Are we there yet?

No, but we are definitely moving in the right direction… Conversations are happening that were uncommon generally, and downright rare in the US only 18 months ago.

I’ve been rabbiting on for some time about the need for a ‘universal health record – an application-independent core of shared and standardised health information into which a variety of ‘enlightened’ applications can ‘plug & play’; thus breaking down the hold of the proprietary and ‘not invented here’ approach of proprietary clinical applications with which we battle most everywhere today.

So it was pleasing to see Margalit Gur-Arie’s recent blog post on Arguments for a Universal Health Record. While I’m not convinced about the reality a single database (see my comments at the end of Margalit’s post), I wholeheartedly endorse the principle of having a single approach to defining the data – this is a very powerful concept, and one that may well become a pivotal enabler to health IT innovation.

In addition, Kevin Coonan has started blogging in recent days – see his Summary of DCMs regarding principles of Detailed Clinical Models (aka DCMs). Now I know that Kevin’s vision for an implementable HL7 DCM is totally different to the openEHR DCMs (=archetypes) that I work with. But we do agree on the basic principles about the basic attributes of these models that he has outlined in his blog post – it is quite a good summary, please read it.

Now these two bloggers are US-based – and this is significant because in the US there has been a huge emphasis on connecting between systems and exchange of document-based health information up until recent times. I view their postings as indicative of a growing trend toward the realisation that standardisation of clinical content is a necessary component for a successful health IT ecosystem in the (medium-longterm, sooner the better) future.

Note that “Detailed Clinical Models”, is the current buzz phrase for any kind of model that might be standardised and shared but is also used very specifically for the HL7 DCMs currently in the midst of an interminable ballot process and the Australian national program’s DCMs, which are actually openEHR archetypes being used as part of their initial specification process. “Detailed Clinical Models” is being used in many conversations rather blithely and with many not fully understanding the issues. On one hand it is positively raising awareness of our need to standardise content and on the other hand, it is confusing the issue as there are so many approaches. See my previous post about DCMs – clarifying the confusion.

It is worth flagging that there has been considerable (and I would also venture to say, rather premature) effort put in by a few to formalise principles for DCMs in the draft ISO13972 standard (Quality Requirements and Methodology for Detailed Clinical Models), currently out for ballot. My problem with this ISO work is that the DCM environment is relatively immature – there are many possible candidates with as many different approaches. It is also important to make clear that having multiple DCMs compliant with generic principles outlined in an ISO standard may mean that the quality of our published silos of “DCM made by formalism X” and “DCM made by formalism Y” models might be of higher quality, but it definitely will not solve our interoperability issues. For that you need a common reference model underpinning the models or, alternatively, a primary reference model with known and validated transformations between clinical model formalisms.

The more recent evolution of the CIMI group is really important in this current environment. It largely shares the principles that Kevin, openEHR and ISO13972 espouse – creation of standardised and shareable clinical content models, bound sensibly to terminology, as the basis for interoperability. These CIMI models will be computable and human readable; they will be based on a single Reference Model (yet to be finalised) and common data types (also yet to be finalised), and utilising the openEHR Archetype Definition Language (ADL) 1.5 as its initial formalism. Transformations of the resulting clinical models to other formalisms will be a priority to make sure that all systems can consume these models in the future. All will be managed in a governed repository and likely under the auspice of some kind of an executive group with expert teams providing practical oversight and management of models and model content.

Watch for news of the CIMI group. It has a influential initial core membership that embraces multiple national eHealth programs and standards bodies, plus all the key players with clinical modelling expertise – bringing all the heavy lifters in the clinical modelling environment into the same room and thrashing out a common approach to semantic interoperability. They met for 3 days recently prior to the HL7 meeting in San Antonio. The intent (and challenge) is to get all of this diverse group singing from the same hymn book! I believe they are about to launch a public website to allow for transparency which has not been easy in these earliest days. I will post it here as soon as it is available.

Maybe the planets are finally aligning…!

I have observed a significant change in the mind sets, conversations and expectations in this clinical modelling environment, over the past 5 years, and especially in the past 18 months. I am encouraged.

And my final 2c worth: in my view, the CIMI experience should inform the ISO DCM draft standard, rather than progressing the draft document based on largely academic assumptions about clinician engagement, repository requirements and model governance – there is so much we still need to learn before we lock it into a standard. I fear that we have put the cart before the horse.

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