Changes between Version 2 and Version 3 of The Origins of openEHR


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Timestamp:
May 18, 2008, 3:04:31 PM (16 years ago)
Author:
KOBAYASHI, Shinji
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  • The Origins of openEHR

    v2 v3  
    1 = The Origins of openEHR = #dsy20-OE
    2  
    3  *  [http://www.openehr.org/about/origins.html#dsy20-OE_intro Introduction]
    4  *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr The Good European Health Record (GEHR) Project Proposal]
    5  *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr-participants Participants in the GEHR Project]
    6  *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr-accomplishments The Accomplishments of the GEHR Project]
    7  *  [http://www.openehr.org/about/origins.html#dsy20-OE_centc251 The Interface between the GEHR Project and Technical
    8 Committee TC/251-Medical Informatics of CEN]
    9  *  [http://www.openehr.org/about/origins.html#dsy20-OE_synapses From GEHR to Synapses in Europe]
    10  *  [http://www.openehr.org/about/origins.html#dsy20-OE_australia Australia awakens the world electronic health care
    11 records community to the approach of GEHR]
    12  *  [http://www.openehr.org/about/origins.html#dsy20-OE_implementation Implementation, Implementation, implementation! -
    13 from GEHR and Synapses to Synex, Medicate and 6-winit in CHIME and UCL]
    14  *  [http://www.openehr.org/about/origins.html#dsy20-OE_openehr openEHR]
    15  *  [http://www.openehr.org/about/origins.html#dsy20-OE_openehr-manifesto First Ideas for the openEHR Foundation]
    16  *  [http://www.openehr.org/about/origins.html#dsy20-OE_whehr Whehr now?]
    17 
    18   ''David Ingram October 2002''
    19 
    20  Some ten years after the GEHR project was established in 1989, partners in
    21 that project have come together again to review experience gained over the
    22 intervening years. It is especially encouraging that a forthcoming ISO standard
    23 will elevate formally defined clinical requirements to the highest level in the
    24 standards process for electronic healthcare records. So many systems describe
    25 themselves as electronic healthcare records and yet share little common concept
    26 of what such an entity is and what it is for.
    27 
    28  The research and development in this field has followed a chaotic and
    29 tortuous evolution, influenced inevitably by commercial, political and academic
    30 considerations and rivalries and also by severe inertia because of powerful
    31 needs to continue to accommodate legacy systems. Confused and confusing
    32 arguments have raged about esoteric models of ill-defined clinical terminology,
    33 processes and communications. Continuing reinvention of wheels at these levels
    34 of abstraction (more precisely concoction of alternative definitions and plans
    35 of possibly wheel-like objects!), has inhibited progress. There is still an
    36 urgent need for empirical study of the implementation and comparative evaluation
    37 of a diverse range of approaches to the provision of high quality electronic
    38 healthcare records. This must be informed by international consensus about the
    39 requirements to be met.
    40 
    41  
     1= openEHRプロジェクト小史 = #dsy20-OE
     2The Origins of openEHR
     3
     4この文章は[!http://www.openehr.org/about/origins.html The Origins of openEHR]の日本語訳です。翻訳の正確さについては一切保証しませんので、適宜原文を参照してください。
     5
     6 
     7
     8[[TOC]]
     9
     10  ''David Ingram October 2002'' ''Translated by Shinji KOBAYASHI 2008''
     11  GEHRプロジェクトが確実なものとなった1989年から10年ほどたった頃、プロジェクトのパートナー達が再び集まって、その間の年月でどのくらいの経験が積み重ねられたのか評価することになった。それは心強いものであり、来るべきISO標準が電子的健康記録(EHR)の標準的プロセスにおいて高いレベルの臨床的要件を公式に定義するために制定されるであろということを示唆していた。EHRとして表現される多くのシステムが存在するが、その間でそのエンティティがどのようなもので何のために存在するのかを共有するための共通概念がほとんどなかった。
     12  Some ten years after the GEHR project was established in 1989, partners in that project have come together again to review experience gained over the intervening years. It is especially encouraging that a forthcoming ISO standard will elevate formally defined clinical requirements to the highest level in the standards process for electronic healthcare records. So many systems describe themselves as electronic healthcare records and yet share little common concept of what such an entity is and what it is for.
     13  この分野での研究開発は必然的に商業的、政策的、そして学術的意図や競争、レガシーシステムを採用し続けようという強力な要求のためのとんでもない惰性によって必然的に混沌に導かれ、歪んだ発展を遂げてきた。間違って定義された臨床用語やプロセス、コミュニケーションに対する難解なモデルについて、議論は混乱させられてきたし、さらに混乱も生み出してきた。このレベルの抽象化のために車輪の再発明（より正確にはおそらく車輪のようなものの代わりになる定義や計画をでっちあげようとする！)が続けられることで、進歩が妨げられてきた。今でも高品質なEHRを帝京するための多様なアプローチを比較検討し、実装について実証的な研究が求められている。したがって、満たされるべき要件について国際的なコンセンサスが知らされなければならない。
     14  The research and development in this field has followed a chaotic and tortuous evolution, influenced inevitably by commercial, political and academic considerations and rivalries and also by severe inertia because of powerful needs to continue to accommodate legacy systems. Confused and confusing arguments have raged about esoteric models of ill-defined clinical terminology, processes and communications. Continuing reinvention of wheels at these levels of abstraction (more precisely concoction of alternative definitions and plans of possibly wheel-like objects!), has inhibited progress. There is still an urgent need for empirical study of the implementation and comparative evaluation of a diverse range of approaches to the provision of high quality electronic healthcare records. This must be informed by international consensus about the requirements to be met.
     15 
     16
    4217== Introduction - the AIM Initiative in Europe == #dsy20-OE_intro
    43  In 1988, the European Union established the Advanced Informatics in Medicine
    44 (AIM) initiative, within the wide-ranging Framework Programme for Research and
    45 Technology Development in Europe.
    46 
    47  The rationale for the Framework Programme was:
    48 
    49  
    50    * To strengthen the economic and social cohesion of the Community
    51    * To offer obvious benefits through the collaboration of several States
    52    * To apply significant and complementary results across the whole Community
    53    * To contribute to a common market and to scientific and technical unification
    54 
    55  It succeeded in catalysing a wave of new partnerships across all sectors of
     18  In 1988, the European Union established the Advanced Informatics in Medicine
     19(AIM) initiative, within the wide-ranging Framework Programme for Research and Technology Development in Europe.
     20
     21  The rationale for the Framework Programme was:
     22 
     23
     24 * To strengthen the economic and social cohesion of the Community
     25 * To offer obvious benefits through the collaboration of several States
     26 * To apply significant and complementary results across the whole Community
     27 * To contribute to a common market and to scientific and technical unification
     28
     29  It succeeded in catalysing a wave of new partnerships across all sectors of
    5630the European economy.
    5731
    58  In relation to health, the Framework Programme objectives set out in 1988
     32  In relation to health, the Framework Programme objectives set out in 1988
    5933were:
    6034
    6135 
    62    * To unify European activities by providing the means for efficient
    63 communication of medical records and knowledge so that these may be understood
    64 and compatible, thereby permitting the integration of health information systems
    65    * To strengthen competitiveness by advancing the technical basis of products
    66 and services and commercialising European inventiveness in all scales of
    67 enterprise
    68    * To improve the quality of life through improving diagnosis and treatment,
    69 increasing public awareness and knowledge of health care and widening access to
    70 improved services
    71 
    72  Thus, from the earliest stages of the Programme, the harmonisation of
    73 electronic health care records was seen as of the highest strategic importance
    74 for health care development in Europe.
    75 
    76  Under the outstanding leadership of Dr Niels Rossing, the AIM Programme was
     36
     37 * To unify European activities by providing the means for efficient
     38
     39communication of medical records and knowledge so that these may be understood and compatible, thereby permitting the integration of health information systems
     40
     41 * To strengthen competitiveness by advancing the technical basis of products
     42
     43and services and commercialising European inventiveness in all scales of enterprise
     44
     45 * To improve the quality of life through improving diagnosis and treatment,
     46
     47increasing public awareness and knowledge of health care and widening access to improved services
     48
     49  Thus, from the earliest stages of the Programme, the harmonisation of
     50electronic health care records was seen as of the highest strategic importance for health care development in Europe.
