Open Source EHR at the Americal Academy of Family Physicians ...

[Christopher Feahr]

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Archetypes and Terminology (was Re: Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...)

[Thomas Beale]

Philippe AMELINE wrote:

> Hi to all,
>
> We are currently experiencing such things ; it is not easy to have 
> people understand the difference between description (As accurate as 
> possible), local study (question 5 can be answered 5.1, 5.2...) and 
> studies using classifications such as ICD or ICPC where you just can 
> use concepts inside the classification (and it is sometimes 
> complicated since, for example, "send to the hospital" as no entry 
> inside ICPC).
>
> I don't think you can expect adressing all these issues through 
> Archetypes 

I would not either...we just need some good oontologies...

> Yes, a validated scale on a particular issue around human functioning 
> could be part of an ontology, but perhaps not always. The Barthel 
> index or the APGAR score e.g. have distinct and different variables 
> that probably would not stand beside each other in an ontology. Or, it 
> would be an ontology with many to many parent - child relationships.
>
> The way we solve this kind of problem is that we incorporated inside 
> the ontology concepts as "ICD10 code", "ICPC code" and so on. These 
> ontology concepts are given the code as a "value" in the same way 
> "patient size (cm)" would be given 180 as a value. 

the ADL supports this more or less as well...

- thomas beale


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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Philippe AMELINE]

Hi to all,

At 04:43 02/10/2003 -0400, Williamtfgoossen at cs.com wrote:
>b
>>) these archetypes will have local vocabulary which defines meanings
>>for exactly what terms need to mean in the exact context of the archetypes.
>
>
>Yes, but, if this is going to be constructed, it is wise to already look 
>at well defined terminology and proceed as follows:
>
>- if a scientifically validated and reliable scale (mini ontology?) is 
>available and meets the clinical need then choose that.
>if this scales are not available, then use some kind of standardized 
>terminology like LOINC, SNOMED, ICF, NANDA or whatever.
>if that is not available to fullfil the needs for the subject, then choose 
>your own wording that defines best the meanings for the clinical area.

It certainly makes sense.
 From what I personnaly experienced, if you don't make the "semantisation" 
work at the very first stages, you will have a hard time doing it afterward 
because an ontology is an accurate but restricted langage ; thus you end up 
translating from natural langage to a more restricted langage - or worse 
from classification terms, triyng to give a meaning to terms that where 
only created for "patient grouping".

Making "semantic Archetypes" is a job that involves a doctor and a 
knowledge manager - this one translates between "doctor langage" and 
"ontological langage", but also asks for the proper level of accuracy in 
the concepts representation.
Very hard to do lately.

>Given the earlier suggestion to already use such terms, a part of the 
>coding has been done. Otherwise, depending on purpose (clinical trial is 
>different from international prevalence study) map from scale / local term 
>to classification.

We are currently experiencing such things ; it is not easy to have people 
understand the difference between description (As accurate as possible), 
local study (question 5 can be answered 5.1, 5.2...) and studies using 
classifications such as ICD or ICPC where you just can use concepts inside 
the classification (and it is sometimes complicated since, for example, 
"send to the hospital" as no entry inside ICPC).

I don't think you can expect adressing all these issues through Archetypes

>Yes, a validated scale on a particular issue around human functioning 
>could be part of an ontology, but perhaps not always. The Barthel index or 
>the APGAR score e.g. have distinct and different variables that probably 
>would not stand beside each other in an ontology. Or, it would be an 
>ontology with many to many parent - child relationships.

The way we solve this kind of problem is that we incorporated inside the 
ontology concepts as "ICD10 code", "ICPC code" and so on. These ontology 
concepts are given the code as a "value" in the same way "patient size 
(cm)" would be given 180 as a value.


>Snomed is probably
>>more in this space than pure terminology, so it may be that we send
>>change requests of some kind to them, based on archetyps.
>
>
>Yes, the process would become interactively with knowledge determiners 
>(ontology, scales) terminology developers (semantics) and information 
>modellers (archetypes as constraining mechanisms for what a record system 
>/ messaging system must do with this particular grouping of patient data.
>
>
>e
>>) due to d), ontologies may change over time in such a way that more
>>direct mappings from archetypes become possible.
>
>
>Yes, that might work two ways from archetype to ontology, but reverse to 
>via including from ontology into archetypes.
>
>
>Hope this helps,
>
>
>
>Sincerely yours,
>
>Dr. William T.F. Goossen
>
>Senior Researcher and Consultant Health and Nursing Informatics
>Acquest Research and Development, Koudekerk aan den Rijn, the Netherlands
>http://www.acquest.nl/
>&
>Adjunct Associate Professor in the College of Nursing, faculty in the 
>Organizations, Systems and Community Health Area of Study, the University 
>of IOWA, Iowa City, Iowa, USA. www.nursing.uiowa.edu/NI
>&
>Country Representative for the Netherlands in the Special Interest Group 
>Nursing Informatics, IMIA.  http://www.infocom.cqu.edu.au/imia-ni/
>&
>Member Evaluation Committee International Classification for Nursing 
>Practice, Geneva, ICN.   International Council of 
>Nurses http://www.icn.ch/   and http://www.icn.ch/icnp.htm
>&
>Associate Professor, Adjunct on the faculty of the School of Nursing,
>University of Colorado Health Sciences Center, Denver, USA.
>&
>Bestuurslid Vereniging voor Medische en Biologische Informatieverwerking
>http://www.vmbi.nl/
>&
>Fellow of the Centre for Health Informatics Research and Development 
>(CHIRAD), School of Social Sciences, Kings Alfred's, Winchester 
>www.chirad.org.uk

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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[williamtfgoos...@cs.com]

Dear all,

Thomas in particular to remind me to send the message to all, instead only to 
him :-)

Some possible additions to Thomas procedure:

> a) some people develop some archetypes , e.g. American College of 
> Opthalmologists (not sure what the proper title is)
> 

Yes, any professional organisation, or multidisciplinary group, or even 
patient organisations develop such things. 


b
> ) these archetypes will have local vocabulary which defines meanings 
> for exactly what terms need to mean in the exact context of the archetypes.
> 

Yes, but, if this is going to be constructed, it is wise to already look at 
well defined terminology and proceed as follows:

- if a scientifically validated and reliable scale (mini ontology?) is 
available and meets the clinical need then choose that.
if this scales are not available, then use some kind of standardized 
terminology like LOINC, SNOMED, ICF, NANDA or whatever.
if that is not available to fullfil the needs for the subject, then choose 
your own wording that defines best the meanings for the clinical area.


c
> ) The mundane task of mappings to ICD or similar classifiers needed for 
> reimbursement and various population & efficiency studies is easy. This 
> will take care of the practical need for these codes.
> 

Given the earlier suggestion to already use such terms, a part of the coding 
has been done. Otherwise, depending on purpose (clinical trial is different 
from international prevalence study) map from scale / local term to 
classification.


d
> ) mappings to ontologies are more challenging, and it may well be that 
> local archetype terms form "capsule vocabularies" that could be the 
> 

Yes, a validated scale on a particular issue around human functioning could 
be part of an ontology, but perhaps not always. The Barthel index or the APGAR 
score e.g. have distinct and different variables that probably would not stand 
beside each other in an ontology. Or, it would be an ontology with many to 
many parent - child relationships. 

Snomed is probably 
> more in this space than pure terminology, so it may be that we send 
> change requests of some kind to them, based on archetyps.
> 

Yes, the process would become interactively with knowledge determiners 
(ontology, scales) terminology developers (semantics) and information modellers 
(archetypes as constraining mechanisms for what a record system / messaging 
system 
must do with this particular grouping of patient data. 


e
> ) due to d), ontologies may change over time in such a way that more 
> direct mappings from archetypes become possible.

Yes, that might work two ways from archetype to ontology, but reverse to via 
including from ontology into archetypes. 


Hope this helps,



Sincerely yours,

Dr. William T.F. Goossen

Senior Researcher and Consultant Health and Nursing Informatics
Acquest Research and Development, Koudekerk aan den Rijn, the Netherlands
http://www.acquest.nl/";>http://www.acquest.nl/
& 
Adjunct Associate Professor in the College of Nursing, faculty in the 
Organizations, Systems and Community Health Area of Study, the University of 
IOWA, 
Iowa City, Iowa, USA. www.nursing.uiowa.edu/NI
& 
Country Representative for the Netherlands in the Special Interest Group 
Nursing Informatics, IMIA.  http://www.infocom.cqu.edu.au/imia-ni/
&
Member Evaluation Committee International Classification for Nursing 
Practice, Geneva, ICN.   http://www.icn.ch/";>International Council of 
Nurses http://www.icn.ch/   and 
http://www.icn.ch/icnp.htm
&
Associate Professor, Adjunct on the faculty of the School of Nursing,
University of Colorado Health Sciences Center, Denver, USA.
&
Bestuurslid Vereniging voor Medische en Biologische Informatieverwerking
http://www.vmbi.nl/";>http://www.vmbi.nl/ 
&
Fellow of the Centre for Health Informatics Research and Development 
(CHIRAD), School of Social Sciences, Kings Alfred's, Winchester http://www.chirad.org.uk/";>www.chirad.org.uk

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Open Source EHR at the Americal Academy of Family Physicians ...

