Category Archives: OpenEHR

Open Digital Platform Challenge Fund

Many  will be aware of the proposal that Tony Shannon and I have been promoting to persuade the NHS to allocate 1% of the money they plan to spend on digital health to an “Open Digital  Platform Challenge Fund” to stimulate the development of an open digital ecosystem based on open standards.

We have had a positive response so far and will shortly be presenting out plans to the NHS CIO and CCIO. We want to be able tell them that there are enough people and projects committed to an Open Digital Ecosystems to make good use of the money we are asking for and give then a good idea of the projects that might come forward if they take up our suggestion.

To this end we have been asking people for expressions of interest via this link . We are looking for expressions of interests from people who support the approach and the specific standards laid out in our document. In not onerous to fill in the form which does not imply a fixed commitment just a general indication of interest.

If you have not already done so I’d urge you to let us have your ideas

Full details below

 

Globe (1)

Untitled drawing

1) Executive Summary

An NHS open digital platform challenge fund will stimulate the development of an open platform in the NHS. Open digital platforms are independently forecast by McKinsey and Co to reduce the delivery of care costs across the NHS by 11%. They will support widescale entry and growth of suppliers into the market, injecting innovation at all levels of service delivery to support improved care outcomes for our patients.

In the context of an NHS struggling through a perpetual winter, open digital platforms present a realisable opportunity to massively stimulate new ways of working, process innovation and a new digital health and care market, based around services. This is independently forecast by McKinsey and Co who predict a positive financial impact in excess of 11% across the whole of health and social care.

By creating an open digital platform and a move towards a services market, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support transformational new models of care, radically improving the care outcomes of our patients and building a sustainable care ecosystem that is fit for the future.

There is little disagreement that platforms represent the future for digital health. Rather the present debate is about who should own them, and how and when they will emerge. The “status quo” retains the closed platform frameworks, introducing open interfaces for exchange of information. This provides a short term stimulus, supporting improvements in patient care and operational efficiencies. However in the longer term, by seeking to control the rules of engagement and restricting the mobility of data, the retention of closed platform frameworks will stifle competition, impede innovation, and continue to drive-up costs.

Open digital platforms are a radical alternative that overcome the serious shortcomings of closed platforms.
They present the most assured approach to achieve consistent, long term and affordable growth in innovation-led service transformation across the complexities of health and social care. They will enable the full competitive aspects of market supply to be exploited, with associated benefits of the injection of innovations on a massive scale. For this reason, open digital platforms are manifestly in the interest of both the NHS and its patients.

The purpose of the proposed Open Digital Platform Challenge Fund is to stimulate the development of an open platform ecosystem through kick-starting the creation of open platforms, building on work already well underway, and the development of exemplar applications to exploit them.

We propose that the fund is created through diverting 1% of the investment each year in NHS digitisation into the challenge fund. This fund would be made available via an annual open competition in the form of relatively small awards to innovative organisations (public, private and third sector). The selection of projects will be balanced to stimulate and develop an open ecosystem of shareable and reusable applications to service across health and social care. We are inviting submissions of expressions of interest into this Open Platform Fund. In so doing, we will gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding.

2) Current Situation

To introduce this bid for funding we need to review the current situation with important context on the bigger picture issues that are at play. We need to acknowledge and understand the current mediocre state of health IT, as an immature and problematic market with mixed/relatively poor value for money and results seen from billions of £ and $ of investment from the UK to the US and elsewhere.

We also need to recognise the related digitisation of the NHS has been over promised and under delivered for some considerable time. Compounding this people/process/technology problem is the ongoing and perpetual winter faced by the frontline in the NHS that is in the news.

We restate the need to continue the critical push towards more personalised, integrated care at home and in the community to meet the 2020 vision. This clearly requires an underpinning patient centred infrastructure to do so. Last February Jeremy Hunt announced £4.2 billion for NHS Health IT. In the last 18-24 months while there have been plans in the form of Integration Pioneers, Vanguards, Local Digital Roadmaps (LDRs), Sustainability Transformation Plans (STPs), there has been little/no allocated funding to date to make these happen.

In Autumn 2016 we were able to read and digest the latest review of the NHS IT, authored by US physician Dr Bob Wachter. Dr Wachter built his reputation as establishing the hospitalist as a medical specialty in the US. In recent years he has become a fearless and honest critic of the state of Healthcare IT in the US, with his book “Digital Doctor : Hope, Hype & Harm at the Dawn of Medicines Computer Age” (2015) exposing the real mediocre state of the health IT market in the US. The book and related opinion pieces on the state of health IT industry he explains some of the real problems with the current supplier market is clear. In a New York Times Op Ed piece on “Why Health Care Tech Is Still So Bad” (2015) he highlights that

“In today’s digital era, a modern hospital deemed the absence of an electronic medical record system to be a premier selling point…That hospital is not alone. A 2013 RAND survey of physicians found mixed reactions to electronic health record systems, including widespread dissatisfaction. Many respondents cited poor usability, time-consuming data entry, needless alerts and poor work flows”.

