HL7 FHIR and OpenEHR in a (52 minute) nutshell

As John Meredith puts it nicely as: 52 minutes and 13 seconds of pure interoperability enlightenment!


You may also be interested to read this insightful post after the significant openEHR event in the UK:



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Recent Gartner openEHR Evaluation Report and more!

Evaluate openEHR Standards for Managing Clinical Content Across the Care Continuum

(Mike Jones, Henrik Hallenberg, 7 April 2017)

openEHR standards offer a potential solution to help HDO CIOs retain control of care delivery data in the long term. New capabilities built using these standards can provide a foundation for federated care record services and innovation, but will require investment in clinical informatics skills.

This important report describes how to reduce the risk of vendor lock-in and create the right conditions for innovation by persisting structured clinical content from proprietary care delivery applications outside the EHR.

A link to the full report is available on the Marand website at:


The report gives an overview of:

  • the challenges of EHR Interoperability
  • the current experience of EHR Capability
  • what is openEHR and how can it support Digital Care Delivery
  • how to build an enterprise architecture and clinical informatics capability when adopting openEHR for:
    • National e-health program
    • A federation of HDOs
    • A large City or large municipality

Another Gartner report also recognised openEHR as a key element for future sustainable architectures of healthcare IT systems. It points out to the need for having a full content standard across the board, indicating openEHR, to enable digital health, and indicates shortcomings of relying on health information exchange only.

Healthcare Provider CIOs Need to Rally Their Enterprise Architects Around Citizen-Centric Care Delivery

(Mike Jones, 7 February 2017)

Gartner believes that truly effective and sustainable open architectures will need a capability for vendor-neutral data persistence, such as utilizing a common schema or set of openEHR archetypes and rules for managing structured and unstructured data (for example, a VNA, openEHR or IHE XDS repository in combination with services for trust/consent, ecosystem governance and oversight, and reuse of data and processes for secondary purposes, such as research and population health).

Providing open messaging standards (for example, FHIR, HL7) for data exchange in specific use cases will only go so far in meeting the architectural challenges of digital citizen-centric care delivery.

Unfortunately this report is not publicly available ūüė¶

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openEHR technical basics for HL7 and FHIR users

Recent discussions on the FHIR chat forum with various HL7 people around the topic of how openEHR and other architectural frameworks (e.g. VA FHIM, CDISC) could work with FHIR led to a realisation …

Source: openEHR technical basics for HL7 and FHIR users

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Call for papers to ACI Special Issue on Interoperability and EHR

I’d like to give a heads up to the call for papers to the special issue on Interoperability and EHR in Applied Clinical Informatics. Prof. Kerstin Denecke from Bern University of Applied Sciences and I are guest editors and the aim of this special issue is to have informed and balanced papers on the theory and practice of standards to achieve interoperability and to develop EHR systems (that are intraoperable with Grahame’s token). Deadline is 15 January, 2017.

Link to call for papers (pdf): https://aci.schattauer.de/fileadmin/assets/zeitschriften/ACI/CFP_ACI_Interoperability.pdf

Here’s the full text for convenience:

Call for Papers:

Applied Clinical Informatics Special Issue on New Trends and Experiences in Interoperability and Electronic Health Records (EHR)

Summary and Scope:

The recent focus on HL7’s emerging Fast Healthcare Interoperability Resources (FHIR) has directed attention on the fact that attempts to achieve interoperability have been only partly successful in the past despite a host of existing terminologies (for example SNOMED CT, ICD and LOINC) and standards for health information exchange and EHR (HL7 v2,v3/CDA, openEHR/13606, IHE, DICOM etc.).

This special topic feature of Applied Clinical Informatics will focus on applied, practical approaches of achieving and maintaining interoperability among disparate systems, including EHRs. We are soliciting submissions that focus on best practice approaches, lesson learned or evaluation of interoperability and EHR systems development or identify causes of failures.

