Progress of openEHR Implementation

in Spain, Europe and the World

Diego Boscá, IBIME Group, Technical University of Valencia, Spain

Index (I)

• Introduction

• MML-openEHR-HL7 CDA project

• Europe

– Sweden

– UK

– Denmark

– epSOS project

– Spain

– Other countries2

Index (II)

• World

– Brazil

– Uruguay

– USA

– Australia

– Other world countries

– Japan

• Discussion

3

Introduction

• The use of standards that take into

account clinical knowledge is gaining

focus

– openEHR

– ISO13606

– HL7 v3

– Detailed Clinical Models (DCM)

• Both openEHR and ISO13606 use

archetypes to describe clinical concepts4

openEHR & ISO13606

• Two norms, different objectives:

– openEHR is for EHR system

– ISO13606 is for the communication of EHR

• CEN EN13606 adopted the openEHR

archetype model.

• Archetypes part of openEHR is ISO norm

(ISO13606-2)

5

openEHR & ISO13606

• ISO13606 model is a subset of openEHR

– Also, ISO13606 is more generic

• ISO13606 not only archetypes:

– ISO13606-1: Reference model

– ISO13606-2: Archetype interchange specification

– ISO13606-3: Reference archetypes and term lists

– ISO13606-4: Security

– ISO13606-5: Exchange models

http://www.en13606.org/ 6

Model comparison

7

ISO 13606 openEHR

FOLDER FOLDER

COMPOSITION COMPOSITION

SECTION SECTION

ENTRY OBSERVATION

INSTRUCTION

EVALUATION

ACTION

CLUSTER CLUSTER

HISTORY

ITEM_TREE

ITEM_TABLE

ITEM_LIST

ITEM_SINGLE

ELEMENT ELEMENT

MML-openEHR-HL7 CDA

Project

• Research stay at Yoshihara Laboratory in

Kyoto University

• My thesis work: How we can integrate

between different standards?

8

• Different parts of the world with different

standards

• Same illness!

Work

• Can MML concepts be represented as

archetypes?

• Can we generate correct MML XML from

the MML archetypes?

• Can we map MML to other standards?

9

MML concepts as archetypes

• MML has two kinds of concepts: Common

concepts (support) and content modules

(clinical concepts).

10

Common formats Content module

Address Patient Information

Personalized Info Basic clinical

ID Surgery Record

Name Diagnosis Record

External reference Lifestyle Information

Creator Clinical Summary

… …

MML concepts as archetypes

• An archetype was created for each

concept on common and content modules

– 9 archetypes for common concepts

– 12+1 archetypes for content modules

• The extra archetype is a reused concept

• Archetypes do not follow openEHR model

11

Example

13

Work

• Can MML concepts be represented with

archetypes?

• Can we generate correct MML XML from

the MML archetypes?

• Can we map MML to other standards?

14

Correct MML from archetypes

• For demostration, some MML archetypes

were mapped with constant values and

with a sample data source

• The example data instances were

modified so they have japanese writing

(kanji, hiragana)

15

Result

Original XML

<patientSummary>

<extractTime>2010-12-21T12:14:05</extractTime>

<id>ID01</id>

<demographics>

<patientName>被記</patientName>

<patientSurname>載者</patientSurname>

<dateOfBirth>1974-06-12</dateOfBirth>

<gender>M</gender>

</demographics>

</patientSummary>

Result XML<?xml version="1.0" encoding="UTF-8"?>

<mmlNm:Name mmlNm:repCode="A“ mmlNm:tableId="MML0025">

<mmlNm:family>載者</mmlNm:family>

<mmlNm:given>被記</mmlNm:given>

<mmlNm:fullname>被記, 載者</mmlNm:fullname>

</mmlNm:Name>

Work

• Can MML concepts be represented with

archetypes?

• Can we generate correct MML XML from

the MML archetypes?

• Can we map MML to other standards?

17

Mapping to other standards

• Only MML clinical modules need to be

mapped, support module classes will be

inserted on the archetypes before

mapping

• A project was proposed: mapping between

openEHR-MML-HL7 CDA

• Transform data from MML and HL7 CDA

into openEHR XML data and store it with

opereffa18

Proposed system

19

Opereffa openEHR

TransformTransform Transform Transform

Where to start?