However in the NHS, Dr Wachter’s recent review led to funding being provided to “digital exemplars” all of which are a small group of hospital trusts in the NHS who will invest in those very same health IT monoliths. While understandable as a means to “do something”, rather than nothing, given the state of affairs is understood, it is sadly limited in its thinking and perpetuates the usual tactics that we have seen in the NHS IT for years, i.e. investing in the same 20th Century monoliths of old. We know that doing the same thing over and over and expecting different results is futile.

Simply put, if a small elite are getting the focus of funding for investments in 20th Century health IT monoliths over the next years then inequity within the system will increase, while original ideas in the sector to bring care into the modern era will decrease.

We have been left asking where has the requirement for integrated person centred care gone, that is ingrained in the other plans that NHS and local authorities have been working towards with STPs and LDRs etc.

What is sorely missing is the open patient centric platform that Dr Wachter looks forward to and that healthcare awaits. As this is a glaring omission, our paper recommends a focussed investment towards that end as part of a bimodal strategy for NHS IT at this challenging time.

3) What can be done

The changes required are radical, if we are to simply survive, yet alone thrive in the years ahead. We know we need a mix of people + process + technology changes. We know too that the leaders of the NHS understand and value the role of innovation and the crucial role of information technology in achieving same.

3.1) The role of an open platform

For some time now leading thinkers on both sides of the Atlantic, in the NHS and indeed the US has been calling for a move towards a more open platform approach. From within the US market, the establishment of Healthcare Services Platform Consortium aims to address the mediocrity of the “big 6” monoliths and the concurrent problem of the thousands of small unrelated vendors.

“EHRs are becoming commodity platforms. The winner will be the EHR vendor that provides the best platform for innovation – the most open and most extensible platform.”

In this we wholeheartedly agree and concur with our US colleagues.

We believe there is now a compelling case for a small but useful investment in Health IT from the bottom up, to the princely sum of 1% of the planned £4 Billion NHS IT expenditure, aimed deliberately at the integrated, patient centred care vision of Personalised Care 2020, based on the principle that all projects should aim to leverage elements of a common open platform.

4) 1% Case for an open platform

We are making a case for an investment of just 1% of available NHS IT funds to offer a way forward to improve the care of 99% of the population. To do so we have highlighted Dr Watchers analysis and writings to focus on the key problems and issues we seek to address;

Usability

“This principle of user-centered design is part of aviation’s DNA, yet has been woefully lacking in health care software design.

Interoperability

“[There are] Political obstacles to overcome, put in place mostly by vendors and healthcare systems that remain reluctant to share.”

Vision for patient centred care

“In essence, there will no longer be an EHR in the traditional sense, an institution-centric record whose patient portal is a small tip of the hat to patient-centeredness. Rather, there will be one digital patient-centered health record that combines clinician-generated notes and data with patient-generated information and preferences. Its locus of control will be, unambiguously, with the patient.”

So in order to address these real issues and support the national ambitions – usability, interoperability and patient centred care we will use the investment fund available to benefit the broader public. We wish to draw attention to that part of the population who could be better served by the NHS with an improved patient centric platform today. We are also mindful of the need to support;

  • Prevention, Self care and management
  • GP patients
  • Community Care Patients
  • Mental Health Patients
  • Social Care

We look to the leadership provided by the Gov UK Digital Service standard to highlight the principles to underpin the approach we commend.

Pursue User Centred Design & Agile Development

Leverage Open Source & Open Standards

In our work to date (on the Ripple programme and Code4Health platform based on openEHR) we have deliberately pursued these principles to useful effect and recommend them to others who wish to transform healthcare with information technology. We welcome wider scrutiny of our open platform work to date. Our work and the leading work of others (such as the Endeavour Foundation and the INTEROPen CareConnect API Collaborative) in this field, leads us to believe there is now a real, significant appetite for wider and deeper moves towards an open digital platform in the NHS.

By creating an open digital platform ecosystem, the NHS opens up the market to innovative commercial and social enterprises who presently have great difficulty breaching the significant barriers to entry. At the same time it creates an environment where health and care professionals can readily create, contribute and share new digital tools to support innovative new models of care.

We firmly believe that a small but focussed 1% investment can deliver against some of the key challenges in Personalised Health and Care 2020 on an open service oriented platform- to stimulate the public & private sector. An open healthcare platform fit for the 21st Century.

 

5) What is an Open Platform?

Platform based architectures power the internet, with the platform providing the plumbing (the infrastructure, data and services) that applications need, freeing the application developer to focus their efforts on their application without the need to build the infrastructure it needs to operate. Platform approaches speed development, make applications more robust and interoperable and open up a new services market in healthcare IT, where suppliers compete on services and the value they add rather than on the proprietary nature of their software.

