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Buying openEHR systems & services�Example RFI & procurement strategies from Sweden (seven regions) and Karolinska University Hospital.

Presented 18th November 2023 at the conference “Unleashing openEHR’s Potential”

Burgers’ Zoo, Arnhem, Netherlands

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by Erik Sundvall, PhD, MSc - Information Architect @Karolinska University Hospital.�Associated researcher @ Karolinska Insitutet. Senior adjunct lecturer @ Linköping University

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Scaling things. Sustainability?�What limits adoption/use?

A researcher journey

  • Patient overviews �(need standardisation of data structure and terminology use - to be possible at all & to be adopted at scale)
  • Scaling storage solutions �(avoid DBA manual indexing/reinterpretation as a limiting factor)
  • Scaling learning/knowledge
  • Scaling local ecosystem beyond one vendor �– openEHR RESTful vendor neutral app ecosystem needs APIs (2010, before FHIR)
  • Why not used? Not bought! �Research --> Healthcare provider?
    • Spread/share knowledge
    • Scaling procurement. Stop buying yesterday’s systems! Push the market/ecosystem in sustainable direction

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Different…�INTEGRATION STRATEGIES …enable different procurement strategies

  • Core system strategy
  • Mapping/conversion-based strategy
  • Shared, model-driven strategy ☺

Karolinska Institutet – A medical university

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16 December 2021

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Agree where?

Karolinska Institutet – A medical university

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16 December 2021

Data transfer�(HL7 FHIR etc.)

Data capture�(openEHR etc)

Data capture�(openEHR etc)

See presentation Introduction to openEHR, part 1: What & Why” by Silje & Erik at Vitalis/MIE2023 https://youtu.be/KgXVsIsr_Ts?feature=shared&t=774

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What can conversion/reinterpretaion solve?

Karolinska Institutet – A medical university

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16 December 2021

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Reinterpretation problems, Type I, II & III

Example

System A

System B

Type I�A <-- --> B �Can be done with algoritm/program

Birth weight: 3300g�Date: 1954-03-13

Body weight: 3,3 kg�TImepoint: 13 Mar 1954

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Type II

A --> B�Semantic loss and distortion �due to reinterpretations.

Hard, dangerous or impossible with algorithm/program…

…but often done manually �by medically skilled staff�over and over for each transfer…

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B --> A�Missing information�impossible with algorithm/program

Needs surgery at latest: 2018-01-30�Surgery scheduled: 2018-01-20 15:30�Main diagnose*:

323291000119108 | Osteoarthritis of left hip joint|�Other Diagnosis*: �25343008 | Secondary localized osteoarthrosis of pelvic region|�299308007 | Hip joint painful on movement | �Procedure*: �19954002 | Reconstruction of hip with use of methyl methacrylate|�Surgery type**: Lubinus SP II �Preferred anesthesia*: 18946005 | Epidural anesthesia |�NEWS2-score at admission: 1�Anesthesia assessment:�- Fitness: can handle light physical exercise�- Cardiovascular: OK�- Lungs: OK�- Throat: OK�- Gastrointestinal*: 16331000 | Heartburn

Surgery date: 2018-01-20�Diagnosis code: M16.7 | Other secondary coxarthrosis�Surgery code***: NFB49 | Primär total höftledsplastik med cement (Primary total hip arthroplasty with cement)�Anesthesia code***: ZXH50 | Epiduralanestesi (epidural anestesia)�ASA-classification: ASA I = normal healthy patient�

*)  Codes from Snomed CT�**) special kind of hip replacement� with cement�***) Codes from the Swedish ”KVÅ”� terminology

Type III�Reinterpretaion impossible (even for skilled humans) due to aggregations etc.

Number of cigarettes smoked per week: 6-10�…specified in a system with the options:�0, 1-5, 6-10, 11-15, 16-30, 31-50, 51-100, 101+

Number of cigarettes per week: ?�…specified in a system with the options:

0, 1-3, 4-7, 8-14, 15-28, 29-69, 70+

�

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Reinterpretation problems, Type I, II & III

Example

System A

System B

Type I�A <-- --> B �Can be done with algoritm/program

Birth weight: 3300g�Date: 1954-03-13

Body weight: 3,3 kg�TImepoint: 13 Mar 1954

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Type II

A --> B�Semantic loss and distortion �due to reinterpretations.

