Socio-technical challenges when the openEHR approach is put to use in Norwegian hospitals

Thomas Beale thomas.beale at
Fri Mar 11 09:15:50 EST 2016

I can only see the abstract for now, but I think the authors seem to 
have developed the misconception that end-users would somehow be 
designing applications. openEHR doesn't try to do that, and it's the 
first time I've heard anyone suggest it. openEHR just enables domain 
experts (generally = a small proportion of healthcare professionals, who 
might also be some kind of system user in some part of the world) to 
more directly define the information content of the system, in such a 
way that it can be processed and queried on a semantic level.

The Business Purpose of Archetypes section in the Archetype Technology 
help to show why this is useful and necessary (it's short!).

There are still many other problems to solve such as clinical workflows 
and user interaction / UX.

I am currently at Intermountain Health in Salt Lake City working with 
the Activity Based Design (ABD) group that has developed a new 
architecture that I think has a realistic chance of addressing a) 
workflow (e.g. typical nursing tasks like cannulation; more complex 
cooperative workflows that involve shared care) and b) some aspects of 
UI interaction within workflows. They are just at an early prototype 
stage, and it has taken nearly 2 years to get to the current 
architecture (naturally taking into account many previous attempts and 

This effort is the first I have seen that has what I think may be the 
needed theoretical understanding and technical architecture to starting 
to solve clinical process and (some of) UI/UX. And what does it rely on? 
Formal clinical models, and it assumes that those models are created by 
clinical experts. Not only that, it explicitly assumes a 'template' 
concept of the same kind as openEHR's, in order to construct useful data 

It considers these 'templates' as the basis of an 'Activity' 
description, which then adds new abilities to blend in some presentation 
directives, pre- and post-conditions, some workflow elements, 
cost-related items (e.g. ICD coding) and so on. The innovation here is 
to consider an Activity a unit of clinical work and to attach these 
process-related semantics into that level of artefact.

So let's just reflect on the fact that this research is only now 
emerging from one of the leading institutions in the world that has 
historically specialised in workflow and decision support.

openEHR as it is today is just a semantic content + querying platform, 
and I think we can reasonably say that we have some handle on generating 
developer-usable artefacts, i.e. things like TDS, TDO etc, but they are 
all content related. These are starting to be standardised now.

The openEHR of today needs to leverage new work such as ABD (or 
something like it) to achieve many of the things that the Norwegian 
paper talks about. The paper seems to be critiquing a somewhat 
unrealistic set of expectations re: openEHR, although I am sure it has 
useful lessons.

I'll provide a proper description of ABD ASAP, which I think will 
provide our community (particularly those working on clinical workflow, 
process etc) new ideas on 'the next layer' for openEHR.

- thomas

On 09/03/2016 23:58, Bakke, Silje Ljosland wrote:
> Hi everyone!
> As some of you may have noticed, a paper called “Evaluating 
> Model-Driven Development for large-scale EHRs through the openEHR 
> approach” 
> ( 
> was recently published by a PhD student at the University of Tromsø. 
> The paper has some pretty direct criticism of the ideal of wide 
> clinical engagement in widely reusable information models, as well as 
> the clear division between the clinical and the technical domain 
> inherent in the openEHR model. I think a lot of the observations 
> detailed in the paper are probably correct, for its limited scope (one 
> Norwegian region and 4 years of observation, half of which was done 
> before the national governance was established). We’ll probably use 
> the paper as a learning point to improve our national governance 
> model, and I’d like to hear any international (and domestic Norwegian 
> for that matter) takes on the implications of the paper.
> Kind regards,
> *Silje Ljosland Bakke*
> **
> Information Architect, RN
> Coordinator, National Editorial Board for Archetypes
> National ICT Norway
> Co-lead, Clinical Models Program
> openEHR Foundation
> Tel. +47 40203298
> Web: <>/ Twitter: 
> @arketyper_no <>
> _______________________________________________
> openEHR-clinical mailing list
> openEHR-clinical at


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