• We have the MML archetypes, we can choose

openEHR archetypes to create the

transformation from openEHR MML

• A set of openEHR archetypes was selected from

CKM (public online archetype repository)

• Already existing Japan related openEHR

archetypes

20

Mapping

• Few MML concepts have similar scope that

openEHR archetypes…

– MML Diagnosis record ≈ openEHR-EHR-

Evaluation.problem-diagnosis

– MML Progress course ≈ openEHR-EHR-

SECTION.soap.v1

• But mostly don’t!

– Missing archetypes

– Multiple archetypes to represent only one concept

– Different granularity or internal structure

– Different codes!21

Missing archetypes

• Some concepts on MML are not represented yet

with openEHR archetypes or information is

Japan specific

– MML Health Insurance module?

– Japanese names?

– Subjective archetypes?

• Create new openEHR archetypes when

needed

22

Multiple archetypes to

represent one concept

• For the patient identification, 10 archetypes where chosen.

• 8 from the openEHR repository:

– openEHR-DEMOGRAPHIC-PERSON.person.v1

– openEHR-DEMOGRAPHIC-PARTY_IDENTITY.person_name.v1

– openEHR-DEMOGRAPHIC-ADDRESS.address.v1

– openEHR-DEMOGRAPHIC-CLUSTER.person_additional_data_iso.v1

– openEHR-DEMOGRAPHIC-CLUSTER.person_identifier_iso.v1

– openEHR-DEMOGRAPHIC-CLUSTER.person_death_data_iso.v1

– openEHR-DEMOGRAPHIC-CLUSTER.person_birth_data_iso.v1

– openEHR-DEMOGRAPHIC-CLUSTER.biometric_identifier_iso.v1

• 2 provided by Kobayashi Shinji:

– openEHR-EHR-CLUSTER.person_name-japan.v1

– openEHR-EHR-CLUSTER.address-japan.v1

23

Different granularity

MML concepts openEHR archetypes

Text or XHTML complex structures on archetypes

Detailed structures Simple_text

Codes with qualifiers (laterality…) Coded_text with only one code!

Mandatory attributes Optional attributes

Boolean (finished?) Care Stage

… …

24

Join or split fields on the mapping process…

…but also, suggest improvements to current openEHR archetypes!

Different codes

• Both MML and openEHR archetypes rely

on internal terminologies

– Valid status

– Valid texts or codes

• Make table mappings between them

– E.g. sex

25

openEHR MML

Male male

Female female

Intersex or indeterminate other

Not declared/inadequately described unknown

openEHR

at0010

at0011

at0012

at0013

Work to be done

• Create the mappings between the openEHR

archetypes and the remaining MML archetypes

• Finish and check the validity of the openEHR to

MML transformation

– Generate valid instances from openEHR archetypes

for testing

• MML to openEHR archetypes.

– Usually, several openEHR archetypes were mapped

to only one MML concept…

– …so one MML concept can be mapped to different

openEHR archetypes27

openEHR use:

Europe

Sweden

• Sweden National Project

• Business:

– CAMBIO

• Transforming openEHR archetypes & templates to

Cambio templates

• Academia

– Linköping University

29

Sweden National Project

• Long term project

• Use both openEHR and ISO13606 at

different stages of the national project

• Their own CKM version

– SKL (Sweden version of CKM)

http://sllocean.karolinska.se/ckm/

30

Sweden National Project

31

© Inger Wejerfelt

Sweden National Project

• Level 1: NPÖ (National Patient Summary)

– Create a 13606 archetype and generate the

NPÖ from current systems

• Level 2:

– Pilot : two healthcare organizations, one

quality register

– Use archetypes to capture information and

send to quality register

– Use of SNOMED

• Level 3: Full openEHR system 32

Linköping University

• LiU EEE (Educational EHR Environment)

– Based on openEHR & REST

– Modular

– Open source

– XML database for storage

– Support for AQL

33

UK

• NHS

• Sintero:

– Wellcome-funded research data

repository (diabetes)

• UCL

– Opereffa(openEHR REFerence Framework and Application)

34

NHS

• Connecting for Health Developed

nearly 1000 openEHR archetypes

and 60+ templateshttps://svn.connectingforhealth.nhs.uk/svn/public/nhscontentmodels/

