Re: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Thomas Beale]

Hi Daniel,

I read most of your thesis, it is fascinating (it's one of those things 
that requires contemplation, so I have not read it straight through). I 
recommend others to have a look 
.


One thing that I think we can say about efforts like openEHR, and indeed 
any large-ish ecosystem project (including SDOs like HL7 etc): there is 
the intended / understood sociological analysis on the part of the 
builders (we who make something in openEHR) and then there is reality. 
How we think it should work in the real world can easily be wrong-footed 
by sociopolitical realities, and these latter are ill-defined. Thus, if 
we are naive (we almost certainly have been in some ways), we get some 
things wrong and then are surprised when the world doesn't work in what 
we consider the most rational way (it rarely does). This is what happens 
around 'adoption' - things get twisted by shifting government policies, 
changing funding programmes, enterprise amnesia and many other 
phenomena. The world is always more complicated than we think it should 
be, and than our abstractions would imply...


Regarding ABD, I won't report too much just yet because I need to be 
sure of what the group leads want to do in terms of presenting their 
thinking over time, i.e. not jump the gun. When I am able, I'll post 
something.


- thomas

On 01/04/2016 12:38, Daniel Curto-Millet wrote:


Hi all,

I’ve been a long-time lurker in the lists while doing my PhD and I 
still try to keep tabs with what openEHR is doing. I wanted to react 
and take part in this discussion particularly because their paper 
resonated with me in some points (and not in others). I think the 
paper has merit and I’m interested (and quite jealous of too) that 
they did what I had wanted to do eventually with openEHR had time been 
kinder: to look and compare the global openEHR and the local openEHR(s).


The paper’s finding that you cannot separate social issues from 
technology is not new; and there is an inherent tension between a 
computer system that is based on simplification and closure 
(determinate states), from desires of freedom and flexibility usually 
associated with the social (yet, has anyone not felt the 
functional-driven approach set by bureaucracy without the need of any 
technology). So, although their point on the illusion of separation 
between the social and technical is correct; it is also true for every 
information system there is, past, present, and no doubt, future. This 
includes the accounting books from the middle-ages which tried to 
settle down some concepts (money in; money out), while giving 
flexibility to other concepts (varying prices of cereals; intangible 
assets, etc.).


When I researched the global openEHR (in contrast to implementing 
ones), I found that the project had harnessed open source in ways 
which made the modelling of ambiguous requirements possible precisely 
because there was no concept of determinacy. I remember a long series 
of discussion (Nov 2010?) between Thomas and Ed regarding openEHR’s 
way of thinking about requirements, contrasting it with the notion of 
design by committee behind (relatively) closed doors. The public space 
that open source affords openEHR is not just a trendy word, but it can 
create what Chris Kelty refers as ‘recursive commons’, a sort of space 
that respects certain values and logics (in his study, Free software) 
that can function with relative independence from competing logics 
that threaten its own existence (in his study, closed software).


As an open source project, openEHR is quite special in what it does. 
Whereas open source usually puts the ability for local populations 
(schools, architects, etc.) to collaboratively ‘own’ methods of 
productions (otherwise in the hands of those who have the key to 
closed software). openEHR creates this ownership ability at a 
conceptual level, necessarily /removed/ (but never quite so) from 
local contexts. I remember a discussion between Heather and Ian (in 
2010?) on an allergen-related archetype with a doctor who was 
particularly concerned for personal reasons and what constituted a 
‘good’ archetype relative to templates and local concerns (thus taking 
local concerns into account at this global level).


What ‘good’ means is extremely ambiguous in all cases, but that’s the 
point and openEHR’s greatest contribution and greatest challenge: the 
global project has purposefully put the definition of ‘good’ in that 
very public space of the open source world, and I don’t think it would 
be inaccurate to say that openEHR has thought this through already 
(e.g. governance change) and will continue to do so (e.g. local 
ambassadors). In this sense, I don’t see at all that openEHR is 
technologically deterministic, on the contrary. Yet the implementation 
side requires some forms of simplifications and closures (Luhmann’s 
concepts, not 

Re: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Daniel Curto-Millet]

Hi all,

I’ve been a long-time lurker in the lists while doing my PhD and I still try to 
keep tabs with what openEHR is doing. I wanted to react and take part in this 
discussion particularly because their paper resonated with me in some points 
(and not in others). I think the paper has merit and I’m interested (and quite 
jealous of too) that they did what I had wanted to do eventually with openEHR 
had time been kinder: to look and compare the global openEHR and the local 
openEHR(s).

The paper’s finding that you cannot separate social issues from technology is 
not new; and there is an inherent tension between a computer system that is 
based on simplification and closure (determinate states), from desires of 
freedom and flexibility usually associated with the social (yet, has anyone not 
felt the functional-driven approach set by bureaucracy without the need of any 
technology). So, although their point on the illusion of separation between the 
social and technical is correct; it is also true for every information system 
there is, past, present, and no doubt, future. This includes the accounting 
books from the middle-ages which tried to settle down some concepts (money in; 
money out), while giving flexibility to other concepts (varying prices of 
cereals; intangible assets, etc.).

