There is a methodology that is pragmatically evolving from my experience in openEHR clinical modelling work over the past few years. It has developed in a rather ad hoc way, and totally in response to working directly with clinicians. The simplicity and apparent effectiveness – both for me and the clinicians involved – continues to surprise me each time I use it.
The clinical content specifications for specialised health records and care plans that we are building are being developed with a sequence of expert input and clinical verification:
- Identifying the clinical requirements and business rules in conjunction with a selected initial domain expert group;
- Broader abstract verification of the notion of ‘maximal data set’ for ‘universal use case’ during formal archetype review cycles;
- Contextual validation during template review by ‘on-the-ground’ clinicians; and finally, although to a lesser degree,
- Validation during mapping and migration of legacy data.
With each project I am refining this process. Starting off a project with face-to-face meetings has been a ‘no brainer’ – after all, it takes a while for everyone to understand the get the idea of what we are doing. However after initial workshops, pretty much everything else can be done via web conference, online collaboration via CKM and email.
I find the initial workshops are usually greatly satisfying. Within hours we can be creating two outputs – a mind map that reflects the clinicians evolving conversation about their requirements and, in parallel, an equally agile template of clinical content specifications that can be verified by the clinicians in real time.
The mind map is displayed on a shared screen or via a data projector and acts as a living document, evolving as we talk through the clinical requirements, and identify the complexities, dependencies and relationships of all the components. The final mind map may be surprisingly different to how it started, and at the end of the conversation, the clinicians can verify that what they’ve said if accurately reflected in the mind map. It is an open source tool, so we can also share this around after the workshop for further comments.
Most recently I have begun building a template on the fly during the workshop, using any existing archetypes that are available, and identifying gaps or the need for new archetypes on the mind map as we go. In this way we are actually building the content specification in front of the clinicians as well. They get an understanding of how the abstract discussion will actually shape the resulting EHR content and they can verify it as we gradually pull it together. The domain experts are immediately equipped to answer the question: “Does this specification match what you have been telling me you do in practice?”
This methodology seems to bring the clinicians along with us on the clinical modelling journey, and most are able to understand at least some of the implications of some of our requirements discussions and, in particular, the ‘shape’ of the data that we can collect. It is a process seems to suit the thinking process of many clinicians and the overwhelmingly consistent feedback from recent workshops is that they have all actually enjoyed the experience and want to know what are the next steps for them to be involved. So that’s certainly a winner.
And the funders/jurisdictions are anecdotally confirming for me that they are finding that this approach is supporting higher quality specifications in a much shorter time frame.
For example, at a project kickoff workshop for a new project recently, in two days we:
- developed a series of mind maps capturing a consensus view of the clinical requirements and business processes;
- identified all the archetypes required for the entire project, including those that existed and were ‘fit for use’, those that needed some extension to meet requirements and new archetypes that needed to be created;
- identified sources of information or mind mapped the requirements for each new archetype identified; and
- built 3 templates comprising all of the existing archetypes available from a number of sources – the NEHTA CKM http://dcm.nehta.org.au/ckm/, the openEHR international CKM http://www.openehr.org/ckm/ and local drafts that I had on my own computer. For a number of the new archetypes we also collectively identified source information that would inform or be the basis for the archetype development.
All of this described above took 8 medical practitioners clinicians away from their everyday practice for only 1-2 days, each according to their availability. Yet it provided the foundation for development of a new clinical application.
Then I go home. Next steps are to refine the mind map, modify/update/specialise any archetypes for which we have identified new requirements and build the new ones. And in parallel start the collaborative process through a CKM project to ensure that existing and modified archetypes are ‘fit for (our project’s) purpose’, and to upload and initiate reviews on the new draft archetypes.
All work to progress these archetypes to maturity (ie aiming for clinical consensus) and then validate the templates as ready for handover to the implementers can be done online, asynchronously and at a time convenient to the clinicians work/life balance!
I live over 2000 kilometres away from these clinicians. Yet the combination of web conference and CKM enables us to operate as an ongoing collaborative team. It seems to be working well at the moment… No doubt I’ll continue to learn how to do it better.