Changes between Initial Version and Version 1 of The Origins of openEHR

Timestamp:

May 18, 2008, 2:29:01 PM (16 years ago)

Author:

KOBAYASHI, Shinji

Comment:

--

The Origins of openEHR

@@ +1 @@
+= The Origins of openEHR = #dsy20-OE
+ 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_intro Introduction] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr The Good European Health Record (GEHR) Project Proposal] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr-participants Participants in the GEHR Project] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_gehr-accomplishments The Accomplishments of the GEHR Project] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_centc251 The Interface between the GEHR Project and Technical
+Committee TC/251-Medical Informatics of CEN] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_synapses From GEHR to Synapses in Europe] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_australia Australia awakens the world electronic health care
+records community to the approach of GEHR] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_implementation Implementation, Implementation, implementation! -
+from GEHR and Synapses to Synex, Medicate and 6-winit in CHIME and UCL] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_openehr openEHR] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_openehr-manifesto First Ideas for the openEHR Foundation] 
+ *  [http://www.openehr.org/about/origins.html#dsy20-OE_whehr Whehr now?] 
+
+  ''David Ingram October 2002'' 
+
+ 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.
+
+ 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.
+
+ 
+== Introduction - the AIM Initiative in Europe == #dsy20-OE_intro
+ In 1988, the European Union established the Advanced Informatics in Medicine
+(AIM) initiative, within the wide-ranging Framework Programme for Research and
+Technology Development in Europe.
+
+ The rationale for the Framework Programme was:
+
+ 
+   * To strengthen the economic and social cohesion of the Community
+   * To offer obvious benefits through the collaboration of several States
+   * To apply significant and complementary results across the whole Community 
+   * To contribute to a common market and to scientific and technical unification 
+
+ It succeeded in catalysing a wave of new partnerships across all sectors of
+the European economy.
+
+ In relation to health, the Framework Programme objectives set out in 1988
+were:
+
+ 
+   * To unify European activities by providing the means for efficient
+communication of medical records and knowledge so that these may be understood
+and compatible, thereby permitting the integration of health information systems 
+   * To strengthen competitiveness by advancing the technical basis of products
+and services and commercialising European inventiveness in all scales of
+enterprise
+   * To improve the quality of life through improving diagnosis and treatment,
+increasing public awareness and knowledge of health care and widening access to
+improved services
+
+ Thus, from the earliest stages of the Programme, the harmonisation of
+electronic health care records was seen as of the highest strategic importance
+for health care development in Europe.
+
+ Under the outstanding leadership of Dr Niels Rossing, the AIM Programme was
+developed in key phases, as follows:
+
+ 
+   *  '''1988 - 90''' Exploratory phase, 20 million ECU, 43 projects 
+   *  '''1990 - 94''' 110 million ECU, 38 projects; 12 concerted
+actions (eg. Medirec)
+   *  '''1994 - 98''' 135 million ECU, ~60 projects
+
+ The first major Call for Proposals under the AIM Workplan was issued in 1989.
+A 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.
+
+ 
+== The Good European Health Record (GEHR) Project Proposal == #dsy20-OE_gehr
+ A Consortium was drawn together by Dr Alain Maskens and Dr Sam Heard to bid
+to 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.
+
+ The Consortium comprised seven professional, industrial and academic
+partners: 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.
+
+ Professor David Ingram, Professor of Medical Informatics at St Bartholomew’s
+Medical 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.
+
+ The project proposal was put together in three months in early 1991 and was
+given 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.
+
+ 
+== Participants in the GEHR Project == #dsy20-OE_gehr-participants
+ In addition, to David and Sam, of those still closely involved in the
+continuing 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.
+
+ Notable contributions in GEHR were also made by:
+
+ Jeff Geboers, HDMP; Christian Aligne, French Red Cross; Olivier Baille,
+France 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.
+
+ Lesley Southgate, is now President of the Royal College of General
+Practitioners of the UK and Daniel Mart is General Secretary of the Association
+of Doctors and Dentists of Luxembourg.
+
+ 
+== The Accomplishments of the GEHR Project == #dsy20-OE_gehr-accomplishments
+ The work of the GEHR project is well documented in its many widely
+communicated 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.
+
+ Working on the GEHR Project was an absorbing and unforgettable experience. It
+tackled 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.
+
+ Key attributes of the project approach and accomplishment were:
+
+ 
+ 1. Experienced, competent, committed and passionate multi-professional
+teamwork. 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.
+ 1. Development of an original, formal approach to electronic health record
+architecture, 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.
+ 1. An empirical and iterative prototyping approach to the evolution of the
+architecture, emphasising implementation and testing of concepts, practically,
+at each stage.
+ 1. The decision of the partners, in the interests of effective dissemination of
+the work, to publish the project results openly, within the public domain. The
+EU Contract in principle vested IPR for the work with the Consortium.
+
+ Warmly supported as it was by Niels Rossing and the Commission and by its
+Project 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.
+
+ 
+== The Interface between the GEHR Project and Technical Committee
+TC/251-Medical Informatics of CEN == #dsy20-OE_centc251
+ At about the same time that the AIM Programme was initiated, CEN established
+a 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.
+
+ During the course of the GEHR Project, a Project Team was established under
+TC/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.
+
+ GEHR sought to work in a spirit of co-operation. Recognising its deficiencies
+and 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.
+
+ 
+== From GEHR to Synapses in Europe == #dsy20-OE_synapses
+ The GEHR Project came to an end at the end of 1994 and two proposals to
+extend 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.
+
+ The project had, throughout, grappled with the issues of relational versus
+object 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.
+
+ At the close of the project, the GEHR partners could see the potential
+requirement 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.
+
+ In summer 1995, the St Bartholomew's team moved with David Ingram, across
+London 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.
+
+ The GEHR approach remained alive in CHIME and its collaborating centres.