     51
     52  Under the outstanding leadership of Dr Niels Rossing, the AIM Programme was
    7753developed in key phases, as follows:
    7854
    7955 
    80    *  '''1988 - 90''' Exploratory phase, 20 million ECU, 43 projects
    81    *  '''1990 - 94''' 110 million ECU, 38 projects; 12 concerted
     56
     57 *  '''1988 - 90''' Exploratory phase, 20 million ECU, 43 projects
     58 *  '''1990 - 94''' 110 million ECU, 38 projects; 12 concerted
     59
    8260actions (eg. Medirec)
    83    *  '''1994 - 98''' 135 million ECU, ~60 projects
    84 
    85  The first major Call for Proposals under the AIM Workplan was issued in 1989.
    86 A Key Action was to be research and development for an electronic health care
    87 record architecture. There was intense competition among rival consortia seeking
    88 funding to work on this challenge. Other Key Actions addressed clinical
    89 terminology and clinical care protocols and important work in these areas
    90 evolved in the early AIM Programme Projects (e.g. Galen, Games, Dilemma), and
    91 colleagues from these days work alongside us to this day.
    92 
    93  
     61
     62 *  '''1994 - 98''' 135 million ECU, ~60 projects
     63
     64  The first major Call for Proposals under the AIM Workplan was issued in 1989.
     65A Key Action was to be research and development for an electronic health care record architecture. There was intense competition among rival consortia seeking funding to work on this challenge. Other Key Actions addressed clinical terminology and clinical care protocols and important work in these areas evolved in the early AIM Programme Projects (e.g. Galen, Games, Dilemma), and colleagues from these days work alongside us to this day.
     66
     67 
     68
    9469== The Good European Health Record (GEHR) Project Proposal == #dsy20-OE_gehr
    95  A Consortium was drawn together by Dr Alain Maskens and Dr Sam Heard to bid
    96 to work within AIM on electronic health record architecture. Alain, a Belgian
    97 oncologist, was running HDMP, a small software company specialising in
    98 electronic healthcare records for GPs. Sam, an Australian General Practitioner,
    99 was lecturer at the Medical College of St Bartholomew’s Hospital in London and
    100 ran a practice in East London and had developed a general practice system
    101 supported by a cooperative of general practices. The two had met through
    102 Professor Mal Salkind, head of General Practice at St Bartholomew’s, during the
    103 AIM exploratory phase and had begun to collaborate on the development of a
    104 generic EHR system.
    105 
    106  The Consortium comprised seven professional, industrial and academic
    107 partners: St Bartholomew’s Medical College (co-ordinating partner); HDMP; The
    108 French Red Cross Hospitals; The Association of Doctors and Dentists of
    109 Luxembourg; The General Practice Institute of Oporto, Portugal; France Telecom;
    110 Smithkline Beecham.
    111 
    112  Professor David Ingram, Professor of Medical Informatics at St Bartholomew’s
    113 Medical College, was invited to lead the Consortium, to prepare the proposal
    114 and, subsequently, as Project Director, to run the project. In this, he worked
    115 closely with Lesley Southgate, who had succeeded Mal Salkind as Head of Primary
    116 Care at St. Bartholomew’s.
    117 
    118  The project proposal was put together in three months in early 1991 and was
    119 given the title ''The Good European Health Record'' (GEHR); the name was
    120 proposed by Alain Maskens. After a final 72 hour, round the clock, weekend
    121 flurry of preparation, it was submitted just in time. It emerged as an
    122 unexpected but warmly endorsed winning proposal, in the adjudication that
    123 followed. Some rival consortia had worked for several years to position
    124 themselves for the work, so the result was controversial. Negotiations, led for
    125 GEHR by David Ingram, were completed with the Commission who were represented by
    126 the Project Officer, Jacques Lacombe, and Michael Wilson. The project commenced
    127 in January 1992.
    128 
    129  
     70  A Consortium was drawn together by Dr Alain Maskens and Dr Sam Heard to bid
     71to work within AIM on electronic health record architecture. Alain, a Belgian oncologist, was running HDMP, a small software company specialising in electronic healthcare records for GPs. Sam, an Australian General Practitioner, was lecturer at the Medical College of St Bartholomew’s Hospital in London and ran a practice in East London and had developed a general practice system supported by a cooperative of general practices. The two had met through Professor Mal Salkind, head of General Practice at St Bartholomew’s, during the AIM exploratory phase and had begun to collaborate on the development of a generic EHR system.
     72
     73  The Consortium comprised seven professional, industrial and academic
     74partners: St Bartholomew’s Medical College (co-ordinating partner); HDMP; The French Red Cross Hospitals; The Association of Doctors and Dentists of Luxembourg; The General Practice Institute of Oporto, Portugal; France Telecom; Smithkline Beecham.
     75
     76  Professor David Ingram, Professor of Medical Informatics at St Bartholomew’s
     77Medical College, was invited to lead the Consortium, to prepare the proposal and, subsequently, as Project Director, to run the project. In this, he worked closely with Lesley Southgate, who had succeeded Mal Salkind as Head of Primary Care at St. Bartholomew’s.
     78
     79  The project proposal was put together in three months in early 1991 and was
     80given the title ''The Good European Health Record'' (GEHR); the name was proposed by Alain Maskens. After a final 72 hour, round the clock, weekend flurry of preparation, it was submitted just in time. It emerged as an unexpected but warmly endorsed winning proposal, in the adjudication that followed. Some rival consortia had worked for several years to position themselves for the work, so the result was controversial. Negotiations, led for GEHR by David Ingram, were completed with the Commission who were represented by the Project Officer, Jacques Lacombe, and Michael Wilson. The project commenced in January 1992.
     81
     82 
     83
    13084== Participants in the GEHR Project == #dsy20-OE_gehr-participants
    131  In addition, to David and Sam, of those still closely involved in the
    132 continuing story of GEHR, Dr Dipak Kalra, who led the GEHR Clinical Task Group,
    133 and David Lloyd, a key contributor to the technical Task Group, joined the St.
    134 Bartholomew's team at the outset. Dr Jo Milan, Director of Information at the
    135 Royal Marsden Hospital, London, and Dr Stanley Sheppard, Chief Executive of
    136 Update, a UK general practice software company, joined as sub-contractors to St.
    137 Bartholomew's. Update had to withdraw from the Consortium in the early days of
    138 the project, but Stan maintained contact on a personal basis. Tom Beale was
    139 employed as a consultant to the Royal Marsden in 1993 and subsequently joined
    140 the St Bartholomew's GEHR team, as a consultant, to assist in the key modelling
    141 phase, leading to the first GEHR object model for the health care record. David
    142 Ingram was appointed Professor of Health informatics at UCL in London in 1995
    143 and the team, moved there to establish the Centre for Health Informatics
    144 (CHIME). Marcia Jacks was the GEHR Project Administrator and is now co-ordinator
    145 of CHIME at UCL, where the St. Bartholomew's team moved.
    146 
    147  Notable contributions in GEHR were also made by:
    148 
    149  Jeff Geboers, HDMP; Christian Aligne, French Red Cross; Olivier Baille,
    150 France Telecom; Daniel Mart, Association of Doctors and Dentists of Luxembourg;
    151 Jose Calado and Helder Machado, Institute of General Practice, Oporto; Mario
    152 Cortelezzi, Luxembourg; Penny Grub, Richard Dixon, University of Hull; Lesley
    153 Southgate, Jeanette Murphy and Sian Griffiths, St Bartholomew's Medical College;
    154 Ian Grey and John Shorter, !SmithKline Beecham; Benoit Hap, C2V Paris;Gerhard
    155 Brenner, Carlos Salvador.
    156 
    157  Lesley Southgate, is now President of the Royal College of General
    158 Practitioners of the UK and Daniel Mart is General Secretary of the Association
    159 of Doctors and Dentists of Luxembourg.