An Open Platform is based on freely available open standards, so that anyone can play. As no one party can control the platform – they must collaborate – just like the Internet.

An Open Platform has the following characteristics:

  • Open Standards Based – The implementation should be based on wholly open standards. Any willing party should be able to use these standards without charge to build an independent, compliant instance of the complete platform;
  • Share Common Information Models – There should be a set of common information models in use by all instances of the open platform, independent of any given technical implementation;
  • Support Application Portability – Applications written to run on one platform implementation should be able to run with either trivial or no change on another, independently developed;
  • Federatable – It should be possible to connect any implementation of the open platform to all others independently developed, in a federated structure to allow the sharing of appropriate information and workflows between them;
  • Vendor and Technology Neutral – The standards should not depend on particular technologies or require components from particular vendors. Anyone building an implementation of the open platform may elect to use any available technology and may choose to include or exclude proprietary components;
  • Support Open Data – Data should be exposed as needed (subject to good information governance practice) in an open, shareable, computable format in near to real-time. Implementors may choose to use this format natively in their persistence (storage) layer of the open platform itself or meet this requirement by using mappings and transformations from some other open or proprietary format;
  • Provision of Open APIs – The full specification of the APIs (the means by which applications connected to the platform a should be freely available.

The key to an open platform is the definition of a set of standard interfaces (APIs) to the range of services that might be provided on a platform defined by an open process that all interested parties can participate in (like Internet standards) and that are freely available for all to use.

While it may be encouraged, not all elements in an open platform need to be open sourced. We believe that “infrastructural” components that are generic, reusable and utility like (e.g see Appendix 1 below) should be open sourced, while the overlying applications do not necessarily need to be open sourced, as long as they leverage open data models and offer open APIs.

6) Why an open digital platform?

We have seen across all sectors how platforms are changing the way people lead their everyday lives, from how we communicate and interact, how we travel and where we stay, how we manage our finances to how we shop, to name but a few. Platforms transform. An open digital platform supports:

  • Unconstrained innovation – ideas and ambitions can be shared by people across the office, street or globe
  • Collaboration – clinicians and care professionals inherently want want to share their good work with the rest of the medical world.
  • Alignment to medical science progression, been based on the spread of ideas – health IT can do the same.
  • “Publish or perish” culture of modern medicine demands that healthcare advances are laid open for scrutiny by our peers
  • Grassroots progress – Complex adaptive systems require decentralized control so people can locally innovate. Amendments and improvement can come from the grassroots and bottom up, without the bureaucracy that innovators often face.
  • A shift in the market towards a healthy, commercially sustainable, services oriented marketplace.

7) Open Platform Fund mechanism

The main aim of this Open Platform bid is;

Support the development of services towards Personalised Care 2020 –

support the development of an NHS ecosystem around an open digital platform

To be clear, while we do not currently have any secured funding for an open platform fund, our aim is to gauge interest in this approach and make the evidence based case to NHS Digital.

The fund is intended to support innovative projects that stimulate the creation of an open digital ecosystem and as such aims to support a large number of small projects that are unlikely to be supported as part of “business as usual” investment by health and care organisations. The aims are to driving innovation and transformation that is scalable, shared, flexible and adaptable and ultimately improve health IT for clinicians and improve care outcomes for patients. Winners will show that they will concentrate their efforts on usability, interoperability, patient centred care that meet the vision. To do so we suggest;

7.1) Request for Expressions of Interest

We initially invite the submission of expressions of interest into this Open Platform Fund. In so doing, we wish to gauge the wider interest in this Open Platform fund proposal to then quickly bring these related responses to the attention of both NHS Digital and NHS England by the end of February 2017 and seek the related funding .

Please submit a brief expression of interest (1-3 page) via this Google forms link; https://goo.gl/forms/4SaNvAgkAe2AfLZ82 by Friday 10th February 2017.


We will acknowledge expressions of interest, collate and feedback the results of our findings, pass on related submissions and summary findings to the Apperta Foundation CIC which we believe is ideally placed to independently oversee this process and support the case for funding from NHS Digital and NHS England. The Apperta Foundation is a not-for-profit community interest company supported by NHS England and NHS Digital led by clinicians to promote open systems and standards for digital health and social care.

While the focus of this paper relates to the NHS in England, we know that colleagues in the health systems of Scotland, Wales, Northern Ireland and indeed the Republic of Ireland are facing the same challenges at the frontline, while aware of the same opportunity on offer from an open platform from a 1% investment, particularly if done openly and collaboratively. Therefore we invite related submissions towards an open platform fund on an All Islands basis – which we also will pass onto the Apperta Foundation and the UK and Ireland CCIO Networks.

