It’s encouraging to see Matthew Gould, the CEO of the newly formed NHSX is spending time at  

the clinical frontline before he formally starts in his post in July.  After reading Matthew Gould’s most recent blog, it’s clear his time so far with care professionals is helping inform his views; recognising that health IT is frustratingly clunky, siloed and way behind other sectors.

We recognise that there is some important new thinking and messages with his most recent welcome declaration;

“we’re going to focus on standards and platforms, keeping the centre as ‘thin’ as possible”. 

This shift is an acknowledgement that the health IT market is underperforming, one size doesn’t fit all and we need a new approach to health IT.

This latest initiative by NHSX, has a good deal in common with the work of the Ripple Foundation. In advocating user centred design, the use of open standards and open source for healthcare, and now this focus on the platform approach in healthcare, these principles resonate with us very much. This more open approach is a good fit with the clinical community too, where sharing knowledge and research for the betterment of health outcomes is understood as a public good. 

While we welcome this shift towards a healthcare platform by NHSX, our experience has taught us this is non-trivial challenge, so would urge NHSX to learn from others in this field tackling this same challenge, both in the UK and abroad such as the Global Goods initiative from Digital Square. 

The state has an important role to play in supporting companies tackle this fragmented market that is dominated by a few big tech players.  If done right, a platform based approach can help to stimulate new entrants to the market and drive innovation. 

One particular challenge NHSX will face will be finding the balance between coordination and control of platform development while letting innovators innovate at the frontline, to get the right information, at the right time, to help care professionals deliver the best possible care. 

What does the NHS mean by a platform in healthcare anyway?

We believe NHSX, should be working towards the definition of an open platform, as defined by Apperta Foundation and  therefore start the move away from closed platform/monoliths, which both Yorkshire & Humber LHCR and NHS Scotland are already working towards. 

“Open platforms liberate both data and applications making them portable and interoperable across different platform implementations…. The open platforms approach is vendor and technology neutral, eliminates lock-in, facilitates innovation and competition, and forces vendors to compete on quality, value, and service”. 

Indeed the Apperta paper on Defining an Open Platforms, defines 8 core platform principles:

1. Open Standards Based 
2. Shared Common Information Models 
3. Supporting Application Portability 
4. Federatable 
5. Vendor and Technology Neutral 
6. Supporting Open Data 
7. Providing Open APIs 
8. Operability (as in DevOps) 

So as well as continuing to meet care professionals at the frontline, we, Ripple Foundation and Apperta Foundation, would welcome a conversation with Matthew Gould and NHSX colleagues to discuss our learnings and expertise in this field as well as to discuss strategic investment into open platform innovation via the 1% Fund to enable a small safe start, the iterative curation of common platform components and collaboration between the frontline and NHSX.

INTEROPen have launched a paper outlining the differing approaches and goals of FHIR and openEHR.  We highly recommend reading the attached to understand the differing approaches and goals of each standard, and why they both have a valid and complementary place in the challenges faced in digitising health and social care.  Please share with colleagues.

INTEROPen openEHR and FHIR

Authors: Dr Ian McNicoll of openEHR Foundation; Dr Amir Mehrkar of INTEROPen; Dr Tony Shannon of Ripple Foundation

 

We are pleased to update the openEHR community on the outcome of our EtherCIS international camp held over 3 days in London, December 2018.

A group of 12 individuals, representing 8 nationalities from academia, commercial and non-profit sectors came together to explore, discuss and plan the growth of EtherCIS and the open source openEHR community via an EtherCIS MkII plan. See here for the related roadmap that was agreed by the group as the way forward.

We are grateful for the help and support of Tom Beale (Ars Semantica & openEHR Foundation) who is now leading an EtherCIS MkII subgroup, working to coordinate this effort towards the public open release of EtherCIS MkII within the next few months.

More information on EtherCIS is available at  http://ethercis.org/ , https://github.com/ethercis and https://gitter.im/Ripple-Foundation/EtherCIS

We welcome interest and involvement from any others who wish to get more involved in this important effort. If you are interested in becoming involved please contact us at info@ripple.foundation

Dr Tony Shannon

It was a great pleasure to meet the Health Secretary on his recent visit to Leeds after launching his new “tech vision” for the health service. I met Matt Hancock MP at the ODI in the centre of Leeds on Friday 19 October 2018 and talked him through our development for Helm – an open platform solution for a person held record.

