimes arbitrary) Diverse recording requirements Complexity / contextual nature of health data • Lack of clinical involvement in standards development • • Too technical, too philosophical • Too time-consuming, too slow •
  11. 11. Archetype Reviews
  12. 12. Template Reviews © 2012 Ocean Informatics
  13. 13. CKM Users • International openEHR CKM instance • • • • > 1000 users From 80 countries From all Health professions and many health domains Also National programs with an instance of CKM Countries
  14. 14. Use the Same Archetypes in Various Applications, Worldwide ... © 2012 Ocean Informatics
  15. 15. If not then ―Clinical systems‖…. •Moorfields: 68 •Leeds: 320 •St Thomas‘: 760
  16. 16. The Role of Standards 2000-2013 • To ensure massive human and financial waste via: • • • Over claiming benefits Employment of consultants Making something quite easy very costly • To stifle innovation and ensure everyone waits as long as possible • To exclude domain experts • • • • Cost of attendance Opportunity cost to other functions Obfuscation Language
  17. 17. I've searched all the parks in all the cities — and found no statues of Committees. G K Chesterton
  18. 18. NEHTA Tool Chain Self validating XML Schema
  19. 19. Tool Chain Governance 1. Clinicians and/or Consumers determine content 2. On line review (maintenance cycles as required) 3. Use case dependent aggregation, term sets and extension 4. On line review (and maintenance cycles as required) 3. Generate artefacts 4. Publish
  20. 20. Tool Chain Archetype Archetype Archetype Archetype Template CDA Spec FIHR Resource Template Data Schema CDA Instance openEHR Repository FHIR Instance
  21. 21. Quality and Safety in Healthcare Why have we failed to improve outcomes?
  22. 22. Quality and Safety Agenda • ―Despite huge investment in quality and safety over the past two decades, healthcare is still failing to learn the lessons from its mistakes.‖ • 1995 Australia: 16.6% of patients had one or more adverse events Only 38% Of these events 18.4% resulted in death (4.9%) or major of adverse events occurred in disability (13.7%) hospital • 50% of these were considered preventable • 1000 patients • 32 • 900m over 5 years established an industry with Serious events • 16 preventable commissions, standards etc • 6 were ‗visible‘ • 2 died • Clinicians remain disengaged. • BMJ 2013;347:f5800 doi: 10.1136/bmj.f5800 Sep 2013
  23. 23. Quality and Safety Agenda • 1999 Australia: 70% of adverse events due to human error • • • • Failure of technical performance Failure to decide or act on available information Failure to investigate or consult Lack of care or failure to attend • 50% associated with an operation • Internal medicine - highest incidence - highest deaths
  24. 24. Models of Failure Futile Circles Model: Michael Bruist Swiss Cheese Model: James Reason
  25. 25. Questions for the future • Why do doctors not act on available information? • Why is there lack of concern? • Why is there failure in care and attendance? • Clinical Engagement, Ownership, Responsibility • Leadership and Mentorship
  26. 26. Guidelines and Checklists Preoperative Surgical Checklist • Death rate Before • After • • • 1.5% 0.8% Inpatient complications Before • After • Febrile Child Guideline 11% 7% NEJM DOI: 10.1056/NEJMsa0810119 Jan 2009 Derived from evidence • Traffic light system • Dealing with rare conditions • BUT • Other extremely rare conditions occur at considerable rate
  27. 27. How can we improve healthcare with IT? Positive Deviance • • • Jerry and Monique Sternin Save the children (Vietnam 1990) Reduced malnutrition by 85% in 2 years without supplements Antifragility • Nassim Nicholas Taleb • Author of ‗The Black Swan‘ • • Can‘t predict unexpected events Antifragility • Fragile v. Robust v. Antifragile
  28. 28. Positive Deviance • Communities are the best experts to solve their own problems with existing solutions. • Communities self-organize and have the human resources and social assets to solve an agreed-upon problem. • Collective intelligence and apply it to a specific problem requiring behavior or social change. • Sustainable and demonstrably successful uncommon behaviours are already practiced in that community within the constraints and challenges of the current situation. • ―It is easier to act your way into a new way of thinking than think your way into a new way of acting‖.