[Thomas Beale]

Christopher Feahr wrote:

> My understanding is that the US open-licence period for SNOMED CT 
> begins Jan 1, 04.  I have also been told that Centers for Medicare and 
> Medicaid Services are planning a number of "demonstration projects" 
> early in 2004, involving EHR systems and SNOMED CT terms. Therefore, I 
> would agree with Ed and others who seem to be suggesting that we move 
> forward with whatever steps are necessary to get SNOMED CT into 
> production systems.
>
> In the context of a reasonably homogenous terminology space like the 
> U.S., what would you see as the main problems with SNOMED that would 
> have to be "fixed"?  Pre-coordination issues have been mentioned along 
> with some even more fundamental (??) issues that Thomas Beale suggests 
> will take several years or possibly a decade to straighten out.  Of 
> course, from my point of view, my biggest problem will likely be 
> scarcity of special vision care concepts/terms.
>
> So, what would we have to do exactly?  And which standards 
> organization would coordinate such a project... HL7? 

my feeling (with apologies to those who have been working for years in 
terminology and I realise know the semantic space much better than I do) 
is that a new process could emerge:

a) some people develop some archetypes , e.g. American College of 
Opthalmologists (not sure what the proper title is)
b) these archetypes will have local vocabulary which defines meanings 
for exactly what terms need to mean in the exact context of the archetypes.
c) The mundane task of mappings to ICD or similar classifiers needed for 
reimbursement and various population & efficiency studies is easy. This 
will take care of the practical need for these codes.
d) mappings to ontologies are more challenging, and it may well be that 
local archetype terms form "capsule vocabularies" that could be the 
basis of change requests to developers of ontologies. Snomed is probably 
more in this space than pure terminology, so it may be that we send 
change requests of some kind to them, based on archetyps.
e) due to d), ontologies may change over time in such a way that more 
direct mappings from archetypes become possible.

- thomas beale


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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Tim Churches]

On Fri, 2003-09-26 at 23:01, Thomas Beale wrote:

> Right now I really think people need to understand that there is still a 
> lot of intellectual work ot go in this area, and that finalising 
> licencing situations will not particularly change things.

And theoretical health informaticists need to understand that the
absence of a widely available termonology/classification is badly
hurting real-life efforts to improve and protect health, right now. I
don't particularly like SNOMED CT - its bulky and inelegant (although
fairly comprehensive), and as Thomas points out, uses way too much
pre-coordination. But from where I sit, as a practicing epidemiologist
who works with practicing clinicians, we need a terminology now. As I
said, SNOMED CT seems to be the best bet, at least for English-speaking
countries, and the license costs at the national level - US$32 million
for the whole US for 5 years, presumably rather less for, say, all of
Australia - are not unsustainable, and at least SNOMED is essentially a
non-profit organisation, not a rapacious multinational corporation.

But efforts on open terminologies, both niche and global, should
definitely continue. Hopefully SNOMED CT can then be replaced in a
decade or so with a free, global alternative.

-- 

Tim C

PGP/GnuPG Key 1024D/EAF993D0 available from keyservers everywhere
or at http://members.optushome.com.au/tchur/pubkey.asc
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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Thomas Beale]

William E Hammond wrote:

>William,
>
>I do not think you are over reacting.  I agree with you.  My only point is
>that we should be driven by what is best and what is a true solution, and
>not by the wrong reasons.  I would be most interested in seeing us compile
>a list of candidates for terminologies that should be considered and a
>process by which we could blend the terminologies.
>
>I don't know what the best method might be and what organization(s) might
>be best for doing the work and distributing the product.  What is the level
>of trust for the NLM around the world?
>
Peter Elkin (Mayo) claims to have identified about 40 or so candidate 
terminologies for use in an open terminology system, according to his 
paper in MIE 2003.

But I don't believe the correct methodology in this area has yet 
surfaced. It will start to when small, targetted knowledge models start 
being used more widely, and terminologists start to see that there is no 
solution based on the idea of a "single , perfect holy grail 
terminology". It just doesn't work like that. There are capsules of 
meaning everywhere which link back into ontologies, and I think that a 
theory and methodology based on this idea will begin to surface in the 
next few years. Snomed-ct will be then seen as a best effort without 
this theory, and may end up being the biggest single resource for 
re-enginering into a new typology of terminologies / ontologies / small 
knowledge models (archytpes, HL7 models, guidelines etc).

Right now I really think people need to understand that there is still a 
lot of intellectual work ot go in this area, and that finalising 
licencing situations will not particularly change things.

- thomas  beale


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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Thomas Beale]

Williamtfgoossen at cs.com wrote:

> In een bericht met de datum 25-9-2003 15:10:09 West-Europa 
> (zomertijd), schrijft hammo001 at mc.duke.edu:
>
> I agree with Ed in that if we can make this resource available, we 
> need to work on that.
> I think it is OK that HL7 uses SNOMED as preferred terminology.
>
> However, I would be very dissapointed if this would become the only 
> terminology that the current v3 RIM and derivates could handle. I 
> believe also local, or specialty or situation specific terminologies / 
> vocabs etc. should be allowed in messages. 

I agree - I would state even more strongly - I don't think it can be any 
other way. Recently, Sam did a review of our models of "Apgar result" 
(your favourite;-) and discovered that the terms used for various things 
on US and UK websites were different (e.g. the terms used for the 0,1,2 
values for each of the 5 input variables). No single global terminology 
can deal with this problem - only capsule terminologies which are 
strongly bound to particular concepts can.

- thomas beale


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Open Source EHR at the Americal Academy of Family Physicians ...

[Thomas Beale]

William E Hammond wrote:

>However, I do think it is important to make sure that SNOMED is the answer
>and will be acceptable before we move aggressively.
>
Ed - how will this happen - what process can be followed to do this? Do 
you mean "clincally" acceptable, or acceptable in terms of licencing, $ 
conditions?

I personally have great doubts that any one refernce terminology can be 
the "one answer" to everything. All the work going on with archetypes, 
RMIMs etc at the moment shows quite clearly that the meaning of any term 
in a specfic context is often (usually) not the meaning of the same work 
in a reference terminiology (which by definition almost, must have a 
kind of compromise definition of its meaning). So even if all the 
licencing and access issues are sorted out to everyone's satisfaction, I 
don't believe that the final solution has been reached. This comment is 
not specific to Smomed of course - it is a general principle.

- thomas beale


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Open Source EHR at the Americal Academy of Family Physicians ...

[Beatriz de Faria Leao]

Dear Ed,
I fully agree with you. We do need an international vocabulary. We need to
make translations to other languages and it is no so easy to convince the
ones who pay the bill that to translate SNOMED ( for example)  to Portuguese
should be done. If this is an international effort with many other countries
aligning  maybe we can try to find funds together. The sooner the better. At
the moment we are defining a new vocabulary for health procedures - sort of
Brazilian CPT...
Best regards,
Beatriz

- Original Message - 
From: "William E Hammond" 
To: "Thomas Beale" 
Cc: "Gerard Freriks" ; "Mark Shafarman"
; "Gunnar Klein" ; "Nan
Besseler" ; "Magnus Fogelberg"
; "P Zanstra" ;
; "Shah, Hemant" ; "Eline
Loomans" 
Sent: Friday, September 26, 2003 10:42 AM
Subject: Re: Open Source EHR at the Americal Academy of Family Physicians
...


>
>
>
>
> I basically agree.  I think I mean both clinical and economical.  What I
am
> hoping for is that we can create a single process in which all the
> appropriate terminologies can be blended, overlaps and mapping, and
> distribution made common.  Do it once not each institution or even each
> country.
>
> I would like to establish a core terminology group that is international
> that works toward this goal.
>
> Ed
>
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org
>


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Open Source EHR at the Americal Academy of Family Physicians ...

[Christopher Feahr]

My understanding is that the US open-licence period for SNOMED CT begins 
Jan 1, 04.  I have also been told that Centers for Medicare and Medicaid 
Services are planning a number of "demonstration projects" early in 2004, 
involving EHR systems and SNOMED CT terms. Therefore, I would agree with Ed 
and others who seem to be suggesting that we move forward with whatever 
steps are necessary to get SNOMED CT into production systems.

