The concept of contribution
Henry Thanks for the 'dumb' contribution. I hope that you can see that openEHR has approached the problem in a way that will allow the sort of scenarion that you have painted as well as a more complex scenario with a distributed record - or even the big brother one record for each patient held centrally. The reason is that we cannot predict the size of future work units or the technology that will be around - only that the technology should not dictate the work practices - only support them. Cheers, Sam -Original Message- From: owner-openehr-technical at openehr.org [mailto:owner-openehr-technical at openehr.org]On Behalf Of Li, Henry Sent: Tuesday, 11 June 2002 11:36 AM To: 'openehr-technical at openehr.org' Subject: FW: The concept of contribution -Original Message- From: Li, Henry Sent: Tuesday, 11 June 2002 9:10 To: 'Denis Nosworthy' Subject: RE: The concept of contribution Hi I am not a real techno but I understand and deeply interested in the discussion. I had this vision of a real good electronic health record. It is one own by the patient, carry by the patient, and presented to the health care provider (whoever they are) by the patient (all over the world). The Browser and XML or its improved version whatever it may be in the future is the way to go. This is the process A patient visits a care provider and presents his e-card as a proof of consent to treatment The health care provider loads up the health record into the browser and download the info into whatever system he is using (this applies to Hospital as well), the health care provider can also choose to discuss the patient with other health profession on line through the web. When the patient leave the care provider, it is the responsibility of the care provider to upload whatever he has done to the patient back to the e-card and the patient goes away. Any subsequent test results etc, it is the responsibility of the health care provider to contact the patient to have the data put into the patient's e-card. (the patient can choose not to do so - but it is of course to the patients benefit to do so) The benefit of this is at any one time, the patient is the only person that has a complete health history of himself and he owns it. (Solve the ownership and privacy issue) After all, currently, the health care provider will only know as much as what the patient choose to tell them anyway. New industry will start up to take care of the situation and provide all sorts of support to the e-card holders. These services include how to download, how to backup or even help retrieve data in emergency etc. etc. - god knows what will come up in the commercial world. Good or bad, no big brothers. When the patient dies, he can choose to sell his e-card for research purposes and has money to bury himself - no burden to next of kin. The reason I write these is that, I think I contribute as from a dumb user's point of view, may be it has some bearing on the design and the structure of the 'database' or 'rules' or whatever you may call it. The only consideration will be where to put different types of health data in the structure. It is upto the provider system to come up with the download and upload method. Cheers Henry Li -Original Message- From: Denis Nosworthy [mailto:Denis.Nosworthy at swsahs.nsw.gov.au] mailto:[mailto:Denis.Nosworthy at swsahs.nsw.gov.au] Sent: Tuesday, 11 June 2002 8:37 To: 'Sam Heard'; openehr-technical at openehr.org mailto:openehr-technical at openehr.org Subject:RE: The concept of contribution File: InterScan_Disclaimer.txt Sam, Well said. We have for many years been operating under the ideas of 'interoperability' and whilst tools such as HL-7 have been very successful in getting us through these times the issue of EHR interoperability will be something else yet again. Source system interoperability is one thing however (mostly constrained within a controlled environment) but receiving systems such as EHRs will have to be truly interoperable if they are to be effective. The EHR is not a messaging system as some would have us believe (in some incantations it could be seen to be just that) but it must be a system that clinicians can rely on to be accurate and reflect 'real life'. If it has to rely heavily on 'real time' messaging then the vagaries of our telecommunications systems will have a significant impact on that level of acceptance -Original Message- From: Sam Heard [mailto:sam.heard at flinders.edu.au] mailto:[mailto:sam.heard at flinders.edu.au
The concept of contribution
Hi, After analysis done by the Smartcard people in the Netherlands they came to the conclusion that Smartcards with significant medical information on it need special safety procedures and back-up facilities. These extra's necessitate a full back-up centrally and create synchronisation problems. Everything is technically feasable. But was to expensive. They concluded: the smartcard must be used in the process of identification, only. And even that was very expensive. With regards, Gerard On 2002-06-12 04:18, Tony Grivell tony.grivell at flinders.edu.au wrote: At 11:34 +1000 12/6/02, Thomas Beale wrote: Li, Henry wrote: This is the process A patient visits a care provider and presents his e-card as a proof of consent to treatment The health care provider loads up the health record into the browser and download the info into whatever system he is using (this applies to Hospital as