  29. 29. Positive Deviance 1. Don‘t presume you have the answer 5. Identify and analyse the deviants 2. Don‘t think of it as a dinner party 6. 3. Let them do it themselves Let the deviants adopt deviations on their own 7. Track results and publicise them 4. Identify conventional wisdom
  30. 30. Antifragile • Biological systems are antifragile by nature • • • • Physical death is necessary Biological decay not oxidation Support the emergence of new life Can we build systems that benefit from shocks and assaults? • • Managing the market with standards is opposing this Introduce appropriate components into a given functionally-based arrangement • • • Most ideal relationships and interactions Self-selection Antifragility is the property of complex organic systems that have survived • Depriving them of volatility, randomness, and stressors will harm them
  31. 31. What does openEHR provide? Positive Deviance • • • Only in kind resources for 10 years Uptake in Slovenia, Sweden, Norway, Brazil , Uruguay, Australia, United Kingdom, Portugal, Angola First 7 Industry Partners have committed to collective activity and funding Antifragility • Software in Java, Eiffel, .Net, Ruby, Python • Three Java Servers • Two open source • One Ruby Server • One .Net Server • Supporting the Clinical Information Modelling Initiative (CIMI) • Federated governance
  32. 32. What does openEHR provide? • A technical specification genuinely independent of technology • An increasingly comprehensive approach to recording, querying and sharing health information • A health record platform that: • • • • • Does not know what will be stored in it Returns data to browsers in default format or any other format required Supports a query language independent of database technology Supports distributed editing of health information A federated international environment for clinicians to agree what structured data they want to collect
  33. 33. openEHR in Use • NT My eHealth Record • Western Sydney Shared Care Planning (incl. mobile app) • Queensland and NT Infection Control • UK: Leeds Trust Clinical Data Repository • UK: Orsini Project – Open Eyes, Open ENT, Open Cardiac, Open Oncology • Slovenia: Hospitals • Moscow: Shared Health Record • Japan: Major Disease Register • Uruguay: Shared EHR Service • Brazil: Private Health Record Aggregation • Angola: Hospitals
  34. 34. NT My eHealth Record: Health Index
  35. 35. NT My eHealth Record: Antenatal
  36. 36. OpenEyes •Web application •Open Source •Clinically led •Flexible •Modular
  37. 37. OpenEyes •Web application •Open Source •Clinically led •Flexible •Modular
  38. 38. Prescribing
  39. 39. Detailed clinical info
  40. 40. The Work of • The first regional activity of the openEHR project • Translation Architectural over view, openEHR licensing • openEHR primer, Eiffel FAQ • openEHR Models, Archetypes and Biomedical Ontologies • • Delegation to international community • • Implementation • • International congress, Medinfo2007, 2010 and 2013. Ruby implementation for openEHR specifications Seminars • MOSS, Seagaia meeting, This EMBC2013 workshop!