    160 
    161  
     85  In addition, to David and Sam, of those still closely involved in the
     86continuing story of GEHR, Dr Dipak Kalra, who led the GEHR Clinical Task Group, and David Lloyd, a key contributor to the technical Task Group, joined the St. Bartholomew's team at the outset. Dr Jo Milan, Director of Information at the Royal Marsden Hospital, London, and Dr Stanley Sheppard, Chief Executive of Update, a UK general practice software company, joined as sub-contractors to St. Bartholomew's. Update had to withdraw from the Consortium in the early days of the project, but Stan maintained contact on a personal basis. Tom Beale was employed as a consultant to the Royal Marsden in 1993 and subsequently joined the St Bartholomew's GEHR team, as a consultant, to assist in the key modelling phase, leading to the first GEHR object model for the health care record. David Ingram was appointed Professor of Health informatics at UCL in London in 1995 and the team, moved there to establish the Centre for Health Informatics (CHIME). Marcia Jacks was the GEHR Project Administrator and is now co-ordinator of CHIME at UCL, where the St. Bartholomew's team moved.
     87
     88  Notable contributions in GEHR were also made by: Jeff Geboers, HDMP; Christian Aligne, French Red Cross; Olivier Baille,
     89France Telecom; Daniel Mart, Association of Doctors and Dentists of Luxembourg; Jose Calado and Helder Machado, Institute of General Practice, Oporto; Mario Cortelezzi, Luxembourg; Penny Grub, Richard Dixon, University of Hull; Lesley Southgate, Jeanette Murphy and Sian Griffiths, St Bartholomew's Medical College; Ian Grey and John Shorter, !SmithKline Beecham; Benoit Hap, C2V Paris;Gerhard Brenner, Carlos Salvador.
     90
     91  Lesley Southgate, is now President of the Royal College of General
     92Practitioners of the UK and Daniel Mart is General Secretary of the Association of Doctors and Dentists of Luxembourg.
     93
     94 
     95
    16296== The Accomplishments of the GEHR Project == #dsy20-OE_gehr-accomplishments
    163  The work of the GEHR project is well documented in its many widely
    164 communicated project reports, publications and software, and described on the
    165 CHIME.ucl.ac.uk web site. The final AIM Conference Paper concluded the first
    166 stage of the story of GEHR. All public deliverables of the Project may be
    167 downloaded from the UCL, CHIME web site.
    168 
    169  Working on the GEHR Project was an absorbing and unforgettable experience. It
    170 tackled an intrinsically difficult and contentious domain. Its results, which
    171 have continued to evolve in many projects and standards developments, have
    172 proved to be enduring accomplishments, from clinical, technical and
    173 organisational perspectives.
    174 
    175  Key attributes of the project approach and accomplishment were:
    176 
    177  
     97  The work of the GEHR project is well documented in its many widely
     98communicated project reports, publications and software, and described on the CHIME.ucl.ac.uk web site. The final AIM Conference Paper concluded the first stage of the story of GEHR. All public deliverables of the Project may be downloaded from the UCL, CHIME web site.
     99
     100  Working on the GEHR Project was an absorbing and unforgettable experience. It
     101tackled an intrinsically difficult and contentious domain. Its results, which have continued to evolve in many projects and standards developments, have proved to be enduring accomplishments, from clinical, technical and organisational perspectives.
     102
     103  Key attributes of the project approach and accomplishment were:
     104 
     105
    178106 1. Experienced, competent, committed and passionate multi-professional
    179 teamwork. The team worked very hard, disagreed and fought at times, but also
    180 evolved a culture of friendship, mutual support and loyalty, through some
    181 difficult challenges.
     107
     108teamwork. The team worked very hard, disagreed and fought at times, but also evolved a culture of friendship, mutual support and loyalty, through some difficult challenges.
     109
    182110 1. Development of an original, formal approach to electronic health record
    183 architecture, based on object modelling methods and founded on a comprehensive
    184 and systematic review of patient and clinical professional roles and
    185 requirements, across Europe, in relation to records.
     111
     112architecture, based on object modelling methods and founded on a comprehensive and systematic review of patient and clinical professional roles and requirements, across Europe, in relation to records.
     113
    186114 1. An empirical and iterative prototyping approach to the evolution of the
    187 architecture, emphasising implementation and testing of concepts, practically,
    188 at each stage.
     115
     116architecture, emphasising implementation and testing of concepts, practically, at each stage.
     117
    189118 1. The decision of the partners, in the interests of effective dissemination of
    190 the work, to publish the project results openly, within the public domain. The
    191 EU Contract in principle vested IPR for the work with the Consortium.
    192 
    193  Warmly supported as it was by Niels Rossing and the Commission and by its
    194 Project Officer, Jacques Lacombe, the Project proved from its very earliest
    195 stages and over time not to be short of powerful opponents, as well. Its results
    196 were provided, step by step as they were available and often before official
    197 publication, into all the stages of the formulation of EU pre-standards of CEN
    198 and further afield.
    199 
    200  
    201 == The Interface between the GEHR Project and Technical Committee
    202 TC/251-Medical Informatics of CEN == #dsy20-OE_centc251
    203  At about the same time that the AIM Programme was initiated, CEN established
    204 a standards initiative for medical informatics through its Technical Committee
    205 TC/251, led by Prof. Georges de Moor. The strategic co-ordination achieved
    206 between the AIM and CEN activities was sometimes disappointing and their goals
    207 and methods were very different. AIM was tackling the domain through extensive
    208 and well funded applied research and development in wide-ranging consortia such
    209 as GEHR. CEN, with much less resource, was tackling its role as a consensus
    210 building process, using task forces of experts to propose standards which were
    211 then voted on by national delegates. Of course, both empirical research and
    212 standards setting activities are needed to advance the field.
    213 
    214  During the course of the GEHR Project, a Project Team was established under
    215 TC/251 of CEN, to propose a pre-standard health record architecture. Some early
    216 deliverables of GEHR, in formulating clinical requirements and proposing early
    217 formal models for the EHCR, were requested by and provided to the CEN project
    218 team, led by Petter Hurlen. This team, in which some members of GEHR
    219 participated, published the first CEN pre standard, ENV 12265. The extensive use
    220 and influence of GEHR project results and concepts available at that time are
    221 clear in the CEN publication. The GEHR project continued to develop and refine
    222 its approach after the pre-standard was published.
    223 
    224  GEHR sought to work in a spirit of co-operation. Recognising its deficiencies
    225 and successively refining its results, in the public domain, was a key feature
    226 of its working method. Opposition and contrary perspectives provide an important
    227 and useful crucible for innovation. GEHR was quite radical in its approach and
    228 no doubt uncomfortable to have as a partner, as a result.
    229 
    230  
     119
     120the work, to publish the project results openly, within the public domain. The EU Contract in principle vested IPR for the work with the Consortium.
     121
     122  Warmly supported as it was by Niels Rossing and the Commission and by its
     123Project Officer, Jacques Lacombe, the Project proved from its very earliest stages and over time not to be short of powerful opponents, as well. Its results were provided, step by step as they were available and often before official publication, into all the stages of the formulation of EU pre-standards of CEN and further afield.
     124
     125== The Interface between the GEHR Project and Technical Committee TC/251-Medical Informatics of CEN == #dsy20-OE_centc251
     126  At about the same time that the AIM Programme was initiated, CEN established
     127a standards initiative for medical informatics through its Technical Committee TC/251, led by Prof. Georges de Moor. The strategic co-ordination achieved between the AIM and CEN activities was sometimes disappointing and their goals and methods were very different. AIM was tackling the domain through extensive and well funded applied research and development in wide-ranging consortia such as GEHR. CEN, with much less resource, was tackling its role as a consensus building process, using task forces of experts to propose standards which were then voted on by national delegates. Of course, both empirical research and standards setting activities are needed to advance the field.
     128
     129  During the course of the GEHR Project, a Project Team was established under
     130TC/251 of CEN, to propose a pre-standard health record architecture. Some early deliverables of GEHR, in formulating clinical requirements and proposing early formal models for the EHCR, were requested by and provided to the CEN project team, led by Petter Hurlen. This team, in which some members of GEHR participated, published the first CEN pre standard, ENV 12265. The extensive use and influence of GEHR project results and concepts available at that time are clear in the CEN publication. The GEHR project continued to develop and refine its approach after the pre-standard was published.
