Please stop buying yesterday’s �'all inclusive' Health IT-systems!�
HI Conversations
13 Jun 2024 @ Karolinska Institutet (online lunch seminar)
Erik Sundvall,
PhD Medical Informatics, MSc Information Technology / Computer Science
Affiliated researcher @ HIC, LIME, Karolinska Institutet (My role during this seminar, and e.g. when teaching at KI)
Information architect @ Karolinska University Hospital, Region Stockholm (Main job)
Adjunct Senior Lecturer in Medical Informatics @ IMT, Linköping University
Scaling things. Sustainability?�What limits adoption/use?
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My journey as a researcher…
Interoperability basics: Agree where?
Karolinska Institutet – A medical university
3
16 December 2021
See presentation Introduction to openEHR, part 1: What & Why” by Silje & Erik at Vitalis/MIE2023 https://youtu.be/KgXVsIsr_Ts?feature=shared&t=774
EHR = Electronic Health Record
What can conversion/reinterpretaion solve?
Karolinska Institutet – A medical university
4
16 December 2021
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 |
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… 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 |
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… 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+ |
�
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 |
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… 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+ |
�
Agree on what, where? How wide is the focus of the procurement?
Karolinska Institutet – A medical university
8
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
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
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
Different knowledge and assumptions of possible…�standardisation & integration strategies� …enable different procurement strategies
Karolinska Institutet – A medical university
11
Agree on what, where?
Karolinska Institutet – A medical university
12
13 June 2024
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
Data capture�(openEHR etc)
Data transfer�(HL7 FHIR etc.)
Data capture�(openEHR etc)
Standardisation strategies 🡪 procurement assumptions
Source: The Swedish ”StandIN”-projects
Data capture�(openEHR etc)
Data transfer�(HL7 FHIR etc.)
Supplier’s proprietary models
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 but will also use �other systems.
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:
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.
3. Shared model-driven strategy
Handle data (semantics and information structure) the same way �within systems using open standardization of the content.
Consequences:
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
Main example: openEHR
Will Region Stockholm choose this? Karolinska University Hospital already uses an openEHR based system for some use cases and will change openEHR- system supplier soon.��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.)
The three integration strategies combined
Not mutually exclusive and can be combined depending on e.g.
Karolinska Institutet – A medical university
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16 December 2021
Source: Martin Grundberg, Cambio, https://www.cambio.se/
Data capture�(openEHR etc)
Supplier’s proprietary models
Data transfer?�(HL7 FHIR etc.)
Supplier’s proprietary models
+
1. Core system strategy
(”Monolith”/all-inclusive)
2. Mapping/conversion based strategy
3. Shared model-driven strategy
Let’s compare!
Best of Breed 2.0 already partially done for medical images (PACS) etc
Karolinska Institutet – A medical university
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16 December 2021
The way it used to be…
Documents�(Scanned, fax, PDF etc)
Image data�(X-ray, ultrasonic imaging, �MR, potos etc.)
Structured data�(from EHR forms etc)
Illustrations based on images from Better, https://www.better.care/
The way it used to be…
Illustrations based on images from Better, https://www.better.care/
Then we shared image and document storage…
Structured data�(from EHR forms etc)
often still not standardised
and thus stuck in
each different system
Illustrations based on images from Better, https://www.better.care/
A goal
Illustrations based on images from Better, https://www.better.care/
Another reason: Speed! ..by sharing the workload�Information models take time to create - if they are to work well for everyone.
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Library and collaboration portal for archetypes, templates, etc. https://ckm.openehr.org/
Positive side effects:
Reuse!�Share the requirements gathering, analysis and information modeling. (globally!
Archetypes (arketyper)�Reusable documentation patterns
Template (mall)�Specific to a use case.�Combines and configures multiple archetypes.
Form (formulär/gränssnitt)�Autogenerated from template, then manually adjusted
Illustration based on content from:�Rector AL, Rogers J, Taweel A. �Models and inference methods for clinical systems: a principled approach. �Stud Health Technol Inform. 2004;107(Pt 1):79-83
2004
Generally applicable knowledge
Terminology systems. �ICD-10, SNOMED CT etc.
