A clinical challenge:

To lead or be led by health-IT? Learn more 9-10 November 2015 in Linköping, Sweden

Speakers: Silje Ljosland Bakke (Norway), Rong Chen, Daniel Karlsson,

Heather Leslie (Australia), Mikael Nyström, Erik Sundvall

http://bit.ly/lead-or-be-led-by-IT

Jointly arranged by: Centrum för hälso- och vårdutveckling (CHV) & Centrum för medicinsk teknik och IT (CMIT), Region Östergötland

The amount of information relevant (and irrelevant) to clinical decisions is increasing, often above human cognitive capacity. IT-solutions in healthcare designed to guide and lead clinicians are increasingly needed to perform best practice care. But who and what guide the design of such systems?

Too often IT-solutions are slow to keep up with the constantly changing needs of healthcare, but guiding systems based on outdated processes and knowledge are not desirable.

The focus of these educational days in Linköping is on how clinicians, and healthcare organizations, can get more control of the development of electronic health record systems and as a result, faster changes. With the right knowledge and tools, clinicians can cooperate better to agree on shared needs and be more directly involved in keeping the system up to date, without losing easy access to older patient data.

We’ll discuss how electronic healthcare record (EHR) systems can share detailed information structures, terminology systems and decision rules – all designed and actively maintained by cooperating skilled clinicians and directly usable in systems (reducing the need of time- and resource-consuming reinterpretation and implementation by IT-staff).

Invitation version 1.4

Updated versions may be available at http://bit.ly/lead-or-be-led-by-IT

November 9 – Introduction, overview and Context Suitable for decision makers, interested clinicians, researchers and, health-IT-department staff. Example content: (for detailed program and times see page 2) Clinician-led e-health records, How the control and

development direction of clinical information systems can be turned back into the hands of skilled clinicians using information structures called “archetypes” and “templates”

SNOMED CT. What it is, content, usage, learning Local, national and international development and

governance of archetypes and templates, international and Norwegian examples.

Clinical Decision Support (exemplified by Cambio CDS) Terminology, clinical models and queries combined Detailed models in CIMI, CEN/ISO, openEHR and HL7

November 10 – Hands-on archetype/template training Suitable for those wanting deeper knowledge and skills in editing openEHR archetypes and templates, for example:

clinicians wanting to engage in international archetype authoring or local prototyping.

IT- and information-governance staff at organizations preparing to use archetype based systems.

Costs and registration Nov 9 only: 500 kr, subject to availability (limited seats)

Nov 9+10: 3700 kr Now fully booked, if you register for this now you will instead be put on a waiting list and not charged for Nov 10 unless you later accept a a possible extra invitation by email.

Costs include lunch and coffee-breaks etc. but exclude v.a.t. (moms). Info & registration shortcut: http://bit.ly/lead-or-be-led-by-IT Registration questions: Erika.Sahlen@regionostergotland.se Course content questions: Erik.Sundvall@regionostergotland.se

Related events: November 23, SFMI Termkonferens 10:00-17:00 Läkaresällskapet, Stockholm, see http://sfmi.se/ Clinician-led bottom-up detailed EHR content modeling in Sweden? Including speech by CEN/ISO & openEHR veteran Prof. Dipak Kalra, UCL, and chairman of the European Institute for Health Records. December 3-4, Medicinska riksstämman Several IT-related sessions, e.g. 3 Dec 13:45 - 14:45 “ehälsa behöver en användbar, standardiserad och strukturerad dokumentation – hur?” See http://www.sls.se/Riksstamman/

Preview-version 0.8. Updated versions will become available at http://bit.ly/lead-or-be-led-by-IT

November 9 – Overview and Context Arriving by train to Linköping at 9:00 should get you to the meeting venue in time with some minutes for coffee. Timing and ordering may change slightly. Location: Scandic Frimurarhotellet, S:t Larsgatan 14.

9:00 Coffee, sandwich etc.