Topics of interest:

This focus theme will enlist and assess different approaches of realizing interoperability and electronic health records. More specifically, topics include:

Current applications of methods and standards

  • Applications and lessons in real world scenarios
  • Assessments of application areas of particular approaches

Innovative solutions to using existing methods and standards

Evaluation and comparison of methods and standards

  • Determining overlaps and gaps in coverage and knowledge on application
  • Identifying patterns of good use (e.g. fitness-for-purpose) and meaningful ways for using different approaches together
  • Evaluation of existing interoperability projects

Implementation strategies

  • Information and knowledge representation, transfer, retrieval, formal semantics, interoperability etc. which can be shared between HIE and EHR approaches
  • Studies on persistence, querying, clinical guideline/workflow support, automated graphical user interfaces, software maintainability and usability ‚Äď mainly around EHR systems


  • Selection of methods and standards
  • Studies of challenges in development of applications, including social and business related


Semantic interoperability is the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged with the same confidence as if that information has been generated in the same system. However, this requires standardization at clinical terminology, information model, and clinical workflow levels and thus continues to be a very active field of research and practice.

Existing attempts to achieve interoperability have only been implemented in practice to a limited extent. Clinical terminology standards are mature and while there is convergence around use and adoption of mainstay terminology standards (in particular SNOMED CT, ICD and LOINC), the use of terminology and information models together (terminology bindings) continue to be a hot topic. Health information exchange (HIE) standards for interoperability, which define explicit models of structured content have existed for a while already (e.g. HL7 v2,v3/CDA, openEHR/13606, IHE, DICOM). HL7’s emerging Fast Healthcare Interoperability Resources (FHIR) is now a working standard (although still in draft status) providing lightweight and implementer-friendly ways to structure and encode clinical data over the wire. While FHIR allows for extensibility by design, there is an expectation for systems to conform to a single set of resources, thus enabling interoperability at a global scale. FHIR’s rapid adoption by key vendors and the worldwide technical enthusiasm generated have inevitably resulted in looking at FHIR beyond an HIE/API standard to deliver on the requirements of EHR. According to Gartner, FHIR is at the peak of the hype cycle! Extensive and mature ongoing research and practice around electronic health records (EHR) in terms of architecture, functionality and implementation methods and technologies exists. Standards also exist in the EHR domain addressing various aspects such as ISO 18308 Health informatics-Requirements for an electronic health record architecture, ISO/HL7 10781 (Health Informatics-HL7 Electronic Health Records-System Functional Model, Release 2 (EHR FM)), openEHR (defining EHR structure, semantics, and record organization), and ISO/EN 13606 based on openEHR but limited to HIE. The openEHR/13606 standard has already been adopted by national and regional EHR programmes and has a dedicated community of business users and implementers. Development of detailed clinical models (Archetypes) occurs through voluntary participation of a wide range of users using online tools in grass-roots and crowd-sourcing fashion. Archetypes are designed to fulfil a very broad set of EHR use-cases and hence are maximal datasets in contrast to FHIR resources for HIE, which capture a minimum set of data elements implemented by most systems. While openEHR doesn’t prescribe a single set of content definitions for global interoperability it is envisioned that natural adoption of core clinical models will lead to interoperability. The Clinical Information Modelling Initiative (CIMI) has recently become an HL7 working group with the aim to drive downstream HIE specifications (such as FHIR profiles) based on the Archetype methodology. Both, HL7 and openEHR/13606 communities feel alignment (of content) will be essential and both groups have successfully undertaken a joint modelling exercise. We believe time is ripe for bringing attention on the current slice of methods and trends in EHR and interoperability research and practice, which will hopefully act as a starting point for informed and evidence based discussion around how to leverage relevant standards and technologies.

Submission Types

Research Articles

Research Articles contain original work based on original research or experimentation not previously published or under consideration by another journal.