7.2) Outline of Proposed Allocation

A) Infrastructural component projects

45% of £40m = £18m over 3 years (until 2020)
Open source tooling & infrastructure components – underpinning standards and compliant components that provides services useful in an open ecosystem (See Appendix 1 examples)

B) Personalised Care: Innovation Incubation and Exemplar Implementations

50% of £40m = £20m over 3 years (until 2020)

Open APIs & open data models based projects as showcases of an open platform in action. (e.g. may include open APIs (e.g. INTEROPen CareConnect FHIR based APIs) + open data models +/- open source data repository (e.g. openEHR based). Examples may include Person Held Records/Electronic Patient Record/Integrated Digital Care Record etc. related projects.

C) Oversight/Custodian of process by an independent CIC such as the Apperta Foundation

Along with the CCIO Network and INTEROPen Collaborative to oversee clinical merit and technical connectathons.

5% of £40m = £2m over 3 years (until 2020)

7.3) Eligibility

We suggest that this open platform fund is open to:

  • UK Registered for-profit commercial entities (Companies and LLPs) and
  • UK Registered not-for-profit entities (CICs,Trusts,Companies limited by guarantee and other recognised forms) meeting UK definition of an SME (In the UK a company is defined as being an SME if it meets two out of three criteria: it has a turnover of less than £25m, it has fewer than 250 employees, it has gross assets of less than £12.5m)
  • UK Public Sector bodies (NHS Bodies, Government agencies and local authorities etc.) irrespective of size.

7.4) Match funding obligations

We suggest that applicants will be required to match fund any award from the fund as follows

  • Social or commercial micro-enterprises 1
    No match funding obligation
  • Social or commercial SMEs 2
    Match funding equal to 50% of the award
  • Public sector bodiesMatch funding equal to 100% of the award

 

1 A business with less than 10 employees and (a turnover < £2 million euro or a balance sheet total of less than £2 million euro)
2 A business with less than 250 employees and (a turnover < £50 million euro or a balance sheet total of less than £43 million euro)
These are the current official definitions applying in the UK

8) Criteria

We suggest that an Open Platform fund is open to projects that stimulate and support both the creation and adoption of an open digital ecosystem which meet the definition in section 5 of What is an Open Platform.

While the main aim of all projects will be to improve NHS services towards personalised health and care 2020, the criteria by which the funding from this fund will be allocated will depend on the concurrent creation of value add in the form of;

  • Collaborative – all projects must establish open channels of communication and means of engagement with other parties in the bid at the time of their application (e.g. INTEROPen Ryver etc).
  • Transparent – all projects must be willing and evidence how they will partake in regular clinical and technical reviews. We suggest these should be in the form of bi-annual CCIO Network led review along with INTEROPen led Connectathons with a minimum of 3 out of 6 Connectathons undertaken.
  • Share Ideas, Knowledge, Experience – i.e. willing and able to openly collaborate with others in this initiative (e.g via online community building via tools such as the Open Health Hub, Ryver etc) and partake in Open Data connectathon against INTEROPen FHIR APIs

9) Judging process

Initial Bid and Review Point Principles

We suggest the related submissions into this fund will need to evidence the following as part of their bids and progress at agreed review points:

  • Clinical merit – against the Personalised Health and Care 2020 Vision
  • Technical merit – against the open platform principles outlined
  • Clinical gap / need / demand
  • Clinical Leadership – all projects need nominated clinical lead
  • User Centred Design – include/demonstrate a commitment to open publish UX design
  • Alignment with Agile Development methodologies
  • Business readiness (preparatory work, governance etc in place)
  • Collaboration with other parties in the open platform bid
  • Open Source track record

10) Conclusion

If public monies are for one purpose, they should be for the common good. Our proposal aims to ensure the efficient and effective allocation of public monies to projects that can impact the health and care of millions of citizens in England, supporting local NHS & Social Care organisations in their hour of need, while leveraging Britain’s long held reputation for industry and innovation to enable a new global open platform fit for the 21st Century.

Our proposal for an open platform technology fund aims to offer a means towards the integrated care vision of Personalised Care 2020 that is in the best interests of the NHS. In aligning patient, clinical and care needs with the investment potential offered by open platforms in healthcare, we believe there is a clear win-win on offer here.

At times of challenge and change the natural instinct may be to withdraw from risk or novel action, yet all our instinct is telling us that now is very time to embrace this challenge and seek the opportunity – which is why we are taking a public lead in getting this Open Digital Platform for Healthcare into action and welcome your interest and support in this effort.

Dr Tony Shannon, Ewan Davis
14th January 2017

Questions or Comments?
Email us at 1percentfund@ripple.foundation or tweet @rippleosi with #1percentfund

11) Declarations of Interest

Both of the authors are unashamedly proponents of an open platform in healthcare for some time. One might argue that this constituents a conflict of interest with the proposed approach. Rather we would suggest that our track record in leading the effort to disrupt the market towards an open platform, equates to a confluence of interest with the approach now required.