well), the health care provider can also choose to discuss the patient with other health profession on line through the web. When the patient leave the care provider, it is the responsibility of the care provider to upload whatever he has done to the patient back to the e-card and the patient goes away. Any subsequent test results etc, it is the responsibility of the health care provider to contact the patient to have the data put into the patient's e-card. (the patient can choose not to do so - but it is of course to the patients benefit to do so) So now there are copies of the EHR a) on the patient's card, and b) on the system. Over time there will be many copies of the EHR, some more up to date than the copy on the patient's card. What's the point of having a copy of the EHR on the patient's card? The benefit of this is at any one time, the patient is the only person that has a complete health history of himself and he owns it. (Solve the This won't be true - over time I doubt that anyone will have a complete history of the patient - they will all have partial histories, which admittedly is the curret situation, but I don't see any utility in having yet another copy of part of the EHR on the card. Re: the fear of big brother - I agree this is real; but the solutions in my opinion lie in: - distributed computing systems - data management by clinical and/or public bodies (non profit enterprises in other words) - strict governance of information and enforcement of consent - data ownership by the patient - thomas beale One attractive option that goes some way to satisfy the above ideals is to have any particular data exist in only one primary location (backed up, of course), and therefore the total record scattered potentially around the world. The patient-held e-card (also backed up somewhere?) carries the _index_ to these locations/data, as well as being the physical part of a key that allows access to this data, and maybe also carrying some portion of the data (at least a summary of key events and critical information such as serious allergies, medication etc) tony grivell - If you have any questions about using this list, please send a message to d.lloyd at openehr.org -- private -- Gerard Freriks, arts Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands +31 252 544896 +31 654 792800 - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
The concept of contribution
On 2002-06-12 03:34, Thomas Beale thomas at deepthought.com.au wrote: Li, Henry wrote: This is the process A patient visits a care provider and presents his e-card as a proof of consent to treatment The health care provider loads up the health record into the browser and download the info into whatever system he is using (this applies to Hospital as well), the health care provider can also choose to discuss the patient with other health profession on line through the web. When the patient leave the care provider, it is the responsibility of the care provider to upload whatever he has done to the patient back to the e-card and the patient goes away. Any subsequent test results etc, it is the responsibility of the health care provider to contact the patient to have the data put into the patient's e-card. (the patient can choose not to do so - but it is of course to the patients benefit to do so) So now there are copies of the EHR a) on the patient's card, and b) on the system. Over time there will be many copies of the EHR, some more up to date than the copy on the patient's card. What's the point of having a copy of the EHR on the patient's card? This is the position of the Dutch Smartcard Group. The benefit of this is at any one time, the patient is the only person that has a complete health history of himself and he owns it. (Solve the This won't be true - over time I doubt that anyone will have a complete history of the patient - they will all have partial histories, which admittedly is the curret situation, but I don't see any utility in having yet another copy of part of the EHR on the card. Re: the fear of big brother - I agree this is real; but the solutions in my opinion lie in: - distributed computing systems - data management by clinical and/or public bodies (non profit enterprises in other words) - strict governance of information and enforcement of consent - data ownership by the patient Agreed. But ... data ownership by the pati?nt will need some consideration. I know that most laws in most countries are politically correct and give rights to patients. But never ownership. Most often a right to inspect, review, remove, and add information. In my way of thinking, the author is the owner and one responsible. The pati?nt has the right to see his information and under certain conditions is able to remove it or change it. But what is Information? I think that there are levels or types of information: Private Opinions consisting of personal interpretations of raw data; Official Statements/opinions consisting of professional interpretations of raw data; Raw uninterpreted data admitted to the EHR; Raw interpreted data not admitted to the EHR, (yet) Pati?nt have rights towards the last two, but none with the first. Healthcare providers must have the facility record private unripe thoughts about the pati?nt and its disease process. The author os the information is acting as the proxy of the pati?nt. Patients should have no direct access to all the information. Only to selected portions of the Official opinions. The preferred way to inspect and change is via the responsible proxy. - thomas beale - If you have any questions about using this list, please send a message to d.lloyd at openehr.org -- private -- Gerard Freriks, arts Huigsloterdijk 378 2158 LR Buitenkaag The Netherlands +31 252 544896 +31 654 792800 - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