• Using a profile of EN13606 (together with

CDA) as part of the Logical Record

Architecture

• How to link SNOMED-CT with archetypes

35

UCL

• Opereffa

– Open source

– Develop clinical applications based on

openEHR archetypes

– Based on the openEHR Java implementation

– Additional functionality

• GUI generation

• Persistence

– Demo: http://opereffa.chime.ucl.ac.uk/MainContainer2.jsf

36

37

Denmark

• Proof-of-concept project:

– Observation archetypes were easily

adopted by vendors

• Non-observation archetypes, not so direct

– Vendors believe on archetyping to import

semantically rich data on their systems

– Vendors not willing to implement non

accepted parts of openEHR, like templates or

export

– Governance is a big challenge38

epSOS Project

• European Patient Smart Open Services (epSOS)

– The project is co-financed by the European Commission and

member states with EUR 22.000.000.

– epSOS was launched on July 1, 2008 and will finish on June 30,

2011

39© David Moner

– It is a Europe-wide project organized by 27

beneficiaries representing twelve EU-

member states, including ministries of

health, national competence centres and

numerous companies.

epSOS Project

• The epSOS project cover three use cases:

– Communication of the Patient Summary, including alerts,

medical problems (past and current), list of medications…

– ePrescription, a medical professional decides

to prescribe medicine to a visiting patient from another

country.

– eDispensation, allowing a pharmacist to electronically

access the prescription from the same eHealth interface

used for prescriptions ordered in the local country.

© David Moner 40

epSOS Project

• Methodology:

1. Clinical specifications were developed by a clinicians

2. A set of terminologies was selected, from international sources or as an own development.

3. Technical specifications in HL7 CDA and ISO 13606 were defined following the clinical specifications.

4. Pilot tests are being implemented.

© David Moner 41

Spain

• Not adopted by the government

(yet)

• But with presence in hospitals and

the academic world.

• 100+ professionals formed on ISO13606

standard

42

Spain

43

• Academia

– Alcalá University

• ArchOnt Framework

– Carlos III Institute

• Archetype instance server

– Murcia University

• openEHR ↔ ISO13606 converter

• Archforms

Spain

44

• Academia

– Vasque Country University

• EHROnt

– Valencia Technical University

• Archetype based legacy data integration

• Business

– Veratech

Alcalá University

• ArchOnt Framework

45

ADL Archetype

Ontologizer

Instance

Mapper

Inference

Patient

data

Risk

data

Reference

Model

Archetype

1

2

3

SNOMED

Carlos III Institute

• Archetype Instance Server

– Based on ISO13606

– Instance repository

– Instance validator

– Use of ISO21090 for data types

• profiling

46

Murcia University

• openEHR ↔ ISO13606 converter

– Transform between openEHR and ISO13606

archetypes via OWL

– http://miuras.inf.um.es:9080/PoseacleConverter/

– Web service

• Archforms

– Generate graphical interfaces from the

reference model semantic model

47

48

Vasque Country University

• EHROnt

– Framework for translation between standards

– EHR classes described in OWL

– Mappings as SWRL rules

– For the moment works with ‘observations’

• More classes will be supported in the future

49

IBIME Group (UPV)

• Leaded by PhD. Prof. Montserrat Robles

• Ten years of experience in the field of

Biomedical Informatics

• ≈ 20 members

• Funded by Regional, National and

European R&D projects and technology

transfer

http://www.ibime.upv.es 50

IBIME Group (UPV)

• LinkEHR Archetype Editor

– Archetype edition

– Reference model independent

– Open Source

• LinkEHR Integration Archetype Editor

– Legacy data source mapping

– XQuery scripts automatic generation

• EHRFlex (EHR Viewer)

– Archetype based EMR system

– Open source 51

LinkEHR Archetype Editor

• Any model can be imported

• Tested models: openEHR, ISO 13606, HL7

CDA, ASTM CCR and CDISC ODM. Therefore,

it is possible to define archetypes based on

these models.

• Archetype creation driven by the reference

model

• Includes a syntactic and semantic validator.

• Connection with CKM

52

LinkEHR Integration

Archetype Editor

• To generate XML documents conformingto the reference model is necessary todefine how archetypes sources of data arerelated: mappings or correspondences.

• The user must specify how to calculatefrom one or several values of the datasource the value of an attribute of thearchetype.

