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National archetype governanceSilje Ljosland Bakke RN
Information architect, Nasjonal IKT HF / Co-lead, openEHR Foundation Clinical Models Program
E-mail: silje.ljosland.bakke@nasjonalikt.no / Twitter: @siljelb
Norwegian public hospital system
•Four Regional Health Authorities (RHAs)
• 24 Hospital Trusts
• 100 % EHR adoption
• No primary care!
•Two main EHR vendors
•One strategic coordinating
health trust for IT
(Nasjonal IKT)
openEHR in Norway
• Clinical use in some speciality areas on DIPS Arena
• DIPS Arena EHR slowly replacing legacy system in 3 of 4
regions
• 4th region currently in procurement
• Several GP system vendors are implementing openEHR
• Nasjonal IKT archetype governance aims for
– high quality archetypes
– semantic interoperability through use of identical
archetypes
Some history…
2008-2011: Feasibility studies on shared
clinical information models: openEHR
encountered and explored
2012: First vendor openEHR
announcement (DIPS). Realisation that
archetypes must be governed.
2013/2014: Development and
deployment of governance model.
Shared clinical information models how?
5
• Because they’re defined by clinicians,
participating must be low threshold
• Because healthcare changes all the time
models must be changeable when needed
• Because vendors and solutions
come and go, the models must be
independent of single vendors
• Because models must be identical
they must be governed strictly
• Because clinical modelling is difficult and expensive, modelling must be
done once and shared freely
• Because persistence and exchange must be based on identical models,
models must be suitable for a variety of use cases
This requires untraditional standardisation
6
• Gradually and step by step instead of all in one go
• Constant maintenance instead of 5 year revision
cycles
• Standardisation of one reusable concept is
infinitely better than no standardisation!
– (Most current solutions are completely
unstandardised and closed…)
Nasjonal IKT
National editorial committee
National coordinators
Regional
representatives
Regional
resource
groups
Clinicians
Vendors
Processes and tools
• Formalised processes for development, review and approval
– Archetype development is a “do-ocracy”; not centrally
prioritised
• Online collaboration through three tools
– Clinical Knowledge Manager (CKM) arketyper.no
– Task management system (JIRA)
– Documentation wiki (Confluence)
• Good tools are critical for transparent online collaboration
Reviews and approval
•National editorial committee defines review
requirements
•Review rounds last one week, several rounds per
archetype
•Until clinicians reach consensus… 
•If requirements are met, the archetype is «Published»
on Norwegian CKM
Approach
• Supporting efforts by healtcare providers and vendors
– Reviewing and approving specific archetypes
• Reviewing and approving basic concept archetypes
– Observations, diagnoses, symptoms, procedures, labs, meds
• International collaboration
– Aim for identical archetypes NO:INT
• Spreading the word
– Presentations, training, workshops
Status
•As of September 20th 2017 there are 61 published
archetypes
– Working on the most complex and most reusable
archetypes right now
•During our first year we only managed to publish 6
archetypes, 5 of them in December
– Clinician participation is crucial, and hadn’t reached a
critical level until late in the year
Clinician engagement
•Difficult!
•Clinicians are busy
treating patients
•Traditional standardisation
proccesses unsuitable
–Expensive
–Don’t necessarily lead to
desired results
So how to get clinicians engaged?
•Make participation quick and easy
– Clinically oriented models
– Good, accessible tools; no meetings!
•Give them something they want
– Help with improving quality
– Spend less time on information entry
•Appeal to their inner geeks
– “Wait, this bit of information isn’t right!"
More ways to engage clinicians
•Get buy in from managers
–Topic for a whole talk in itself…
•Get into their clinical meetings
•Give them time (money)
Participant statistics
Clinical MD
28%
MD/IT
5%
Clinical RN
16%
RN/IT
14%
Other
clinical
11%
Other non-
clinical
26%
Non-clinical
55 % active clinicians!