Dr Tony Shannon, Director – Ripple Foundation C.I.C
Director – Frectal Ltd

Ewan Davis, Director – Synapta C.I.C
Director – Handi Health C.I.C
Director – Open Health Hub C.I.C
Director – Operon Ltd
Director – Woodcote Consulting Ltd

12) Related Links

Ripple Foundation Community Interest Company http://rippleosi.org/
HANDI Health Community Interest Company http://handihealth.org/
Synapta Community Interest Company http://synapta.org.uk/
Endeavour Health Charitable Trust http://www.endeavourhealth.org/
Apperta Foundation Community Interest Company http://www.apperta.org/
INTEROPen Collaborative http://www.interopen.org/
openEHR Foundation http://openehr.org/
HL7 FHIR https://www.hl7.org/fhir

Appendix 1 – Open Platform Infrastructural Component Candidates

The aim here is to initially outline examples/suggestions of a “top 10” set of federated service components in a Service Oriented Architectural world that would be useful to in healthcare. In doing so we welcome further suggestions and related expressions of interest that would aim to provide open source solutions to plug gaps / provide enhancements towards the open digital platform movement. The fund may support the open sourcing of existing components or their development.

Identification & Authorisation
Master Patient Index
User Interface framework
Integration technologies
Clinical Data Repository
Terminology services
Workflow services
Rules engine
Scheduling
Business intelligence
Clinical content collaboration/authoring tools (i.e. openEHR/FHIR etc)

Applications for these open source infrastructure projects are encouraged to state their preferred OS license (weighting towards non copyleft (Apache 2/MIT/BSD) or AGPL licensing)

 



 

The Future of Applications


I was recently passed a link to an interesting paper from Accenture “The Future of Applications – Three Strategies for the High-velocity, Software-driven Business”. This paper is directed at a general business audience, but has much of relevance for the digital health world and in particular resonates with the points I was trying to make in my recent blog  “Would you like to build Health and Care Software 100 times Faster?”

Picking up a few key points from Accenture:

“The fact is, many companies are trying to compete in the world of social, mobile, analytics and cloud with applications that were designed for another era. Monolithic applications are often built from the ground up— slow to implement and slow to change. “

Very true of the systems in health and care, not just the big megasuites, but most of the applications in use today.

“What’s needed is a new way to build software—faster, flexible and more liquid—with reusable components that allow for rapid assembly of applications in support of dynamic business needs. This approach requires modular architectures……”

In the context of health and care this sounds very much like openEHR.

The other two other key points the paper makes: The need to build intelligent applications and to build and nurture  [open] ecosystems also seem to provide further support for the work I’ve been in with colleagues in NHS Englands Code4Health Programme.

There is much more in the Accenture paper which is well worth reading and thinking about how we can apply its recommendations in the context of health and care. You will find the paper on the Accenture web site here.

Would you like to build health and care software 100 times faster?


I’ve written before about openEHR and how I think its time has come. I been talking to lots of people about openEHR and it’s clear it takes a while to really understand its power – It took me 15 years. In this blog I try and summarise what I think makes it different and special. If you are new to openEHR I suggest you read this first and then go to my previous blog and openEHR.org  for more detail.

OpenEHR is not a piece of software it’s an open specification from which software can be built. It has it roots as a way of creating electronic health records, but can be used to build records across the whole of the health and social care domain.

Its key benefits are:

  • It enables those designing systems to work at the information level rather than at the level of a particular technology separating
    • “content” – the domain of the clinician or social care professional
    • from “technical infrastructure” – the domain of the software engineer
  • enabling both to concentrate on their own domain without needing to worry about the complexity of the other.
  • It’s independent of any particular vendor or technology – There are multiple implementations from a number of vendors, built on various technologies, including open source options.
  • There is a vibrant global openEHR clinical community creating archetypes (the building blocks of openEHR), which are generally “open source” and can thus be freely shared, used and adapted. See Wooland’s  Cat for more on this 
  • There is an active vendor community which supports the clinical content development and a number of examples of implementation at scale, mainly outside the UK where it was invented!
  • The specifications are amazingly rich. There is very little than its creators have not covered including:
    • Interoperability, openEHR makes it easier to achieve interoperability than not.
    • Multilingual support and language independence
    • Federated multi-vendor implementations, with cross vendor querying
    • Complex access control capabilities
    • Intermittently connected devices
    • Versioning and backward comparability
    • Cybersecurity
    • Privacy protection and consent management
    • Terminology bindings

However, the most remarkable and powerful feature of openEHR is its ability to support new requirements with minimal changes to systems. To support a new requirement it is simply necessary to create new archetypes. These will be immediately deployable, storable and queryable; will not require any database schema changes, won’t affect parts of the system not connected with the new requirement and won’t break anything – This means that new requirements can often be deployed in hours rather than months. Let me explain further:

New requirements generally mean new information has to be collected and stored. Anybody, who has worked at the database level will know how problematic this can be. You have to modify the database schema, modify existing tables, maybe create new ones and then migrate data from the old schema to the new. In a database of any complexity it’s easy to break things and can require the rework of lots of software unconnected with the new requirement. While modern databases have tools that can help developers avoid schema changes like the plague and when they do consider them, the rework and testing required means that changes will be expensive and slow if they happen at all often leaving people with no recourse than another  Feral System

Supporting new models of care means being able to meet new requirements 10 – 100 faster, by utilising openEHR’s ability to incorporate changes simply by creating new archetypes, the large preexisting set of open source archetypes, its openAPIs we can now achieve this.

