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Norwegian national governance of archetypes
Silje Ljosland Bakke RN
Information architect, National ICT Norway
Norwegian public hospital system
The Norwegian public hospital system consists of
four Regional Health Authorities (RHAs), with a
total of 24 Hospital Trusts, each of which have
one or more hospitals. 100% of the hospitals
have adopted EHRs. Two vendors dominate
the hospital EHR market; Siemens (Central
Norway) and DIPS (the three
remaining regions). One
common health trust, National
ICT (Norwegian: “Nasjonal
IKT”), acts as a strategic
coordinating unit for the
hospital sector’s common ICT
commitments.
openEHR in Norway
As of yet, only Oslo University Hospital is using an
openEHR based system in a production
environment. DIPS is finalising its implementation of
openEHR, and their solution is being tested in
hospitals around the country. Several other vendors
are either in the process of or are looking into
implementing openEHR as part of their products.
National ICT has developed and deployed a scheme
for the national governance of archetypes. The goals
of the governance scheme is ensuring a high quality
of archetypes as well as enabling semantic
interoperability between systems through the use of
identical archetypes. The governance scheme is
heavily dependent on a common tool for both
collaborative development and sharing of
archetypes and templates. For this purpose,
National ICT has chosen the Clinical
Knowledge Manager (CKM) from
Ocean Informatics.
The governance model
The governance model has three
main phases; development, review
and approval.
Development
Development of archetypes is based
on a so-called “do-ocracy”, where
those who actually spend time and
resources doing something decide what gets done
and in which fashion. Whoever wants to influence
decisions can do so, but only by participating
actively in the development process. This has the
advantage that as long as someone is willing to
spend the resources to do something, it will get
done whether or not anyone else is interested in
participating. To ensure a real possibility of
participation in new initiatives, this model also
requires a very open and transparent development
process, something the CKM does very well.
The actual archetype development is done in a
geographically distributed manner, using the CKM as
a collaborative tool. Requirements are defined by
the originating initiative, alternatively in
collaboration with vendors
and other participants. Re-use of
archetypes already developed internationally is
encouraged, but these must be translated into
Norwegian and then put through the same review
process as locally developed archetypes no matter
their approval status at their origin.
During this process, the local initiatives can get
archetype design assistance from their Regional
Resource Group.
Review
When a development initiative is satisfied with a
developed archetype, they can submit it for review.
The National Editorial Committee will then initiate a
review of the archetype in question, and define the
requirements of the review, the most important
being which professions and specialties should be
represented among the reviewers. The Regional
Resource Groups in each of the four regions then
recruit suitable reviewers, and the archetype is
iteratively reviewed and improved until there is
consensus among the reviewers that the archetype
is acceptable for clinical use.
Approval
Once there is consensus on an archetype among the
reviewers, the National Editorial Committee
assesses the quality of the review, using parameters
such as
number of
reviewers,
geographical and professional spread of reviewers,
and if any other stated requirements for the review
are met. If the review is considered to be of
acceptable quality, the archetype is approved for
clinical use. Once approved, the archetype is given a
new status “Published” in the CKM, which marks it
as stable and suitable for actual clinical use.
Deployment
The governance model was formally approved in
October 2013, and the governance model including
online tools at http://arketyper.no were deployed in
January 2014. The National Editorial Committee was
formed with members from each of the four RHAs
as well as from the Directorate of Health. The
National Design Committee is temporarily
considered to be part of the Editorial Committee.
Two full time positions were created to coordinate
the work of the Editorial Committee. As of August
2015, only the South-Eastern RHA has been able to
get a Regional Resource Group up and running. For
the remaining four RHAs, the coordinators for the
Editorial Committee are filling this gap until the
regional groups can be put in place.
Experiences & results
The first year of operation was mainly spent getting
the governance structure up and running, including
the recruitment of large numbers of clinicians for
review participation. Only 6 archetypes were
published during 2014, with the total number rising
to 20 by August 2015. All but one are translations of
archetypes adopted from the international
openEHR.org CKM (http://openehr.org/ckm).
Success factors
The greatest success factor identified is the
participation of clinicians. The limiting factor that
led to the approval of only 6 archetypes
during 2014 were the lack of clinicians
for review participation. Once this
number reached a certain critical level
(around 150-200), the rate of review
increased significantly, and 5 of the 6
archetypes were published in
December 2014. Other major
success factors are:
 good tooling; not having to rely
on distributing documents with UML
diagrams for clinician review
 resourcing for coordinators to do the practical
work, and for training clinicians and others
 collaboration with the sizable international
community, which saves a lot of development and
review time by providing both a large number of
models as well as experienced modellers.
Pitfalls
Translation has proved to be tougher than
anticipated, since not many clinicians are bilingually
trained in their clinical professions. Project
management practices not taking into account time
for designing and reviewing information models has
also been a challenge, leading to many models not
being approved in time for the appropriate project
milestone. As mentioned, regional resource groups
have been hard to get going, which means the work
of recruiting clinicians and supporting initiatives has
fallen on the coordinators and regional
representatives.
National ICT
National
Editorial
Committee
National Design
Committee
 Define review
requirements
 Approve reviews
National
coordinators
 Edit archetypes
 Organise reviews
 Administer arketyper.no
 Make sure archetypes
are technically sound
 Conformity w/ other
standards/formalisms
Regional
representatives
Regional
resource groups
Clinicians
 Participate in
reviews
 Start local
initiatives
 Represent the RHAs in
the Editorial Committee
 Recruit
clinicians
 Support local
initiatives
Vendors
 Implement archetypes in software
 Supplement requirements
What are archetypes?
 Archetypes are formalised information models
based on the openEHR specification
 An archetype is a collection of information ele-
ments relating to a single clinical concept
 Archetypes are defined by domain experts, and
exist independently of vendors and solutions
 Archetypes are made to be maximum datasets,
and can be grown over time
 Archetypes are not complete data sets, user
interfaces or terminologies