     131
     132  GEHR sought to work in a spirit of co-operation. Recognising its deficiencies
     133and successively refining its results, in the public domain, was a key feature of its working method. Opposition and contrary perspectives provide an important and useful crucible for innovation. GEHR was quite radical in its approach and no doubt uncomfortable to have as a partner, as a result.
     134
     135 
     136
    231137== From GEHR to Synapses in Europe == #dsy20-OE_synapses
    232  The GEHR Project came to an end at the end of 1994 and two proposals to
    233 extend its work plan were not immediately successful. One of these was for a
    234 Support Action to maintain co-ordination in health record architecture work and
    235 the other for more extensive field trials of the architecture. GEHR had
    236 delivered a significant, but by no means completed, advance in the application
    237 of object modelling approaches to the electronic health care record (EHCR) and
    238 its evaluation against comprehensive clinical and ethical requirements as well
    239 as implementation experience. It was clear to the team that this first stage
    240 GEHR architecture, the first GEHR Object Model, would require continuing
    241 refinement in the light of implementation experience.
    242 
    243  The project had, throughout, grappled with the issues of relational versus
    244 object database representations of clinical data. At the stage of evolution of
    245 database technology then pertaining, these concepts were in a state of
    246 considerable flux. Aspects of functionality were highly desirable, but they were
    247 hard to combine. Both camps argued their case, responding to the emerging needs
    248 of complex applications domains, of which the medical record was an obviously
    249 challenging example.
    250 
    251  At the close of the project, the GEHR partners could see the potential
    252 requirement for a public domain foundation to take forward their work. It was
    253 resolved to leave this issue open until some future stage, when the rationale
    254 for how this might operate had become more apparent.
    255 
    256  In summer 1995, the St Bartholomew's team moved with David Ingram, across
    257 London to UCL, when he was recruited to establish the new UCL Centre for Health
    258 Informatics and Multi-Professional Education (CHIME). Sam Heard and Tom Beale,
    259 now both based in Australia, have remained in close touch with the UCL team have
    260 continued regular visits to and fro. David Ingram has made academic visits to
    261 Australian Universities and as participant and keynote lecturer at two national
    262 Health Informatics Conferences, in Melbourne and Hobart.
    263 
    264  The GEHR approach remained alive in CHIME and its collaborating centres.
    265 Successive research results and implementations of record servers based on this
    266 are now making key contributions within the newly launched UK ''Information
    267 for Health'' Strategy. The GEHR approach was taken forward on a broader
    268 front, beyond the UK and Europe, especially by Sam Heard, Tom Beale and Peter
    269 Schloeffel and their colleagues in Australia.
    270 
    271  Reactions against GEHR: When the GEHR project came to an end, a reaction set
    272 in against it. The first GEHR Object Model became a focus of concerted
    273 opposition within some groups working in the domain in the UK and within CEN
    274 standards bodies. The questioning of the assumptions and approaches of existing
    275 products and approaches had been inevitable, but did not make GEHR popular,
    276 although its approach always sought to be constructive. It was unfortunate that
    277 the work of GEHR came, apparently, to be perceived as a threat to other
    278 interests and ambitions, evidenced by the manner in which it was opposed, early,
    279 tentative and incomplete as its results were.
    280 
    281  One important area of controversy arose in the confrontation between the
    282 record architecture paradigm and the paradigm of healthcare messages between
    283 systems, as typified by the EDIFACT initiatives and the HL7 consortium of
    284 suppliers, for interoperability between their products. The advocacy by GEHR and
    285 its successors of a record architecture to anchor information standards and
    286 services and their contexts within records was controversial and was, and still
    287 is, opposed. It did not help that most available clinical systems claiming to be
    288 clinical records systems did not meet the commonly agreed clinical understanding
    289 of what a clinical record is and the requirements it must meet.
    290 
    291  It is interesting that, in facing the technical and clinical challenges of
    292 implementing real clinical record systems within real health care contexts,
    293 health care and international standards bodies have only recently begun to
    294 explore rigorously what the requirements for such systems are and how their
    295 performance may be assessed against these. This is inexorably drawing the issues
    296 raised by the GEHR project, over ten years ago, back into play. The need to
    297 focus efforts in this way, as we enter the post Human Genome Project era, is, if
    298 anything, more crucial today.
    299 
    300  The objective of reverse engineering a health record information model from
    301 the legacy of an evolving messaging semantics, as typified by successive HL7
    302 versions, is difficult! In GEHR, such messages were seen as being derivable
    303 straightforwardly from the GEHR object model underlying the record formalism, in
    304 a clinically comprehensive and ethically acceptable manner. However, without an
    305 accessible public domain implementation of such a record architecture, it is
    306 quite understandable that existing suppliers of systems, struggling to evolve
    307 their products to meet the requirements of patient centred and clinically more
    308 accountable care, view such an initiative with some concern.
    309 
    310  Synapses: In 1995, David Ingram and the UCL team joined forces with Professor
    311 Jane Grimson of Trinity College Dublin in a new consortium aiming to propose a
    312 project to explore the legacy systems integration issues in progressing towards
    313 a federated electronic healthcare record. From the other GEHR participants,
    314 Daniel Mart of The Association of Doctors and Dentists of Luxembourg and Jo
    315 Milan of the Royal Marsden also joined this larger consortium of EU teams and
    316 industries, which included Siemens and Hiscom as major suppliers.
    317 
    318  Reflecting on the results of the GEHR Project, and looking at the new
    319 challenges of implementation of a federated approach, Jo Milan and David Ingram
    320 developed and wrote the methodological section of the Synapses Project Proposal
    321 that proposed a new paradigm for implementation of the record, which divided the
    322 formal description of the architecture into a high level structural model
    323 (Synom) and a model of clinical content (Synod), implemented through a clinical
    324 object dictionary.
    325 
    326  The Synapses project from 1995-98 succeeded in implementing several pilot
    327 record servers, built according to the Synom/Synod principle, across Europe (see
    328 CHIME and TCD web sites). The user requirements and information modelling
    329 workpackage was led by Dipak Kalra, and the implementation workpackage by David
    330 Ingram.
    331 
    332  Controversy still dogged the formal methods to be adopted and the principles
    333 and detail of the Synom and Synod were difficult and contentious matters within
    334 the Synapses consortium. Legacy environments in the demonstrator sites inhibited
    335 freedom to design ''de novo'' and reconciling those who wished to restrict
    336 implementation to the concepts of the earlier CEN pre-standard model and those
    337 who favoured further evolution, utilising the later results of GEHR and moving
    338 forward from there was also difficult. Synapses proved another burning crucible
    339 of endeavour, where staying power was challenged to the full!
    340 
    341  Synapses reached a compromise to extend the fundamental concepts of Env
    342 12265, with new aggregation structures to accommodate the requirements analysed
    343 and provided for within the GEHR Object Model (GOM) in the later stages of the
    344 GEHR project. The low-level Synom/Synod approach, as further developed by the
    345 UCL team, proved a robust foundation of implementation, avoiding some of the
    346 implementation difficulties associated with the fine granularity of the single
    347 level architecture of the original GOM. Progress at UCL with the concept of the
    348 object dictionary and tools to support it was encouraging.
    349 
    350  
    351 == Australia awakens the world electronic health care records
    352 community to the approach of GEHR == #dsy20-OE_australia
    353  Aware of the anti-GEHR sentiments in the UK and in CEN in Europe, Sam Heard
    354 and Tom Beale joined forces again in Australia, in 1996, to work together to
    355 refine the GEHR Object Model through implementation. This also led to a two
    356 level modelling approach - the health record architecture itself and the
    357 clinical models or standards required for automatic processing of information.