If you not looked an openEHR already then I suggest you do and if you loked at it a while ago I suggest you look again.

This video produced by Dr Wai Keong Wong (@wai2k )provides a useful introduction to openEHR

openEHR a Game Changer Comes of Age


I’ve been watching openEHR over more than fifteen years, and although I have always been impressed by its potential to enable us to do things differently, I must admit it has been a slow burn, and take up has been limited, particularly in the UK where it was invented. However, due to some recent developments, I think this is about to change, and that openEHR is going to take off in a big way. This is going to revolutionise how we think about and do digital health, and it should increase the speed at which we can do it by at least two orders of magnitude. Why do I say this, and what evidence is there to support my assertion?

openEHR has come of age with a large number of successful small implementations, and a few much larger ones (1) which have proven the approach works at scale. We have also seen the use of openEHR by governments and major health providers across the globe, including the NHS (2), as the mechanism for the creation and curation of clinical content standards in their territories. In addition, changes to the openEHR Foundation have made it unarguably an open source organisation with a global user community; a growing vendor community has developed offering both open source and proprietary tools and components supporting the standard; and there is serious interest from major system integrators. These changes make openEHR look like a much better alternative to the hegemony of the big US megasuite providers, who still want to shape health and care systems in their image and who own the platforms on which these providers will increasingly depend.

UPDATE (12 April 16)

Possibly the best explanation of openEHR I’ve seen “openEHR technical basics for HL7 and FHIR users” Well worth reading.

UPDATE (15 March 16)

Some great videos here which provide an easy way to understand various aspects of openEHR.

In particular:

Clinician-led e-health records – An introduction to openEHR for clinicians

National governance of openEHR archetypes in Norway – A national approach to building information models with openEHR. Many lessons here for HSCIC who have just started doing something similar here.

UPDATE (13 July 15)

In their PQQ which kicks of the procurement for the Datawell to support Devo Manch,  Manchester have mandated openEHR along with other established standards including IHE-XDS. This could potentially lead to the largest implementation of openEHR in the UK with Manchester building on pioneering work in Moscow and Leeds

UPDATE  (24 Apr 15) Further information and news about the growing interest in openEHR will be found here

Firstly, everything I read and all of the people I talk to across the globe about digital health agree on a couple of things.

  • Firstly, we need to move towards a platform architecture into which we can plug the thousands of apps and hundreds of traditional systems that we currently use in health and care; an architecture which will enable all of these to interoperate and work together.

  • Secondly, we need to separate content (the data, information and knowledge that applications consume and update) from the applications that process it; and that content needs to be expressed in a modular, computable and reusable format.

Beyond this, agreement breaks down – people do argue about business models (who should own and control the platform), and also the details of the particular standards and technology to be used – but on the core principles, everyone with any credibility agrees.

When it comes to business models, some would like to own the platform, because doing so would create a massive commercial opportunity. And while some still pursue this goal, most significantly Apple, others have decided, as I have, that ownership of the platform is neither achievable (competitive and customer pressures mean even the mighty Apple can’t win this battle) nor is it desirable from the perspective of citizens, health and care providers and payers – none of whom wish to be locked in or to pay the ‘fruit tax’ or its equivalent.

Others, including me, and more significantly some big players, have come to the view that while it might be great to own the platform, that isn’t going to happen and so we need to move to an open platform which nobody owns (in the sense that nobody owns the Internet). As for commercial opportunities, they will still exist higher up the value chain, and the existence of the platform will create such opportunities by the spadeful. Surely it’s more fruitful to concentrate on these, rather than waste time and resource on a battle no one can win.

On the details of implementation, disagreement is less significant. The two major contenders, openEHR and the Healthcare Consortium, both have similar approaches, and they are already converging through the Clinical Information Modeling Initiative (CIMI) to reduce their differences to the point where they really don’t matter and can be dealt with at a purely technical level, with their components being easily interchangeable.

So, if we want to create an open platform, what do we need? We need openEHR or something like it – and frankly there is nothing else as mature or as well supported as openEHR.

OpenEHR is not software, nor is it a particular technology. It’s an open specification or standard for the representation of a key bit of content – the health and care record. The specification is open source (insofar as you can apply this term to something that is not software), and it’s curated by the openEHR Foundation, which is a not-for-profit company democratically controlled by those who choose to be part of the global openEHR community (and anybody can). The community is truly global and growing, and consists of both users and developers; and is supported by a number of vendors who can offer tools, components and services supporting the standard.

openEHR provides a simple, robust and stable over-arching reference model (3) which defines a formalism for the representation of the modular components of a health and care record. openEHR calls these ‘archetypes’ and they define the elements of a record, their properties, and how they are represented (including bindings to terminologies and classifications). Archetypes are intended to represent a superset of all those properties that might be associated with the concept they represent (at a high level these will be either an observation, an evaluation, an instruction or an action). Archetypes can then be constrained and/or combined in a ‘template’ to provide practical interoperable components for use in a particular context or system.