State of the Art / Best Practice Paper

State of the Art / Best Practice Papers would be generally solicited contributions that describe the state of the art in a particular area of Clinical Informatics. These papers will be based on published research and personal experience with the topic. They will be heavily geared towards lessons learned, best approaches, safety and quality considerations, and outcomes. These submissions are intended to serve as an evidence-based summary of current thinking and practice on an issue with the aim of providing individuals and organizations with a condensed, practical, highly applicable resource relating to an applied clinical informatics issue. They may also signal areas for future research. Systematic literature reviews are not required for this type of submission.

Case reports

Case reports are intended to be an ACI equivalent to case reports in clinical medicine. However, the focus in case reports will be an information system. Case reports focus on cases of interest with the emphasis on ‚Äělessons learned‚Äú. Case reports that focus on failures or successes and their analysis are preferred. Short case reports are preferred and they should not exceed 2,000 words.

Paper submission:

Submitted papers should describe original work, present significant results, and provide rigorous, principled, and repeatable evaluation. Papers must be formatted according to the guidelines for Applied Clinical Informatics authors. Please indicate your intention of submission by sending a short E-Mail to kerstin.denecke@bfh.ch

To ensure that your paper is considered for the special issue, the title must start with ‚ÄúSpecial Topic Interoperability and EHR: ‚ÄĚ followed by your paper title.

Guest Editors:

  • Kerstin Denecke (Bern University of Applied Sciences, Switzerland), kerstin.denecke@bfh.ch
  • Koray Atalag (The University of Auckland, New Zealand), k.atalag@auckland.ac.nz

Important Dates

Paper submission: January 15, 2017

First Round Review Notifications: March 30, 2017

Revision Due: April 31, 2017

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Another good one – oldish but still true


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Shared from WordPress

Why IT people can’t build information systems Рhttp://wp.me/pzYm3-eJ

I thought there are good lessons in it for us kiwis attempting to build a national EHR with exactly this kind of mindset

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A Call to Action – Getting our information right

Hi all, it’s been quite a while…So it’s going to be long. I’m going to make a complete dump of my mind which over the past few days was quite full; feeling really angry, first, then hopeless and then it ‘clicked’ and now I can think really clearly and know which direction I want to take. I hope, as a¬†member of the public and academician, some of the ideas and rather informal tone won’t offend any person or organisation – if so it is completely unintentional. Read on…

OK the topic is a completely professional one: all about what is happening (well for the most part what is NOT happening – but please bear with me) in NZ health IT. I think we, as a country, are at an important cross-road now:

– We have a new health minister who’s forward thinking and willing to take reasonable risks – that is the NZ EHR, or officially known as “Single EHR”. I strongly support the idea and personally don’t see any other option as this is clearly what every developed nation is currently doing. So we ought to take the step – full stop.

– Unfortunately, Health IT, like healthcare delivery in NZ, has been way too fragmented. Over the past 8 years that I have been fortunate enough to call this beautiful country home, the investments have been overly cautious and mainly risk averse. The word “EHR” has been a tabu but new words have been invented to circumvent the acute need in some key areas: Shared Care Systems. I myself have been on the bandwagon for a while. It is basically a mini EHR plus a multidisciplinary workflow tool – how cool is that? It became apparent during implementation that, while the scope of EHR might be small, this is like overcoming the escape velocity to overcome Earth’s gravity and reach space: you’ve got to overcome all of¬†the hurdles – technical and information-wise no matter how small or big the payload is. What happened? Bigtime FAIL (except for a few places, such as Canterbury, where truly stars have aligned).