    358 The latter has become known as the GEHR archetype system.
    359 
    360  The SynOD and Archetype approachesweresubsequently discovered to be largely
    361 the same and have been progressively haremonised within a common ''open''EHR architecture. Peter Schloeffel had met David Ingram with
    362 Michael Britton, at UCL, in 1996 Michael and David Newble obtained British
    363 Council support to invite him to contribute key lectures at a symposium in
    364 Adelaide in August 1998, with Sam Heard, and there he met Peter again, as a
    365 local systems supplier.
    366 
    367  Following this event, Peter subsequently met Stan Sheppard and started to
    368 develop a business partnership. In these partnerships began the renewed
    369 Australian focus on developing the results of the original GEHR project which
    370 has had a considerable influence, internationally in the ISO, HL7, CEN and, more
    371 importantly in many Net discussion groups and in meetings about the EHCR in the
    372 USA. In Australia, the team achieved considerable success in moving to the
    373 centre of the national development programme for the EHCR. They worked with
    374 systems R&D teams at DSTC on implementation of a GEHR server or kernel,
    375 based on the archetype model for content within a higher level information model
    376 close to the higher levels of the original GEHR object model.
    377 
    378  
     138  The GEHR Project came to an end at the end of 1994 and two proposals to
     139extend its work plan were not immediately successful. One of these was for a Support Action to maintain co-ordination in health record architecture work and the other for more extensive field trials of the architecture. GEHR had delivered a significant, but by no means completed, advance in the application of object modelling approaches to the electronic health care record (EHCR) and its evaluation against comprehensive clinical and ethical requirements as well as implementation experience. It was clear to the team that this first stage GEHR architecture, the first GEHR Object Model, would require continuing refinement in the light of implementation experience.
     140
     141  The project had, throughout, grappled with the issues of relational versus
     142object database representations of clinical data. At the stage of evolution of database technology then pertaining, these concepts were in a state of considerable flux. Aspects of functionality were highly desirable, but they were hard to combine. Both camps argued their case, responding to the emerging needs of complex applications domains, of which the medical record was an obviously challenging example.
     143
     144  At the close of the project, the GEHR partners could see the potential
     145requirement for a public domain foundation to take forward their work. It was resolved to leave this issue open until some future stage, when the rationale for how this might operate had become more apparent.
     146
     147  In summer 1995, the St Bartholomew's team moved with David Ingram, across
     148London to UCL, when he was recruited to establish the new UCL Centre for Health Informatics and Multi-Professional Education (CHIME). Sam Heard and Tom Beale, now both based in Australia, have remained in close touch with the UCL team have continued regular visits to and fro. David Ingram has made academic visits to Australian Universities and as participant and keynote lecturer at two national Health Informatics Conferences, in Melbourne and Hobart.
     149
     150  The GEHR approach remained alive in CHIME and its collaborating centres.
     151Successive research results and implementations of record servers based on this are now making key contributions within the newly launched UK ''Information for Health'' Strategy. The GEHR approach was taken forward on a broader front, beyond the UK and Europe, especially by Sam Heard, Tom Beale and Peter Schloeffel and their colleagues in Australia.'''''''
     152
     153  Reactions against GEHR: When the GEHR project came to an end, a reaction set
     154in against it. The first GEHR Object Model became a focus of concerted opposition within some groups working in the domain in the UK and within CEN standards bodies. The questioning of the assumptions and approaches of existing products and approaches had been inevitable, but did not make GEHR popular, although its approach always sought to be constructive. It was unfortunate that the work of GEHR came, apparently, to be perceived as a threat to other interests and ambitions, evidenced by the manner in which it was opposed, early, tentative and incomplete as its results were.
     155
     156  One important area of controversy arose in the confrontation between the
     157record architecture paradigm and the paradigm of healthcare messages between systems, as typified by the EDIFACT initiatives and the HL7 consortium of suppliers, for interoperability between their products. The advocacy by GEHR and its successors of a record architecture to anchor information standards and services and their contexts within records was controversial and was, and still is, opposed. It did not help that most available clinical systems claiming to be clinical records systems did not meet the commonly agreed clinical understanding of what a clinical record is and the requirements it must meet.
     158
     159  It is interesting that, in facing the technical and clinical challenges of
     160implementing real clinical record systems within real health care contexts, health care and international standards bodies have only recently begun to explore rigorously what the requirements for such systems are and how their performance may be assessed against these. This is inexorably drawing the issues raised by the GEHR project, over ten years ago, back into play. The need to focus efforts in this way, as we enter the post Human Genome Project era, is, if anything, more crucial today.
     161
     162  The objective of reverse engineering a health record information model from
     163the legacy of an evolving messaging semantics, as typified by successive HL7 versions, is difficult! In GEHR, such messages were seen as being derivable straightforwardly from the GEHR object model underlying the record formalism, in a clinically comprehensive and ethically acceptable manner. However, without an accessible public domain implementation of such a record architecture, it is quite understandable that existing suppliers of systems, struggling to evolve their products to meet the requirements of patient centred and clinically more accountable care, view such an initiative with some concern.
     164
     165  Synapses: In 1995, David Ingram and the UCL team joined forces with Professor
     166Jane Grimson of Trinity College Dublin in a new consortium aiming to propose a project to explore the legacy systems integration issues in progressing towards a federated electronic healthcare record. From the other GEHR participants, Daniel Mart of The Association of Doctors and Dentists of Luxembourg and Jo Milan of the Royal Marsden also joined this larger consortium of EU teams and industries, which included Siemens and Hiscom as major suppliers.
     167
     168  Reflecting on the results of the GEHR Project, and looking at the new
     169challenges of implementation of a federated approach, Jo Milan and David Ingram developed and wrote the methodological section of the Synapses Project Proposal that proposed a new paradigm for implementation of the record, which divided the formal description of the architecture into a high level structural model (Synom) and a model of clinical content (Synod), implemented through a clinical object dictionary.
     170
     171  The Synapses project from 1995-98 succeeded in implementing several pilot
     172record servers, built according to the Synom/Synod principle, across Europe (see CHIME and TCD web sites). The user requirements and information modelling workpackage was led by Dipak Kalra, and the implementation workpackage by David Ingram.
     173
     174  Controversy still dogged the formal methods to be adopted and the principles
     175and detail of the Synom and Synod were difficult and contentious matters within the Synapses consortium. Legacy environments in the demonstrator sites inhibited freedom to design ''de novo'' and reconciling those who wished to restrict implementation to the concepts of the earlier CEN pre-standard model and those who favoured further evolution, utilising the later results of GEHR and moving forward from there was also difficult. Synapses proved another burning crucible of endeavour, where staying power was challenged to the full!
     176
     177  Synapses reached a compromise to extend the fundamental concepts of Env
     17812265, with new aggregation structures to accommodate the requirements analysed and provided for within the GEHR Object Model (GOM) in the later stages of the GEHR project. The low-level Synom/Synod approach, as further developed by the UCL team, proved a robust foundation of implementation, avoiding some of the implementation difficulties associated with the fine granularity of the single level architecture of the original GOM. Progress at UCL with the concept of the object dictionary and tools to support it was encouraging.
     179
     180== Australia awakens the world electronic health care records community to the approach of GEHR == #dsy20-OE_australia
     181  Aware of the anti-GEHR sentiments in the UK and in CEN in Europe, Sam Heard
     182and Tom Beale joined forces again in Australia, in 1996, to work together to refine the GEHR Object Model through implementation. This also led to a two level modelling approach - the health record architecture itself and the clinical models or standards required for automatic processing of information. The latter has become known as the GEHR archetype system.
     183
     184  The SynOD and Archetype approachesweresubsequently discovered to be largely
     185the same and have been progressively haremonised within a common ''open''EHR architecture. Peter Schloeffel had met David Ingram with Michael Britton, at UCL, in 1996 Michael and David Newble obtained British Council support to invite him to contribute key lectures at a symposium in Adelaide in August 1998, with Sam Heard, and there he met Peter again, as a local systems supplier.
     186
     187  Following this event, Peter subsequently met Stan Sheppard and started to
     188develop a business partnership. In these partnerships began the renewed Australian focus on developing the results of the original GEHR project which has had a considerable influence, internationally in the ISO, HL7, CEN and, more importantly in many Net discussion groups and in meetings about the EHCR in the USA. In Australia, the team achieved considerable success in moving to the centre of the national development programme for the EHCR. They worked with systems R&D teams at DSTC on implementation of a GEHR server or kernel, based on the archetype model for content within a higher level information model close to the higher levels of the original GEHR object model.