The tools available for the creation of archetypes and templates are open source (as are the vast majority of the archetypes and templates created with them), and this makes openEHR easily accessible to clinicians and other domain experts while also providing system developers with robust components to handle many of the technical complexities. openEHR enables clinicians to concentrate of the clinical stuff, and developers to concentrate on the technical stuff, without needed to understand more about the other domain than they want to.

By building systems using openEHR, system development work shifts from the technical level to the domain level. A repository that has been built to store an openEHR health and care record does not need to take account of the particular content of a given archetype. Whatever that archetype might represent, the repository will be able to store it, and you will be able to query that repository about its content. This feature of openEHR is the key enabler of much faster application development, because the addition of new features will not require changes to database schemas (with all the associated testing and data migration that entails). Instead, all that is needed is the addition of some archetypes and/or templates – and these may already be available as the result of work by others in the community, or else they can be created rapidly by a relevant domain expert – plus the creation of some new user interface components, and these can often be generated automatically from the underlying templates. In this way changes can be made by end users, or by people close to them. This will reduce the time to add new features from months to hours, and the time to build new systems from years to weeks.

openEHR is also technology independent. Applications don’t need to concern themselves with the technology of a particular implementation of an openEHR repository – that’s purely a matter for the implementer, who can chose whatever technology works best for them at a particular time and in a particular context. The applications that use it will not be affected, so long as they remain compliant with the standard. We can see this happening in the dozen or so existing implementations of openEHR repositories: they use different operating systems, different databases (SQL and NOSQL) and various development tools to create both open source and proprietary implementations of the standard. Compliant implementations of the standard from different vendors are interchangeable, and a single query can be executed across multiple implementations. openEHR is vendor independent, and it eliminates vendor lock-in.

Suppliers of openEHR repositories will have to compete on performance, security, robustness, value and service – they cannot rely on customer lock-in, as the vendors of many traditional EHR systems have in the past. From the perspective of health and care providers, openEHR puts them back in charge of their own destiny. This contrasts with most of the current successful approaches to the delivery of enterprise-wide EHR, where customer institutions have adopted one of the four big US megasuites, and then have had to adapt internal processes and organisation to fit with the chosen system – in effect, you become an EPIC, Cerner, Allscripts or Meditech institution, rather than a customer who calls the shots.

The ‘megasuite model’ has worked spectacularly well (if expensively) in a number of big US hospitals, particularly for EPIC, but that model starts to break down when you seek to extend the scope of a system from an institution to an integrated health and care community. It also fits badly with UK and other European models of health and care, which are not so close to the US model as the megasuite vendors might hope them to be.

Of course European health and care providers don’t want to remodel their processes along American lines – why would relatively successful European providers want to adopt systems designed primarily for the inequitable and unsustainable US system? According to the well respected US Commonwealth Foundation the United States ranks last among eleven leading developed countries on measures of access, equity, quality, efficiency, and healthy lives (and, by the way, the UK’s NHS takes the number one spot).

Much of my conviction about openEHR comes from work I’ve been involved in with HANDI, in building HANDI-HOPD – the HANDI Open Platform Demonstrator, which has now been adopted by NHS England as the NHS England Code4Health Platform. This platform provides a simulation environment for any system or service that wants to expose an API (interface) within an open ecosystem, and it includes an openEHR repository loaded with test data from the Leeds Lab Project.

We have exposed SMART and FHIR APIs, as well as the native openEHR service API, on top of the repository; we have used this to build a number of apps, and also demonstrated how you can simply plug in apps that were developed elsewhere using the SMART API. We have also used this platform to prototype a UK localisation of an open source ePrescribing product (www.openep.org), and the speed at which we have been able to carry out the localisation and meet some special mental health requirements has been impressive – indeed so impressive that we will shortly be announcing the first NHS Trusts who will be taking the system live.

Work is currently being completed to re-brand the HANDI platform as the NHS Code4Health Platform, and this will shortly be available for those who want to learn more and experiment with this and other open technologies.

openEHR has come of age – If you don’t believe, me give it a try.

Notes:

This is a slightly updated version of the original with a few minor changes to make it more readable to the general reader and correct some typos my thanks for this to my friend and colleague Conrad Taylor.

1) Large scale implementations of openEHR include:

Moscow – Integrated health and social care 12 million population 

Slovenia – Country wide 2 million population

Brazil – Unimed Medical cooperative

2) Health systems using openEHR to create curate and publish clinical content.

