How to fix CKM biggest issue

Heather Leslie heather.leslie at
Fri Mar 13 01:10:08 EDT 2015

Thanks Evelyn,

Even I forget the real roots… We should document it so we don’t lose the provenance.



From: openEHR-clinical [mailto:openehr-clinical-bounces at] On Behalf Of Evelyn Hovenga
Sent: Friday, 13 March 2015 2:53 PM
To: 'For openEHR clinical discussions'
Subject: RE: How to fix CKM biggest issue

Thanks you for this historical overview Heather.  I’d like to add that the original CKM was developed, maintained and funded by Central Queensland University.  It was taken over by Ocean Informatics when that University decided to shut down its entire HI Research Centre at the end of 2007.

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Dr Evelyn J.S.Hovenga, FACS
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From: openEHR-clinical [mailto:openehr-clinical-bounces at] On Behalf Of Heather Leslie
Sent: Friday, 13 March 2015 1:12 PM
To: For openEHR clinical discussions
Subject: RE: How to fix CKM biggest issue

Hi Gustavo and the openEHR community,

I’m really sad and disappointed if Gustavo’s opinion is mirrored elsewhere in the openEHR community.

I’m sure it reflects a frustration with the slow process over past years. But anyone who has bothered to ask me about how I feel about the progress will hear that I am much more frustrated than any of you.

We, as the openEHR community really need to do a bit of soul searching. From my point of view we’ve all been very passive about this modelling work, all waiting for someone else to do it or take responsibility for it.

The reality is that when Ocean first launched the openEHR CKM, the work fell to Ocean people. Either Ocean funded it OR Ian and I did the editorial work in our own time… no other option, and has been the way for years. Truth is, after a couple of years and getting a couple of hundred archetypes publicly available on CKM, I was really burned out and unwell. No-one seemed to notice the effort, to be honest. Certainly no-one seemed to appreciate it.  I stopped doing the work in my own time and reclaimed my evenings and weekends. I hoped that there would be a cry of outrage from the community – “Why has the CKM work stopped?” But no one noticed; no one said anything, for at least 18 months, possibly more.

This passivity has astounded me.

Over 2 years ago, there was a bit of an epiphany – a special strategic board meeting was held in London where others were invited, including myself. The attendees all agreed that one of the highest priorities was to get archetypes published. I was able to present calculations on how much it would cost to fund some editorial work to get this happening. Nothing happened.

Finally, in the second half of last year, the Industry Group has been able to offer the first funded work to Ian and myself to try to fast track some archetypes through to publication. This is the first funding that has been raised in the openEHR community for this critical modelling work ever. The scope is clearly limited to publishing 69 archetypes. Unfortunately there was no extra allocated for the extra time required to train or mentor others to do the work.

The Industry Sprint hasn’t been as fast or as focussed as either Ian or I would like as we both have ‘day jobs’ that require our attention as well. However you will have seen a flurry of activity in the past couple of weeks – 9 archetypes have been refined and sent out for review in the past 10 days. I really appreciate that the Industry Group has collaborated and committed to this support. And of course it is really exciting that this is one of the first times we will see potential competitive vendors working together to get clinical content standardised – breaking down the siloes!

So the situation IS changing…

And in addition, we need to recognise what we do have – an amazing set of building blocks and an approach to clinician engagement that has not been emulated in any other domain or standards work. This current openEHR approach is world-leading and with fairly modest resources we can do a lot more that needs to be done.

The community has a fantastic problem. As of today we have 1300 users from 85 countries registered on the openEHR CKM. What a spectacular resource we have at our finger tips; 381 people have specifically volunteered to review and 199 to translate archetypes – all through word of mouth, no advertising. We have a purpose-built tool has been developed and provided free of charge to the community for over 7 years in order to manage the library, collaboration and governance of information models use that. We have only two trained Editors and a handful of others with limited experience and zero resources committed to managing it. So far it has been run on the ‘smell of an oily rag’ – not sure how that will translate outside of Australia – and this needs to change to become sustainable.

From a tooling point of view, CKM has been purpose-designed and gradually enhanced to do all the things that Gustavo dreams of – projects and incubators (acting as sandpits for raw archetype development); multiple roles for reviewers, editors, CKAs have all been there for at least a year; archetypes can be proposed in the next release of CKM. Community participation is the focus, and the capability is not currently being leveraged as it could, and the healthy tension between ‘bottom-up’ and ‘top down’ can be managed. But the real problem is that there are not enough people trained as Editors, and no one resourced to manage/govern the work.