I was able to share with him the UI/UX experience of Helm as it looks right now and was pleased to hear very positive responses both from the Health Secretary and his Chief Technology Advisor, Hadley Beeman.  Helm has been in development for a number of months to ensure that we’ve got strong foundations for people accessing and contributing to their own health and wellbeing information. It has involved passionate work from a number of highly experienced technical people as well as clinically direction from Dr Tony Shannon, along with strong creative development from Simon Gamester.

 

Helm benefits from a number of innovative technologies supported by Ripple Foundation, namely, PulseTile, QEWD.js and EtherCIS and is underpinned by the internationally leading open standard for healthcare,  openEHR.  It also conforms to the well received paper “Defining an Open Platform” by Apperta Foundation.  

The exciting journey of Helm being tested by people in Leeds starts very shortly.  People are at the heart of this product and they will now lead the way in its future development.  Users of Helm will be able to tell us what works and what doesn’t, what would be useful, what is missing and Ripple Foundation is very excited to be a large part of this new innovation with the city of Leeds, led by Leeds City Council.  The plans for Helm are for rapid expansion into the Yorkshire and Humber region. We will keep posting news on the Ripple Foundation website but do get in touch if you would like to understand more about our open platform approach for addressing some of the issues faced by Health IT.  

Thank you to ODI Leeds for supplying the photos taken during the session with the Health Secretary.

By Phil Barrett

Director

Ripple Foundation

 

EtherCIS Clinical Data Repository is developing at pace with radical new improvements in its latest V1.2 release including enhanced security, more complex querying, federation,  improved configuration capabilities and much more. EtherCIS is the leading open source implementation of the openEHR standard in action (including AQL support) and these new developments make the use of EtherCIS even more compelling in the marketplace.  

EtherCIS development is supported by the non profit Ripple Foundation and is a key component of their “showcase stack” and work towards an open platform in healthcare.  It is led by Christian Chevalley of ADOC Software Development who said, “We’re thrilled with the latest release of EtherCIS and proud that our work combines contributions by the community across the globe.  It is helping Health IT to become sustainable, open, vendor neutral and delivers patient centered clinical data handling with knowledge engineering.  Helping to deliver this message to key decision makers and leaders has been part of Ripple Foundation’s mission and we are excited to be part of the action.”

Dr Tony Shannon, Director of Ripple Foundation said, “We welcome the work that Christian and his company is continuing to deliver for EtherCIS, it’s a great achievement and really helps to ensure that open platforms are the future of Health IT.   We are also thankfully that cities like Leeds in Britain are implementing EtherCIS in their area for Helm, the adoption of an open platform Person Held Record.  EtherCIS is helping to contribute to the global endeavour of improving data quality, access, storage and research which is fit for 21st Century care.”

Below is some further information on the enhancements made or if you require an indepth understanding please visit Github at https://github.com/ethercis/ethercis .  

Enhanced Security

EtherCIS upgrade ensures sensitive data is further protected against eavesdropping and it controls access to the database, so users can only access the data they have been authorised to see.  

Enhanced openEHR querying (AQL)

Users can now perform more complex querying due to new enhancements using openEHR templates for meta data. The openEHR standard has been adopted and implemented across healthcare systems throughout the world, representing the future of health IT.

Federation

Improved federation which allows information retrieval technology to simultaneously search in multiple resources. This means that a user can make a single query request which is then distributed to the search engines, databases or other query engines participating in the federation.

More configuration capabilities

EtherCIS REST server now supports a full set of parameters for basic HTTP, SSL, low resource monitoring and request logging.

Under the hood improvements

There has been an upgrade to a number of critical components including REST server, DB programmatic interface and XML handling. EtherCIS libraries have been cleaned up and simplified to reduce dependency conflicts and many unit tests have been finalised

To find out more about Ripple Foundation please visit www.ripple.foundation

 

ENDS

Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.

