openEHR-clinical Digest, Vol 35, Issue 7

WILLIAM R4C wgoossen at
Wed Mar 11 12:33:21 EDT 2015

Dear Tom,

Thanks for your comments.

It is getting a long tail, so I will break it down in small pieces.

Glad we agree on the need for binding to ontologies. 
I see no need to wait for BFO 2.0 where 1.0 is available. 
Our model challenge will be exactly to handle such differences of different ontologies all the time.

Glad we agree on GCM being helpful in analysis.

My point of no EHR implementations is supported again by your answer. Yes there are many CKM instances and archetype developing projects.

I followed your link to who is using...

I SEE NO REFERENCE to a hospital I can visit running an EHR using archetypes. Similarly No GP or No nursing system in your list. It all seem to be pilots and trials or systems with viewers and partial functionality.

Vriendelijke groet,

Dr. William Goossen

Directeur Results 4 Care BV

> Op 11 mrt. 2015 om 16:50 heeft openehr-clinical-request at het volgende geschreven:
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> Today's Topics:
>   1. Re: How to fix CKM biggest issue (Ian McNicoll)
>   2. Re: openEHR-clinical Digest, Vol 35, Issue 4 (Thomas Beale)
>   3. Re: Clinical Modeling - A critical analysis (Philippe Ameline)
> ----------------------------------------------------------------------
> Message: 1
> Date: Wed, 11 Mar 2015 13:40:24 +0000
> From: Ian McNicoll <ian at>
> To: For openEHR clinical discussions
>    <openehr-clinical at>
> Subject: Re: How to fix CKM biggest issue
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>    <CAG-n1KzfiBTLQ7i9WCeXNYZ1RY5VqNDcXV69Tb+S9jmW2h8w2Q at>
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> Hi Gustavo,
> I think you raise a very important issue, and at key point where the new
> Management Board is in a strong position to take a careful look at how to
> move forward.
> I see that Sebastian has responded to explain the upcoming changes to CKM
> which will make broader community interaction much clearer.
> I also wholly agree that we badly need to expand the Editorial group for
> the international CKM. The constraints there have been largely about
> resourcing, and of course in getting people trained up and comfortable in
> taking on that role. Although the Industry Sprint has gone slower than we
> had hoped, it has provided much-needed protected time for the current
> Editors to get the publication process moving. Our priority still has to be
> to get the green ticks up but I would hope we will soon be in a position to
> expand the team and share some of the burden.
> You are also correct that we need to make it much easier for people to
> share archetypes and collaborate at an early stage, using the incubator
> facility but we do have a challenge in coming up with some fair rules of
> engagement, given that CKM, though a commercial tool, is provided
> free-of-charge to the openEHR Foundation.
> I don't think that it would be fair, either to Ocean, or to Ocean's other
> paying customers, for people to use the international CKM for any local (or
> indeed commercial ) projects they choose. We would also face the problem of
> competing local and national archetypes, co-existing in the same space.
> Philosophically I don't have a problem in moving to a more Wikipedia type
> model but I think we are some way of being able to achieve this in terms of
> effective governance or a funding model that would be commercially-viable
> and sustainable (whoever supplies the tooling).
> Coming back to the original issue around Editorial resource, a more liberal
> approach to community uploads also puts more load on the Editors, in terms
> of monitoring and advising which resources should be pulled in to Projects.
> The worst thing that could happen is that due to lack of Editorial
> resource, many useful incubated archetypes remain in that state for a
> prolonged period
> Let's continue the discussion. I think we need to start with looking at how
> to expand and resource the Editorial team.
> Regards,
> Ian
> Dr Ian McNicoll
> mobile +44 (0)775 209 7859
> office +44 (0)1536 414994
> skype: ianmcnicoll
> email: ian at
> twitter: @ianmcnicoll
> Director, freshEHR Clinical Informatics
> Director, openEHR Foundation
> Director, HANDIHealth CIC
> Hon. Senior Research Associate, CHIME, UCL
>> On 11 March 2015 at 09:54, Gustavo Bacelar <gbacelar at> wrote:
>> Dear all,
>> I would like to suggest some very important changes for governance model
>> of CKM. As you all know, CKM is a keystone to openEHR, but its actual
>> governance model is outdated and holds the development and inclusion of new
>> archetypes.
>> As long as I know there are only 2 main editors that can import any type
>> of archetypes to CKM. I'm an editor too, but I can only import to
>> Ophthalmology Project and some other Incubators. The inclusion of new
>> archetypes can not depend on only 2-3 people. It is a huge constraint to
>> the development of openEHR, we must have more main editors.
>> What I propose is to follow a governance model similar to Wikipedia. It
>> should be possible to anyone to submit archetypes, but these would be in a
>> sandbox, which already exists: the Incubators. These would stimulate other
>> participants of CKM to develop new archetypes and to improve them much
>> faster. When an archetype is sufficiently mature, an editor would include
>> it to public use.
>> Kind regards
>> --
>> Gustavo Bacelar
>> MD + MBA + MSc Med Informatics
>> Skype: gustavobacela
>> ?r
>> LinkedIn:
>> _______________________________________________
>> openEHR-clinical mailing list
>> openEHR-clinical at
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> Date: Wed, 11 Mar 2015 14:50:43 +0000
> From: Thomas Beale <thomas.beale at>
> To: openehr-clinical at
> Subject: Re: openEHR-clinical Digest, Vol 35, Issue 4
> Message-ID: <55005643.7030503 at>
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> 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 
> <>being 
> 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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> Message: 3
> Date: Wed, 11 Mar 2015 16:50:35 +0100
> From: Philippe Ameline <philippe.ameline at>
> To: openehr-clinical at
> Subject: Re: Clinical Modeling - A critical analysis
> Message-ID: <5500644B.9060603 at>
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> Le 11/03/2015 13:41, Thomas Beale a ?crit :
>> In that case, I suggest a starting point is to dig out the original 
>> article and come up with a framework /headings for an article that 
>> properly addresses the same questions, providing evidence from the 
>> many projects around the place (I meant to mention Linkoping, and I 
>> see Mikael Nystrom has chimed in). I would suggest an off-list email 
>> loop for this.
>> - thomas
> Hi all,
> Being myself pretty "ontology based", and maybe more prone to understand 
> what Blobel meant (understanding isn't approving ;-) ), I would be glad 
> to be part of this group writing process.
> Typical question that could be asked, since we all "tell stories" in 
> natural language by making sentences made of words arranged according to 
> a grammar (but grammatical concepts are nowhere inside our sentences), 
> is why should we need an external structure such as the one present 
> inside the Archetypes to "tell a patient health journey"?
> Answer may be that there is no universal/commonly agreed ontology and 
> "grammar"... but the structure that compensates for this as a 
> "grammatical exoskeleton" could appear somewhat dated would the web 2.0 
> provide patient centered languages.
> Best,
> Philippe
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