FW: The concept of contribution
Tony Grivell wrote: One attractive option that goes some way to satisfy the above ideals is to have any particular data exist in only one primary location (backed up, of course), and therefore the total record scattered potentially around the world. The patient-held e-card (also backed up somewhere?) carries the _index_ to these locations/data, as well as being the physical part of a key that allows access to this data, and maybe also carrying some portion of the data (at least a summary of key events and critical information such as serious allergies, medication etc) whether it could even carry a reliable index of these locations is doubtful in my mind - people are too forgetful, they won't usually make the effort. But the critical information should of course be there. Most critical info is fairly non-volatile and does not need to be updated that often (current medications the probable exception). - thomas - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
FW: The concept of contribution
-Original Message- From: Li, Henry Sent: Tuesday, 11 June 2002 9:10 To: 'Denis Nosworthy' Subject:RE: The concept of contribution Hi I am not a real techno but I understand and deeply interested in the discussion. I had this vision of a real good electronic health record. It is one own by the patient, carry by the patient, and presented to the health care provider (whoever they are) by the patient (all over the world). The Browser and XML or its improved version whatever it may be in the future is the way to go. This is the process A patient visits a care provider and presents his e-card as a proof of consent to treatment The health care provider loads up the health record into the browser and download the info into whatever system he is using (this applies to Hospital as well), the health care provider can also choose to discuss the patient with other health profession on line through the web. When the patient leave the care provider, it is the responsibility of the care provider to upload whatever he has done to the patient back to the e-card and the patient goes away. Any subsequent test results etc, it is the responsibility of the health care provider to contact the patient to have the data put into the patient's e-card. (the patient can choose not to do so - but it is of course to the patients benefit to do so) The benefit of this is at any one time, the patient is the only person that has a complete health history of himself and he owns it. (Solve the ownership and privacy issue) After all, currently, the health care provider will only know as much as what the patient choose to tell them anyway. New industry will start up to take care of the situation and provide all sorts of support to the e-card holders. These services include how to download, how to backup or even help retrieve data in emergency etc. etc. - god knows what will come up in the commercial world. Good or bad, no big brothers. When the patient dies, he can choose to sell his e-card for research purposes and has money to bury himself - no burden to next of kin. The reason I write these is that, I think I contribute as from a dumb user's point of view, may be it has some bearing on the design and the structure of the 'database' or 'rules' or whatever you may call it. The only consideration will be where to put different types of health data in the structure. It is upto the provider system to come up with the download and upload method. Cheers Henry Li -Original Message- From: Denis Nosworthy [mailto:Denis.Nosworthy at swsahs.nsw.gov.au] mailto:[mailto:Denis.Nosworthy at swsahs.nsw.gov.au] Sent: Tuesday, 11 June 2002 8:37 To: 'Sam Heard'; openehr-technical at openehr.org mailto:openehr-technical at openehr.org Subject:RE: The concept of contribution File: InterScan_Disclaimer.txt Sam, Well said. We have for many years been operating under the ideas of 'interoperability' and whilst tools such as HL-7 have been very successful in getting us through these times the issue of EHR interoperability will be something else yet again. Source system interoperability is one thing however (mostly constrained within a controlled environment) but receiving systems such as EHRs will have to be truly interoperable if they are to be effective. The EHR is not a messaging system as some would have us believe (in some incantations it could be seen to be just that) but it must be a system that clinicians can rely on to be accurate and reflect 'real life'. If it has to rely heavily on 'real time' messaging then the vagaries of our telecommunications systems will have a significant impact on that level of acceptance -Original Message- From: Sam Heard [mailto:sam.heard at flinders.edu.au] mailto:[mailto:sam.heard at flinders.edu.au] Sent: Tuesday, June 11, 2002 10:07 AM To: openehr-technical at openehr.org mailto:openehr-technical at openehr.org Subject: RE: The concept of contribution Dear All There is no doubht that the solution will have a degree of complexity - just look at HL7 v3 which is aimed at messaging. I believe that the HL7 and CEN EHR approaches will align - and will include the level 3 CDA demands - though it will take some time and must arise through implementation experience. The time for smoked filled rooms and EHR standards is over for us at openEHR and Ocean Infomatics. It is very helpful to have lots of ideas, but unless people are working