When I researched the global openEHR (in contrast to implementing ones), I 
found that the project had harnessed open source in ways which made the 
modelling of ambiguous requirements possible precisely because there was no 
concept of determinacy. I remember a long series of discussion (Nov 2010?) 
between Thomas and Ed regarding openEHR’s way of thinking about requirements, 
contrasting it with the notion of design by committee behind (relatively) 
closed doors. The public space that open source affords openEHR is not just a 
trendy word, but it can create what Chris Kelty refers as ‘recursive commons’, 
a sort of space that respects certain values and logics (in his study, Free 
software) that can function with relative independence from competing logics 
that threaten its own existence (in his study, closed software).

As an open source project, openEHR is quite special in what it does. Whereas 
open source usually puts the ability for local populations (schools, 
architects, etc.) to collaboratively ‘own’ methods of productions (otherwise in 
the hands of those who have the key to closed software). openEHR creates this 
ownership ability at a conceptual level, necessarily removed (but never quite 
so) from local contexts. I remember a discussion between Heather and Ian (in 
2010?) on an allergen-related archetype with a doctor who was particularly 
concerned for personal reasons and what constituted a ‘good’ archetype relative 
to templates and local concerns (thus taking local concerns into account at 
this global level).

What ‘good’ means is extremely ambiguous in all cases, but that’s the point and 
openEHR’s greatest contribution and greatest challenge: the global project has 
purposefully put the definition of ‘good’ in that very public space of the open 
source world, and I don’t think it would be inaccurate to say that openEHR has 
thought this through already (e.g. governance change) and will continue to do 
so (e.g. local ambassadors). In this sense, I don’t see at all that openEHR is 
technologically deterministic, on the contrary. Yet the implementation side 
requires some forms of simplifications and closures (Luhmann’s concepts, not 
mine), not necessarily at odds. The question I think, becomes one of building 
bridges between the diverse communities involved (whether level—national, or 
context—small clinic, etc.) in processes of community engagement. How this can 
take place is extremely challenging involving both strategic and tactical 
thinking. Strategic: how to create a coherent whole (e.g. that openEHR’s 
mission is shared and adapted by the various levels), and tactical: how to 
involve clinicians more easily (e.g. the use of soft systems methodologies to 
understand local worlds).

By the way Thomas, I’m really interested in what you have to say regarding the 
ABD. There are theories in information systems regarding activity theory and 
I’m curious to see if there are any connections with that.

Daniel___
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RE: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Koray Atalag]

That's great call - many thanks

Cheers,

-koray


-Original Message-
From: openEHR-technical [mailto:openehr-technical-boun...@lists.openehr.org] On 
Behalf Of Ian McNicoll
Sent: Tuesday, 15 March 2016 1:55 a.m.
To: For openEHR technical discussions
Subject: Re: Socio-technical challenges when the openEHR approach is put to use 
in Norwegian hospitals

Many thanks Jan (and of course to the author),

Clearly this paper has aroused considerable interest/debate. It is good that 
the whole community can see it and and discuss in details.

Ian


Dr Ian McNicoll
mobile +44 (0)775 209 7859
office +44 (0)1536 414994
skype: ianmcnicoll
email: i...@freshehr.com
twitter: @ianmcnicoll

Co-Chair, openEHR Foundation ian.mcnic...@openehr.org Director, freshEHR 
Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL


On 14 March 2016 at 06:47, jan@home  wrote:
> I asked to author to send the accepted version of the manuscript to the 
> mailing list. She is not on the list, but I got permission to so so. Please 
> see attached.
>
> Jan Talmon
>
> ___
> openEHR-technical mailing list
> openEHR-technical@lists.openehr.org
> http://lists.openehr.org/mailman/listinfo/openehr-technical_lists.open
> ehr.org

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Re: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Bert Verhees]

I think my reaction of last weekend must have been confusing.

I mixed up two subjects
- The fantastic ideas about how information and communication and 
software development should work, and good discussions about that, but 
also theoretical,
- The reality, which seems we are still stuck in the year 2000, in the 
Netherlands, but also on many other places, using HL7v2, Edifact, email 
as message transportation, no fine grained authorizations, and spending 
lots of money without making much progress. Fore example, now there is a 
official advise not to use WhatsApp for communicating medical information.


I should not have mixed up these two subjects, although they always mix 
up at my daily routines.


I am sorry for the confusion I might have caused.

Best regards
Bert Verhees

On 14-03-16 13:55, Ian McNicoll wrote:

Many thanks Jan (and of course to the author),

Clearly this paper has aroused considerable interest/debate. It is
good that the whole community can see it and and discuss in details.

Ian


Dr Ian McNicoll
mobile +44 (0)775 209 7859
office +44 (0)1536 414994
skype: ianmcnicoll
email: i...@freshehr.com
twitter: @ianmcnicoll

Co-Chair, openEHR Foundation ian.mcnic...@openehr.org
Director, freshEHR Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL


On 14 March 2016 at 06:47, jan@home  wrote:

I asked to author to send the accepted version of the manuscript to the mailing 
list. She is not on the list, but I got permission to so so. Please see 
attached.