9:30 Welcome, introduction to the field and today’s program [Erik]

9:50 Clinician-led e-health records How the control and development direction of clinical information systems can be turned back into the hands of skilled clinicians – the role of archetypes and templates. Introduction to openEHR archetypes and templates, their use and context.[Heather]

10:50 Break

11:00 Local, national and international development and governance of archetypes and templates – exemplified by Norway’s archetype governance and openEHR’s international repository [Heather & Silje]

11:45 SNOMED CT. What SNOMED CT is, what it contains and how it may be used. How clinicians and others can get involved and improve content. +How to get (free) Snomed CT training [Mikael] This part will be in Swedish.

12:30 Buffet Lunch

13:15 You can start today! - Demo: How to “adopt an archetype” and take part in international review and translation. +How to find (free) video/text guides to get you started [Heather &Silje]

13:35 Terminology, clinical models and queries combined. Boundary problems. “Terminology binding” in archetype based systems. Archetype- and terminology based queries for patient specific and epidemiological/statistical use. [Heather, Daniel & Erik]

14:10 Clinical Decision Support (CDS) Decision support using decision rules, information models and terminology systems - Exemplified by Cambio CDS using GDL, openEHR archetypes and SNOMED CT [Rong]

14:45 CIMI, CEN/ISO and HL7 – more international modeling collaboration & conversion partly using archetypes. CIMI now becoming a working group within the HL7 organization. Relation to HL7 FHIR. +Info about SFMI event with Dipak Kalra in Stockholm November 23 [Daniel]

15:00 Break

15:15 Questions & Answers (primarily about archetypes, terminology and CDS)

15:40 Discussion (wider scope and Swedish context) First discussion questions: Some Swedish regions will start using archetypes in their EHR systems soon. Can the their detailed clinical modeling and translations of international efforts be used in clever ways also in non-archetype based EHR systems? Would it be clever to do like in Norway and have a vendor neutral nationwide collaboration and governance? Who? How? Health Professional organizations, authorities, others?

16:20 End #1 = Break + bye-bye to those needing to catch early trains etc.

16:30 Deeper introduction to archetype/template thinking and tooling (Necessary for those attending day 2. Also open to curious attendees of day 1) [Heather & Silje]

17:30 End#2

19:00 Possibility to meet for dinner at some restaurant for those that want to (not included in fee).

November 10 – Hands-on archetype/template training Tutors during Nov 10 will be Heather Leslie and Silje Ljosland Bakke, partly assisted by Erik Sundvall. The number of possible participants is limited. Participants are expected to bring their own computers with Archetype- and Template-tools already installed. Instructions have been sent to participants. Location: Region Östergötland, Klostergatan 19c

8:00 Meet, set up computers etc (Times for lunch and breaks will be specified later)

8:15 Hands-on archetype/template training with real examples mixed with theory and demos. Main content: Archetypes, Templates, Practical online reviewing. Modelling lessons learned (by years of experience)

16:20 End #1 = Break + bye-bye to those needing to catch early trains etc.

16:30 Last Q&A, reflections and end discussion. How would we like to continue? Tutoring help via web etc? Good example starting/prototyping projects?

17:30 End #2, the end, really…

Archetype examples

Entry screen example

Filtering, defaults,

terminology binding

via templates etc.

adapt the usage of

shared models to

clinical use case.

Heather Leslie, MD (Australia) As Clinical Program Lead at openEHR, Heather is one of the world’s most experienced archetype and template authors. She has worked as a clinician for 15 years and transitioned to health informatics in 2000. Heather joined Ocean Informatics in 2005 where she is now Director of Clinical Modeling. She has worked with national health IT programs in Australia, UK, Norway, Sweden, Brazil and Slovenia

and run training courses on clinical modelling in the EU, USA, South America and Australia. In her openEHR role she oversees the development, quality assurance and governance of clinical archetypes through an active online community of clinicians and other domain experts from over 80 countries.