The concept of contribution
Sam, I agree that a certain degree of convegence is desirable and inevitable and will evolve over time based on implementation experience, but what is the reference to smoke filled rooms about? Liora At 09:37 AM 6/11/02 +0930, Sam Heard wrote: Dear All There is no doubht that the solution will have a degree of complexity - just look at HL7 v3 which is aimed at messaging. I believe that the HL7 and CEN EHR approaches will align - and will include the level 3 CDA demands - though it will take some time and must arise through implementation experience. The time for smoked filled rooms and EHR standards is over for us at openEHR and Ocean Infomatics. It is very helpful to have lots of ideas, but unless people are working on an implementation it is almost impossible to contribute in a major way. I have put the challenge to CEN to have some pilot implementations of Clinical Applications to GEHR (using our current trial implementations) and see what the implications are of our current approach. At least 2 European companies are interested. I also believe that the EHR demands an information model designed specifically for that purpose - the interoperability of EHRs. The fantacy that sharing information based on different information models will be straight forward is evolving - one only has to look at the difficulty of sharing a word document amongst different software - it is often close. The order of magnitude of complexity with health information is far greater. So let us address the difficulties of information models, of clinical models in a two level approach and work to create an EHR that is genuinely interoperable. It will take resources - but to have it working as a sharable component will take 0.1% of about 3 countries health IT development budget and 10 good minds. I think it is really starting to happen! Cheers, Sam Dr Sam Heard The Good Electronic Health Record Ocean Informatics, openEHR 105 Rapid Creek Rd Rapid Creek NT 0810 Ph: +61 417 838 808 sam.heard at flinders.edu.au www.gehr.org www.openEHR.org __ Why the focus on HL7 only? CEN/TC251 has started work on the EN 13606 and is precisely what you want. HL7 version 3 and CDA will be to unstable for some time to come. HL7 doesn't adopt the GEHR (CEN) two model approach. Artifacts based on the present HL7 version 3 RIM will prove to be unimplementable as a system or object. We can be very encouraged that you may get together with HL7 on this. However you (or was it Gunnar Klein) did say in your ?Berlin CEN meeting 2002 presentation (the presentation has disappeared from the www.openehr.org. site) that EN 13606 had limited uptake because it was: a) incomplete or have offered only partial coverage of the healthcare domain; b) unnecessarily complex; c) too generic, leaving the various implementations too much variability in how the models are applied to a given domain; d) flawed, with some classes and attributes not implementable as published; e) requiring expensive re-engineering of systems; f) containing features not required by the purchasers of clinical systems. The time is evidently ripe for a synthesis. I agree about the importance of narrative: You said: It is a narrative for personal usage. When information is to be shared the author will select and rewrite parts of his notes in order to meet a specific request by an other healthcare provider. This is the way people work. This is the way healthcare providers know how to work with using paper systems. Perhaps the record is a resource to make stories out of? The original 'syntagm' is just the first, and even that was an interpretation.The 'true' story is unknowable. I can see that objective information (orders, test results) can be shared by all without real problems. But people (good healthcare) will need subjective narrative as recorded in their personal Medical Records. Free text remains indispensable, structured data is just the debris left behind - it's a point of view... Regards Mike Mair - If you have any questions about using this list, please send a message to d.lloyd at openehr.org - If you have any questions about using this list, please send a message to d.lloyd at openehr.org - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
The concept of contribution
aniket Joshi wrote: Dear Sir, The concept of contribution is definitely 'essential' for the functioninig of an efficient EHR model. For all practical purposes the memory of the patient and the HCP is in term of events. Each of these events have a distinct title for eg.Appendicectomy and have a number of examinations inside them. Each examination has a versioned_transaction as a record. Thus the event is a cluster of examinations and contribution can act as a cluster of versioned_transactions with a title. it seems to me this use of the word event is more what I would call an episode, i.e. a period of time during which a number of related things happen (e.g. admission, examination, operation, review, discharge). The defining aspect of contribution we are saying is that it is the unit of change to the EHR - it is due to a single clinical session, which might be - a patient contact - a set of test results - the acquisition and merging of an EHR extract or message During retrieval the Health care provider will have to select a contribution after which only the related Versioned_transactions will have to be retrieved. Will this reduce the speed? DR ANIKET JOSHI not completely clear on the querying scenario you are proposing here. - thomas beale - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