EtherCIS Clinical Data Repository. More info available at  ethercis/

openEHR: openEHR Foundation. More info available at http://www.openehr.org/

AQL: Archetype Query Language. More info available at
http://www.openehr.org/releases/QUERY/latest/docs/AQL/AQL.html

For media enquiries about Ripple, please contact info@ripple.foundation or visit the website for more information www.ripple.foundation

For technical enquiries about EtherCIS, please contact ethercis@ripple.foundation.

 

Defining an Open Platform – Thought-provoking collaborative document from the Apperta Foundation that we highly recommend reading.  

The paper has pulled together with the experience and knowledge from a wide range of clinical, health informatics and health system economics including our very own Dr Tony Shannon but also….   

Ewan Davis – Woodcote Consulting

Dr Ian McNicoll – openEHR Foundation

Dr Roland Appel – Maycroft Consulting

Silas Davis – Monax

Dr Rebecca Wassall – Apperta Foundation

Peter Coates – NHS Digital Code4Health

We believe that the thinking within the report is relevant not just to the UK and Ireland but across the globe so please share this document with colleagues.

 

The world of healthcare can now begin to leverage the power and potential of the EtherCIS Clinical Data Repository. EtherCIS development has been supported by the non profit Ripple Foundation and this leading technology now provides the key foundation of its “showcase stack” and work towards an open platform in healthcare.  EtherCIS development is led by Christian Chevalley of ADOC Software Development and the EtherCIS technology is now the leading open source implementation of the openEHR standard in action (including AQL support). The openEHR standard has been adopted and implemented across healthcare systems throughout the world, representing the future of health IT.

Christian Chevalley of ADOC Software Development said, “EtherCIS being open sourced is not accidental, it is organically inherited from its fundamental components and philosophy. It is based on the open standard openEHR that specifies an open, vendor neutral, patient centred clinical data handling and knowledge engineering. Its implementation has been feasible due to the remarkable progress of the open source database PostgreSQL supporting the combination of relational and document typed data efficiently. Most of EtherCIS components have been derived from open source building bricks: service architecture, object oriented database querying, data serialisation, Web communication etc. As such, it is the result of the contributions of hundreds of analysts and developers.

Christian continued to say, “Open Source entitles anybody to have access to the source code, uses and copies the software and contributes to it; it is technically extremely convenient, however to promote successfully EtherCIS into the highly competitive Healthcare IT arena, it had to be free as in Libre. As a free and open software platform, it gives the freedom to anyone to create copy and run a clinical applications that is respectful of the fundamental right to store, query and interchange medical information without being tied to a specific vendor, proprietary encoding or physical location.

“Ripple Foundation has been instrumental to make this achievable; it has not only provided the necessary means to achieve EtherCIS development, but has also stimulated the collaboration, contributions and reviews by clinicians and IT peers, internationally. The result is a solid and relevant IT platform that is now naturally and logically fully integrated into the Ripple Foundation, supporting the adoption of an open health and care platform. The mission and values that Ripple Foundation is abiding by firmly sits with my own views, so I’m thrilled that EtherCIS is now officially part of the Ripple Foundation family.”

Dr Tony Shannon, Director of Ripple Foundation said, “We are honoured to be supporting EtherCIS as a key element of the Ripple Foundation’s open platform showcase stack.  We know to improve health IT we need data, information and knowledge to support the complex and highly pressurised health and care system.  EtherCIS ensures that information and data can be accessed, stored and exchanged securely because it a world leading open source example of the vendor-neutral & technology-neutral openEHR standard in action, developed and tested in the context of a highly usable clinical application. EtherCIS is a Clinical Data Repository fit for 21st Century Health and Care.”  

 

ENDS

Ripple Foundation is a community interest company that is supporting the adoption of an open health and care platform.  It is a clinically led team that working with communities to support using an integrated digital care platform for today and the future. Open source, open standards and underpinned by an open architecture that can be used worldwide.

Ripple Foundation is supporting and promoting the #1percent open digital platform challenge fund that is hoped will stimulate and support both the creation and adoption of an open digital ecosystem for the nation.

EtherCIS Clinical Data Respository. More info available at  ethercis/

openEHR: openEHR Foundation. More info available at http://www.openehr.org/

AQL: Archetype Query Language. More info available at
http://www.openehr.org/releases/QUERY/latest/docs/AQL/AQL.html

For media enquiries about Ripple, please contact info@ripple.foundation or visit the website for more information www.ripple.foundation

For technical enquiries about EtherCIS, please contact ethercis@ripple.foundation.