Silje Ljosland Bakke, RN (Norway) Informatician and registered nurse, with clinical background in surgery as well as clinical research from the University Hospital of Northern Norway. She has worked in health IT for more than five years, first in the Bergen Hospital Trust and she’s now an information architect in the National ICT health trust for strategic IT cooperation in the Norwegian hospital system. She has been a leading figure in Norway’s

national archetype governance since the start in 2013. She has joined Heather as Clinical Program Lead at openEHR.

Mikael Nyström, PhD (Sweden) Lecturer in Medical Informatics at IMT, Linköping University. One of Sweden’s top technical experts regarding clinical terminology systems, including SNOMED CT. He has served in many roles at IHTSDO (the organization governing SNOMED CT) where one of his current tasks is focused on providing education and training. His research interests include: Ontology engineering with special focus of SNOMED CT,

ontology and terminology use in electronic health records, electronic health record architecture and information reuse.

Daniel Karlsson, PhD (Sweden) Senior Lecturer in Medical Informatics at IMT, Linköping University. Chairman of the Swedish Association for Medical Informatics (SFMI). He has served in many roles at IHTSDO and has also been actively participating in CIMI (Clinical Information Modeling Initiative). Daniel’s research spans over terminologies/ontologies, documentation models and decision support systems, and includes the

intersections and boundaries between those domains.

Rong Chen, MD, PhD (Sweden) Rong Chen is the Chief Medical Informatics Officer and the head of Medical Informatics Group at Cambio Healthcare Systems, Sweden, where he is responsible for the research and development in clinical decision support and knowledge management. Rong’s PhD from Linköping University was focused on EHR semantic interoperability. He is now an associated researcher at the Health Informatics Centre at Karolinska Institutet, where he lectures and

supervises PhD and master students.Rong has contributed to several core openEHR design specifications, and has for many years led the Java Reference Implementation of openEHR. Rong is the lead author of Guideline Definition Language (GDL), which is designed to express clinical logic for scalable decision support with openEHR underpinning. Within openEHR he is member of the Management Board and the Specifications Editorial Committee

Erik Sundvall, PhD (Sweden) Information Architect at Region Östergötland working with future directions of clinical IT systems he is also Act. Lecturer in Medical Informatics at IMT, Linköping University. Within openEHR he is Software Program Lead and member of the Specifications Editorial Committee. Erik has researched archetype based EHR systems, REST based openEHR component designs making it easier to deploy EHR systems by putting

together components from different projects/vendors/platforms. Erik has also designed archetype editing tools and SNOMED CT browsers.

Färre bromsar i vårdens lärande kretslopp? Läkekonstens och vårdens kretslopp för innovation och förnyelse fanns långt innan datorerna. Bra IT- och eHälso-lösningar kan snabba upp iterationerna och föra oss snabbare från data, via information, till kunskap, men då krävs tillräcklig struktur, samordning och samarbete i de olika stegen. Trögändrade IT-lösningar kan å andra sidan försena önskade förändringar.

Figur 1. Delar av vårdens lärande kretslopp

Att få till bra stödjande IT-system innebär mycket arbete, därför bör det arbetet delas och återanvändas. I möjligaste mån vill man även minimera antalet led (och tillhörande omtolkningar) från vårdpersonalens behovsbeskrivning till implementerade IT-system.

Bristande kunskap om vikten av nationellt och internationellt samarbete kring konkreta detaljerade kliniska modeller inuti system (mallar, ”arketyper” etc.) bromsar också. Ett syfte med de arbetssätt som presenteras under utbildningsdagen är att hälso- och sjukvårdsverksamheter i samverkan ska kunna påverka systemen och uppleva färre eller kortvarigare bromsar av typen ”det nya arbetssättet ni vill ha matchar inte hur IT-systemet funkar ” eller ”vi får se om det kanske kommer i nästa systemversion”.