     189
     190 
     191
    379192== Implementation, Implementation, implementation! == #dsy20-OE_implementation
    380   '''- from GEHR and Synapses to Synex, Medicate and 6-winit in CHIME and
    381 UCL '''
    382 
    383  The behaviour of standards communities in these times, spending much time,
    384 money and energy disputing and seemingly seeking above all else to dominate one
    385 another’s agendas, was scientifically extremely questionable, yet seemed to
    386 brook no questioning. It is not sufficient justification that standards for
    387 health information management are deemed crucially needed, that a crude
    388 consensus and legislative process be adopted for their definition, when the
    389 underpinning empirical foundations for organising and modelling information in
    390 the domain are still in process of evolution through empirical research.
    391 Monolithic modelling of healthcare information domains is clearly a fascinating
    392 exercise but, if devoid of empirical and practical context, clear domain
    393 definitions and verifiable objectives, has little if any meaning. Such models
    394 are in any case inevitably non-identifiable or non-unique formulations,
    395 incapable of purposive application within implementable and clinically viable
    396 systems.
    397 
    398  This may all sound rather obvious but a review of much work from many bodies,
    399 especially governmental and inter-governmental bodies over recent decades, will
    400 show that information standardisation has frequently proceeded devoid of
    401 empirical testing and validation and that many costly failures have resulted
    402 therefrom. This matters to patients and has been disastrous in the quest to use
    403 information technology to support cost-effective health care services!
    404 
    405  Given this flow of events, the UCL team concluded that three immediate things
    406 now mattered more than any other. These were implementation, implementation and
    407 implementation!
    408 
    409  The team thus put its head down to get on with developing its new research,
    410 alongside new graduate and educational programmes. In developing its ideas, post
    411 GEHR, it started a prolonged period of intensive software implementation and
    412 evaluation of the record architecture and object dictionary, led by Dipak Kalra
    413 with Tony Austin, David Lloyd and Alexis O’Connor, and Vivienne Griffith. This
    414 work was conducted throughout the EU Synapses project, then in the EU Synex,
    415 Medicate and now the 6-WINIT and CLEF projects, and with David Patterson as an
    416 invaluable clinical sponsor as head of the Whittington Hospial Cardiology
    417 services. In these projects, the underlying concepts evolved beyond GEHR were
    418 widely tested for implementation in cardiology, cancer and respiratory medicine
    419 domains, in hospital, telecare and now in mobile systems contexts. In the Synex
    420 Project a wider grouping of record architecture, terminology (GALEN) and
    421 protocols (Proforma) formalisms were drawn into the Consortium. This six-year
    422 trial by implementation rather than trial by standardisation committee has borne
    423 much fruit in implemented practical clinical exemplars of the record
    424 architecture and object dictionary at work.
    425 
    426  David Lloyd, co-ordinating the EHCR-SupA project, put a great deal of effort
    427 into continuing inputs to the next CEN team established to take record
    428 architecture forward and also into a concerted action within the Framework
    429 Programme, to look at synthesis among the different modelling approaches to the
    430 EHCR.
    431 
    432  
    433 ==  ''open''EHR == #dsy20-OE_openehr
    434  In 1998, at the conclusion of the Synapses Project, David Ingram circulated a
    435 paper about the need for a clinically focused Foundation to own the content
    436 domain around standards for clinical information management. It attracted
    437 interested comment and it was left with UCL to take it forward. In late 1999, a
    438 joint meeting of the Australian and UCL teams, in London, considered the forward
    439 pathway for the work of their two teams, in this context. They feared that some
    440 divergencies in their respective implementation pathway, architecture and
    441 content models were emerging and wished to work towards convergence again, if
    442 possible. The meeting decided to work to establish an open source foundation to
    443 take forward harmonisation in the field, from patient and clinical perspectives.
    444 The name ''open''EHR, proposed by David Ingram, was adopted. Membership, it
    445 was felt, should be open to all signing up to a set of principles guiding the
    446 Foundation’s activities, which emphasised constructive, inclusive and
    447 empirically based evolution of rigorously defined software and systems,
    448 organised around the two level strategy of the UCL object dictionary and the
    449 Australian archetype methodology. It was agreed to allow implementation to
    450 proceed in parallel over a further period of about a year before meeting to seek
    451 to reconcile a common achievable way forward.
    452 
    453  David Lloyd undertook the task of drawing together the threads from the
    454 meeting and developing an ''open''EHR web site. David Ingram was given a
    455 brief as chairman of the initiative to seek early funding of an umbrella to hold
    456 together the concept of a three-time zone foundation with component groups in
    457 Europe, Australia and the USA. Peter Schloeffel was asked to pursue a role as
    458 ambassador for ''open''EHR, to press ahead with Sam and Tom to establish
    459 the Australian chapter as the first step and to seek to find a USA partner.
    460 
    461  
     193  '''- from GEHR and Synapses to Synex, Medicate and 6-winit in CHIME and'''
     194UCL ''' '''
     195
     196  The behaviour of standards communities in these times, spending much time,
     197money and energy disputing and seemingly seeking above all else to dominate one another’s agendas, was scientifically extremely questionable, yet seemed to brook no questioning. It is not sufficient justification that standards for health information management are deemed crucially needed, that a crude consensus and legislative process be adopted for their definition, when the underpinning empirical foundations for organising and modelling information in the domain are still in process of evolution through empirical research. Monolithic modelling of healthcare information domains is clearly a fascinating exercise but, if devoid of empirical and practical context, clear domain definitions and verifiable objectives, has little if any meaning. Such models are in any case inevitably non-identifiable or non-unique formulations, incapable of purposive application within implementable and clinically viable systems.
     198
     199  This may all sound rather obvious but a review of much work from many bodies,
     200especially governmental and inter-governmental bodies over recent decades, will show that information standardisation has frequently proceeded devoid of empirical testing and validation and that many costly failures have resulted therefrom. This matters to patients and has been disastrous in the quest to use information technology to support cost-effective health care services!
     201
     202  Given this flow of events, the UCL team concluded that three immediate things
     203now mattered more than any other. These were implementation, implementation and implementation!
     204
     205  The team thus put its head down to get on with developing its new research,
     206alongside new graduate and educational programmes. In developing its ideas, post GEHR, it started a prolonged period of intensive software implementation and evaluation of the record architecture and object dictionary, led by Dipak Kalra with Tony Austin, David Lloyd and Alexis O’Connor, and Vivienne Griffith. This work was conducted throughout the EU Synapses project, then in the EU Synex, Medicate and now the 6-WINIT and CLEF projects, and with David Patterson as an invaluable clinical sponsor as head of the Whittington Hospial Cardiology services. In these projects, the underlying concepts evolved beyond GEHR were widely tested for implementation in cardiology, cancer and respiratory medicine domains, in hospital, telecare and now in mobile systems contexts. In the Synex Project a wider grouping of record architecture, terminology (GALEN) and protocols (Proforma) formalisms were drawn into the Consortium. This six-year trial by implementation rather than trial by standardisation committee has borne much fruit in implemented practical clinical exemplars of the record architecture and object dictionary at work.
     207
     208  David Lloyd, co-ordinating the EHCR-SupA project, put a great deal of effort
     209into continuing inputs to the next CEN team established to take record architecture forward and also into a concerted action within the Framework Programme, to look at synthesis among the different modelling approaches to the EHCR.