Bringing on new Editors is absolutely welcome – both Ian and I are very keen to share the Editorial and Clinical Knowledge Administrator load more broadly, because otherwise the CKM work is not sustainable. All this talk of the community being unable to participate is not actually fair or reasonable – when I’ve put out a call for Editors we’ve had a few people volunteer, true. To be honest though, most of those that I have discussed it with in more detail have then declined when I’ve explained the amount of commitment or they’ve simply participated in an editorial meeting. For those remaining, they need training and then ongoing mentoring. But who is to do this? How is this to be resourced? It absolutely does need to be resourced appropriately.

By contrast, I have been working under contract with the Norwegian CKM team recently – they have been resourced to develop archetypes and develop processes for governance and in many aspects after only one year of activity they are now more advanced than the openEHR community. We are working closely with the Norwegian CKM team to ensure that we can develop processes for collaboration between CKMs. Silje Bakke from the Norwegian CKM agreed last week to co-edit the Problem/Diagnosis archetype with me and that archetype was sent out for review last night. other archetypes have had guest editors involved as well, under Ian and my mentorship.

Key learning: in order for the openEHR work to accelerate, there needs to be modest financial resources committed to the archetype standardisation work, beyond the very limited scope of the sprint, and the resources need to be dedicated, not fitting it in between other work committments.

As an aside, personally,  I’m sick and tired of personally being considered a ‘blocker’. If only you can imagine how keen I am to upskill others and share this onerous responsibility with others; of course at the same time this will ensure that this approach will be sustainable into the future, and all my work, passion and vision will have been worth it. If I keep ‘control’, as some choose to view it, then I can be sure that all this effort will have been in vain.

And I’m thoroughly sick of Ocean involvement being regarded as ‘the enemy’. I’m not going to address accusations of ‘conflict of interest’ in this forum – the assumption of huge commercial advantage never gets balanced by the huge cost of volunteering leadership. Perhaps one day one of us will write our memoirs… ☺

Back to the main point again - the community should be rightly feeling indignant about a lot of things, but rather than complaining or ‘thinking about it’ we need to be actively doing something about it. We have a new openEHR Management Board – I hope they will do something about this? But, also, if you are one of the indignant what are YOU personally going to do about it?

I’ve done what I can with essentially zero resources, now what do you propose?…



From: openEHR-clinical [mailto:openehr-clinical-bounces at] On Behalf Of Gustavo Bacelar
Sent: Friday, 13 March 2015 3:51 AM
To: For openEHR clinical discussions
Subject: Re: How to fix CKM biggest issue

Hi Ian, Sebastian and everyone,
on early 2009 Microsoft discontinued its encyclopedia, Encarta. MS Encarta had a limited selection of professionally edited content, but it was defeated by an initiative of non-professional edited content: Wikipedia. By that time, Wikipedia offered 2.7 million articles in English, Encarta had 42,000 entries.

Encarta did try to adapt, inviting users to submit suggestions for changes to articles, but those suggestions first had to be checked by a member of the Encarta staff. And Encarta did not allow users to submit new entries.

My point is: openEHR has a huge potential, but it is still too bureaucratic. It must be free to follow its path.

Someone can say: "but the quality of wikipedia is questionable, the Editors are not professionals!". In 2005, Nature famously reported<> that Wikipedia articles on scientific topics contained just four errors per article on average, compared to three errors per article in the online edition of Encyclopaedia Britannica.

​I've been spreading the word about openEHR through courses ( and consulting and I can see more and more people aware of it, but the barriers are not moving. I've tested the beta version of CKM, thanks Sebastian! It seems to be a very important upgrade, including the CKA role.

I understand that the focus of the Editorial group is to get green ticks, but if there were more Editors would be more green ticks as well. By mid-2012 there was a Call for CKM Editors. There were at least three people interested: Domingo Liotta, ​Pablo Corradini and I. Nothing happened since then.

When it comes to using CKM to local projects, I really think it would be much better for the community. It a local project would like to develop new archetypes, it would be better to do it within an international context instead of developing them locally.

It is important to separate the interests of openEHR Foundation from Ocean's, at his time there in conflict. Ocean wants to sell their products, I don't blame it, but the international CKM needs to be a central hub for archetype development. It doesn't matter if its for commercial projects or not as long as the content:

  *   Is of interest and not repeated (e.g. a local version of an existing archetype)
  *   Is not a specific admin data for particular use
  *   Is available in CKM for community.
Many of the existing archetypes in CKM were created to fulfill commercial use, so it should be used as a source of resources. I will use the words on openEHR website and openEHR Wiki:

"The openEHR CKM has gathered an active Web 2.0 community (...) for sharing health information between individuals, clinicians and organisations; between applications, and across regional and national borders."

​A moral liberal approach would put more load on the Editors, but only if we don't increase the Editorial team. It is better to have many useful incubated archetypes ​than not having then in CKM. If these archetypes are so important, we will be able to see and improve them as soon as possible. Let's think about Encarta.

Best regards!
Gustavo Bacelar
MD + MBA + MSc Med Informatics
Skype: gustavobacela
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