• The data sources can be relational, XMLor archetypes

53

Patient_Data

First Name

Family Name

Age

Sex

Patient

Age

Full Name

GenderCondition Function

$Patient_Data.sex=‘m’ 0

$Patient_Data.sex=‘f’ 1

true -1

Data source: demographics

concat

Archetype

Standardization Process

with LinkEHR-Ed

EHR Viewer (EHRflex)

• EHRflex is an archetype-based Electronic

Medical Records system.

– Independent of the reference model.

– Uses web technologies (Google Web Toolkit).

– Automatic generation of archetype-based

interfaces for view and edit clinical data.

– Open source project.

EHR Viewer (EHRflex)

EHR Viewer (EHRflex)

Open source project: http://ehrflex.sourceforge.net/

Real Experiences

• Hospital General Universitario de Valencia

– Pangea-LE implementation for over 5 years

• Integration of distributed data sources (more than

25 databases).

• Virtual Federated EHR viewer.

– Full migration to ISO13606 EHR Extracts in

development.

Sistema LinkEHR 60Other uses EHR

communication

EHR

viewer

Legacy

data sources

Map

Standardization

Archetype

Proprietary

XML

Standardize

d

XML

LinkEHR-Ed

Real Experiences

EHR petition

Integration

Pangea-LEXML

Real Experiences

• Hospital de Fuenlabrada (Madrid)

– Use of openEHR and ISO13606 archetypes

for pressure ulcer nursing control.

• The archetype creation methodology was

evaluated.

• Both reference models were compared and tested.

Real Experiences

• Hospital de Fuenlabrada (Madrid)

– Use of EN13606 for medication conciliation

between primary and specialised care.

• Agreed definition of a primary-care summary

archetype.

• Communication of normalised legacy data to

support patient transitions between primary care

and the hospital.

Real Experiences

• The semantic interoperability of the Patient

Summary is being tested between the Hospital

General Universitario in Valencia (HGUV) and

the Hospital de Fuenlabrada in Madrid.

– Based both on the Spanish and epSOS definition of

the contents of the Patient Summary.

– The information is communicated using the CEN

EN13606 norm.

Real Experiences

Hospital de Fuenlabrada

Madrid

Hospital General Universitario

Valencia

Communication of standardized

EN13606 informationEHR

Server

EHR

Server

Methodology

1. Agree a concept definition and define the archetype

• We have used two different definitions

– Spanish National Patient Summary

– epSOS Patient Summary final dataset

• They can be easily edited or modified

with open source archetype editors like

LinkEHR-Ed

http://www.linkehr.com

Methodology

2. Map the archetype to original/legacy data

• With these mappings we can

automatically generate transformation

programs for the EHR system.

XML

Existing

EHR systems

Methodology

3. Deploy the transformation program in the EHR server

• Set up a standard EN13606 extract server in both hospitals to

generate and communicate the standardized information

– Transformation is applied on demand

– Web-service based

– Includes a standard EN13606 web viewer

EHR

Server

XML

EN13606

Standard

Information

Mapped

Archetype

CHGUV

HISHF

HIS

EHR

Server

Mapped

Archetype

Real Experiences

• Virgen del Rocío Hospital

– HL7 CDA can be archetyped. Archetypes can

be used as templates for HL7.

– HL7 CDA has some characteristics that do not

follow Object Oriented Modeling, but are XML

Schema specifications. Archetypes are only

applicable to OO models, so some tweaks

had to be implemented.

– LinkEHR can use CDA archetypes to

generate valid CDA instances of existing data.69

Other Countries

• Slovakia: National eHealth program based on openEHR

• Portugal: Integrating legacy data (National system) with

openEHR archetypes and templates

• Russia: Interest in openEHR

• Netherlands: ZorgGemak. Health record based on

openEHR

• Austria: University of Vienna. Archetype repository

• Germany:Helmholtz Center München. CCR equivalence

in ISO13606

• Romania: ISO13606 compatibility with Romanian

healthcare system

70

openEHR use:

World

Brazil

• openEHR and archetypes for the

shareable EHR at three levels of

government

- federal, state and municipal.