     210
     211 
     212
     213== ''open''EHR == #dsy20-OE_openehr
     214  In 1998, at the conclusion of the Synapses Project, David Ingram circulated a
     215paper about the need for a clinically focused Foundation to own the content domain around standards for clinical information management. It attracted interested comment and it was left with UCL to take it forward. In late 1999, a joint meeting of the Australian and UCL teams, in London, considered the forward pathway for the work of their two teams, in this context. They feared that some divergencies in their respective implementation pathway, architecture and content models were emerging and wished to work towards convergence again, if possible. The meeting decided to work to establish an open source foundation to take forward harmonisation in the field, from patient and clinical perspectives. The name ''open''EHR, proposed by David Ingram, was adopted. Membership, it was felt, should be open to all signing up to a set of principles guiding the Foundation’s activities, which emphasised constructive, inclusive and empirically based evolution of rigorously defined software and systems, organised around the two level strategy of the UCL object dictionary and the Australian archetype methodology. It was agreed to allow implementation to proceed in parallel over a further period of about a year before meeting to seek to reconcile a common achievable way forward.
     216
     217  David Lloyd undertook the task of drawing together the threads from the
     218meeting and developing an ''open''EHR web site. David Ingram was given a brief as chairman of the initiative to seek early funding of an umbrella to hold together the concept of a three-time zone foundation with component groups in Europe, Australia and the USA. Peter Schloeffel was asked to pursue a role as ambassador for ''open''EHR, to press ahead with Sam and Tom to establish the Australian chapter as the first step and to seek to find a USA partner.
     219
     220 
     221
    462222== First Ideas for the ''open''EHR Foundation == #dsy20-OE_openehr-manifesto
    463  A draft "manifesto" was prepared for discussion with interested parties, as
     223  A draft "manifesto" was prepared for discussion with interested parties, as
    464224follows.
    465225
    466  The ''open''EHR Foundation is an international, on-line community whose
    467 aim is to promote and facilitate progress towards electronic healthcare records
    468 of high quality, to support the needs of patients and clinicians everywhere. It
    469 will publish the theoretical foundations and evaluations of its work in the
    470 public domain and make available relevant EHCR source programs and datasets
    471 under an !OpenSource license. This continues the tradition of the GEHR project,
    472 from which ''open''EHR has emerged, of placing results in the public
    473 domain. We recognise that there is a certain initiative fatigue in the field and
    474 we would not propose a new initiative were we not sure that something radically
    475 different is now essential. So many systems describe themselves as electronic
    476 healthcare records and yet share little common concept of what such an entity is
    477 and what it is for.
    478 
    479  The research and development in this field has followed a chaotic and
    480 tortuous evolution, influenced inevitably by commercial, political and academic
    481 pressures and rivalries and also by severe inertia because of the need to
    482 continue to accommodate legacy systems. Confused and confusing arguments have
    483 persisted about esoteric models of ill-defined clinical terminology, processes
    484 and communications. Continuing reinvention of wheels at these levels of
    485 abstraction has inhibited progress. There is an urgent need for more empirical
    486 study of the implementation and comparative evaluation of a diverse range of
    487 approaches to the provision of high quality electronic healthcare records,
    488 informed by and informing international consensus about the requirements to be
    489 met. It is especially encouraging that the ISO has now adopted work which will
    490 elevate formally defined clinical requirements to the highest level in the
    491 standards process for electronic healthcare records.
     226  The ''open''EHR Foundation is an international, on-line community whose
     227aim is to promote and facilitate progress towards electronic healthcare records of high quality, to support the needs of patients and clinicians everywhere. It will publish the theoretical foundations and evaluations of its work in the public domain and make available relevant EHCR source programs and datasets under an !OpenSource license. This continues the tradition of the GEHR project, from which ''open''EHR has emerged, of placing results in the public domain. We recognise that there is a certain initiative fatigue in the field and we would not propose a new initiative were we not sure that something radically different is now essential. So many systems describe themselves as electronic healthcare records and yet share little common concept of what such an entity is and what it is for.
     228
     229  The research and development in this field has followed a chaotic and
     230tortuous evolution, influenced inevitably by commercial, political and academic pressures and rivalries and also by severe inertia because of the need to continue to accommodate legacy systems. Confused and confusing arguments have persisted about esoteric models of ill-defined clinical terminology, processes and communications. Continuing reinvention of wheels at these levels of abstraction has inhibited progress. There is an urgent need for more empirical study of the implementation and comparative evaluation of a diverse range of approaches to the provision of high quality electronic healthcare records, informed by and informing international consensus about the requirements to be met. It is especially encouraging that the ISO has now adopted work which will elevate formally defined clinical requirements to the highest level in the standards process for electronic healthcare records.
    492231
    493232  ''open''EHR directs its efforts towards:
    494 
    495  
     233 
     234
    496235 * well-formulated clinical requirements, offered as a contribution towards
     236
    497237international consensus
     238
    498239 * rigorous development, implemention and evaluation methodology for systems
    499240 * common information model for the record, where clinical requirements dictate
    500 that this is necessary and where the relationship between model and requirements
    501 is made explicit
     241
     242that this is necessary and where the relationship between model and requirements is made explicit
     243
    502244 * diversity of information models and implementations, where these will enrich
    503 experience of a variety of approaches and systems and thereby promote the
    504 evolution towards high quality and cost-effective EHR solutions offered
     245
     246experience of a variety of approaches and systems and thereby promote the evolution towards high quality and cost-effective EHR solutions offered
     247
    505248 * empirical evaluation of systems performance against clinical requirements
    506249
    507250  ''open''EHR recognises that achieving its aims is extremely complex on
    508 many levels and certainly beyond the co-ordination powers of any one group. It
    509 believes that progress can be enhanced by interested groups coming together to
    510 promote and facilitate implementation and evaluation of systems using a
    511 co-ordinated methodology, and working openly within the public domain. It has
    512 not proved possible for the power of commercial and political organisations to
    513 devise and mandate solutions which demonstrate that they provide good quality
    514 EHCRs. An open developmental process is proposed in an effort to break this
    515 damaging impasse. ''open''EHR has started a process of bringing together
    516 like-minded conceptual thinkers and systems implementers, prepared to offer
    517 their work to the EHR community in this way.
    518 
    519  In pursuing its aims, ''open''EHR will:
    520 
    521  
     251many levels and certainly beyond the co-ordination powers of any one group. It believes that progress can be enhanced by interested groups coming together to promote and facilitate implementation and evaluation of systems using a co-ordinated methodology, and working openly within the public domain. It has not proved possible for the power of commercial and political organisations to devise and mandate solutions which demonstrate that they provide good quality EHCRs. An open developmental process is proposed in an effort to break this damaging impasse. ''open''EHR has started a process of bringing together like-minded conceptual thinkers and systems implementers, prepared to offer their work to the EHR community in this way.
     252
     253  In pursuing its aims, ''open''EHR will:
     254 
     255
    522256 * be open to all who sign up to its objectives and methods of work
    523257 * have free individual membership
    524258 * charge membership fees for official bodies, on a not-for-profit basis
    525259 * help to define and support a common process of specification of clinical
    526 requirements, specification and implementation of systems and evaluation of the
    527 electronic healthcare records provided (Note: this will be termed the GEHR (Good
    528 Electronic Healthcare Record) methodology, since it will rest initially very
    529 heavily on the methods set out and followed for the first time in the GEHR
    530 project from 1989. This 7-country R&D project developed concepts, object
    531 model and early prototypes and tools for a common European Health Record
    532 Architecture and has been drawn on in subsequent partnerships and projects
    533 across the world. The work was placed by the partners in the public domain and
    534 fed into and adopted by standards bodies)
     260
     261requirements, specification and implementation of systems and evaluation of the electronic healthcare records provided (Note: this will be termed the GEHR (Good Electronic Healthcare Record) methodology, since it will rest initially very heavily on the methods set out and followed for the first time in the GEHR project from 1989. This 7-country R&D project developed concepts, object model and early prototypes and tools for a common European Health Record Architecture and has been drawn on in subsequent partnerships and projects across the world. The work was placed by the partners in the public domain and fed into and adopted by standards bodies)
     262
    535263 * publish the work of projects and systems conducted within the ''open''EHR community and adopting the GEHR methodology.
    536264 * offer the sources of such GEHR-based systems, in which IPR will be assigned
    537 to ''open''EHR, under an open-source license within the community.
    538 Individuals or companies assigning IPR to the Foundation may where necessary and
    539 appropriate be remunerated under contract or through license fees.