 

Ripple Foundation is launching a series of three videos that introduces viewers to openEHR. openEHR is an open, clinically lead approach to creating a standards based healthcare platform for the 21st Century. This includes standardised clinical content and information models for the health and care market.  Allowing vendors and developers of front-end and back-end solutions to leverage a common set of standards to help design, store and querying rich clinical information sources.  openEHR is leading the international field in this effort, with benefits for stakeholders and key decision makers which allows them to :

•   let their clinical experts be directly involved in solution development, via archetype authoring
•   built a patient centred record while avoiding technology and/or vendor lock-in
•   retain ownership of the data for primary and secondary use

Put another way… it is an open data standard, both vendor and technology neutral, that’s been designed to support the needs of 21st Century Healthcare. 

Each video is approximately two minutes long and can be shared with anyone who wishes to understand more about openEHR.

Watch. Learn. Share. #openEHR

 

This short video is part 2 of a 3 part series to help explain openEHR, the future of healthcare IT.

Watch. Learn. Share. #openEHR

 

Ripple Foundation’s showcase stack encompassing three open source elements – front end UX/UI framework, middleware and backend/data repository.  Each component harnesses the power of open source and aims to demonstrate open standards in action to show that there is a different way to provide technology to our care professionals and patients.

Ripple Foundation was established in 2016 to support the adoption of an open health and care platform internationally.  As part of its mission, the team has supported the development of a leading edge UX/UI framework which they’ve recently launched called PulseTile. The clinically led team has also been reviewing complementary products and components that meet the increasing demands of the modern day health and care system.  They are proud to support and promote the incredible versatility of both the middleware – JSON API oriented QewdJS framework led by Rob Tweed of MGateway Ltd, plus the openEHR compliant backend of EtherCIS led by Christian Chevalley of ADOC Software Development.   

Dr Tony Shannon, Director of Ripple Foundation said, “We are promoting Ripple Foundation’s showcase stack to demonstrate how health IT can be done in the complex and highly pressurised health and care system.  For years care professionals have had to put up with inadequate, antiquated clinical systems and we believe this showcase stack shows what can be applied to any health and care setting to help provide a better solution for both the clinical requirements but also the business needs of health and care technology.  Information and data that you can access, store and exchange securely is an option if you adopt an open source, open standards underpinned by open architecture approach.

“I’m calling out to the health and care community to take a look at our showcase stack and have a play with what’s now openly available to reuse.  At Ripple Foundation we are here to support you and can answer any questions you may have and help to move health IT into the 21st Century.  

Tony continued, “We are also appealing for an open digital platform challenge fund that we have called #1percentfund.  Diverting 1% of available healthcare IT funds to an open digital challenge fund we believe could improve the care of 99% of the population by stimulating and supporting both the creation and adoption of an open digital ecosystem internationally.  We hope this Open Platform Challenge Fund could help any interested clinical and technical leaders out there to implement a different approach to issues we are facing.”

It is clear that Health IT is not good enough to support 21st Century care, Ripple Foundation believe their showcase stack components, used separately or in combination will help to meet the needs of clinical systems that are easy to use but also communicate and interoperate using open source and open standards.

The showcase stack can be explored from the Ripple Foundation website, including full “showcase stack” documentation.

For everyone who is working to move healthcare into the 21st Century …. we are all on a change journey, made up of people + process + technology elements… which is particularly challenging when we aim towards integrated care. In the past I’ve looked in particular at the key patterns we see across technical elements required, explaining the key current options in fairly simple A/B/C terms.

Most people are not starting from a blank technical slate, rather their patch is often littered with (A) Myriad of Siloes. Some have already gone on a (B)est of Breed 1.0 Journey and others have gone down/are facing towards the (C)orporate/Conglomerate choice of proprietary monolithic technology systems.

Beyond these current constraints, the market is slowly but steadily shifting towards “Healthcare Best of Breed 2.0, the open platform that will transform 21st Century Healthcare”.  That platform can be described as made up of  5 key elements ;

1) Usability

2) Integration

3) Clinical Kernel

4) Community & Code

5) Leadership & Governance

I’d like to explain the approach that we suggest can support the effective union of these elements and a migration path from the old proprietary world towards an open platform .. via (1) clean and simple user interface design, (2) integration with existing/other systems and the path to the (3) clinical kernel oriented platform approach.