In the context of a reasonably homogenous terminology space like the U.S., 
what would you see as the main problems with SNOMED that would have to be 
"fixed"?  Pre-coordination issues have been mentioned along with some even 
more fundamental (??) issues that Thomas Beale suggests will take several 
years or possibly a decade to straighten out.  Of course, from my point of 
view, my biggest problem will likely be scarcity of special vision care 
concepts/terms.

So, what would we have to do exactly?  And which standards organization 
would coordinate such a project... HL7?

-Chris

Christopher J. Feahr, O.D.
Optiserv Consulting (Vision Industry)
http://Optiserv.com
http://VisionDataStandard.org
Office (707) 579-4984
Cell(707) 529-2268
At 09:03 AM 9/25/2003 -0400, William E Hammond wrote:

>I agree with Gerard that we need to be careful.  However, that does not
>mean that we go to the lowest denominator.  IF we think SNOMED is the best
>solution, then we need to spend our time and energy on finding how to make
>SNOMED available to the rest of the world.  We have a debate in our school
>system in Durham.  The poorer kids do not have access to the Internet and
>to laptops.  The debate is whether to prohibit the use of computers and
>Internet for school work or to try to find methods that will provider
>laptops and Internet access to the poorer kids.  I think the answer is
>simple.
>
>However, I do think it is important to make sure that SNOMED is the answer
>and will be acceptable before we move aggressively.
>
>Ed Hammond
>
>-
>If you have any questions about using this list,
>please send a message to d.lloyd at openehr.org

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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Tim Churches]

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Open Source EHR at the Americal Academy of Family Physicians ...

[William E Hammond]

I basically agree.  I think I mean both clinical and economical.  What I am
hoping for is that we can create a single process in which all the
appropriate terminologies can be blended, overlaps and mapping, and
distribution made common.  Do it once not each institution or even each
country.

I would like to establish a core terminology group that is international
that works toward this goal.

Ed

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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Tim Churches]

On Fri, 2003-09-26 at 04:04, lakewood at copper.net wrote:
> 3)Rigorous testing, including scalability, of SNOMED seems to be sparse:
> 
> PERFORMANCE; Google search: "SNOMED performance |"
> http://etbsun2.nlm.nih.gov:8000/publis-ob-offi/pdf/2000-tal-ob-Ft.pdf
> (1 hit)
> 
> SCALABILITY: Google search: "SNOMED scalability |"
> (no hits)
> 
> EFFECTIVENESS: Google search: "SNOMED effectiveness |"
> (no hits)
> 
> RELIABILITY: Google search: "SNOMED reliability |"
> (no hits)
> 
> AVAILABILITY: Google search: "SNOMED availability |"
> http://quickstart.clari.net/qs_se/webnews/wed/bx/Bga-mckesson-info-sols.Rn1s_Dl9.html
> (1 hit); DIFFERENT KIND OF 'availability', i.e., availabile for use
> 
> COMPLAINTS: Google search: "SNOMED complaint |"
> (no hits)
> 
> ERRORS: Google search: "SNOMED error |"
> (no hits)
> 
> SUSTAINABILITY: Google search: "SNOMED sustain |"
> (no hits)
> 
> OK! I give up!
> 
> SNOMED, it appears, has never been subjected to any kind of analysis. It 
> appears to be in the same category as home repair contractors who 
> provide an on-the-spot 'tail-light' warranty.

Only a tiny percentage of the biomedical literature is accessible to
Google - you need to search PubMed - see
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed

A completely naive search on "SNOMED evaluation" yielded 33 hits, most
of which we on topic. More extensive searches would flush out a lot more
papers, I'm sure.

BTW, please talk about "SNOMED CT" which is the original SNOMED
classification combined with a clinical terms, including the Read codes.

Personally I think that SNOMED CT is far from perfect (as has been
discussed on this list in the past), but it is the best show in town for
the near and medium future.  The fact that there is a universal license
to use it in the US, and some form of NHS-wide license in the UK, makes
it attractive to software developers. I understand that serious
consideration is being given to negotiating a national license for
SNOMED CT for Australia, but there is some due process to be gone
through first before a decision is made.

Tim C

-- 

Tim C

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Open Source EHR at the Americal Academy of Family Physicians ...

[Gerard Freriks]

Ed,

I agree with you.
Today I had an discussion with Diane Ashman on this topic.
She is very willing to think along those lines.
But we all must move with caution, think of the many consequences and find
the proper balance.

Gerard


--   --
Gerard Freriks, arts
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands

+31 252 544896
+31 654 792800


> From: William E Hammond 
> Date: Thu, 25 Sep 2003 09:03:42 -0400
> To: Gerard Freriks 
> Cc: Mark Shafarman , Gunnar Klein
> , Nan Besseler , Magnus Fogelberg
> , P Zanstra ,
> , "Shah, Hemant" , Eline 
> Loomans
> 
> Subject: Re: Open Source EHR at the Americal Academy of Family Physicians ...
> 
> 
> I agree with Gerard that we need to be careful.  However, that does not
> mean that we go to the lowest denominator.  IF we think SNOMED is the best
> solution, then we need to spend our time and energy on finding how to make
> SNOMED available to the rest of the world.  We have a debate in our school
> system in Durham.  The poorer kids do not have access to the Internet and
> to laptops.  The debate is whether to prohibit the use of computers and
> Internet for school work or to try to find methods that will provider
> laptops and Internet access to the poorer kids.  I think the answer is
> simple.
> 
> However, I do think it is important to make sure that SNOMED is the answer
> and will be acceptable before we move aggressively.
> 
> Ed Hammond

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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[lakew...@copper.net]

Hi Tim,

Pieces of the 33 hits are included below:

-Sarcomatoid carcinoma of the cervix
-An evaluation of the usefulness of two terminology models for 
integrating nursing diagnosis concepts into SNOMED Clinical Terms
-Improved coding of the primary reason for visit to the emergency 
department using SNOMED
-Which coding system for therapeutic information in evidence-based medicine
-Automating SNOMED coding using medical language understanding: a 
feasibility study
-An evaluation of the utility of the CEN categorical structure for 
nursing diagnoses as a terminology model for integrating nursing 
diagnosis concepts into SNOMED
-Semantic features of an enterprise interface terminology for SNOMED RT
-Evaluation of a method that supports pathology report coding
-Evaluation of SNOMED3.5 in representing concepts in chest radiology 
reports: integration of a SNOMED mapper with a radiology reporting 
workstation
-Representation by standard terminologies of health status concepts 
contained in two health status assessment instruments used in rheumatic 
disease management
-An evaluation of ICNP intervention axes as terminology model components
-[Medical data in pathology--evaluation of a large collection. (530,000 
diagnoses coded in SNOMED II)]
-Scalable methodologies for distributed development of logic-based 
convergent medical terminology
-The role of peer review in internal quality assurance in cytopathology
-Evaluation of a "lexically assign, logically refine" strategy for 
semi-automated integration of overlapping terminologies
-Phase II evaluation of clinical coding schemes: completeness, taxonomy, 
mapping, definitions, and clarity. CPRI Work Group on Codes and Structures
-The surgical pathologist in a client/server computer network: work 
support, quality assurance, and the graphical user interface
-Comparison of the reproducibility of the WHO classifications of 1975 
and 1994 of endometrial hyperplasia
-Planned NLM/AHCPR large-scale vocabulary test: using UMLS technology to 
determine the extent to which controlled vocabularies cover terminology 
needed for health care and public health
-Mass screening for cervical cancer in Norway: evaluation of the pilot 
project
-The LBI-method for automated indexing of diagnoses by using SNOMED. 
Part 2. Evaluation
-Representing HIV clinical terminology with SNOMED
-The LBI-method for automated indexing of diagnoses by using SNOMED. 
Part 1. Design and realization
-A comparison of four schemes for codification of problem lists
-Can SNOMED International represent patients' perceptions of 
health-related problems for the computer-based patient record?
-Extraction of SNOMED concepts from medical record texts
-Terms used by nurses to describe patient problems: can SNOMED III 
represent nursing concepts in the patient record?
-[Descriptive epidemiology from autopsies at the Ospedale Maggiore di 
Milano from 1986 to 1987]
-[Development of a findings and results data system for forensic 
medicine autopsy cases]
-Medical linguistics: automated indexing into SNOMED
-Evaluation of the CAP microcomputer-based SNOMED encoding system
-[A new microglossary for biopsy pathology]

None of these hits can be related in any significant way to to the 
implementation and deployment of a system with SNOMED functionality, 
i.e., based wholly on SNOMED or integrating it as a plug-in or an 
integral function.

My original posting included some major review topics typically 
encountered in a software product design (the focus immaterial).

There is an old saying where I come from:
Quiting playing with the design and produce something before the 
competition does.

Design, develop, deploy sustain and upgrade later.