Success factors
• Clinician participation
• Good tooling
• Resourcing for coordinators
• Resourcing for training and consulting
• Collaboration with international community
• Vendor participation
Anticipated problems
• Standardisation takes longer than non-standardisation
– Project planning must account for this (but isn’t)
– Some unpublished archetypes are being deployed
• This leads to compatibility issues down the road…
• Several specialties/professions aren’t well represented
– This slows down the review process
• Two coordinators wasn’t enough
– Bottleneck, little redundancy
Unanticipatedproblems
• Translation is difficult and
time-consuming
• Implementation projects
aren’t used to take into
account the time needed to
review and approve
archetypes
• Regional resource groups
are hard to get going
Summary
•To achieve semantic interoperability, clinical
information models must be shared freely, and
governed tightly
•Key success factors are clinician involvement,
tooling, resourcing and international
collaboration

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National archetype governance in Norway

  • 1. National archetype governanceSilje Ljosland Bakke RN Information architect, Nasjonal IKT HF / Co-lead, openEHR Foundation Clinical Models Program E-mail: silje.ljosland.bakke@nasjonalikt.no / Twitter: @siljelb
  • 2. Norwegian public hospital system •Four Regional Health Authorities (RHAs) • 24 Hospital Trusts • 100 % EHR adoption • No primary care! •Two main EHR vendors •One strategic coordinating health trust for IT (Nasjonal IKT)
  • 3. openEHR in Norway • Clinical use in some speciality areas on DIPS Arena • DIPS Arena EHR slowly replacing legacy system in 3 of 4 regions • 4th region currently in procurement • Several GP system vendors are implementing openEHR • Nasjonal IKT archetype governance aims for – high quality archetypes – semantic interoperability through use of identical archetypes
  • 4. Some history… 2008-2011: Feasibility studies on shared clinical information models: openEHR encountered and explored 2012: First vendor openEHR announcement (DIPS). Realisation that archetypes must be governed. 2013/2014: Development and deployment of governance model.
  • 5. Shared clinical information models how? 5 • Because they’re defined by clinicians, participating must be low threshold • Because healthcare changes all the time models must be changeable when needed • Because vendors and solutions come and go, the models must be independent of single vendors • Because models must be identical they must be governed strictly • Because clinical modelling is difficult and expensive, modelling must be done once and shared freely • Because persistence and exchange must be based on identical models, models must be suitable for a variety of use cases
  • 6. This requires untraditional standardisation 6 • Gradually and step by step instead of all in one go • Constant maintenance instead of 5 year revision cycles • Standardisation of one reusable concept is infinitely better than no standardisation! – (Most current solutions are completely unstandardised and closed…)
  • 7. Nasjonal IKT National editorial committee National coordinators Regional representatives Regional resource groups Clinicians Vendors
  • 8. Processes and tools • Formalised processes for development, review and approval – Archetype development is a “do-ocracy”; not centrally prioritised • Online collaboration through three tools – Clinical Knowledge Manager (CKM) arketyper.no – Task management system (JIRA) – Documentation wiki (Confluence) • Good tools are critical for transparent online collaboration
  • 9. Reviews and approval •National editorial committee defines review requirements •Review rounds last one week, several rounds per archetype •Until clinicians reach consensus…  •If requirements are met, the archetype is «Published» on Norwegian CKM
  • 10. Approach • Supporting efforts by healtcare providers and vendors – Reviewing and approving specific archetypes • Reviewing and approving basic concept archetypes – Observations, diagnoses, symptoms, procedures, labs, meds • International collaboration – Aim for identical archetypes NO:INT • Spreading the word – Presentations, training, workshops
  • 11. Status •As of September 20th 2017 there are 61 published archetypes – Working on the most complex and most reusable archetypes right now •During our first year we only managed to publish 6 archetypes, 5 of them in December – Clinician participation is crucial, and hadn’t reached a critical level until late in the year
  • 12. Clinician engagement •Difficult! •Clinicians are busy treating patients •Traditional standardisation proccesses unsuitable –Expensive –Don’t necessarily lead to desired results
  • 13. So how to get clinicians engaged? •Make participation quick and easy – Clinically oriented models – Good, accessible tools; no meetings! •Give them something they want – Help with improving quality – Spend less time on information entry •Appeal to their inner geeks – “Wait, this bit of information isn’t right!"
  • 14. More ways to engage clinicians •Get buy in from managers –Topic for a whole talk in itself… •Get into their clinical meetings •Give them time (money)
  • 15. Participant statistics Clinical MD 28% MD/IT 5% Clinical RN 16% RN/IT 14% Other clinical 11% Other non- clinical 26% Non-clinical 55 % active clinicians!
  • 16. Success factors • Clinician participation • Good tooling • Resourcing for coordinators • Resourcing for training and consulting • Collaboration with international community • Vendor participation
  • 17. Anticipated problems • Standardisation takes longer than non-standardisation – Project planning must account for this (but isn’t) – Some unpublished archetypes are being deployed • This leads to compatibility issues down the road… • Several specialties/professions aren’t well represented – This slows down the review process • Two coordinators wasn’t enough – Bottleneck, little redundancy
  • 18. Unanticipatedproblems • Translation is difficult and time-consuming • Implementation projects aren’t used to take into account the time needed to review and approve archetypes • Regional resource groups are hard to get going
  • 19. Summary •To achieve semantic interoperability, clinical information models must be shared freely, and governed tightly •Key success factors are clinician involvement, tooling, resourcing and international collaboration

Editor's Notes

  1. four Regional Health Authorities 24 Hospital Trusts between them, each running one or more hospitals All of these are using EHRs, with mainly electronic documentation As opposed to the Swedish system, the Norwegian hospital system is organisationally separate from the primary care system. This has and is still causing a lot of problems with continuity of care. All Norwegian hospitals use one of two EHR vendors; DIPS or Siemens. Siemens is used in the Central Norway Regional Health Authority area, and DIPS everywhere else. National ICT Jointly owned by the four Regional Health Authorities National ICT was created as a proper health trust in 2014 has existed as a collaboration forum for the RHAs since 2003 main responsibility is strategic coordination of ICT in the specialist healthcare system.
