The document discusses the challenges of healthcare informatics and proposes multilevel modeling (MLM) and open source software as solutions. It argues that MLM separates reference and knowledge models, allowing knowledge to adapt over time without replacing the whole system. Open specifications and tools support sharing knowledge artifacts and ensuring interoperability. MLM and open source align with principles of beneficence, non-maleficence, and efficiency in healthcare informatics. The approach has potential to address issues like information chaos, system failures, and costs that traditional approaches have faced.

1. Health Informatics: the Relevance of Open Source and Multilevel Modeling Luciana T. Cavalini, MD, PhD Timothy W. Cook, MSc “ Multilevel Healthcare Information Modeling“ (MLHIM) Laboratory (UFF/UERJ) Associated to the National Institute of Science and Technology – Medicine Assisted by Scientific Computing

2. Introduction Healthcare is a dynamic and complex system The spatial changes are close

3. The time changes are fast

4. The number of basic concepts is 300,000+ Cavalini's conjecture: given a group of medical experts without any hierarchical relationship among them, the probability of them reaching 100% of agreement about any set of concepts from their domain tends to zero

5. Introduction A single monolithic system for the complete health record of a person “from cradle to grave” is not feasible

6. Integration projects that were successful in other businesses have been attempted in healthcare over the last 46 years, spending trillions of dollars, with a 100% failure rate

7. The result: healthcare is the less computerized business in economy

8. Introduction Electronic Health Records (EHR) have promised (and yet not delivered): ↓ waste of citizen's time in lines for appointments and referral

9. ↓ waste of staff time in search of critical information

10. ↓ duplication of tests, medications and procedures

11. ↑ early detection and prevention

12. ↑ adherence to therapeutic protocols

13. ↓ risk of adverse events and medical errors

14. ↓ avoidable hospitalization and mortality

15. Total loss: £ 12 billion in 10 years

16. Total loss: not published (6 years)

17. Total loss: US$200 million (13 years)

19. Introduction Currently, medical records have a chaotic mixture of old (paper) and new (computer) support medias

20. The electronic records already implemented seldom follow any of the ISO TC 215 recommendations or any other standardization

21. The mixture of incompatible systems runs across the entire system: from inside the hospitals up to the local, regional, national and international levels

22. The reality of British NHS = The reality of American Medicare = The reality of Brazilian SUS etc.

23. Hardware is not the problem anymore

24. What about software?

25. What software???

26. Interoperability

27. Interoperability!

28. Interoperability?

29. Where is the context?

30. Here is the context!

31. IHE HL7 IHTSDO ISO WHO CEN ASTM Documents Security Services Content models Terminology Thanks to: Thomas Beale (openEHR Foundation) SNOMED CT ICDx CDA EN13606-1 CCR v2 messages v3 messages Data types PDQ CCOW HSSP PIX HISA RID XDS PMAC EN13606-4 RBAC EN13606-3 EN13606-2 Templates

32. Traditional Modeling

33. Traditional Modeling Information is modelled to “serve” the current needs of the healthcare system; but those needs change very fast and they are very different from one facility to another

34. Adding new concepts and “customizing” a legate system for another facility demands the total re-make of the system (re-modelling, re-implementation, re-test, re-deployment)

35. Unaffordable costs, frustrated users, abandonment of the systems (average time = 2 years)

36. Multilevel Modeling This approach is compliant to the ISO 20514 standard

37. Multilevel Modeling Fundamental Principle: separation between the Reference Model and Knowledge Modeling