The motivation to charge for SNOMED may well prompt competition to 
action . Right now, in my opinion, SNOMED needs relevant 
Google/developer entries.

Additional comments in your text.

Thanks!

-Thomas Clark

Tim Churches wrote:

>On Fri, 2003-09-26 at 04:04, lakewood at copper.net wrote:
>  
>
>>3)Rigorous testing, including scalability, of SNOMED seems to be sparse:
>>
>>PERFORMANCE; Google search: "SNOMED performance |"
>>http://etbsun2.nlm.nih.gov:8000/publis-ob-offi/pdf/2000-tal-ob-Ft.pdf
>>(1 hit)
>>
>>SCALABILITY: Google search: "SNOMED scalability |"
>>(no hits)
>>
>>EFFECTIVENESS: Google search: "SNOMED effectiveness |"
>>(no hits)
>>
>>RELIABILITY: Google search: "SNOMED reliability |"
>>(no hits)
>>
>>AVAILABILITY: Google search: "SNOMED availability |"
>>http://quickstart.clari.net/qs_se/webnews/wed/bx/Bga-mckesson-info-sols.Rn1s_Dl9.html
>>(1 hit); DIFFERENT KIND OF 'availability', i.e., availabile for use
>>
>>COMPLAINTS: Google search: "SNOMED complaint |"
>>(no hits)
>>
>>ERRORS: Google search: "SNOMED error |"
>>(no hits)
>>
>>SUSTAINABILITY: Google search: "SNOMED sustain |"
>>(no hits)
>>
>>OK! I give up!
>>
>>SNOMED, it appears, has never been subjected to any kind of analysis. It 
>>appears to be in the same category as home repair contractors who 
>>provid

Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[lakew...@copper.net]

Hi William,

A small addition:

1)It seems unlikely that Practitioners, Patients and associated parties 
would be UNABLE to effectively communicate without speaking SNOMED.

2)It seems likely that a single, dominating system for handling 
day-to-day Healthcare-related activities it become efficient on a global 
scale.

3)Rigorous testing, including scalability, of SNOMED seems to be sparse:

PERFORMANCE; Google search: "SNOMED performance |"
http://etbsun2.nlm.nih.gov:8000/publis-ob-offi/pdf/2000-tal-ob-Ft.pdf
(1 hit)

SCALABILITY: Google search: "SNOMED scalability |"
(no hits)

EFFECTIVENESS: Google search: "SNOMED effectiveness |"
(no hits)

RELIABILITY: Google search: "SNOMED reliability |"
(no hits)

AVAILABILITY: Google search: "SNOMED availability |"
http://quickstart.clari.net/qs_se/webnews/wed/bx/Bga-mckesson-info-sols.Rn1s_Dl9.html
(1 hit); DIFFERENT KIND OF 'availability', i.e., availabile for use

COMPLAINTS: Google search: "SNOMED complaint |"
(no hits)

ERRORS: Google search: "SNOMED error |"
(no hits)

SUSTAINABILITY: Google search: "SNOMED sustain |"
(no hits)

OK! I give up!

SNOMED, it appears, has never been subjected to any kind of analysis. It 
appears to be in the same category as home repair contractors who 
provide an on-the-spot 'tail-light' warranty.

To roll on this one and push it on the global healthcare community needs 
some justification I can't provide.

-Thomas Clark




Williamtfgoossen at cs.com wrote:

> In een bericht met de datum 25-9-2003 15:10:09 West-Europa 
> (zomertijd), schrijft hammo001 at mc.duke.edu:
>
>
>>
>> I agree with Gerard that we need to be careful.  However, that does not
>> mean that we go to the lowest denominator.  IF we think SNOMED is the 
>> best
>> solution, then we need to spend our time and energy on finding how to 
>> make
>> SNOMED available to the rest of the world.  We have a debate in our 
>> school
>> system in Durham.  The poorer kids do not have access to the Internet 
>> and
>> to laptops.  The debate is whether to prohibit the use of computers and
>> Internet for school work or to try to find methods that will provider
>> laptops and Internet access to the poorer kids.  I think the answer is
>> simple.
>>
>> However, I do think it is important to make sure that SNOMED is the 
>> answer
>> and will be acceptable before we move aggressively.
>>
>> Ed Hammond
>>
>> -
>> If you have any questions about using this list,
>> please send a message to d.lloyd at openehr.org
>
>
>
>
> I agree with Ed in that if we can make this resource available, we 
> need to work on that.
> I think it is OK that HL7 uses SNOMED as preferred terminology.
>
> However, I would be very dissapointed if this would become the only 
> terminology that the current v3 RIM and derivates could handle. I 
> believe also local, or specialty or situation specific terminologies / 
> vocabs etc. should be allowed in messages.
>
> But maybe I am overreacting, I did not hear / read that this would not 
> be the case.
>
>
> William Goossen



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Open Source EHR at the Americal Academy of Family Physicians ...

[lakew...@copper.net]

Hi Gerard,

Appreciate your post. It confirms a suspicion of mine that a workable 
global solution, regardless of topic, is one where compatibility, 
interoperability and usability are prime concerns, e.g., the drive for 
globalization is modified so that common goals and objectives with 
workable interfaces are targets.

To justify this recall that in the US we are still on the English system 
of measurement rather that the metric system simply because a majority 
of the populace considers metric measurement more difficult and a cheat.

One can purchase a set to tools for the the automobile in English or 
Metric, and perhaps both. The various legislatures in the US have backed 
off many efforts to drive one of the other.

H7 is a good effort. However, considerable time, effort and resources 
can be wasted attempting to derive a common standard. As long as the 
different systems interface well, why bother.

Our politicians are still attacking those countries, cultures, people, 
etc that opposed the invasion of Iraq. Efforts to get the population to 
accept 'French Fries' are still failing. Heard a business brief that 
indicates that sales of these food items are still down from prior levels.

Charge ahead with the European approach and develop good interfaces.

-Thomas Clark


Gerard Freriks wrote:

>
> Dear colleagues,
>
> It is laudable that HHS obtained the rights for the use of
> SNOMED-CT in the USA.
> It is understandable that pressure will be used to deploy SNOMED
> as the preferred terminology.
> It is perfectly understandable that this pressure will result in
> the incorporation of SNOMED into HL7 v3.
>
> But...
>
> In Europe CEN/TC251 has declared to base its activities on HL7 v3
> RIM. And for several years we at CEN are co-operating in a very
> fruitful way with HL7 on the basis of a renewed Memorandum of
> Understanding.
> In Europe we have to take into account the requirements of several
> European countries.
> Not all countries have easy access tot SNOMED or have plans to
> obtain the rights to use SNOMED.
>
> Meaning, that HL7 must carefully investigate how and to what
> extend SNOMED-CT will become incorporated in HL7 v3.
>
> ('There is a need to bring into sync UMLS and HL7 at some level.
> To my mind Semantic Network and HL7 V3 RIM have to be reconciled.
> This will facilitate reuse in an object oriented way while
> retaining semantic validity. We can then have a true unified
> health information infrastructure.')
>
> This topic will be a good one to place on the next agenda when the
> board of HL7 and CEN/TC251 chairman and convenors will meet.
>
> With regards,
>
> Gerard Freriks
>
> -- 
> Gerard Freriks, MD
> Convenor CEN/TC251 WG1
>
> TNO-PG
> Zernikedreef 9
> Leiden
> The Netherlands
>
> +31 71 5181388
> +31 654 792800
>
>
>     *From: *"Shah, Hemant" 
>     *Reply-To: *"Shah, Hemant" 
> *Date: *Wed, 27 Aug 2003 09:53:45 -0700
> *To: *openehr-technical at openehr.org
> *Subject: *RE: Open Source EHR at the Americal Academy of Family
> Physicians ...
>
> The recent agreement between the Health and Human Services and the
> College of American Pathologists about integrating SNOMED into
> UMLS, and making it available for free to everyone in USA, was a
> landmark.
>
> Is there a thought process within HL7 that is exploring such
> opportunities? If HHS agrees to support HL7 to allow it to make
> its standards available for free, it will hasten its adoption and
> development while it serves the goals of the federal government too.
>
> There is a need to bring into sync UMLS and HL7 at some level. To
> my mind Semantic Network and HL7 V3 RIM have to be reconciled.
> This will facilitate reuse in an object oriented way while
> retaining semantic validity. We can then have a true unified
> health information infrastructure.
>
> Regards,
>
>


-
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please send a message to d.lloyd at openehr.org

Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[William E Hammond]

William,

I do not think you are over reacting.  I agree with you.  My only point is
that we should be driven by what is best and what is a true solution, and
not by the wrong reasons.  I would be most interested in seeing us compile
a list of candidates for terminologies that should be considered and a
process by which we could blend the terminologies.

I don't know what the best method might be and what organization(s) might
be best for doing the work and distributing the product.  What is the level
of trust for the NLM around the world?