Om flera aktörer kan arbeta med samma öppna informationsstrukturer, beslutsregler m.m. istället för att sådant arbete blir inlåst i enskilda system så kan leverantörernas ”inlåsningseffekter” minska och en mer levande marknad för journalsystem gynnas. Ett sådant ”ekosystem” öppnar även upp för innovation hos mindre aktörer som kan använda de öppna standarderna. De kan t.ex. fokusera på behoven hos mindre kunder (t.ex. kommunala) och ändå erbjuda system som är kompatibla med de större vårdgivarnas system. Alternativt kan de satsa på att vara bättre än de stora systemen inom speciella nischer och erbjuda kompatibla tillägg till de stora systemen.

Figur 3. Illustrationen visar viktiga detaljerade delar som behövs inuti eHälso-system (t.ex. journalsystem) och nödvändiga samband mellan dem.

Dessutom finns meddelandemodeller/mekanismer (från t.ex. INERA/SKL, CEN, ISO, HL7 och IHE) för kommunikation mellan system.

WHO förvaltar ICD och ICF. Snomed CT förvaltas av IHTSDO. Dessa begreppssystem och klassifikationer förvaltas i Sverige av Socialstyrelsen.

Socialstyrelsens ”Gemensam Informationsstruktur” berör flera av bildens modellområden.

Dagens dokumentationsstöd är strukturerat i varierande grad, det finns många skäl till att vilja förbättra och strukturera information i klinisk tillämpning (se figur. 1) t.ex. ökad användbarhet och patientsäkerhet. Bättre struktur bidrar till underlättad journalföring (bl.a. mindre dubbeldokumentation), sökfunktioner, översikter, integrationer och även informationsflöden mellan olika discipliner, verksamheter, system och organisationer. Om strukturer tas fram och underhålls utan tillräcklig möjlighet till engagemang från aktiv vårdpersonal så kommer systemen gå i otakt med verksamheten.

Att säga att forskning (se figur 1) underlättas av att ha ordning på data är förhoppningsvis att slå in öppna dörrar. Att få till en kontinuerlig utbildning (se figur 1) och assisterande system i vård-vardagen kan underlättas av t.ex. beslutsstödsystem. Mängden digitalt lagrad information växer exponentiellt med ungefär en fördubbling vartannat år. Konkret innebär det att mängden beslutsgrundande information växer snabbt medan mänsklig kognitionsförmåga inte utvecklas nämnvärt. Utan aktiva stödfunktioner kommer gapet (se figur 2) mellan vilken kunskap vi faktiskt baserar vården på

och vad vi skulle kunnat basera den på, att öka.

Noggrannhetskravet på aktiva stöd är dock mycket högt för att de ska vara patientsäkerhetsmässigt och arbetsmiljömässigt acceptabla. För att få hög noggrannhet krävs god ordning på journalföringen (dokumentationsmodellerna), vilket i sin tur kräver bra funktionella uppdaterade strukturer/mallar att journalföra i. Det krävs också bra begreppssystem och klok tillämpning av de olika delarna. Beroenden mellan modelltyper illustreras i figur 3 nedan (med pilar mellan cirklarna).

Första dagen (9 Nov) ger en internationell överblick av alla tre delarna i figur 3 och hur de påverkar varandra. Andra dagen (10 Nov) ger en fördjupning i en öppen internationell variant av dokumentations-modeller som länge använts i en del andra länder och succesivt nu börjar användas i t.ex. Norska (DIPS) och Svenska (Cambio Cosmic) journalsystem.

Länktips Kortfilm om ”arketyper” och tillhörande norskt arbete https://youtu.be/JW8pBJvdsHQ

Om Snomed CT: http://www.ihtsdo.org/snomed-ct

Titta i Snomed CT: http://browser.ihtsdotools.org/

Om CIMI: http://www.opencimi.org

Om openEHR: http://openehr.org/

Titta på arketyper: http://www.openehr.org/ckm/ och

http://arketyper.no/ckm/

Exempel på norsk leverantör:

http://www.vitalis.nu/nyhetsbrev/nyhetsbrev1/Vitalis-2015---

News-nr-18-mars/Oppen-plattform-framgangsfaktor-kring-

elektroniska-patientjournaler

Program or be programmed: https://youtu.be/imV3pPIUy1k

Figur 2