Documentation of what has been done, observed, planned etc. �openEHR, FHIR etc.
Decision support rules, AI etc.
SNOMED CT, an example of a polyhierarchy, where every concept can have multiple ”parents”…
…and many other kinds of relations between concepts
Rector AL, Rogers J, Taweel A. �Models and inference methods for clinical systems: a principled approach. �Stud Health Technol Inform. 2004;107(Pt 1):79-83
How Karolinska University Hospital views standards in the data life cycle. �Any may be useful for a given purpose, depending on the need and relevant constraints.
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“Gartner believes that truly effective and sustainable open architectures will need a capability for vendor-neutral data persistence, such as utilizing a common schema or set of openEHR archetypes and rules for managing structured and unstructured data (for example, a VNA, openEHR or IHE XDS repository in combination with services for trust/consent, ecosystem governance and oversight, and reuse of data and processes for secondary purposes, such as research and population health).
Providing open messaging standards (for example, FHIR, HL7) for data exchange in specific use cases will only go so far in meeting the architectural challenges of digital citizen-centric care delivery”
Healthcare Provider CIOs Need to Rally Their Enterprise Architects Around Citizen-Centric Care Delivery, Gartner 2017
Extended from a slide by Patrik Georgii-Hemming, CMIO at Karolinska University Hospital
OMOP etc.
Most of the proprietary �EHR internal models
All these standards can be combined with
Public Procurement – avoids corruption?�Not simpler (not always cheaper)
The basic procurement principles are:
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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Public Procurement – avoids corruption?�Not simpler (not always cheaper)
Too common today:
More sustainable:
Maintaining long term healthty competition – we want many experienced suppliers to pick from
Dilemmas - risks to handle/mitigate:
Encourage new suppliers� vs �Not become alpha testers of�immature products
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If going for ”Shared model-driven strategy” – are there any good ”open” systems to buy?��(Spoiler: Yes!)
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openEHR is nowadays a well established possibility
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Sources:
2023, seven Swedish regions, RFI (Request for information)
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What did the RFI 2023 participants do next?
Stockholm/Gotland procurement, coordinated by Karolinska, �Three (3) procurement areas
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Catalonia, Spanish region, 8 million inhabitants
Procurement-related activities
Contrast: (Stockholm) risk for old style ”all inclusive”, 12-16 years? I hope I am wrong in�https://www.linkedin.com/feed/update/urn:li:activity:7057401873397334018/
Catalan 25-year retrospective https://preprints.jmir.org/preprint/58933
Managing lock-in effects - A telephone analaogy
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What if you/someone bought an �”all inclusive” system anyway?
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Not necessarily evil, it’s just very hard to maintain and quickly improve a giant system
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…but openEHR system content is 100% open by design 🡪 no need to increase APIs by 300%
How change?
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years
months
Health IT organizations & vendors are often slower than Gartners average system examples (perhaps due to complexity, regulations etc?)
Region Östergötland
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Reliability+Agility? Quality+Speed/Innovation? Bimodal IT (1+2)�Finding suitable abstraction layers and suitable management (people+process)…�
Specifications, e.g.: XML,
XML Schema (the ”language”),
XPath & XQuery
General XML database systems
XML Schema V (national?)
XML Schema U
General XML Tools (editors, processors etc)
XML Schema Y using V+W
X instances
Software manipulating/using X instances
XML Schema X using U+V
XML Schema W (international?)
Y instances
Rule engines
Rules & data flows
Spreadsheet
Software
(e.g. Excel)
Spreadsheet
template, e.g.
time report
for company X
Mr Smith’s
time report
for June
(an instance)
Specifications, e.g.:
-Reference Model (RM),
-Archetype Model (AM),
-AQL (query language)
-GDL (decision support lang.)…
EHR storage system RM+AQL+…
Archetype V (national?)
Archetype U
Archetype W (international?)