  2. Oslo University Hospital A&E started using DIPS Arena in October 2014 Some structured information using archetypes Mainly accident reporting Several different Norwegian vendors are implementing structured EHRs based on openEHR National ICT governs the national Norwegian archetypes The main goals of the governance is that the archetypes that are put to clinical use are of good quality through having been reviewed by many clinicians of a wide spectrum of professions and specialties And facilitating semantic interoperability through enabling organisations and vendors to use identical data models
  3. I’m not going through this in detail, but I’m showing it to give a small insight in the history of the archetype governance. It started out with a feasibility study in 2008, and the governance scheme was deployed in 2014.
  4. Part of the national governance scheme is the formal processes for development, review and approval of archetypes. The development process is based on a model called a «do-ocracy». Who haven’t heard of…? A do-ocracy is similar to a meritocracy, only instead of the people with a proven track record making the calls, the people who actually spend the resources to do something make decisions. This only means that the development isn’t centrally prioritised. There’s no committee deciding what to do and when, this is all decided by the actual requirements of whichever projects are going on at the moment. Important to avoid losing momentum To be able to do this we’re using two online tools, both of which are critical to be able to involve large numbers of people in a transparent manner
  5. The national editorial committee defines the review requirements of each archetypes, which basically means, which professions and specialities should and must take part in the review Review rounds last one week each, after which requested changes are made, and a new round started, until the clinicians agree……… If the requirements are met once the clinicians reach concensus, the archetype is published. Unpublished archetypes can change drastically overnight, and our recommendation is that they should not be used in a production environment
  6. Our main approach is to support (ie review and approve) all the archetypes needed by healthcare providers and vendors, as per the do-ocracy. Secondly, we do initiate reviews of certain fundamental, ultra-reusable archetypes ourselves, because we anticipate they’ll be used almost everywhere When we do review rounds on archetypes, we try to do them in parallel with the international reviews, to leverage the international feedback in Norway, and the Norwegian feedback internationally. We also spend a lot of our time telling people about what we do, as presentations, courses, and workshops
  7. This doesn’t sound like a lot, and it isn’t. But some archetypes are more important (in other words, reusable) than others. Once we have say 30-50 of these very reusable archetypes approved, we can probably represent at least 90% of primary care in a structured way. The rest will be mostly specialist stuff.
  8. This graph shows the proportion of users who are mainly clinical and actually work with patients on a regular basis, and the users who either have a purely technical background or a combined clinical/technical background and don’t see patients regularly. We’re very happy to have so many active clinicians participating, as this kind of thing often only attracts the ones who mainly work in IT.
  9. We’ve identified some success factors to what we’re doing. Obviously clinician participation is crucial, since the clinicians are the ones who both define and approve the data models. Next, without the good tools we have we wouldn’t have been able to get the clinicians involved. Doctors and nurses don’t want to read through long PDFs with UML diagrams, and then write their response in a word document. The coordination of this governance scheme takes a lot of time, and couldn’t have been done without dedicated resources. This sort of thing is new to almost everyone, and without the means to do training and consulting with international experts, making good models without making too many mistakes would have been much harder. Finally, since there’s a sizable international community also making and sharing archetypes, we haven’t had to make many ourselves, but mainly translating and adapting. This saves loads of time.
  10. Then the things we could have done better. Translation has proved to be a tough issue, since not many clinicians are trained to do clinical work in both Norwegian and English. Most of the review comments haven’t been about actual structure, but about language and wording. Secondly, development projects aren’t used to having to get their information models reviewed and approved before they can be deployed. From our point of view, this would work much better if the models were developed early in the project, and then submitted for review asap Finally, as I mentioned earlier, the regional resource groups have been hard to get started. This means the job of recruiting clinicians and supporting initiatives fall to the coordinators and regional representatives, which they’re not resourced to do. This can be a huge bottleneck to getting archetypes reviewed and approved.
  11. Summing up, clinical models should never be proprietary or vendor-specific, but be shared with everyone. At the same time, to enable semantic interoperability, they need to be strictly governed to avoid divergence. Success factors do cost a little bit of money, but is probably much cheaper than the alternative, especially in the long run.