The concept of contribution [long]
I'll preface my comments by stating that after a very useful discussion with Andrew Goodchild today at the DSTC, I have agreed to write up a 2 or 3 page discussion paper on the subject of contributions with diagrams, whch I will put on the web. This will describe change management of the EHR seen from the configuration management paradigm, and describe what we think a contribution really is. I will publish this in the next couple of days, to help the discussion... Mike Mair wrote: I agree with it, but I was looking to the HL7 CDA to be the basic HES Template, and then the objects (archetypes) fit in that. Bob Dolin from the HL7 Structured Documents Group has described a way of doing this. Their model might have a different emphasis from your 'versioned transaction' concept. All 'Health Event Summaries' would have the same basic structure, from simple free text documents to the Level 3 CDAs. These can then provide a searchable data warehouse. It will be searchable at some levels only. A CDA document is pretty close to what we are calling a contribution. The differences are: - with an openEHR contribution, multiple transactions can be updated due to an interaction with the record,.e.g family history, plan etc. This is good from the point of view of having this information in thematically meaningful buckets. With CDA, all the content is in the document. If you want to build a picture of family history or current medications or care plan - especially if you want it nicely arranged under an agreed set of headings - it is going to be challenging... - due to the level 1,2,3 conformance levels of CDA, any particular query searching for a particular kind of information, e.g, facts about family history will potentially work well for level 3 documents, but nothing can be said about the level 1 and level 2 documents in the repository, since in general there is no way for the level 3 query to work. Likewise, queries on level 2 attributes will only work for level 2 and 3 documents; only level 1 queries will correctly return results for all documents. This is not a criticism - it is exactly the expected behaviour of a repository of documents whose job is to provide different levels of structuring capability, due to the need to cope with input of varying quality. Health event summaries appear (according to our work so far) to be a relatively easily archetypable family of structures. Some of their informatino will be what we call persistent information, i.e. what is found in the persistent transactions (what I called thematic transactions above). I have often thought that the distinction between 'persistence' and 'event' transactions was unnecessary. I don't think we should be constructing an ideal EHR at all. We should be working on a communication standard. I agree Interestingly, as we work with this concept, it becomes more and more obvious. Consider the EHR as a repository of documents or information entities, some of which are defined by purpose or theme, such as the typical transactions for family history, current meds, lifestyle, social history, vacc history, therapeutic precautions, plan, problem list, etc. These are what we call persistent transactions, and it is very clear that most EHR applications - both interactive and batch - will be hitting these transactions all the time. In openEHR we are in the business of specifying the semantics of information in health records. It is true that some of the discussion goes beyond the remit of defining a communication standard. As long as this is clear, I don't think anyone has a problem with this. It is formally differentiated by the specification of EHR_EXTRACT versus EHR - the former is the basis for communication, while the latter is the basis for systems. But it is extremely useful to talk about what EHR systems need to be able to do, in order to figure out what the communication model should look like - I would go so far as to say that no-one is going to be able to design a good commuication standard without thinking about what is in the systems from which information comes (others disagree with this but that's the nature of debate!) that a HES or RDS system is not an EHR, but it should not try to be. I would agree Instead, it might provide the currency to make EHRs out of. That's what vendors are for. There can also be open source developers. If we just capture the essentials, in containers of objects from all the health events, that will give all the base data we need. The HES may start off primitive (mainly free text), but will come to contain harvested data objects (including prescription objects, family history objects etc.). Interestingly, in discussions at HL7 Atlanta, the gulf between free text and structured information emerged - there appears to be a much greater free text data problem in the US than elsewhere, presumably due to the transcribing culture there. Designers of systems in the UK