Template Y using V+W
Template X using U+V
Tools, editors…
http://www.gartner.com/it-glossary/bimodal/
GUIs generating/reading/querying instances
Region Östergötland
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Support
Sys. admin
Customer group
Delivery
Release mgmnt. Programming
Test
Configuration
Roll-out (during planned service ”windows”)
Find/create archetypes�Create template
Create form/GUI�incl. dynamic via ”low code”
Sometimes: Modify or create CDS rules
Upload to system�(”live” in an active system)
Test and quality control
Sometimes: Extra programming & optimisations
Mode 1
”Marathonl”
Mode 2
”Sprint”
Adjusting related systems (integrations
Statistical reports etc)
Custromer repr.�Investigation
Prioritisation
Pre-study
GUI/client-design
API-design
Database design
Objekt-modelling
Mode 1
”Maratonlöpare”�Stabil informatik och teknisk grundplattform
Tech sys. administration and improvement�of CDR and tools
Mode 2
”Sprinter”, delar�konfigurerbara av verksamhet
Support
Förvaltning
Kundgrupp
Leverans
Releasehantering�Programmering
Test
Konfiguration
Utrullning (servicefönster för planerade driftstopp)
Leta/skapa arketyper�Skapa template
Skapa formulär/GUI och ”task planning” �inkl. dynamik m. ”low code”
Ev. Modifiera/skapa beslutsregler
Ladda in i system�(”live” i aktivt system)
Test/granskning�Ev. kompletterande programmering och optimering
Mode 1
”Maratonlöpare”
Mode 2
”Sprinter”
Anpassning av kringsystem
(integrationer
Statistik, uppföljning)
Kundkontakt�Utredning
Prioritering
Förstudie
GUI/klient-design
API-design
Databasdesign
Objekt-modellering
Mode 1
”Maratonlöpare”�Stabil informatik och teknisk grundplattform
Teknisk förvaltning av grundplattform och ”verktygslåda”
Mode 2
”Sprinter”, delar�konfigurerbara av verksamhet
https://youtu.be/RYTmMQJFpAc?t=718
"...still many organizations choosing ... traditional route and we know that this will be the last cohort adopting this… already a legacy technology… not going to be what we use in the future"
https://youtu.be/RYTmMQJFpAc
How change?
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’all-inclusive side effects’
The transition to a monolith EHR usually uses up resources and stalls most other development during years. An “all-inclusive effect” often starts already when buying a monolith is considered, and then continues during the lifetime of the contract. The “all-inclusive effect” is a combination of economic lock-in, transition fatigue and integration difficulties. It is often expressed in terms like
“Yes, the monolith does not support your clinical IT-need X very well yet, but the system supplier has promised to improve, please don’t suggest/consider any objectively better competing solution. We are already bound in a 12-year contract paying for the monolith’s (possibly inferior) functionality covering need X. Also, it was a pain to do the transition and integrations so we won’t have energy and resources even if the competing solution would be free or cheap.”
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Questions? Discussion!��(Swedish slide about integration details follows)�
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Mer om långlivad data t.ex. från system som avvecklas
PoC TakeCare
Färgkodning av sannolik destinationsmodell: �CKM-arketyper, Blandning, Integrationsarketyper, FHIR
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”Integrations-arketyper”
”CKM-arketyper”
”klassisk” manuell mappning
System som ska avvecklas
Översikt/visualiseringar (ev. specialanpassade)
API & verktyg
Journalhandlings-visare m. sökfunktion
Datauttag, arkivärenden etc.
Kan göras senare, vid behov. AI-stött?
Källa till engelska delen av bilden:
https://specifications.openehr.org/releases/RM/latest/integration.html
Tekniska implementationsdetaljer: delarna märkta ”Switch” och ”EHR Repostory” kan, om så önskas, vara del av samma CDR, men flaggade/märkta på ett sätt så att man enkelt vid anrop (exempelvis AQL-sökfrågor) kan välja om man vill ha svar bara från en specifik del eller båda.