eHealth Foundations: Can openEHR Provide One Layer?


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

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  • Organic theme in Powerpoint 2013
  • Foundation Co-Chair of the EHR Special Interest Group and then Technical Committee of HL7 with Linda Fischetti from DVA (USA)
  • Change in each language and behaviour happens at different rates. Technical language faster than clinical language faster than spokenlanguage
  • Ailsa & ConsumerA lot of things happen with health records in any environment that need to be spelled out (and allow opt out). If a clinician writes a record of care they are required to maintain it for a certain period.
  • UK: Standards-based approach 11 Billion GBPAUS: Standards-based approach 1 Billion AU$ - $200K per record after 17 months.
  • Design by committee
  • I don’t know how many times I have heard a new recruit to national eHealth programs pronounce with great authority (vested by?) that one or two Jumbo Jets of people are dying unnecessarily from mistakes made by doctors and this needs to be changed. Further, it is the national eHealth program that is going to do it.
  • James Reason “Swiss cheese” model. An adverse event occurs when “holes” inorganisational defences (represented as slices of Swiss cheese) align to allow a “trajectory of accident opportunity.”Michael Buist “Futile Circles” Healthcare adverse events occur not because ofignorance or inability but because of the circular way that staff apply the unwritten rules and work practices that exist in healthcare. This circular thinking or clinical futile cycles that staff use to try to solve the problem prevents escalation to the next level in the clinical hierarchy. This continual cycle of clinical thinking and action is slow and consumes valuable time when confronted with a deteriorating patient.
  • Maybe, says Jerry Sternin, the problem isn't with the outside experts or with the company. "The traditional model for social and organizational change doesn't work," says Sternin, 62. "It never has. You can't bring permanent solutions in from outside." Maybe the problem is with the whole model for how change can actually happen. Maybe the problem is that you can't import change from the outside in. Instead, you have to find small, successful but "deviant" practices that are already working in the organization and amplify them. Maybe, just maybe, the answer is already alive in the organization -- and change comes when you find it.
  • Black swans are the unknown future events that provide the stressors on current systems. Preparing for known events is not sufficient to deal with unforeseen events.
  • 50,000+ remote Indigenous people registered, 300 read/writes per hour.
  • Think!EHR Integration Import/Export EhrData (HL7v2,CDA,...)
  • 3. doing CDS with ehrscape and GDL tool-- user defines guidelines with GDL which we integrated with our Think!EHR server and with our CDS engine-- once guidelines are uploaded to CDS they are visible and accessible within ehrscape portal-- furthermore you can use rules directly within Think!Med Clinical; pokažikako se rule lahkodirektnouporabiv Think!Med zaposameznegapacienta-- and population based querying and guidelines are also possible - show Leandro portal
  • 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