+Successive 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.
+
+ Reactions against GEHR: When the GEHR project came to an end, a reaction set
+in 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.
+
+ One important area of controversy arose in the confrontation between the
+record 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.
+
+ It is interesting that, in facing the technical and clinical challenges of
+implementing 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.
+
+ The objective of reverse engineering a health record information model from
+the 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.
+
+ Synapses: In 1995, David Ingram and the UCL team joined forces with Professor
+Jane 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.
+
+ Reflecting on the results of the GEHR Project, and looking at the new
+challenges 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.
+
+ The Synapses project from 1995-98 succeeded in implementing several pilot
+record 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.
+
+ Controversy still dogged the formal methods to be adopted and the principles
+and 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!
+
+ Synapses reached a compromise to extend the fundamental concepts of Env
+12265, 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.
+
+ 
+== Australia awakens the world electronic health care records
+community to the approach of GEHR == #dsy20-OE_australia
+ Aware of the anti-GEHR sentiments in the UK and in CEN in Europe, Sam Heard
+and 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.
+
+ The SynOD and Archetype approachesweresubsequently discovered to be largely
+the 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.
+
+ Following this event, Peter subsequently met Stan Sheppard and started to
+develop 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.
+
+ 
+== Implementation, Implementation, implementation! == #dsy20-OE_implementation
+  '''- from GEHR and Synapses to Synex, Medicate and 6-winit in CHIME and
+UCL ''' 
+
+ The behaviour of standards communities in these times, spending much time,
+money 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.
+
+ This may all sound rather obvious but a review of much work from many bodies,
+especially 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!
+
+ Given this flow of events, the UCL team concluded that three immediate things
+now mattered more than any other. These were implementation, implementation and
+implementation!
+
+ The team thus put its head down to get on with developing its new research,
+alongside 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.
+
+ David Lloyd, co-ordinating the EHCR-SupA project, put a great deal of effort
+into 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.
+
+ 
+==  ''open''EHR == #dsy20-OE_openehr
+ In 1998, at the conclusion of the Synapses Project, David Ingram circulated a
+paper 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.
+
+ David Lloyd undertook the task of drawing together the threads from the
+meeting 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.
+
+ 
+== First Ideas for the ''open''EHR Foundation == #dsy20-OE_openehr-manifesto
+ A draft "manifesto" was prepared for discussion with interested parties, as
+follows.
+
+ The ''open''EHR Foundation is an international, on-line community whose
+aim 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.
+
+ The research and development in this field has followed a chaotic and
+tortuous 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.
+
+  ''open''EHR directs its efforts towards:
+
+ 
+ * well-formulated clinical requirements, offered as a contribution towards
+international consensus
+ * rigorous development, implemention and evaluation methodology for systems 
+ * common information model for the record, where clinical requirements dictate
+that this is necessary and where the relationship between model and requirements
+is made explicit
+ * diversity of information models and implementations, where these will enrich
+experience of a variety of approaches and systems and thereby promote the
+evolution towards high quality and cost-effective EHR solutions offered
+ * empirical evaluation of systems performance against clinical requirements 
+
+  ''open''EHR recognises that achieving its aims is extremely complex on
+many 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.
+
+ In pursuing its aims, ''open''EHR will:
+
+ 
+ * be open to all who sign up to its objectives and methods of work
+ * have free individual membership
+ * charge membership fees for official bodies, on a not-for-profit basis
+ * help to define and support a common process of specification of clinical
+requirements, 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)
+ * publish the work of projects and systems conducted within the ''open''EHR community and adopting the GEHR methodology.
+ * offer the sources of such GEHR-based systems, in which IPR will be assigned
+to ''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.
+ * offer all its work openly in a spirit of a public enterprise, believing that
+this is the best and perhaps only way that appropriate high quality and
+interoperable systems are likely to emerge, worldwide.
+ * seek constructive relationships with groups and communities focusing on
+other aspects of clinical information management such as messages, terminology,
+knowledge-management and decision-support.
+
+  '''''open''EHR will not:''' 
+
+ 
+ * campaign against or obstruct others working on electronic healthcare
+records. On the contrary, it will welcome and endorse their success in meeting
+the aims and objectives of ''open''EHR.
+
+ 
+== Whehr now? == #dsy20-OE_whehr
+ Until implementations have been conclusively demonstrated and a pathway of
+development 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!
+
+ A presentation was made to The Provost of UCL and he enthusiastically gave
+his support to UCL providing co-ordination of ''open''EHR, through its team
+in CHIME.
+
+ This presentation was also introduced to The Wellcome Trust, NHS Executive
+and to the UK NHS Information Authority and Policy Unit.
+
+ Following the UK CSR2000 public spending review, in which David Ingram
+participated 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.
+
+ Through the NHS National Plan, the opportunity arises to take forward
+demonstrators 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.
+
+ A week long meeting of the embryonic ''open''EHR international
+co-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. 
+
+ The clinical and technical motivations for the Australian work on GEHR since
+1997 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.
+
+ Now that the outcomes of the two streams of work are drawing together again
+in 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.
+
+ In the mean time, the Australian team has succeeded wonderfully well in
+creating 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.
+
+ We need to focus on these opportunities for cross-governmental funding for ''open''EHR, perhaps splitting the main open source and content
+standardisation roles of the foundation from a trading arm, owned by the
+Foundation, to develop revenue streams to support the goals of the Foundation. 
+
+ At the same time, we have to remain firmly focused on our continuing pathway
+of keeping our teams together, expanding our partnerships and delivering the
+results needed to win the day!