NHS HSCIC

NHS Scotland

Australia

Norway

Slovenia

Brazil

openEHR Foundation 

Applications built on openEHR platform

OPENeP EPMA product www.openep.org

Marand Think!Med Clinical, Ljubljana Children’s Hospital http://www.marand-thinkmed.com

Ocean Multiprac Infection control, Queensland Health, Australia http://www.multiprac.com/?portfolio_4=infection-control-2

Ocean LinkedEHR, Western Sydney, Australia  http://openehr.org/news_events/industry_news.php?id=121

DIPS Arena, Norway http://openehr.org/news_events/industry_news.php?id=97

mConsole, Mental Health patient portal, Code24, Netherlands

Clinical Decision Support, Cambio, Sweden http://www.cambio.lk/News-and-facts/Produktnytt/COSMIC-Clinical-Decision-Support1/

See also http://www.openehr.org/who_is_using_openehr/healthcare_providers_and_authorities

3 Some key documents on OpenEHR

OpenEHR Architecture Overview

OpenEHR Reference Model

Moscow eHealth a Model for the UK


The approach that Moscow City Council has adopted to create an open platform to support health and social care services in Moscow which uses some of the same technology as the Code4Health platform would seem to have relevance to the UK and in particular is a good fit for the needs of emerging new approaches to the integration of health and social care like that recently announced for Manchester.

Many of you will know about HANDI-HOPD the HANDI Open Platform Demonstrator  that we have been working on for the last few months, this has now morphed into the NHS Code4Health Platform launched by NHS England during eHealth Week in London this week (5th March 2015).  However, what you probably won’t know is that one of the key pieces of technology available on the platform is the same as that which is currently powering the whole of the eHealth system in Slovenia and even more impressively Moscow.

Moscow

The Platform deployed in these two places brings together OpenEHR www.openehr.org and IHE XDS  in a very impressive way. And I believe provides a model for what we might do in the UK and even more interestingly aligns with the thinking in a number of UK city regions who are already looking at IHE XDS and/or OpenEHR and who in a number of cases have already implemented one or the other. However, the UK initiatives appear to know little of what’s been done in Slovenia and Moscow and in particular how XDS has been successfully integrated with OpenEHR, which I believe takes the capabilities of the platform to a new level – This blog aims to put this right.

One of our key partners in the Code4Health Programme who have provided the core of platform and open source components for the OPENeP Project www.openep.org are Marand,  and they are also the company who provided the platform for both Slovenia and Moscow and it is from their charismatic CEO Tomaž Gornik that I draw much of my inspiration and information.

Before turning to some of the technical details I’d like to describe a little of what I understand of the somewhat different approaches in Slovenia and Moscow and the motivations behind them, as while both use what is fundamentally the same technical platform they came to the solution from different directions in ways which graphically illustrate the flexibility of the underlying technology.

Moscow City Council is responsible for pretty much all of the health and social services serving Moscow’s 11 million citizens covering broadly what we call primary, community and social care and outpatient clinics. Moscow is a complex environment and has large number of siloed legacy systems, which made interoperability difficult and created significant vendor lock-in of data and systems. Moscow wanted to separate data from applications and store its data in a vendor and technology neutral format and chose OpenEHR to do this. They piloted this approach using the Marand Think!EHR OpenEHR implementation (which is one of the components on the Code4Health Platform) and IHE XDS components from  www.forcare.com. The same basic technology as Marand had already successfully implemented in Slovenia where the IHE componets were supplied by www.tiani-spirit.com . The pilot was successfully and the platform is now rolling out across the City.

While both Slovenia and Moscow have ended up with broadly similar solutions they reached this point from opposite directions. Slovenia started simply wanting to implement IHE XDS to allow sharing at a document level, but came to realise that this did not support their need for fine-grained structured data to support big data analytics. They solved this problem with the integration of  OpenEHR. Moscow on the other hand started with a view they just needed OpenEHR, but were persuaded of the quick wins IHE XDS could bring with document level sharing and in particular its ability to mobilise documents already produced by legacy systems that would take some time to be replaced or upgraded to take full advantage of the power of OpenEHR.

In both Moscow and Slovenia the same proprietary components have been used to implement both XDS and OpenEHR.  However, both have the comfort that because the data is stored in an open format, these components can easily be replaced if alternatives emerge which appear to offer better performance or value. Indeed this portability of data is something that HANDI have already proven in the creation of the Code4Health platform which required the data to be moved between two competing OpenEHR implementations.

Requirements and technology will evolve, but for me for now and the foreseeable future the approach taken in Moscow seems like the best bet for the integration of systems and information in the complex environment of health and social care across a city region. It brings the long-term benefits of OpenEHR, which has the capacity to put data into an open, fine grained, structured format that is technology and vendor neutral, with the tools to easily engage frontline clinicians and other Health and Care Professionals in its curation while delivering the quick wins with XDS that can ensure the right document is available in the right place at the right time to support safe, efficient care.