Hard, dangerous or impossible with algorithm/program…

…but often done manually �by medically skilled staff�over and over for each transfer…

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B --> A�Missing information�impossible with algorithm/program

Needs surgery at latest: 2018-01-30�Surgery scheduled: 2018-01-20 15:30�Main diagnose*:

323291000119108 | Osteoarthritis of left hip joint|�Other Diagnosis*: �25343008 | Secondary localized osteoarthrosis of pelvic region|�299308007 | Hip joint painful on movement | �Procedure*: �19954002 | Reconstruction of hip with use of methyl methacrylate|�Surgery type**: Lubinus SP II �Preferred anesthesia*: 18946005 | Epidural anesthesia |�NEWS2-score at admission: 1�Anesthesia assessment:�- Fitness: can handle light physical exercise�- Cardiovascular: OK�- Lungs: OK�- Throat: OK�- Gastrointestinal*: 16331000 | Heartburn

Surgery date: 2018-01-20�Diagnosis code: M16.7 | Other secondary coxarthrosis�Surgery code***: NFB49 | Primär total höftledsplastik med cement (Primary total hip arthroplasty with cement)�Anesthesia code***: ZXH50 | Epiduralanestesi (epidural anestesia)�ASA-classification: ASA I = normal healthy patient�

*)  Codes from Snomed CT�**) special kind of hip replacement� with cement�***) Codes from the Swedish ”KVÅ”� terminology

Type III�Reinterpretaion impossible (even for skilled humans) due to aggregations etc.

Number of cigarettes smoked per week: 6-10�…specified in a system with the options:�0, 1-5, 6-10, 11-15, 16-30, 31-50, 51-100, 101+

Number of cigarettes per week: ?�…specified in a system with the options:

0, 1-3, 4-7, 8-14, 15-28, 29-69, 70+

�

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Reinterpretation problems, Type I, II & III

Example

System A

System B

Type I�A <-- --> B �Can be done with algoritm/program

Birth weight: 3300g�Date: 1954-03-13

Body weight: 3,3 kg�TImepoint: 13 Mar 1954

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Type II

A --> B�Semantic loss and distortion �due to reinterpretations.

Hard, dangerous or impossible with algorithm/program…

…but often done manually �by medically skilled staff�over and over for each transfer…

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B --> A�Missing information�impossible with algorithm/program

Needs surgery at latest: 2018-01-30�Surgery scheduled: 2018-01-20 15:30�Main diagnose*:

323291000119108 | Osteoarthritis of left hip joint|�Other Diagnosis*: �25343008 | Secondary localized osteoarthrosis of pelvic region|�299308007 | Hip joint painful on movement | �Procedure*: �19954002 | Reconstruction of hip with use of methyl methacrylate|�Surgery type**: Lubinus SP II �Preferred anesthesia*: 18946005 | Epidural anesthesia |�NEWS2-score at admission: 1�Anesthesia assessment:�- Fitness: can handle light physical exercise�- Cardiovascular: OK�- Lungs: OK�- Throat: OK�- Gastrointestinal*: 16331000 | Heartburn

Surgery date: 2018-01-20�Diagnosis code: M16.7 | Other secondary coxarthrosis�Surgery code***: NFB49 | Primär total höftledsplastik med cement (Primary total hip arthroplasty with cement)�Anesthesia code***: ZXH50 | Epiduralanestesi (epidural anestesia)�ASA-classification: ASA I = normal healthy patient�

*)  Codes from Snomed CT�**) special kind of hip replacement� with cement�***) Codes from the Swedish ”KVÅ”� terminology

Type III�Reinterpretaion impossible (even for skilled humans) due to aggregations etc.

Number of cigarettes smoked per week: 6-10�…specified in a system with the options:�0, 1-5, 6-10, 11-15, 16-30, 31-50, 51-100, 101+

Number of cigarettes per week: ?�…specified in a system with the options:

0, 1-3, 4-7, 8-14, 15-28, 29-69, 70+

�

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Agree on what, where? How wide is the focus of the procurement?

Karolinska Institutet – A medical university

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16 December 2021

Type I can be �solved here

Type II & III must �be solved here�also solves type I

Type II & III must �be solved here�also solves type I

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Agree on what, where?

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Type I can be �solved here

Type II & III must �be solved here�also solves type I

Type II & III must �be solved here�also solves type I

Fax is a common workaround today

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Agree on what, where?