  41. 41. EMBC2013, Osaka Hiroyuki Yoshihara Shinji KOBAYASHI Koray Atalag Jussara Rotzch John Halamka
  42. 42. openEHR Archetypes: open source Clinical information components • Clinically-led + collaboratively authored • • • • open-source ‗crowd-sourcing‘ methodology democratised clinical content development Shared open repository CC-BY-SA licence Agility to respond to continually changing clinical demand • • Clear ownership, change request mechanism Tight version control
  43. 43. INDUSTRY/Profession-driven standardisation ‗open Governance‘ Implementation Clinical Knowledge Administrators Blood pressure Archetype Editors Secondary endorsement Opthalmology Project Editors Archetype Reviewer Visual fields archetype Archetype Reviewer Visual acuity archetype Reviewer Review
  44. 44. openEyes Glaucoma : Initial authoring Gather evidence Refine mindmap (inclusive dataset) First draft mindmap Create /Upload Initial archetype
  45. 45. openEyes Glaucoma : Implementation Template Data Schema
  46. 46. Professional oversight [1] Clinical content NHSvista Care API [3a] LCR apps (Leeds) NHSvista Reporting API [3b] ESB / ITK / Spine components [2] NHS vistaopenEHR Adaptors [8] openENT (UCLP) Wardware2 (Kings) OpenEyes (Moorfields) openEHR API integration [7] Local SQL DB EHRPaaS [9] openEHR API openEHR Repository (vendor #1) openEHR API openEHR Repository (vendor #2) openEHR API openEHR Repository [10] (open source)
  47. 47. Leeds NHS Care Record: open Platform OpenEHR Clinical Content “Archetypes”: • • • • Medication, allergies (GP2GP/ RCP/NHSS) Problems, procedures (international) End of Life content (ISB) Vital Signs, NEWS (international) Open APIs: ESB/Spine ITK Integration component openEHR Foundation accredited Open Standards CDR Service layer SMARTPlatforms Commit Retrieve Query N3 hosted Leeds Clinical Portal Clinical data repository
  48. 48. Leeds Innovation Lab: open Platform Demonstrator OpenEHR open source Clinical Content : “Archetypes”: • • • • Medication, allergies (GP2GP/ RCP/NHSS) Problems, procedures (international) End of Life content (ISB) Vital Signs, NEWS (international) Open APIs: FHIR ITK Integration component openEHR Foundation accredited Open Standards CDR Service layer SMARTPlatforms Commit Retrieve Query N3 hosted Leeds Clinical Portal Clinical data repository
  49. 49. openEHR CLOUD ‗Platform as a Service‘ ITK Integration component N3 hosted ESB/Spine Value-add components openEHR Foundation accredited Terminology Server Pathways KB Commit Retrieve Implementation-agnostic CDR Service layer Query Oracle Marand SQL Server Ocean NHS OSS? openEyes Postgres SQL Code24 CDR Solutions
  50. 50. Think!EHR PlatformTM November 2013 Tomaž Gornik
  51. 51. eHealth – City of Moscow Moscow city medical institutions network comprises 780 medical and preventive treatment facilities, including: • 149 hospitals, 76 health centers, 428 policlinic institutions, 28 centers, 63 maternal and child health care institutions, 36 extended care facilities, 12 special type health care institutions Numbers: • Patients- 12 million, Beds in hospitals – 83,000 • Physicians – 45,000, all users – 130,000 • Patient Visits/year - 161 million • Documents/year - 1 Billion, 25TB Based on IHE and Think!EHRTM Platform! 57
  52. 52. SMART API integration 58
  53. 53. Medication Prescribing 59
  54. 54. Fluid Balance 60
  55. 55. Lines, Tubes, Drains 61
  56. 56. Care Protocols 62
  57. 57. Nursing Care Plan 63
  58. 58. EHR Search
  59. 59. CDS/GDL Integration
  60. 60. Think!EHR Explorer 4.0 66
  61. 61. Overview Introduction of Guideline Definition Language (GDL) Rong Chen MD, PhD CMIO, Cambio HINZ 2013
  62. 62. Guide Definition Language (GDL) Design A minimum language to glue together archetypes, terminologies and rules Three Pillars • Bindings between archetype elements and variables in the rules • Rule expressions easily converted to industry rule engine languages • Bindings between local concepts used in the rules and concepts from reference terminologies
  63. 63. EhrGen: Pablo Pazos Open source openEHR server and test environment.
  64. 64. Paul Downey: ―Standards are Great! Standardisation is a really bad idea..‖ 2009
  65. 65. There are no shortcuts Sam Heard Chair openEHR Foundation