Ed

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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[Tom Culpepper]

Hi all,
Just wanted to let folks know that at the "Computational Level" the work of 
the OMG Healthcare Domain Task Force's Lexicon Query Service 
(LQS) 
address the issue of multiple terminologies and their use in IT settings. 
This technology is being used today as a mediator between systems that 
utilize different terminologies which makes it possible to use legacy and 
new terminologies. The concept is that there will never be 1 terminology 
system in the world due to human, technological and legacy systems but you 
can narrow the focus and then utilize technology (LQS) to assist you. The 
specification was designed and development in an international setting with 
many of the prominent terminology experts as contributors. As HL7 moves 
forward at the "Informational Level" maybe they can glean some insights 
from LQS in terms of working with multiple terminologies.

Tom
___
2AB, Inc.
1700 Highway 31
Calera, Alabama 35040
205-621-7455 ext 107
_iLock & 
orb2
"Trusted Solutions for Distributed Business"

Confidentiality Notice:
This Email message and its attachments are for the sole use of the intended 
recipients.
Any unauthorized review, use, disclosure or distribution is prohibited.

At 10:19 AM 9/25/03 -0400, William E Hammond wrote:




>William,
>
>I do not think you are over reacting.  I agree with you.  My only point is
>that we should be driven by what is best and what is a true solution, and
>not by the wrong reasons.  I would be most interested in seeing us compile
>a list of candidates for terminologies that should be considered and a
>process by which we could blend the terminologies.
>
>I don't know what the best method might be and what organization(s) might
>be best for doing the work and distributing the product.  What is the level
>of trust for the NLM around the world?
>
>Ed
>
>-
>If you have any questions about using this list,
>please send a message to d.lloyd at openehr.org
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Antw: Re: Open Source EHR at the Americal Academy of Family Physicians ...

[williamtfgoos...@cs.com]

In een bericht met de datum 25-9-2003 15:10:09 West-Europa (zomertijd), 
schrijft hammo001 at mc.duke.edu:


> 
> I agree with Gerard that we need to be careful.  However, that does not
> mean that we go to the lowest denominator.  IF we think SNOMED is the best
> solution, then we need to spend our time and energy on finding how to make
> SNOMED available to the rest of the world.  We have a debate in our school
> system in Durham.  The poorer kids do not have access to the Internet and
> to laptops.  The debate is whether to prohibit the use of computers and
> Internet for school work or to try to find methods that will provider
> laptops and Internet access to the poorer kids.  I think the answer is
> simple.
> 
> However, I do think it is important to make sure that SNOMED is the answer
> and will be acceptable before we move aggressively.
> 
> Ed Hammond
> 
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org


I agree with Ed in that if we can make this resource available, we need to 
work on that.
I think it is OK that HL7 uses SNOMED as preferred terminology.

However, I would be very dissapointed if this would become the only 
terminology that the current v3 RIM and derivates could handle. I believe also 
local, 
or specialty or situation specific terminologies / vocabs etc. should be 
allowed in messages. 

But maybe I am overreacting, I did not hear / read that this would not be the 
case.


William Goossen
-- next part --
An HTML attachment was scrubbed...
URL: 

Open Source EHR at the Americal Academy of Family Physicians ...

[William E Hammond]

I agree with Gerard that we need to be careful.  However, that does not
mean that we go to the lowest denominator.  IF we think SNOMED is the best
solution, then we need to spend our time and energy on finding how to make
SNOMED available to the rest of the world.  We have a debate in our school
system in Durham.  The poorer kids do not have access to the Internet and
to laptops.  The debate is whether to prohibit the use of computers and
Internet for school work or to try to find methods that will provider
laptops and Internet access to the poorer kids.  I think the answer is
simple.

However, I do think it is important to make sure that SNOMED is the answer
and will be acceptable before we move aggressively.

Ed Hammond

-
If you have any questions about using this list,
please send a message to d.lloyd at openehr.org

Open Source EHR at the Americal Academy of Family Physicians ...

[Gerard Freriks]

> 
> Dear colleagues,
> 
> It is laudable that HHS obtained the rights for the use of SNOMED-CT in the
> USA.
> It is understandable that pressure will be used to deploy SNOMED as the
> preferred terminology.
> It is perfectly understandable that this pressure will result in the
> incorporation of SNOMED into HL7 v3.
> 
> But...
> 
> In Europe CEN/TC251 has declared to base its activities on HL7 v3 RIM. And for
> several years we at CEN are co-operating in a very fruitful way with HL7 on
> the basis of a renewed Memorandum of Understanding.
> In Europe we have to take into account the requirements of several European
> countries.
> Not all countries have easy access tot SNOMED or have plans to obtain the
> rights to use SNOMED.
> 
> Meaning, that HL7 must carefully investigate how and to what extend SNOMED-CT
> will become incorporated in HL7 v3.
> 
> (?There is a need to bring into sync UMLS and HL7 at some level. To my mind
> Semantic Network and HL7 V3 RIM have to be reconciled. This will facilitate
> reuse in an object oriented way while retaining semantic validity.  We can
> then have a true unified health information infrastructure.?)
> 
> This topic will be a good one to place on the next agenda when the board of
> HL7 and CEN/TC251 chairman and convenors will meet.
> 
> With regards,
> 
> Gerard Freriks
-- 
Gerard Freriks, MD
Convenor CEN/TC251 WG1

TNO-PG
Zernikedreef 9
Leiden
The Netherlands

+31 71 5181388
+31 654 792800


> From: "Shah, Hemant" 
> Reply-To: "Shah, Hemant" 
> Date: Wed, 27 Aug 2003 09:53:45 -0700
> To: openehr-technical at openehr.org
> Subject: RE: Open Source EHR at the Americal Academy of Family Physicians ...
> 
> The recent agreement between the Health and Human Services and the College of
> American Pathologists about integrating SNOMED into UMLS, and making it
> available for free to everyone in USA, was a landmark.
> 
> Is there a thought process within HL7 that is exploring such opportunities? If
> HHS agrees to support HL7 to allow it to make its standards available for
> free, it will hasten its adoption and development while it serves the goals of
> the federal government too.
> 
> There is a need to bring into sync UMLS and HL7 at some level. To my mind
> Semantic Network and HL7 V3 RIM have to be reconciled. This will facilitate
> reuse in an object oriented way while retaining semantic validity.  We can
> then have a true unified health information infrastructure.
> 
> Regards, 


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Open Source EHR at the Americal Academy of Family Physicians ...

[William E Hammond]

Forgive me for a late comment, but I would like to clear the record at
little concerning hL7.  HL7 is an accredited ANSI body, and follows ANSI
rules.  Itis an organization that is not funded by any outside group.  As
such, the organization deopends on membership for dues to support the
organization.  I agree that totally free standards would be the best, and I
have argued that position within the HL7 Board.  The best I have been able
to do is to get the draft available free.  At the same time, release of a
new standard is always accompanied by an increase in membership.  Also, I
must point out, that I think it is reasdonable for anyone who will gain
advantage from the standard to contribute.  The proce for the standard is
just slightly greater than membership dues.  Also, I point out that ISo and
ANSI sells standards - actually for more than HL7.

I hope you all will continue to support HL7 and its work.  I always find it
interesting when people talk about HL7 as if it was a them and us.  I hope
it is just us, and we struggle to support the tremendous cost of producing
the standard.  I think the US may be the only country whose government does
not support the creation of standards - but at the same time, I don't think
that is all wrong.

We need the support of all the poeple who understand the value of standards
to work together and get the appropriate standards out there while the
stars are aligned.  All of you are making important contributions.

Ed H




David Forslund @openehr.org on 08/20/2003 09:37:41 AM

Please respond to David Forslund 

Sent by:owner-openehr-technical at openehr.org


To:HOPTIMIS at aol.com, bish at hathway.com, openehr-technical at 
openehr.org
cc:

Subject:    Re: Open Source EHR at the Americal Academy of Family
   Physicians  ...


At 09:22 AM 8/20/2003 -0400, HOPTIMIS at aol.com wrote:
To give to HL7 the name of an "exclusive club" is very strange; could you
give some explanations?
I don't know that it merits the name of an "exclusive club", but the "open"
standards that the
HL7 produces are only available to paying members, which makes them a
little less than open,
in my opinion.? This is a practice followed by other SDO's, but not by all
open standards bodies.


David W. Forslund???dwf at lanl.gov
Computer and Computational Sciences
http://www.acl.lanl.gov/~dwf
Los Alamos National Laboratory??Los Alamos, NM 87545
505-663-5218FAX: 505-663-5225



-
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please send a message to d.lloyd at openehr.org

Open Source EHR at the Americal Academy of Family Physicians ...