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Type I can be �solved here

Type II & III must �be solved here�also solves type I

Type II & III must �be solved here�also solves type I

Many reinterpretation problems remain even if fax is replaced by PDF sharing…

…but may become less visible

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Different…�INTEGRATION STRATEGIES …enable different procurement strategies

  • Core system strategy
  • Mapping/conversion-based strategy
  • Shared, model-driven strategy ☺

Karolinska Institutet – A medical university

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16 December 2021

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1. Core system strategy

Buy the same system, install the same way at all organizations that will share or exchange information. Pretend “there is no system B”

Consequence: Causes vendor dependency and anti-competitive effects at the level where the strategy is applied. A single system rarely does everything well.

It is a common strategy locally/regionally: Large systems exist, but they are not comprehensive and thus need to be combined with other strategies �… and then the interoperability problems usually reappear!

Example: A region procures large EHR system + encourages municipalities and others within the geographic area to use the same system for the information to be shared.

Stockholm started but cancelled a core system procurement, but now in practice started a �”smaller” core system procurement again.... VGR (Gothenburg etc) and Skåne (Malmö etc) �have bought and are now installing Cerner Millenium as a core system.

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2. Mapping/conversion based strategy

Translate, where possible (only works for ”type 1” differences), from system specific semantics and structures to a standardized exchange format (message format, API, etc.).

Consequences:

  • Reinterpretations increase risk of loss or distortion of information, �Data that is too different may need to be omitted (Sometimes no data may be better than incorrect data…)
  • Can sometimes require health-IT systems to be rebuilt internally to be able to capture and export required shared data in some agreed form (This can be expensive, time/resource consuming, and dependent on vendors’ priorities).

It is a common strategy today in national cross-regional information exchanges.

Examples: HL7 v2, HL7 v3 CDA, HL7 FHIR, certain applications of ISO 13606, Swedish national "service contracts" in the service platform coordinated by SKR/Inera.

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3. Shared model-driven strategy

Handle data (semantics and information structure) the same way �within systems using open standardization of the content.

Consequences:

  • facilitates vendor independence
  • limits selection to products that can internally use the open standardized models, or that can be configured flexibly enough to broadly match the standardized

Used today in the Nordic region in components of several EHR systems (but is rarely a requirement in procurements). Further development is underway at several suppliers, including open-source alternatives

Examples: openEHR, HL7 CIMI and some applications of ISO 13606

Region Stockholm might choose this, Karolinska University Hospital has procured and are setting �up an openEHR based system.��Most Swedish regions use or will use Cambio Cosmic that is piece by piece converting modules to openEHR�(Norwegian DIPS started such a transition several years ago.)

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The three integration strategies combined

Not mutually exclusive and can be combined depending on e.g.

  • Geographical granularity �(international, national, regional and local)
  • Timeframe – gradual changes�(1 year, 5 years, 20 years)

Karolinska Institutet – A medical university

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16 December 2021

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Public Procurement – avoids corruption?�Not simpler (not always cheaper)

The basic procurement principles are: 

  • non-discrimination
  • equal treatment
  • proportionality
  • transparency
  • mutual recognition

They mean that procuring organisations must always remain objective and neutral to the stakeholders that wish to become suppliers, and the entire procurement process must be characterised by transparency and proportionality.

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https://www.upphandlingsmyndigheten.se/en/about-public-procurement/

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Public Procurement – avoids corruption?�Not simpler (not always cheaper)

Too common today:

  • What did others pick (without getting fired)?
  • The procurement (ir)responsible just want to finish the procurement project and go on to new positions/projects… �…but the harder implementation, integration and maintenance work is dumped on others [Stockholm 3rd/4th attempt now…]
  • Pick your favourite and bend the procurement requrements to fit it? [High corruption risk!]

More sustainable:

  • Maintaining long term healthty competition – we want many experienced suppliers to pick from

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Dilemmas - risks to handle/mitigate:

  • Encourage new suppliers

vs � Not become alpha testers of� immature products

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Variants of EU procurement

  • Open procedure�Anyone may submit a full tender. This procedure is used most frequently.
  • Restricted procedure �anyone may ask to participate … but only those who are pre-selected may submit tenders.
  • Competitive negotiated procedure�…anyone may ask to participate, but only those who are pre-selected will be invited to submit initial tenders and to negotiate. (used when negotiations are necessary due to the specific or complicated nature of the purchase)
  • Competitive dialogue�This procedure can be used by a contracting authority with the aim of proposing a method of addressing a need defined by the contracting authority.
  • Innovation partnership�This procedure may be used when there is a need to purchase a good or service that is still unavailable on the market. A number of companies may participate throughout the process.
  • Design contest�This procedure is used to obtain an idea for a design.�
  • Additional tendering techniques … a contracting authority may:
    • sign a framework agreement with one or a number of companies for tenders requiring recurring purchases
    • when using the restricted procedure - authorise the use of the electronic dynamic purchasing system for making recurring purchases
    • decide that to get the best offer, the final choice of the winner will be made through an electronic auction

https://europa.eu/youreurope/business/selling-in-eu/public-contracts/public-tendering-rules/index_en.htm

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Legal variants of EU procurement

  • Open procedure�Anyone may submit a full tender. This procedure is used most frequently.
  • Restricted procedure �anyone may ask to participate … but only those who are pre-selected may submit tenders.
  • Competitive negotiated procedure�…anyone may ask to participate, but only those who are pre-selected will be invited to submit initial tenders and to negotiate. (used when negotiations are necessary due to the specific or complicated nature of the purchase)
  • Competitive dialogue�This procedure can be used by a contracting authority with the aim of proposing a method of addressing a need defined by the contracting authority.
  • Innovation partnership�This procedure may be used when there is a need to purchase a good or service that is still unavailable on the market. A number of companies may participate throughout the process.
  • Design contest�This procedure is used to obtain an idea for a design.�
  • Additional tendering techniques … a contracting authority may:
    • sign a framework agreement with one or a number of companies for tenders requiring recurring purchases
    • when using the restricted procedure - authorise the use of the electronic dynamic purchasing system for making recurring purchases
    • decide that to get the best offer, the final choice of the winner will be made through an electronic auction

https://europa.eu/youreurope/business/selling-in-eu/public-contracts/public-tendering-rules/index_en.htm

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Region Östergötland

openEHR referral 2020

Region Stockholm ”traditional” EHR

K/Region Stockholm openEHR platform procurement 2023-2024

Good for national cooperation?

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Region Östergötland 2020+

  • Pre-procurement presentations
  • Requirement referral – round 1
  • Requirement referral – round 2
  • Internal reorganisation + covid cancelled the �procurement ☹

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All available via

https://discourse.openehr.org/t/swedish-openehr-procurements-rfis/247

including presentations on YouTube

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RFI – Request for information

  • Very low legal risks for all parties…
  • …but still consumes time/resources from all parties
  • Collaborate to save time/resources that could be used for important things!

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Current procurement �3-phases + 3 areas

  1. openEHR-based Software. With subcategories:
    • 1a. Software for storage and management of openEHR-based data (CDR etc)
    • 1b. Software for fine-grained access control
    • 1c. Software for fast development, publication and maintenance of openEHR-based applications
    • 1d. Software Services

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  • Software for openEHR content Creation and Transformation

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  • Consulting Services

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https://discourse.openehr.org/t/karolinska-stockholm-procurement-of-digital-health-platform-cdr-tools-services-consultants/4457

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Collaboration! Cross-regional question-bank based on previous work in Sweden, Germany, Great Britain. �Will be openly published.

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Managing lock-in effects - A telephone analaogy

  1. Telecom operator (Vodaphone, KPN, …)
    • Number portability (keep your old phone number when switching) crucial!
    • Minor capability differences (but sometimes important, like rural coverage)
  2. Operating system (iOS, Android, …)
    • Not as standardised as GSM/3G/4G/5G
  3. Important applications
    • Things with very standardised content, like mail clients, can be switched
    • App versions for each operating system can be made
      • By others, e.g. for commercial apps like Spotify, LinkedIn, …
      • By yourself for ”homegrown” apps
      • By you and others in collaboration (e.g. open source apps)

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  1. openEHR CDR (used via standard APIs) …and having control of your own template- and archetype usage
  2. Form/Low-code tools, integration tools, portals etc*
    • Very limited openEHR standardisation for this now, but SMART on openEHR (draft) and some simplified integration formats are available
  3. Important applications
    • App versions or components for each vendor specific portal/framework can be made
      • By others
      • By yourself for ”homegrown” apps
      • By you and others in collaboration (e.g. open source apps)

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*) Freestanding apps using the CDR via APIs can skip using tools and some parts of portals/frameworks (#2 above)

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The healthcare professionals and units are now asking for well structured information! (No longer asking just for ”some useful IT-system”)

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Questions? Discussion!

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