• Minas Gerais 13606 project

• Business

– Zilics: eZ-EHR

– P2Z: ProntuárioUniversal P2D

72

Brazilian National Project

• Defined the standards going to be used on

the National Brazilian Project

– EHR information model: openEHR

– clinical reference terminology: SNOMED CT

– clinical documents: HL7 CDA

– record location: IHE PIX (Patient Identifier

Cross-Referencing) and PDQ (Patients

Demographics Query)

• Not much more information yet73

Minas Gerais Project

• Largest Brazilian state

– 853 cities

– Over 5000 health units

• Store every citizen patient summary and

demographic data using 13606 archetypes

• Duration: from 2009 to 2015

• Developed archetypes availabe at:

http://sres.saude.mg.gov.br/arquetipo/listar

74

Uruguay

• Open EHR-Gen Framework:

– Automatic generation of GUI

– Data validation

– Data persistence

– Generation of CDA

– Open source (apache license)

https://code.google.com/p/open-ehr-gen-framework/75

Open EHR-Gen Framework

76

Open EHR-Gen Framework

77

USA

• Ethidium

– Evolution EMR: small to medium sized

facilities EMR openEHR based system

• PatientOS

– open source

– Complete HIS based on openEHR archetypes

• American College of Rheumatologists

– Designing EHR content using openEHR

78

Australia

• Bussiness

– Ocean Informatics

– Medical Objects

– Extensia

– Meridian Health Informatics

• Projects

– GastrOS

79

Ocean Informatics

• Archetype editor (Free)

• Template designer (Licensed)

• Ocean EHRBank (Licensed)

• Ocean Clinical Knowledge Manager

(CKM): Archetype Repository (Licensed)

• Archetype Workbench (open source,

Eiffel)

• Terminology Server

• Query builder 80

GastrOS

• Endoscopic reporting application

– Based on openEHR and MST (Minimal Standard Terminology for Digestive Endoscopy)

– Open source (C# and .NET)

– Annotations on templates show how GUI is

displayed

– http://gastros.codeplex.com/

81

GastrOS

82

Australia

• Queensland Health:

– openEHR repository for discharge

summary management

• Cancer Council of Victoria:

– openEHR to aggregate current data in the

repository

• NEHTA

• openEHR – HL7 relationship

83

NEHTA

• Adopted openEHR archetypes to

represent clinical concepts

• Created their own CKM repository

– http://dcm.nehta.org.au/ckm/

• Involving the Australian clinicians in the

concept creation process

• The archetypes will be transformed into

platform and reference model agnostic

models (based upon ISO 11179)84

openEHR – HL7 relationship

• People from openEHR and HL7 meet on the last

HL7 WGM on Sydney

• openEHR archetypes ≈ DCM ≈ HL7 templates

• There is an intersection!

• Create a technical document with the differences

and similarities

• A HL7 DCM is an archetype, but not a openEHR

archetype!

85

Japan

• Kano Laboratory

– Virtual EHR editor

– openEHRApp

• Ehime University/Kyoto University

– Intractable disease surveillance program

• Yoshihara Laboratory

– MML ↔ openEHR transformation

86

Kano Laboratory

• Virtual EHR editor

– EHR application

– Open source

• openEHRApp

– Generic EHR processing platform

– Open source

• In use on different projects:

– For emergency medical service in Jakarta, Indonesia

– For tuberculosis data collection in Cambodia

– For maternal and child care

87

Kano Laboratory

88

JavaServer Faces (XHTML) pages

Web Data Entry / Display Screens

Medical History

Generic EHR processing platform1. Available openEHR service model (EHR Service, Demographic Service, etc.)

2. REST web service communication

3. Available openEHR API (openEHR Java Reference Implementation)

4. Available Wrapper technique (http://www.openehr.org/projects/opereffa.html)

5. Java object-oriented database (db4o, open source)

Virtual EHR Editor

Back-end

User Interface

©Kong Saran

Intractable Disease

Surveillance Program

• Distributed data bases with more than

600k patients

• Model clinical research forms using

openEHR archetypes and templates

• Translation & adaptation of archetypes

– Demographic, Insurance

• Implementation of a server and a registry

89

Other world countries

• Chile: National program

• South Africa: Two companies working to

provide a national solution

• Canada: pilot

• New Zealand: Shared Health Information

Platform (SHIP)

• Kazakhstan

90

Discussion

• Dual model approaches are on the focus

of governments, enterprises and

universities

• A lot of open source approaches

• CKM Archetypes have creative commons

license

• 4 working archetype repositories + several

archetype repositories on the works

• New openEHR specifications in the works91

Discussion

• Archetypes can be used to describe

clinical knowledge, even outside openEHR

and ISO13606

• Transforming archetypes (concepts)

between standards will be very important

in the future… and now!

92

93

おわり