     265
     266to ''open''EHR, under an open-source license within the community. Individuals or companies assigning IPR to the Foundation may where necessary and appropriate be remunerated under contract or through license fees.
     267
    540268 * offer all its work openly in a spirit of a public enterprise, believing that
    541 this is the best and perhaps only way that appropriate high quality and
    542 interoperable systems are likely to emerge, worldwide.
     269
     270this is the best and perhaps only way that appropriate high quality and interoperable systems are likely to emerge, worldwide.
     271
    543272 * seek constructive relationships with groups and communities focusing on
    544 other aspects of clinical information management such as messages, terminology,
    545 knowledge-management and decision-support.
     273
     274other aspects of clinical information management such as messages, terminology, knowledge-management and decision-support.
    546275
    547276  '''''open''EHR will not:'''
    548 
    549  
     277 
     278
    550279 * campaign against or obstruct others working on electronic healthcare
    551 records. On the contrary, it will welcome and endorse their success in meeting
    552 the aims and objectives of ''open''EHR.
    553 
    554  
     280
     281records. On the contrary, it will welcome and endorse their success in meeting the aims and objectives of ''open''EHR.
     282
     283 
     284
    555285== Whehr now? == #dsy20-OE_whehr
    556  Until implementations have been conclusively demonstrated and a pathway of
    557 development of the Foundation is clear, no-one will listen very much or take
    558 risks in what ''open''EHR is advocating - that is to start basing national
    559 strategies on the approach we are advocating. Governments in every country are
    560 receiving such contradictory advice from people who say either that HL7 already
    561 solves everything or that EHCRs are easy/too difficult and don’t need/cannot
    562 have a common approach to the record architecture!
    563 
    564  A presentation was made to The Provost of UCL and he enthusiastically gave
    565 his support to UCL providing co-ordination of ''open''EHR, through its team
    566 in CHIME.
    567 
    568  This presentation was also introduced to The Wellcome Trust, NHS Executive
     286  Until implementations have been conclusively demonstrated and a pathway of
     287development of the Foundation is clear, no-one will listen very much or take risks in what ''open''EHR is advocating - that is to start basing national strategies on the approach we are advocating. Governments in every country are receiving such contradictory advice from people who say either that HL7 already solves everything or that EHCRs are easy/too difficult and don’t need/cannot have a common approach to the record architecture!
     288
     289  A presentation was made to The Provost of UCL and he enthusiastically gave
     290his support to UCL providing co-ordination of ''open''EHR, through its team in CHIME.
     291
     292  This presentation was also introduced to The Wellcome Trust, NHS Executive
    569293and to the UK NHS Information Authority and Policy Unit.
    570294
    571  Following the UK CSR2000 public spending review, in which David Ingram
    572 participated on the national research councils’ informatics committee,
    573 substantial investment is planned in the UK and Europe into GRID demonstrator
    574 projects. An opportunity arises to link bio-informatics and health informatics
    575 research and development here. The UCL team linked with Alan Rector in
    576 Manchester, with Don Detmar in Cambridge , and with other colleagues in
    577 Sheffield and Brighton to bid successfully for the CLEF project.
    578 
    579  Through the NHS National Plan, the opportunity arises to take forward
    580 demonstrators for the EHR in e-health incubator projects. Dipak Kalra has
    581 established excellent links with Oracle and the NHS project delivering an EHR
    582 for the national Cardiovascular disease service framework, building on the now
    583 very strong collaborative work at the Whittington Hospital.
    584 
    585  A week long meeting of the embryonic ''open''EHR international
    586 co-ordination group was held in London in February 2001, to review progress. It
    587 was attended by Sam, Tom, Peter, Mary, Dipak, David L and chaired by David I.
    588 
    589  The clinical and technical motivations for the Australian work on GEHR since
    590 1997 and its focus on splitting the original GEHR approach into a two level
    591 architecture, centred on user defined clinical archetypes, was closely studied,
    592 alongside the implementations of the UCL ''open''EHR server incorporating
    593 the two level object model and object dictionary concept, evolved by UCL through
    594 its post GEHR projects. These systems are now seen, in the light of
    595 implementation experience of both teams over the year, to have been largely
    596 identical. UCL, now freed from the constraints of working within the compromises
    597 of Synapses and Synex in Europe, has reverted to its earlier GEHR approaches, to
    598 deliver clinical prototypes of its own EHCR record server, which is now termed
    599 an ''open''EHR server. This has been adopted, with Oracle Corporation as
    600 the basis of middleware for the South West Region of the NHS ERDIP project on
    601 electronic records for cardiovascualr disease.
    602 
    603  Now that the outcomes of the two streams of work are drawing together again
    604 in renewed collaboration, the differences appear small and the benefits of
    605 aligning them completely are compelling. At the meeting, the Australian and UCL
    606 teams worked intensively to define a convergence pathway for their work, within
    607 the emerging ''open''EHR Foundation.
    608 
    609  In the mean time, the Australian team has succeeded wonderfully well in
    610 creating the Australia and Far East ''open''EHR Foundation as a pilot
    611 initiative towards the vision of three such Foundations in Australia, Europe and
    612 the USA.
    613 
    614  We need to focus on these opportunities for cross-governmental funding for ''open''EHR, perhaps splitting the main open source and content
    615 standardisation roles of the foundation from a trading arm, owned by the
    616 Foundation, to develop revenue streams to support the goals of the Foundation.
    617 
    618  At the same time, we have to remain firmly focused on our continuing pathway
    619 of keeping our teams together, expanding our partnerships and delivering the
    620 results needed to win the day!
     295  Following the UK CSR2000 public spending review, in which David Ingram
     296participated on the national research councils’ informatics committee, substantial investment is planned in the UK and Europe into GRID demonstrator projects. An opportunity arises to link bio-informatics and health informatics research and development here. The UCL team linked with Alan Rector in Manchester, with Don Detmar in Cambridge , and with other colleagues in Sheffield and Brighton to bid successfully for the CLEF project.
     297
     298  Through the NHS National Plan, the opportunity arises to take forward
     299demonstrators for the EHR in e-health incubator projects. Dipak Kalra has established excellent links with Oracle and the NHS project delivering an EHR for the national Cardiovascular disease service framework, building on the now very strong collaborative work at the Whittington Hospital.
     300
     301  A week long meeting of the embryonic ''open''EHR international
     302co-ordination group was held in London in February 2001, to review progress. It was attended by Sam, Tom, Peter, Mary, Dipak, David L and chaired by David I.
     303
     304  The clinical and technical motivations for the Australian work on GEHR since
     3051997 and its focus on splitting the original GEHR approach into a two level architecture, centred on user defined clinical archetypes, was closely studied, alongside the implementations of the UCL ''open''EHR server incorporating the two level object model and object dictionary concept, evolved by UCL through its post GEHR projects. These systems are now seen, in the light of implementation experience of both teams over the year, to have been largely identical. UCL, now freed from the constraints of working within the compromises of Synapses and Synex in Europe, has reverted to its earlier GEHR approaches, to deliver clinical prototypes of its own EHCR record server, which is now termed an ''open''EHR server. This has been adopted, with Oracle Corporation as the basis of middleware for the South West Region of the NHS ERDIP project on electronic records for cardiovascualr disease.
     306
     307  Now that the outcomes of the two streams of work are drawing together again
     308in renewed collaboration, the differences appear small and the benefits of aligning them completely are compelling. At the meeting, the Australian and UCL teams worked intensively to define a convergence pathway for their work, within the emerging ''open''EHR Foundation.
     309
     310  In the mean time, the Australian team has succeeded wonderfully well in
     311creating the Australia and Far East ''open''EHR Foundation as a pilot initiative towards the vision of three such Foundations in Australia, Europe and the USA.
     312
     313  We need to focus on these opportunities for cross-governmental funding for ''open''EHR, perhaps splitting the main open source and content
     314standardisation roles of the foundation from a trading arm, owned by the Foundation, to develop revenue streams to support the goals of the Foundation.
     315
     316  At the same time, we have to remain firmly focused on our continuing pathway
     317of keeping our teams together, expanding our partnerships and delivering the results needed to win the day!