gms | German Medical Science

53. Jahrestagung der Deutschen Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie e. V. (GMDS)

Deutsche Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie

15. bis 18.09.2008, Stuttgart

Interoperability through standardized representation of health information

Meeting Abstract

Suche in Medline nach

  • Sebastian Garde - Ocean Informatics, Düsseldorf, Deutschland
  • Sam Heard - Ocean Informatics, Sydney, Australien

Deutsche Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie. 53. Jahrestagung der Deutschen Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie (gmds). Stuttgart, 15.-19.09.2008. Düsseldorf: German Medical Science GMS Publishing House; 2008. DocMI15-3

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Veröffentlicht: 10. September 2008

© 2008 Garde et al.
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There has been an ongoing effort to achieve semantic interoperability in Health Informatics for more than two decades. Improved patient safety, less repeated tests, and less interfaces in the US alone are predicted to lead to over $70 billion savings p.a [1]. The UK National Health Service (NHS) and Canada (Infoway) have led international efforts for a national electronic health record based on standards with others like Australia moving in the same direction. The US is aiming at developing regional networks and proprietary personal health records services established by insurance companies have been reasonably successful, although interoperability is limited. Recently, Microsoft and Google have announced their offerings in this space. This paper is exploring how to achieve standard representation of Health Information (and eventually semantic interoperability) in this scenario.

The formal process of standardisation

There are 3 broad categories of means to achieve standardisation in the Health IT industry that all have advantages:

  • The traditional processes of (inter)national standards organisations. Standards are committee authored and finally agreed through balloting.
  • Industry standards where everyone agrees informally to use the specifications of something that is very widely used.
  • Third, where a community of interest publishes a specification for use.

As far as health computing is concerned, HL7 is the main example of the standards path, Microsoft and Google will likely be trying to establish a default standard through very wide uptake and the openEHR Foundation ( is the main public specification from a community of interest.

Achieving uptake of standards

Directives to use a standard have been relatively unsuccessful around the globe. Ideally an 'organic' pathway to achieving standardisation of health information is required to achieve interoperability in a cost effective manner. For example, NICTIZ, the organisation aiming to achieve interoperability in Health in the Netherlands, has mandated the use of HL7 version 3 messages. Uptake has been slow due largely to the cost of implementation and the difficulty in agreeing on a suitable specification of the messages. The UK has taken a similar approach and has found the need to produce clinical data specifications using openEHR archetypes. Canada has been in planning mode for many years and will send the first clinical messages this year. Despite this extended planning and billions of dollars, the comprehensive Electronic Health Record (EHR) is still beyond the scope. One can conclude that a mandated approach which does not offer a clear and gentle pathway to implementation is unlikely to lead to major improvements. This is where the openEHR specifications offer a special advantage: an 'evolutionary' approach to standardisation of health information. This facility is the reason the openEHR platform is now in use in the UK (NHS) and the Netherlands (private sector) and there has been interest in Canada and uptake in Australia. NICTIZ, the Netherlands, and the Swedish Department of Health have released reports recommending the use of openEHR and Denmark is proceeding with a proof of concept phase.

The architecture: Messaging or a logical EHR?

HL7 has remained agnostic about the health record architecture within systems and has provided a means of (limited) communication of health information. The focus is the format during transfer - there is a great deal more work to do on top of this to specify the exact content of the actual messages in use - e.g. carried out in Australia within the Standards Australia environment or in Europe by producing a CEN EHR communication standard based on an early version of the openEHR specifications.

A different approach is possible through provision of Personal Health Record (PHR) services. Here, a proprietary-format health record is developed by the vendor, and a service interface published so that others can, with appropriate authority, access and write to these health records. The hope is that the dominant PHR provider will become the standard for communication. The advantage of this approach is that there are a range of business models to fund these services including advertising and value-added services to consumers, employers and others. At the moment, this is leading to further fragmentation through the plethora of offerings in this space.

The specification of a logical EHR, such as the openEHR specifications, offers a much more comprehensive approach, but one that demands acceptance by a significant sector in order to proceed. It requires vendors and PHR providers to either base their systems on the specifications or understand the mappings of their systems to these specifications. A gentle path for migration is essential for this to succeed. Having a logical record architecture that provides the EHR as a service and does not depend on any particular implementation pathway is very powerful for this.

Agreeing on the content

The major effort internationally at present is to get an agreed set of archetypes for use across the health system. The NHS is leading this effort to provide clinical content specifications to the vendor community. Meanwhile the openEHR Foundation has established the Archetype Editorial Group which will collaborate openly on the web using the openEHR Knowledge Management environment. This involves teams of professionals authoring archetypes and registering these after due consideration and feedback within a comprehensive ontology. A screenshot of this tool is presented in Figure 1 [Fig. 1]. These archetypes can be used by vendors to configure their systems and can be used directly in those with openEHR based systems. They can be used within the ubiquitous HL7 v2 environment to specify messages and as the basis for specifying and generating HL7 CDA documents. Standardised EHR queries [2] can be expressed in terms of openEHR archetypes thus providing a much needed standard for expressing decision support statements; an essential and yet elusive component for generic expression of high quality algorithms. openEHR archetypes therefore provide the basis for shared content specifications which can be used with a range of technologies. These same specifications can be used in personal health records, clinical applications, hospital systems and regional repositories. With a growing set of archetypes and an international framework for governance, the collaborative configuration of systems can soon be a reality.


Anyone who has configured a clinical system from scratch will understand the enormity of the task and the huge drain on resources locally. Messaging standards have been the only means of achieving this to date. Next generation systems, however, are embracing the new service oriented architecture approach supported by the rapid advance of web service technology. Effective standardisation of the representation of personal health information remains the single most significant barrier to achieving real cost benefits. Archetypes as the model of health information are now gaining ground in areas that have worked hard to solve the solution using message-oriented solutions. Implementations of large scale clinical modelling HER services are now under way. National jurisdictions are increasingly considering openEHR as the logical health record architecture for the future. Uptake of the presented approach for collaborative specification of clinical content will provide a highway to genuine interoperability of personal health information.


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