Jan Talmon

___
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Re: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Ian McNicoll]

Many thanks Jan (and of course to the author),

Clearly this paper has aroused considerable interest/debate. It is
good that the whole community can see it and and discuss in details.

Ian


Dr Ian McNicoll
mobile +44 (0)775 209 7859
office +44 (0)1536 414994
skype: ianmcnicoll
email: i...@freshehr.com
twitter: @ianmcnicoll

Co-Chair, openEHR Foundation ian.mcnic...@openehr.org
Director, freshEHR Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL


On 14 March 2016 at 06:47, jan@home  wrote:
> I asked to author to send the accepted version of the manuscript to the 
> mailing list. She is not on the list, but I got permission to so so. Please 
> see attached.
>
> Jan Talmon
>
> ___
> openEHR-technical mailing list
> openEHR-technical@lists.openehr.org
> http://lists.openehr.org/mailman/listinfo/openehr-technical_lists.openehr.org

___
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Re: Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

[Bert Verhees]

Just a thought on the reading of the article

Good article, until I found this sentence: "domain models are now 
separate from the software (but not the product), and they can be built 
by non-IT personnel, assuming a tool with a reasonable user interface."


Making user-interfaces is a profession, not something you learn on a 
rainy sunday afternoon.


When I read that users should be able to build systems when having the 
tooling, it gives me doubts about its efficiency.
When I write that users are King, I do not mean that Users must do the 
work.
Kings don't work, maybe they have a hobby, but mainly, they drink the 
wine, they don produce it.


I have spent many hours with non-technical medical doctors who learned 
programming BASIC and assembler as a hobby in the eighties, they should 
not interfere, they should not try to understand what Codd has to do 
with database-systems. We, technicians don't try to understand diseases, 
we accept a fairy tale about little monsters inside our body. No 
problem. We understand that we don't need to understand. We want to be 
cured, we trust medical doctors that they do what good is for us.


There are so many ways for non-technical end users to explain what they 
want to technical staff. It is the result that counts, isn't it?
And the price is very high, and of course the tax payer is happy to pay. 
I think that is one of the problems, in normal commercial markets, 
companies are much more efficient.


We have the situation in the Netherlands that we spent 500 million Euro 
for a information-exchange-environment for medical data. Not only 500 
million, but also we waited 15 years.


Now we have it.
But it does not have, even the most basic, authorization, everyone who 
has legal access to the system can look at every patients-record.
Not only that, it has no logging accessible for patients, a patient 
cannot see who looked at his medical records.
The use of the system is against every privacy law in the Netherlands, 
so there was a court needed to use it, and the court gave its blessing 
because patients are voluntary in the system (opt-in)


If you would have designed the system from requirements, and gave it to 
a technical company, together with domain-experts to define a message 
standard, I think the system would have been ready ten years earlier, 
for 20% of the costs, and no court needed to approve its use.


I think in medical ICT, the best role of the user in ICT is widely 
misunderstood. We, technical experts and domain experts should inform 
users that democracy does not mean that people need to understand how to 
run a country or build an ICT system.


On 11-03-16 15:15, Thomas Beale wrote:


I can only see the abstract for now, but I think the authors seem to 
have developed the misconception that end-users would somehow be 
designing applications. openEHR doesn't try to do that, and it's the 
first time I've heard anyone suggest it. openEHR just enables domain 
experts (generally = a small proportion of healthcare professionals, 
who might also be some kind of system user in some part of the world) 
to more directly define the information content of the system, in such 
a way that it can be processed and queried on a semantic level.


The Business Purpose of Archetypes section in the Archetype Technology 
Overview 
may 
help to show why this is useful and necessary (it's short!).


There are still many other problems to solve such as clinical 
workflows and user interaction / UX.


I am currently at Intermountain Health in Salt Lake City working with 
the Activity Based Design (ABD) group that has developed a new 
architecture that I think has a realistic chance of addressing a) 
workflow (e.g. typical nursing tasks like cannulation; more complex 
cooperative workflows that involve shared care) and b) some aspects of 
UI interaction within workflows. They are just at an early prototype 
stage, and it has taken nearly 2 years to get to the current 
architecture (naturally taking into account many previous attempts and 
experience).


This effort is the first I have seen that has what I think may be the 
needed theoretical understanding and technical architecture to 
starting to solve clinical process and (some of) UI/UX. And what does 
it rely on? Formal clinical models, and it assumes that those models 
are created by clinical experts. Not only that, it explicitly assumes 
a 'template' concept of the same kind as openEHR's, in order to 
construct useful data sets.


It considers these 'templates' as the basis of an 'Activity' 
description, which then adds new abilities to blend in some 
presentation directives, pre- and post-conditions, some workflow 
elements, cost-related items (e.g. ICD coding) and so on. The 
innovation here is to consider an Activity a unit of clinical work and 
to attach these process-related semantics into that level of