[William E Hammond]

-
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please send a message to d.lloyd at openehr.org

Open Source EHR at the Americal Academy of Family Physicians ...

[David Forslund]

Thank you Ed for clearing stating the HL7 position, which has always been 
clear, in my opinion.
It is understandable, but, as you suggest, it would be desirable that the 
standards once
they are complete be free.   I'm not clear on what the licensing issues are 
in terms of redistribution
of those standards, however.   I also agree that HL7 isn't alone in 
charging a fee and is probably
on the lower end of cost for those who do charge.

There are other models, of course, for handling standards within a 
non-profit organization, and it might be useful for HL7 to
explore those.  I don't want to suggest that people not support HL7 and its 
important work because of the fee.

Thanks,

Dave
At 12:23 PM 8/27/2003 -0400, William E Hammond wrote:




>Forgive me for a late comment, but I would like to clear the record at
>little concerning hL7.  HL7 is an accredited ANSI body, and follows ANSI
>rules.  Itis an organization that is not funded by any outside group.  As
>such, the organization deopends on membership for dues to support the
>organization.  I agree that totally free standards would be the best, and I
>have argued that position within the HL7 Board.  The best I have been able
>to do is to get the draft available free.  At the same time, release of a
>new standard is always accompanied by an increase in membership.  Also, I
>must point out, that I think it is reasdonable for anyone who will gain
>advantage from the standard to contribute.  The proce for the standard is
>just slightly greater than membership dues.  Also, I point out that ISo and
>ANSI sells standards - actually for more than HL7.
>
>I hope you all will continue to support HL7 and its work.  I always find it
>interesting when people talk about HL7 as if it was a them and us.  I hope
>it is just us, and we struggle to support the tremendous cost of producing
>the standard.  I think the US may be the only country whose government does
>not support the creation of standards - but at the same time, I don't think
>that is all wrong.
>
>We need the support of all the poeple who understand the value of standards
>to work together and get the appropriate standards out there while the
>stars are aligned.  All of you are making important contributions.
>
>Ed H
>
>
>
>
>David Forslund @openehr.org on 08/20/2003 09:37:41 AM
>
>Please respond to David Forslund 
>
>Sent by:owner-openehr-technical at openehr.org
>
>
>To:HOPTIMIS at aol.com, bish at hathway.com, openehr-technical at 
>openehr.org
>cc:
>
>Subject:Re: Open Source EHR at the Americal Academy of Family
>Physicians  ...
>
>
>At 09:22 AM 8/20/2003 -0400, HOPTIMIS at aol.com wrote:
>To give to HL7 the name of an "exclusive club" is very strange; could you
>give some explanations?
>I don't know that it merits the name of an "exclusive club", but the "open"
>standards that the
>HL7 produces are only available to paying members, which makes them a
>little less than open,
>in my opinion.  This is a practice followed by other SDO's, but not by all
>open standards bodies.
>
>
>David W. Forslund   dwf at lanl.gov
>Computer and Computational Sciences
>http://www.acl.lanl.gov/~dwf
>Los Alamos National Laboratory  Los Alamos, NM 87545
>505-663-5218FAX: 505-663-5225

-
If you have any questions about using this list,
please send a message to d.lloyd at openehr.org

Open Source EHR at the Americal Academy of Family Physicians ...

[Shah, Hemant]

The recent agreement between the Health and Human Services and the College
of American Pathologists about integrating SNOMED into UMLS, and making it
available for free to everyone in USA, was a landmark.
Is there a thought process within HL7 that is exploring such opportunities?
If HHS agrees to support HL7 to allow it to make its standards available for
free, it will hasten its adoption and development while it serves the goals
of the federal government too. 
There is a need to bring into sync UMLS and HL7 at some level. To my mind
Semantic Network and HL7 V3 RIM have to be reconciled. This will facilitate
reuse in an object oriented way while retaining semantic validity.  We can
then have a true unified health information infrastructure. 

Regards,

Hemant

 -Original Message-
From:   David Forslund [mailto:d...@lanl.gov] 
Sent:   Wednesday, August 27, 2003 9:32 AM
To: William E Hammond
Cc: HOPTIMIS at aol.com; bish at hathway.com; openehr-technical at 
openehr.org
Subject:Re: Open Source EHR at the Americal Academy of Family
Physicians ...

Thank you Ed for clearing stating the HL7 position, which has always been 
clear, in my opinion.
It is understandable, but, as you suggest, it would be desirable that the 
standards once
they are complete be free.   I'm not clear on what the licensing issues are 
in terms of redistribution
of those standards, however.   I also agree that HL7 isn't alone in 
charging a fee and is probably
on the lower end of cost for those who do charge.

There are other models, of course, for handling standards within a 
non-profit organization, and it might be useful for HL7 to
explore those.  I don't want to suggest that people not support HL7 and its 
important work because of the fee.

Thanks,

Dave
At 12:23 PM 8/27/2003 -0400, William E Hammond wrote:




>Forgive me for a late comment, but I would like to clear the record at
>little concerning hL7.  HL7 is an accredited ANSI body, and follows ANSI
>rules.  Itis an organization that is not funded by any outside group.  As
>such, the organization deopends on membership for dues to support the
>organization.  I agree that totally free standards would be the best, and I
>have argued that position within the HL7 Board.  The best I have been able
>to do is to get the draft available free.  At the same time, release of a
>new standard is always accompanied by an increase in membership.  Also, I
>must point out, that I think it is reasdonable for anyone who will gain
>advantage from the standard to contribute.  The proce for the standard is
>just slightly greater than membership dues.  Also, I point out that ISo and
>ANSI sells standards - actually for more than HL7.
>
>I hope you all will continue to support HL7 and its work.  I always find it
>interesting when people talk about HL7 as if it was a them and us.  I hope
>it is just us, and we struggle to support the tremendous cost of producing
>the standard.  I think the US may be the only country whose government does
>not support the creation of standards - but at the same time, I don't think
>that is all wrong.
>
>We need the support of all the poeple who understand the value of standards
>to work together and get the appropriate standards out there while the
>stars are aligned.  All of you are making important contributions.
>
>Ed H
>
>
>
>
>David Forslund @openehr.org on 08/20/2003 09:37:41 AM
>
>Please respond to David Forslund 
>
>Sent by:owner-openehr-technical at openehr.org
>
>
>To:HOPTIMIS at aol.com, bish at hathway.com, openehr-technical at 
>openehr.org
>cc:
>
>Subject:Re: Open Source EHR at the Americal Academy of Family
>Physicians  ...
>
>
>At 09:22 AM 8/20/2003 -0400, HOPTIMIS at aol.com wrote:
>To give to HL7 the name of an "exclusive club" is very strange; could you
>give some explanations?
>I don't know that it merits the name of an "exclusive club", but the "open"
>standards that the
>HL7 produces are only available to paying members, which makes them a
>little less than open,
>in my opinion.  This is a practice followed by other SDO's, but not by all
>open standards bodies.
>
>
>David W. Forslund   dwf at lanl.gov
>Computer and Computational Sciences
>http://www.acl.lanl.gov/~dwf
>Los Alamos National Laboratory  Los Alamos, NM 87545
>505-663-5218FAX: 505-663-5225

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communication may contain information that 

HL-7 standards [was Re: Open Source EHR at the Americal Academy of Family Physicians ...]

[USM Bish]

On Wed, Aug 20, 2003 at 09:45:36AM -0600, David Forslund wrote:
>
> Actually,  I  think the  situation  is  the reverse.  It  is
> usually fairly  easy to  get the  preliminary versions  of a
> standard from  HL7 for free (from  their web site),  but you
> have to pay for the final approved versions.
>
> The OMG policy is a little different. It is easy to get both
> preliminary and final  copies of standards from  the OMG for
> free, but you  can't really participate in  the formation of
> the  specification standard  without  being  a member.  This
> doesn't mean  that others  can't make  suggestions, but  the
> responsibilty of  finalizing the  standard lies  solely with
> the members.

I would assume that the path set by Object Management Group,
W3C Consortium etc  would be the expected thing.  It is fair
enough  to  keep  the policy  making  aspects  inhouse,  but
availability of the standards themselves need to be open. 

Bish



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HL-7 standards [was Re: Open Source EHR at the Americal Academy of Family Physicians ...]

[USM Bish]

On Wed, Aug 20, 2003 at 09:22:18AM -0400, HOPTIMIS at aol.com wrote:
>
> To  give to  HL7 the  name of  an "exclusive  club" is  very
> strange; could you give some explanations?
>
---end quoted text---

If you see the  mail that I attached, all that  I asked is a
place where  I could obtain  the HL-7 standard  (still under
evolution) for  study and  knowledge. The  reply I  got from
HL-7 (India) was that I need to be a member of HL-7.

There are two issues which are discrete:

a) Membership of a core group.  
b) Access to standards themselves.

