openEHR-clinical Digest, Vol 35, Issue 4

Thomas Beale thomas.beale at
Wed Mar 11 10:50:43 EDT 2015

Hi William,

there are quite a number of widely known facts and resources ignored by 
the paper. See below.

On 11/03/2015 13:16, WILLIAM R4C wrote:
> Hi all,
> As one of the author's of the criticized paper by Blobel et al, I feel 
> some need to react and give you some thoughts:
> - OpenEHR after 20 or more years is still largely under construction.

you're the only person I've ever heard say such a thing. As you can see 
from this page 
<>, available 
online for a decade, the Release 1.0.2 has been stable since 2008. 
Hardly 'under construction' (although specific things are of course 
always being worked on). The opposite criticism (not enough recent 
releases) would make more sense.

> I have asked many times to get names and locations of reference sites 
> where I can see a real world archetypes based system in action. No 
> response.

Quite the contrary: see this page 
easily findable from the home page, also visible for a decade in 
different forms. Also the well-known locations of various national CKMs, 
containing archetypes used in these systems. (Australia 
<>, Slovenia 
<>, UK 
<>, Norway 
<>, Moscow CKM offline due to trade war with 
Russia..., Brazil being moved as we speak.)

> - the approach with the archetypes is technology driven: 
> implementation specific, not clinically driven. It lacks the basic 
> conceptual, logical, implementation perspective of ISO 11179. In 
> particular the logical modeling is what Blobel et all discuss.

Quite the contrary - the archetype approach is completely clinically 
driven, as everyone knows. Unlike every other effort I know of, 
including HL7v3 and FHIR, openEHR archetypes are /only /built by 
clinical people, in a separated space (CKM). Technical people don't even 
come into it, unless they are also docs or health informatics experts 
who have clinical / lab / other relevant expertise. I'm not trying to 
criticise HL7 or FHIR here, merely pointing out that openEHR clinical 
modelling is literally in a dedicated clinical / health informatics space.

Getting /more /clinician input into FHIR's clinical models and more 
technical input into openEHR's was one of the motivations for the recent 
HL7+openEHR Adverse Reaction joint review (admittedly well after the 
paper publication).

Why an academic paper would report the opposite is a mystery. As I said 
to Jan Talmon, statements demonstrably contrary to reality don't help 
the reputation of the journal at all.

ISO 11179 is a meta-data and registry standard, it has no clinical 
content. Whether it has value for standardising meta-data in registries 
is another (implementation) matter, unrelated to the design concepts of 
clinical modelling.

> - use and grounding the Modelling in formal ontologies is lacking in 
> any of the Modelling approaches: HL7 templates, HL7 FHIR, OpenEHR 
> archetypes, 13606 archetypes, CEMLS, CIMI, DCM in UML. The articles 
> discussed that with respect to 3 examples. All modelers have a job to 
> do. For justification have a look at semantic health net work.

That is more or less true. Semantic Health Net and also years of IHTSDO 
activity shows just how difficult it is to get even the most basic 
agreements on how to do this. Even BFO, which is a much needed as an up 
upper level underpinning ontology has not yet been released as BFO 2.0, 
which is sorely needed.

I would say it is widely recognised that the ontology / model 
relationship needs major attention.

> - the GCM model allows a much deeper analysis of domain, modeling and 
> implementation eg through domains on z axis, business bottom up and 
> top down on y axis, and Reference Model – Open Distributed Processing 
> (RM-ODP) system development standard on x axis.

Well, speaking as an engineer and software engineer, I would beg to 
differ. RM/ODP isn't a formal approach to domain analysis, it's a system 
engineering meta-model - a way of formalising different aspects 
(viewpoints) of systems. I have actually talked with people involved in 
RM/ODP development at ISO (Kerry Raymond 
one such person, but also others) and they agreed that RM/ODP is 
specifically weak in representing any domain / semantic viewpoint (it 
weakly represents it via the 'enterprise' viewpoint). I actually 
produced a health informatics-specific version RM/ODP years ago that was 
presented at HL7. It was met with mild interest, and subsequently never 
used again. Including by me.

The GCM cube is one of those things that looks nice on paper, and noone 
can say it's wrong, but it doesn't provide any useful analytical output. 
It's not dissimilar from Zachman, FEAF and other similar enterprise 
modelling grids. These are designed to help systems engineers not forget 
specific aspects of system design. I have been aware of the GCM cube 
since about 2003, and have never found a use for it other than a general 
explanatory one in academic papers.

If you are going to claim that GCM should be used to help clinical 
domain modelling, you have to say how it is going to do this. The paper 
doesn't do that.

> OpenEHR, like many others have not a complete picture.

well, that's true at least. We need to have some work to do tomorrow...

> Of course you may critique a paper exposing this lack. But it feels 
> like shooting the messenger(s) instead of listening to the message.
> Guys, you've got work to do.

We always have work to do. But apart from the ontology question it's 
probably not where you think it is.

Publishing academic papers that ignore well-known available evidence and 
projects, and make numerous assertions unsupported by relevant evidence 
doesn't help the common cause I'm afraid.

- thomas

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