8 1open ehr-helsinki_29oct2018

Copyright 2018 openEHR Foundation
Thomas Beale, openEHR board,
Helsinki 29 Oct 2018

 Currently
◦ Co-lead of Specifications project
openEHR
◦ openEHR Management Board
◦ Principal, Ars Semantica
 Background
◦ Elec Eng + Comp Sci
◦ 6y real-time systems
◦ 5y finance
◦ 23y in e-health
 Interested in
◦ Realist philosophy
◦ Reality, unreality, and modern
politics
◦ Wine, beer and other coping
mechanisms
Copyright 2018 Ars Semantica

 Taking care of patients to identify and resolve
problems, and to achieve goals.
 Care is usually supplied by multiple clinics,
multiple visits and multiple professionals
 To complete a ‘care episode’ requires a
process view over time
 This is Continuity of Care

Patient visits
multiple provider
facilities
Clinical data, appts,
etc recorded in
dozens of systems

 07 Aug – Bilbao Emergency – chest pain
◦ ECG, xray, echocardiogram, Troponin, biochem
◦ Recommend CTCA
 14 Aug – Chiswick GP
◦ tests, Rx, referral to cardiologist (2 errors)
 19 Aug – Charing X hospital emergency
◦ Chest pain at rest
◦ ECG, Troponin
◦ Hospital can’t refer me to own cardiology unit
◦ wrote letter to GP requesting CTCA scan
 25 Aug - Charing X hospital emergency
◦ ECG, Troponin

 30 Aug – Cardiologist
◦ Order for CTCA at W Middlesex hospital
 Appointment radiology 25 Sep (one error)
 17 Sep – W Middlesex Emergency – chest pain
◦ ECG, Troponin
◦ 30 mins to complete xray order Cerner  Philips
◦ Stayed overnight
◦ CTCA, ordered from Emergency

Docs love me when I turn up with
this paper. It’s the only longitudinal
patient record they have access to.

 3 hospitals
 1 GP
 1 cardiology clinic
 Delay for test: 6 weeks
 Referral errors: 2 / 2
 Order errors: 2/5
 Electronic health data sharing between
institutions: 0
 Still in Dx phase…

 Almost no health data sharing across
enterprises, including between same-vendor
systems in UK
 Continual errors in system-system messaging
inside hospital
 Referrals routinely wrong
 Errors in orders
 This is after £10.7bn spent from 2002 – 2013
on e-health.
◦ Summary health record already legacy
◦ Main technology: HL7 CDA, HL7v3

X X X
Process? X
xxx ?
?

NICE.org.uk

Guideline:
clinical steps
Planning level:
Logistic steps,
e.g. referrals, orders
ECG
(here)
CTCA
(appt)
2 weeks
CTCA
(radiology)
report
(radiologist)

 A ‘copilot’ for Guidelines
 A picture of the process
 Where are we in the process right now?
 Who is taking care of the patient now?
 All the orders and status of interventions
 All the exams, notes, results (the standard
EHR)

Guideline level
Plan level
Info level
(traditional EHR)

Data, but proprietary, fragmented, and mostly unshareable
Fragments of process

guideline
planning
clinical
information
My EHR

Two dimensions have to be solved:
 The technical
 The political / economic

A designed open platform
 Services (SOA)
 Semantic architecture
 Semantically flexible and scalable
 Model-based
 Terminology-based
 Tool-driven development

Guidelines
- Models of clinical
process
Plans
- Detailed definition of
clinical care steps
Healthcare information

3 levels of modelling
Why? Because:
• need a logical model of data
•  reference model
• ~30-50,000 clinical data points needed –
too many for simple UML model
•  archetypes
• single definition of each data point/group,
but re-use in multiple data sets
•  templates
Services, standardised data
controlled by models

 Incorporates 20y of research
 150 classes
 Extremely stable
 All openEHR clinical data in the world are
logical instances of the openEHR RM
 Provides the basic interoperability
 Supports ‘marking’ by archetypes
 Enables openEHR repositories to be built and
deployed without prior development of
clinical data definitions

 Used to model data at the domain level
◦ Lab results, BP, Diagnosis, pregnancy notes etc
 ~700 publicly available archetypes
 ~10,000 re-usable data-points and groups
 ~2,000 clinical modelling participants
 Expressed in Archetype Definition Language
(ADL)
◦ developed by openEHR, an ISO standard 13606-2
◦ used in HL7 CIMI
◦ multi-lingual, including all glyph-based langs
 Usually published as standard models
 4+ editing tools

 They just define particular, valid
arrangements of RM building blocks that
represent particular domain-level information
items
 Like the instructions that come with LEGO®

https://www.openEHR.org/ckm

Data types
from the
reference
model

 Used to model data use-case specific data
sets, for things like:
◦ Forms – GUI apps
◦ Messages – e.g. lab result
◦ Documents – e.g. discharge summary
◦ Can be standardised as well
 Templates have two software engineering
functions:
◦ They are used to generate design-time artefacts
like XSDs and forms for building applications
◦ They are the artefacts injected into runtime EHR
systems

 APIs
◦ REST
◦ Others in future?
 AQL – Archetype Query Language
◦ Based on archetypes and RM, no connection to
physical DB schemas
◦  AQL queries are portable across openEHR vendor
systems, no matter what DB they use!

SELECT
obs/data[id2]/events[id7]/data[id4]/items[id5]/value/magnitude,
obs/data[id2]/events[id7]/data[id4]/items[id6]/value/magnitude
FROM EHR [ehr_id/value=$ehrUid]
CONTAINS
COMPOSITION [openEHR-EHR-COMPOSITION.encounter.v1]
CONTAINS
OBSERVATION obs [openEHR-EHR-OBSERVATION.blood_pressure.v1]
WHERE
obs/data[id2]/events[id7]/data[id4]/items[id5]/value/magnitude >= 140 OR
obs/data[id2]/events[id7]/data[id4]/items[id6]/value/magnitude >= 90

 RM Instruction and Action
 Task Planning

 Major new specification, based on:
◦ 2y analysis & workshops with Marand, DIPS, Tieto
◦ 3y ABD project at Intermountain Healthcare
◦ Review of literature
◦ Review of existing workflow standards including
BPMN, CMMN and YAWL

Characteristics:
• Designed for ad hoc data retrieval, not writing to EHR
• FHIR imposes its own set of models for data extraction. These are not
connected to models of content such as openEHR or even HL7 CIMI or
models of the EHR.
• If content is defined with private profiles, it will not be interoperable.
• So far, mapping real EMR data has not proved easy
FHIR will be used to extract data from legacy systems

 Moscow City patient record
◦ 13m citizens: includes Task Planning
 Slovenia
 Norway
 Netherlands
 Australia
 China
 UK
 Brazil

 ~1,000 members
 50 countries
 ~2,000 clinical modelling community

 UK-based Community Interest Company (CIC)
/ non-profit
 Board structure
 Governance of specifications – SEC
 Governance of archetypes – clinical editors

 FHIR compared to openEHR
 openEHR technical basics for HL7 and
FHIR users
 Who is using openEHR?
 openEHR in China
 http://www.openEHR.org

8 1open ehr-helsinki_29oct2018

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8 1open ehr-helsinki_29oct2018