Linking these  two issues,  to my  assessment is  definitely
incorrect. For  all computer related  standards there  is an
well established system of RFCs, and is available openly for
perusal  and  contribution,  specially so  in  the  evolving
stages.

When an  International Standard (presently 11  odd countries
being signitory) is under evolution,  it is logical that the
standards  themselves be  open to  suggestions, rather  than
being restricted by alternate clauses. 

The term "exclusive club" may be  rather harsh, but I was at
a  loss  to  find  some alternate  term  of  describing  the
situation. Sincere apologies.

As it stands, unless  you are a member of the  HL-7, you are
denied  access  to what  is  "cooking"  ! More  openness  is
expected from  any standards  forming body,  if it  needs to
evolve to an internationally accepted  standard ... like all
other internationally accepted standards in vogue.

Bish




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HL-7 standards [was Re: Open Source EHR at the Americal Academy of Family Physicians ...]

[David Forslund]

I agree with you.  I don't like the HL7 policy.  The side effect that is 
bad is that "selling" the specification
becomes a conflict of interest issue, because it generates revenue.

Dave
At 06:30 AM 8/21/2003 +0530, USM Bish wrote:
>On Wed, Aug 20, 2003 at 09:45:36AM -0600, David Forslund wrote:
> >
> > Actually,  I  think the  situation  is  the reverse.  It  is
> > usually fairly  easy to  get the  preliminary versions  of a
> > standard from  HL7 for free (from  their web site),  but you
> > have to pay for the final approved versions.
> >
> > The OMG policy is a little different. It is easy to get both
> > preliminary and final  copies of standards from  the OMG for
> > free, but you  can't really participate in  the formation of
> > the  specification standard  without  being  a member.  This
> > doesn't mean  that others  can't make  suggestions, but  the
> > responsibilty of  finalizing the  standard lies  solely with
> > the members.
>
>I would assume that the path set by Object Management Group,
>W3C Consortium etc  would be the expected thing.  It is fair
>enough  to  keep  the policy  making  aspects  inhouse,  but
>availability of the standards themselves need to be open.
>
>Bish
>
>
>
>-
>If you have any questions about using this list,
>please send a message to d.lloyd at openehr.org

-
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HL-7 standards [was Re: Open Source EHR at the Americal Academy of Family Physicians ...]

[David Forslund]

Actually, I think the situation is the reverse.It is usually fairly 
easy to get the preliminary versions
of a standard from HL7 for free (from their web site), but you have to pay 
for the final approved versions.

The OMG policy is a little different.  It is easy to get both preliminary 
and final copies of standards
from the OMG for free, but you can't really participate in the formation of 
the specification standard
without being a member.  This doesn't mean that others can't make 
suggestions, but the responsibilty
of finalizing the standard lies solely with the members.

This latter state is true for HL7, too, since only HL7 members can vote on 
a standard.  But in HL7, once
the standard is approved as final, it costs money to get it.   I think this 
is true of other bodies such
as ANSI and ISO.

Dave
At 02:21 AM 8/21/2003 +0530, USM Bish wrote:
>On Wed, Aug 20, 2003 at 09:22:18AM -0400, HOPTIMIS at aol.com wrote:
> >
> > To  give to  HL7 the  name of  an "exclusive  club" is  very
> > strange; could you give some explanations?
> >
>---end quoted text---
>
>If you see the  mail that I attached, all that  I asked is a
>place where  I could obtain  the HL-7 standard  (still under
>evolution) for  study and  knowledge. The  reply I  got from
>HL-7 (India) was that I need to be a member of HL-7.
>
>There are two issues which are discrete:
>
>a) Membership of a core group.
>b) Access to standards themselves.
>
>Linking these  two issues,  to my  assessment is  definitely
>incorrect. For  all computer related  standards there  is an
>well established system of RFCs, and is available openly for
>perusal  and  contribution,  specially so  in  the  evolving
>stages.
>
>When an  International Standard (presently 11  odd countries
>being signitory) is under evolution,  it is logical that the
>standards  themselves be  open to  suggestions, rather  than
>being restricted by alternate clauses.
>
>The term "exclusive club" may be  rather harsh, but I was at
>a  loss  to  find  some alternate  term  of  describing  the
>situation. Sincere apologies.
>
>As it stands, unless  you are a member of the  HL-7, you are
>denied  access  to what  is  "cooking"  ! More  openness  is
>expected from  any standards  forming body,  if it  needs to
>evolve to an internationally accepted  standard ... like all
>other internationally accepted standards in vogue.
>
>Bish
>
>
>
>
>-
>If you have any questions about using this list,
>please send a message to d.lloyd at openehr.org

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Open Source EHR at the Americal Academy of Family Physicians ...

[hopti...@aol.com]

To give to HL7 the name of an "exclusive club" is very strange; could you 
give some explanations?
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Open Source EHR at the Americal Academy of Family Physicians ...

[David Forslund]

At 09:22 AM 8/20/2003 -0400, HOPTIMIS at aol.com wrote:
>To give to HL7 the name of an "exclusive club" is very strange; could you 
>give some explanations?

I don't know that it merits the name of an "exclusive club", but the "open" 
standards that the
HL7 produces are only available to paying members, which makes them a 
little less than open,
in my opinion.  This is a practice followed by other SDO's, but not by all 
open standards bodies.



David W. Forslund   dwf at lanl.gov
Computer and Computational Sciences http://www.acl.lanl.gov/~dwf
Los Alamos National Laboratory  Los Alamos, NM 87545
505-663-5218FAX: 505-663-5225
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Open Source EHR at the Americal Academy of Family Physicians ...

[USM Bish]

On Mon, Aug 18, 2003 at 04:29:37PM -0700, Christopher Feahr wrote:
> 
> Personally, I  would like to  see all  EHR-related standards
> work... at least in the US... coordinated under the umbrella
> of HL7. At the moment, the CCR project does not appear to be
> headed toward HL7.

I really don't know if HL7 would  be the way things would go
unless  they  remove  the  image  that  they  belong  to  an
exclusive club. The response I received from HL-7 (India) is
placed below for your perusal.

Dr USM Bish

--
>
> You could receive the same from  HL7 Inida. This is provided
> along  with HL7  India membership.  ( membership  fee is  Rs
> 35,000)
> 
> regards
> 
> Saji
>
> > bish at hathway.com wrote:
> > On 2003-04-10 at 03:14:04
> > 
> > I am interested in obtaining the full HL-7 specs valid as on
> > date. It  is requested,  that I may  kindly be  advised from
> > where I could obtain the same.
> >
> > USM Bish
--





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Open Source EHR at the Americal Academy of Family Physicians ...

[David Forslund]

I'm a member of HL7, but I believe the requirement to pay for the standards is
not the best approach.  Once the standards are complete, they should
be entirely free.   It is reasonable to charge for the participation
and influence in the process to create the standard.   It isn't the membership
fee that I object too, but the fact that the standards can't be obtained
without paying.

