William, There are still a few missing links in the V3 Care Plan model in regard to work flow modelling, some of which are supported in openEHR and others that are left to more dedicated work flow modelling and tooling, deliberately. The key issue in the V3 Care Plan is the lack of work flow decision points. The event criterion (EVN.CRT) mood is only supported on the Observation Act in the Clinical Statement and hence the Care Plan model, therefore you can not model decision points that are not Observations like Procedures and Substance Administrations, which I would have thought to be rather key. This is not to downgrade HL7, just to correct your statement that these can be done in HL7. It is true that it could be done but not with the current Care Plan Clinical Statement model. The second issue is the use of derivation expression. This is an interesting attribute that is just a catch all that is not already supported. So we can do some modelling using RMIMs but then what we can't say we put into derivation expression but then what is the language to use here? HL7 doesn't have an endorsed constraint language (although it has a standard for one, GELLO) and it also doesn't have work flow language. So to actually make what you suggest can be done in HL7 you need to invent your own rule expressions. My main issue here is not that they don't have these, but that you have more than one way of representing these. To build software on this you need to be able to process the HL7 event criterion and the derivation expressions in what ever invented language you used. That doesn't seem to be overly interoperable. As you said it's not perfect. openEHR has drawn the line and said, we will not reinvent the wheel on Work Flow. openEHR will provide the data required, record the states and the recommendations but not the actual rules used by software. It is intended to use existing work flow engines in conjunction with an openEHR repository. Although, I understand that there might be a future effort to develop an abstract model of work flow that work with archetypes that could be mapped into the existing Work Flow models and engines. Now this needs to be proven and worked through and as the original Author of the HL7 V3 Care Plan I am very interested in working this through in openEHR. The HL7 V3 Care Plan model is just to cumbersome even though I agree that the mood code did allow for a very powerful representation of a Guideline and Care Plan. I just don't think we can reliably write software to process those models within the development budgets that we have in Healthcare, even in the UK, and certainly not in Australia. Considering the amount of money spent in the UK (I don't know the Netherlands budget) on building an EHR repository which is nothing more than a message store using V3 compared with what we have achieved with a very small team to build an openEHR repository, I suspect we can extrapolate this into clinical work flow processing. It is this cost of implementation (not that it can't be done, but how much it costs to do it) that has turned me away from HL7 V3 whereas the more I do with openEHR the more I am amazed how easy things are to implement. Again, I didn't want to beat up on HL7 V3, but I did want to present my experience being someone that is intimate with both sides of the fence and up until recently sat on the fence but I am certainly getting blown to one side where the implementation experience is more favourable. And on a final note, the CEN 13606 based RMIM I developed that was the cyclone that hit me considering you need an A3 page to represent something that fits on an A4 page in UML, just imagine if we represented HL7 V3 models in UML :>. And there are so many issues that HL7 still have not solved around versioning, attestation, templates, term bindings and queries. I really do hope that we can collaborate in a two-way exchange. As Gerard mentioned, there are agreements to collaborate with HL7 but that presently appears to be one-directional and it would be a nice change if HL7 parties begin actively participating the development of knowledge artefacts in openEHR/CEN space. Now I know there is an initiative in the US to trial this but I wonder if the likes of yourself could start getting deeper into the Instruction model and how it will work for care planning and make an objective assessment between the two approaches. We don't have enough people that are fluent in both and those that are get caught up in time wasting religious debates. I think you said it a couple of time, we need to determine what the requirements first, but we never get to do this because we argue about it it can or can't be done in a particular technology. I know the archetype and template tools don't support the requirements gathering you require but we should have an archetype repository that is able to store additional meta-data fairly soon. There is nothing wrong using Word and Excel as you are now. What we need is equivalent openEHR archetype for each of your Care Statement RMIMs and in your mapping spreadsheet a couple of columns for the openEHR archetype mappings. Once we get the process right we can then develop the tools to support it. BTW, a member of my development team (who was a obstetrician) is going through the process of developing a pregnancy clinical scenario (mega storyboard) and mapping the data element and sample data into archetypes. I wonder of you would be interested in working with her or at least sharing your experiences and current process? Regards Heath Heath Frankel Product Development Manager Ocean Informatics
Ground Floor, 64 Hindmarsh Square Adelaide, SA, 5000 Australia ph: +61 (0)8 8223 3075 fax: +61 (0)8 8223 2570 mb: +61 (0)412 030 741 email: <mailto:heath.frankel at oceaninformatics.biz> heath.frankel at oceaninformatics.biz _____ From: [email protected] [mailto:openehr-technical-bounces at openehr.org] On Behalf Of Williamtfgoossen at cs.com Sent: Tuesday, 19 September 2006 7:01 AM To: openehr-technical at openehr.org Subject: Antw: Re: Antw: Re: Antw: Re: EHRcom/openEHR the new exciting paradigm In een bericht met de datum 18-9-2006 10:45:04 West-Europa (zomertijd), schrijft Thomas.Beale at OceanInformatics.biz: There are guideline and workflow languages (not provided by HL7 or openEHR), and the beginnings of models for choreography coming from WfMC and other places. I have looked into the WfMC materials, and the basic process flow descriptions are currently met with the HL7 v3 Care Plan. (This is not a point if HL7 can do, it is the point that it is possible to define the clinical process using a standard, I think it is transferable to OpenEHR archetype as well). The key here is the use of the following mood codes: definition will tell you wat according to best practice or evidence base should be done for a patient with problem x. (including monitoring of observations, tests, meds etc). The OpenEHR template specification that links archetypes could perhaps do similar things. intent mood helps the clinician to carry over from guideline into the care plan what is necessary for individual patient P. Thus the set of data required can be determined, and it can be justified why items are not carried from guideline to plan. (E.g. you do not female things for a male patient). Then if some professional wants to order a observation this can be done with request. e.g. the doctor askes the nurse to measure the blood pressure 4 times a day. In the Goal mood, the expected value can be set, e.g. the expected value of BP in a week should best be 130/90. the observatoin is carried out say 7 days 4 times a day leading to 7 x 4 = 28 observations in event mood. The statement collecter allows to trend this. The comparison of goal versus the event(s) trends, or the last value of day 7 allows to determine if the goal is met (conclusion being then the 29th observation). The derivation method allows to specify also workflow rules like: do BP measurements until 4 x < 130/90 or similar as a criterion for the do X until Y workflow standard. I am not telling this is best handled in HL7 v3, I just want to say that a] it is possible to express clinical meaningful workflows, that at EHR level are pretty handy for a nurse to pop up on the worklist every 6 hours, and that it is possible to exchange the semantics of such a workflow / careplan via a message. Yes, this is interesting stuff and needs a lot of work. William -------------- next part -------------- An HTML attachment was scrubbed... URL: <http://lists.openehr.org/mailman/private/openehr-technical_lists.openehr.org/attachments/20060919/6fb3e1b3/attachment.html>