**As part of our work towards this open platform push the key aspects of our chosen PulseTile UX/UI framework   – this framework follow key patterns in clinical process and information management, from business/clinical intelligence to multi-patient view to single patient view – all focused around a few key UI patterns. **

Clinical UI Patterns- from ClinUiP.wordpress.com

We introduce our user interface with its north, south, east and west panels. We offer this open sourced UX/UI framework not as a perfect solution but one we find to be good enough for most/all the challenges we throw at it .. while we look forward to others offering improved alternatives.

Within this framework we can offer an approach that is akin to a bridge.. both to access to a wide range of existing/other systems as well as access to the open platform of the future. To emphasise, the essence of the approach here is to enable access to both legacy data in its varied formats and to more future proof architectural elements (e.g. openEHR for structured data and VNA for unstructured data) in a single User Interface framework. (See screenshots 3 & 4 below to illustrate this further).

We explain this framework along a stepwise progression or maturing of healthcare integration, towards integrated digital care records/longitudinal care records that are centred around the patient.

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**Level 0            ** No Sharing

**We start the baseline here, with no patient information sharing between healthcare providers as for many  people sharing of data between systems is a real problem. It is worth noting that the challenges of interoperability in healthcare are increasingly acknowledged as a real barrier to improved healthcare. **

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**Level 1            ** Sharing Via HTML (Presentation Only)

This first level of integrated care within an Integrated Digital Care Record (IDCR) is a very simple level of access to data in today’s information age. Here the user is logged into the patient’s record and hoping to see information from more than 1 healthcare organisation. (for example,  professional based in Primary Care/GP, wanting access to patient information from the hospital… and/or vice versa).

Here we show the usual patient record, with the patient banner and a “tab” allows us to display data incoming from an outside source. The tab view access is analogous to accessing a regular website today, where the website provider chooses what information they want to share (including healthcare Documents as HTML/CDA etc) and how they want to present it. With this level of information sharing we accept whatever view we can from the information provider who shares it ( example selected here a Primary Care  organisation). This ability to view data from external systems is one of the key drivers behind the clinical portal market we see in healthcare today.

**Of course access to such data is a breakthrough for many of us, though further processing of that data for purposes such as decision support, clinical/business intelligence etc is not possible. So it is a first, albeit limited step, better than no data, but certainly not adequate to support truly integrated care ( for example cross organisational pathways support etc). **

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**Level 2            ** Sharing via Structured Data + Presentation Transformation

This next level involves the sharing of structured data. For some time messaging between systems has been at the frontier of healthcare integration -referral messages for example Primary Care to Hospital and/or discharge messages  – Hospitals back to Primary Care) etc.

Data Messages  – in data formats such as HL7v2, XML, JSON (eg FHIR) etc –  allow for the “transformation” of that data so it can be shared and presented in a variety of ways, especially to align with the receiving system. Here our centre pane displays the source/provenance of that incoming data (e.g. GP, Hospital) etc and we may apply stylesheet or other technology to align the data, so that it can be viewed under common record headings, for example Medications.

This data may be incoming as the result of a “push” mechanism (eg triggered messaging from an external system”) , or a “pull” mechanism (calling out to another system and getting that information back over an Application Programming Interface (API)). Again we see these as key features in the health integration engine and clinical portal market.

Note that at this level we explain that we are presenting this data momentarily “on the fly” i.e. without persisting the information in a local Clinical Data Repository.

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**Level 3            ** Sharing of Structured Data + Presentation + Persistence

To the end user this next level may look identical but under the hood there are further changes.

The data sharing is made available either as a result of the pull mechanism/API call (eg FHIR based API) mentioned earlier, or the result of a “push” mechanism whereby the originating system sends the information as an update to some form of trigger to the integrated digital care record.

The significant additional step here is that the data is now persisted in a local Clinical Data Repository (aka Integrated Digital Care Record Repository). The key issue here is the data model/standard and ownership. The vast majority of the CDR market is based on proprietary data models, so further access to/analysis or exchange of that data is dependent on the vendor involved.