Dave
At 05:18 PM 8/19/2003 -0700, Christopher Feahr wrote:
>Dr. Bish,
>I'm not sure that I understand your comment about HL7 being an
>"exclusive club"... although you seem to be alluding to the cost of
>membership.  I have only dealt with individual membership dues which run
>about $500/yr. While it's true that other classes of membership are more
>costly, I believe this reflects the present operational costs of an ANSI
>accredited standards committee.  X12 costs are similar.
>
>I agree that from the provider perspective, the costs to participate in
>HL7 are often seen as prohibitive... particularly when time, travel, and
>lodging costs are considered for meeting attendance.  The same is true
>of  X12N and UN/CEFACT, which explains the dearth of provider input to
>these organizations.  It also helps to explain why the US govt. is
>presently attempting to force big-payer-inspired EDI standards onto our
>entire healthcare community, when the X12 EDI model is clearly of no
>value to >300,000 provider organizations.  However, there were no
>provider-centric standards that the government could have adopted in
>lieu of X12's... because there are no provider-centric SDOs, or even
>Insurance-centric SDOs with significant provider input.  HL7 is
>"provider-centric" in theory, but all SDOs end up being "dues-paying
>member"-centric in actual operation... something that can be changed.
>simply by having provider associations participate as members.
>
>Providers need an SDO that is focused on the functional requirements of
>*healthcare* delivery in all 30 or so major specialty domains and care
>settings.  From SDO-maintained functional models, vendors should be able
>to design provider systems with reasonable levels of interoperability...
>and any sort of EHR system that a user may require.
>
>This approach to standards development is not supported by the
>part-time, all-volunteer, big-enterprise-member SDO model used by HL7.
>Providers require a standards organization with a predictable revenue
>stream and reliable, full-time human resources.  But... that means
>provider associations and specialty societies must step forward... as
>HL7 members... and insist on a mechanism for getting their members'
>needs baked into our global standards.  HL7 will always adapt to the
>needs of its members, as it has for 15 years.
>
>NCVHS, DHHS, CMS, and the agencies behind the Consolidated Health
>Informatics initiative (DOD, Veterans Adm, Indian Health, Homeland
>Security, etc.)... are unanimous in selecting HL7 are the lead SDO for
>health care in the US.  The federal govt. is particularly interested in
>the EHR work and is expecting HL7 to take the lead there, as well.
>There has never been a better opportunity or a more obvious need for
>massive provider input than around these "EHR" issues.
>
>It's time providers got themselves onto the Big SDO Radar Screen.  At
>this time, HL7 appears to be our best entry point for providers in the
>US and abroad.
>
>Best regards,
>-Chris
>
>Christopher J. Feahr, O.D.
>Optiserv Consulting (Vision Industry)
>Office: (707) 579-4984
>Cell: (707) 529-2268
>http://Optiserv.com
>http://VisionDataStandard.org
>- Original Message -
>From: "USM Bish" 
>To: 
>Sent: Tuesday, August 19, 2003 2:30 PM
>Subject: Re: Open Source EHR at the Americal Academy of Family
>Physicians ...
>
>
> > On Mon, Aug 18, 2003 at 04:29:37PM -0700, Christopher Feahr wrote:
> > >
> > > Personally, I  would like to  see all  EHR-related standards
> > > work... at least in the US... coordinated under the umbrella
> > > of HL7. At the moment, the CCR project does not appear to be
> > > headed toward HL7.
> >
> > I really don't know if HL7 would  be the way things would go
> > unless  they  remove  the  image  that  they  belong  to  an
> > exclusive club. The response I received from HL-7 (India) is
> > placed below for your perusal.
> >
> > Dr USM Bish
> >
> > --
> > >
> > > You could receive the same from  HL7 Inida. This is provided
> > > along  with HL7  India membership.  ( membership  fee is  Rs
> > > 35,000)
> > >
> > > regards
> &

Open Source EHR at the Americal Academy of Family Physicians ...

[Christopher Feahr]

Dr. Bish,
I'm not sure that I understand your comment about HL7 being an
"exclusive club"... although you seem to be alluding to the cost of
membership.  I have only dealt with individual membership dues which run
about $500/yr. While it's true that other classes of membership are more
costly, I believe this reflects the present operational costs of an ANSI
accredited standards committee.  X12 costs are similar.

I agree that from the provider perspective, the costs to participate in
HL7 are often seen as prohibitive... particularly when time, travel, and
lodging costs are considered for meeting attendance.  The same is true
of  X12N and UN/CEFACT, which explains the dearth of provider input to
these organizations.  It also helps to explain why the US govt. is
presently attempting to force big-payer-inspired EDI standards onto our
entire healthcare community, when the X12 EDI model is clearly of no
value to >300,000 provider organizations.  However, there were no
provider-centric standards that the government could have adopted in
lieu of X12's... because there are no provider-centric SDOs, or even
Insurance-centric SDOs with significant provider input.  HL7 is
"provider-centric" in theory, but all SDOs end up being "dues-paying
member"-centric in actual operation... something that can be changed.
simply by having provider associations participate as members.

Providers need an SDO that is focused on the functional requirements of
*healthcare* delivery in all 30 or so major specialty domains and care
settings.  From SDO-maintained functional models, vendors should be able
to design provider systems with reasonable levels of interoperability...
and any sort of EHR system that a user may require.

This approach to standards development is not supported by the
part-time, all-volunteer, big-enterprise-member SDO model used by HL7.
Providers require a standards organization with a predictable revenue
stream and reliable, full-time human resources.  But... that means
provider associations and specialty societies must step forward... as
HL7 members... and insist on a mechanism for getting their members'
needs baked into our global standards.  HL7 will always adapt to the
needs of its members, as it has for 15 years.

NCVHS, DHHS, CMS, and the agencies behind the Consolidated Health
Informatics initiative (DOD, Veterans Adm, Indian Health, Homeland
Security, etc.)... are unanimous in selecting HL7 are the lead SDO for
health care in the US.  The federal govt. is particularly interested in
the EHR work and is expecting HL7 to take the lead there, as well.
There has never been a better opportunity or a more obvious need for
massive provider input than around these "EHR" issues.

It's time providers got themselves onto the Big SDO Radar Screen.  At
this time, HL7 appears to be our best entry point for providers in the
US and abroad.

Best regards,
-Chris

Christopher J. Feahr, O.D.
Optiserv Consulting (Vision Industry)
Office: (707) 579-4984
Cell: (707) 529-2268
http://Optiserv.com
http://VisionDataStandard.org
- Original Message - 
From: "USM Bish" 
To: 
Sent: Tuesday, August 19, 2003 2:30 PM
Subject: Re: Open Source EHR at the Americal Academy of Family
Physicians ...


> On Mon, Aug 18, 2003 at 04:29:37PM -0700, Christopher Feahr wrote:
> >
> > Personally, I  would like to  see all  EHR-related standards
> > work... at least in the US... coordinated under the umbrella
> > of HL7. At the moment, the CCR project does not appear to be
> > headed toward HL7.
>
> I really don't know if HL7 would  be the way things would go
> unless  they  remove  the  image  that  they  belong  to  an
> exclusive club. The response I received from HL-7 (India) is
> placed below for your perusal.
>
> Dr USM Bish
>
> --
> >
> > You could receive the same from  HL7 Inida. This is provided
> > along  with HL7  India membership.  ( membership  fee is  Rs
> > 35,000)
> >
> > regards
> >
> > Saji
> >
> > > bish at hathway.com wrote:
> > > On 2003-04-10 at 03:14:04
> > >
> > > I am interested in obtaining the full HL-7 specs valid as on
> > > date. It  is requested,  that I may  kindly be  advised from
> > > where I could obtain the same.
> > >
> > > USM Bish
> --
>
>
>
>
>
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org

-
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Open Source EHR at the Americal Academy of Family Physicians ...

[Christopher Feahr]

My understanding is that it is evolving from the "CCR" (continuity of
care record) project involving the state of Massachusets and the ASTM
medical records standards project outlined at:
http://www.astm.org/cgi-bin/SoftCart.exe/COMMIT/COMMITTEE/E31.htm?L+mystore+qkvm5991+1061259141

Personally, I would like to see all EHR-related standards work... at
least in the US... coordinated under the umbrella of HL7.  At the
moment, the CCR project does not appear to be headed toward HL7.

Christopher J. Feahr, O.D.
Optiserv Consulting (Vision Industry)
Office: (707) 579-4984
Cell: (707) 529-2268
http://Optiserv.com
http://VisionDataStandard.org
- Original Message - 
From: "angelo rossi mori" 
To: 
Sent: Monday, August 18, 2003 5:31 AM
Subject: Open Source EHR at the Americal Academy of Family Physicians
...


> Dear friends,
> perhaps someone of you knows more about this initiative ?
>
> --
-
>
> Open-Source Electronic Health Record for Office-Based Practice
> The American Academy of Family Physicians is taking a leadership role
in
> organizing a broad public-private consortium whose mission is to
distribute
> and maintain an open source electronic health record (EHR) 
> http://www.aafp.org/x19017.xml
>
> --
-
>
>
>
> Regards
>
> Angelo
>
>
>
> Angelo Rossi Mori   angelo at itbm.rm.cnr.it
> Istituto Tecnologie Biomediche, Consiglio Nazionale delle Ricerche
> viale Marx 15, I-00137, Roma, Italy
> tel. + 39 - 06 86 090 250   fax + 39 - 06 86 090 340
> http://e-osiris.it   -  il portale sull'ICT in sanit?
> http://www.prorec.it  -  Centro PROREC Italia per la promozione della
> cartella clinica elettronica
>
> -
> If you have any questions about using this list,
> please send a message to d.lloyd at openehr.org

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Open Source EHR at the Americal Academy of Family Physicians ...

[angelo rossi mori]

Dear friends,
perhaps someone of you knows more about this initiative ?

---

Open-Source Electronic Health Record for Office-Based Practice
The American Academy of Family Physicians is taking a leadership role in 
organizing a broad public-private consortium whose mission is to distribute 
and maintain an open source electronic health record (EHR) 
http://www.aafp.org/x19017.xml

---



Regards

Angelo



Angelo Rossi Mori   angelo at itbm.rm.cnr.it
Istituto Tecnologie Biomediche, Consiglio Nazionale delle Ricerche
viale Marx 15, I-00137, Roma, Italy
tel. + 39 - 06 86 090 250   fax + 39 - 06 86 090 340
http://e-osiris.it   -  il portale sull'ICT in sanit?
http://www.prorec.it  -  Centro PROREC Italia per la promozione della 
cartella clinica elettronica

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