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**Level 4            ** Sharing of Data + Present + Persist + Model

After some time, if tackling decision support/business intelligence within an IDCR setting, the issue of data/information models invariably comes up. For these more sophisticated purposes though we may be digesting similar data from multiple source systems, we need to agree on a common data model to run computerised rules over the data.

Whether we want to support clinical decision support/business intelligence over patient information that is distributed (aka federated) or centralised, a process to normalise the data towards a common information model is key. All our experience in this field points to the openEHR specification, methodology and tooling as world leading in this area .

**** ****

Clinical information modelling effort may be at “design time” rather than “run time” but it gives us a common semantic target which is necessary if we ever want to run local Clinical Decision Support over the combined data/information… be that distributed or centralised.  

Here our information modelling work on medications highlights that Medications for example:

Name – Aspirin

Numeric dose – 300g

Unit dose – mg

**Frequency – once a day **

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**Level 5            ** Sharing of Data + Present + Persist + Model + Reconcile

The fifth step on this journey, is a reconciliation step whereby, after discussion between the people involved and a process is agreed, a decision to reconcile towards one entry may be possible.

For example -Aspirin prescription from both the GP and the Hospital having been modelled we note that they are representing the same medication, so a decision is made to reconcile this to one medication instance.

**In reaching this point we draw attention to the fact that a patient-centred view of medication information has required the sharing of information from multiple organisational sources, the modelling of that information and the reconciliation of duplicate information (aka deduplicate the information). It should be noted that such an endpoint requires not only a solid information and technical architecture to make this possible, but requires people and process to collaborate beyond traditional boundaries…. in the patient’s best interest.   **

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An IDCR Maturity Model

We include a summary slide to explain the steps along this integration journey/IDCR maturity model.

It is worth noting that the Ripple showcase stack (inc PulseTile UI framework) has been designed to cater for and support this journey (all IDCR Maturity Model Levels 0-5) towards integrated care.

• The PulseTile UI/UX framework supports a simple yet effective approach to Usability, which encourages the user to explore existing information about the patient before new data is added.

The QEWD framework handles integration “out of the box” and does so in a way that caters for unstructured/structured data, from data that is available “on the fly” to data that is persisted locally.

* **In doing so it introduces clinical information that is modelled to the openEHR standard, the clinical kernel that is the firm foundation of the “[21st Century Open Platform that will transform Healthcare](http://frectal.com/2014/06/30/21stc-healthcare-open-platform)“ and is supported by the EtherCIS Clinical Data Repository. **

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An IDCR Maturity Model in practice…

We now include a couple of screenshots to illustrate this model in practice

ScreenShot 1
Leeds Care Record Single Patient View
IDCR Maturity Level 1: Tabbed View- Primary Care – Information Sharing (View Only)  

ScreenShot 2
PPM+ Single Patient View
IDCR Maturity Level 3:  Sharing of Data (from PAS) + Presentation + Persistence

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Screenshot 3
Ripple Foundation Showcase Stack Single Patient View
IDCR Maturity Level 2 – Sharing via Structured Data + Presentation Transformation

Screenshot 4
Ripple Foundation Showcase Stack Single Patient View
IDCR Maturity Level 4 – Sharing of Data + Present + Persist + Model

Please note in Screenshots 3 and 4, the Ripple showcase stack allows us to blend the IDCR maturity model in one approach.

With access to Level 2 existing/legacy data (e.g. Problem/Diagnosis: Hypertension – from VistA service shown in example) which in this case is read-only,

…while also allowing access to the Level 4 robust information models (e.g. Problem/Diagnosis: Lactose Intolerance – from openEHR service in example here) which we make editable.

**Adding new data via the Create Button, launches a new modal which enters data against the Level 4 approach (i.e. openEHR service) **

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Acknowledgements

The model explained here is based on a simple yet effective model to information sharing that evolved during work on the Leeds Care Record. Thanks to Geoff Hall, for his help and support on the User Interface framework and to Richard Pugmire on the maturity model that underpins this approach.

We believe the principles here are widely applicable across healthcare which is why we are openly sharing this for wider discussion/learning.

Dr Tony Shannon

Director, Ripple Foundation