– At the same time, while in many developed jurisdictions¬†hospitals have been blessed with fully integrated EMR systems, we kept on patching our fragmented systems and establish individual integration between disparate systems. It is hilarious that DHBs have just recently gotten rid of IE6! Way too many DHBS, way too many systems and way too many ways of healthcare practice and administration. Makes one think, whether this might actually been a deliberate way to create more jobs! Naah ūüėČ

– The primary care health IT, together with NHI, has been the main factor for NZ to score at the top among many developed nations (see slides 4-8), something magical had happened: almost all GPs have been meaningfully and actively using an EMR: Practice Management Systems (PMS). So much so that when the system was down I observed GPs were¬†really upset as they couldn’t get a patient’s history during the short¬†encounter. I really think the single vendor who held like 95% of market, MedTech, has done a monumental job and single-handedly carried NZ to the top of the league. Yes All Blacks of health IT, in primary care. But once you’re at the top there’s only one way you can go – rest of the world has caught up and now passed us. Sad but true. Sorry I have no hard evidence but you may ask your GP next time you visit what they’re thinking about their PMS ūüėČ

– We do have a counterpart star in secondary care – Orion Health. I, like many NZers, feel very proud about their great successes internationally. Like Lorde…But because there has not been a drive in NZ for fully integrated hospital information systems they didn’t build¬†such a product for a long time. Naturally their core competence has been around health information exchange. Their integration engine, Rhapsody, is truly an amazing product – as many say. I don’t have any practical experience with it as yet but it now natively supports the all new HL7 FHIR standard. And the smart Concerto – a web based clinician portal in secondary care powered by Rhapsody. That was the sensible¬†area to focus¬†– since the reality was that there were heaps of disparate systems in a hospital they had to excel in bringing useful information to the clinicians to support direct care. Absolutely crucial. They have also recently acquired a fully integrated hospital EMR from Microsoft – but we don’t hear much about it.

So why am I telling all this – this blog has so far been followed by only a few, already knowledgeable about health IT in NZ, either technically enthused clinicians or clinically enthused developers and a few of us who are formally in between. I’m intending to disseminate this post (I’ll probably shorten and make a¬†more formal version later) very widely, even internationally. Please bear with me…Here’s the deal:

I was at HISO meeting yesterday – yes I’m an expert advisory member of our National Health Information Standards Organisation. I’m not aiming at showing off – but I’m also a member of the Sector Architects Group and have co-authored the National Interoperability Reference Architecture which in 3 parts published as a HISO standard. I am also a Board Member of HL7 NZ¬†(recently resigned from vice-chair as I have a full-time job at the University!). I’m in the steering committee (I think!) of the Integrated Data Initiative of Stats NZ – for secondary use. I’m also member of the Management Board of openEHR¬†– that’s international and I’m really loving it. Well that explains why my CV is weak on academic publications – I have been¬†so eager to work¬†in¬†the ‘Real World’ ūüėČ So one might think I must have been awfully busy and making a lot of contribution these days. Not the case in NZ and that was my wake up call today! I had a brilliant day with family – helped me to reflect on my experiences over the past years and I reckoned what was bothering me. I am absolutely not contributing enough and kind of started to feel worthless instead of all that glitter ūüėČ And even start to criticise things…what a loser – right?

The reality is, I honestly think, the government is doing as best as they could. With so little resources and capacity for health IT. So instead of criticising and feeling miserable about things I chose to contribute – more effectively and directly. So I’ll try to portray how I was feeling until this afternoon (OK I admit, it was a glorious day in Auckland and I got out early from work and went to the beach with family ūüôā

The pessimist view: I heard from the govt¬†officially that¬†openEHR will not be used in NZ EHR. Wow how dare! This is the only fit-for-purpose EHR standard in the world and I’m bloody on top of this… Our very Interoperability Reference Architecture actually is underpinned by openEHR. So what happened? And yes now we have FHIR – the panacea in health interoperability. Oh and SNOMED CT – humanity’s most expensive terminology. But IHTSDO knows the business, it works with governments. Since there’s no competitor¬†there is no risk. So governments happily subscribe – some even pay tens of millions! Don’t get me wrong, I strongly support standardisation in clinical terminology and have actually developed one of the first clinical systems with an automated SNOMED encoder (back in 1998 – PATHOS-WEB, my anatomic pathology system. Yes I was once a developer – for 15 odd years! It held >2 million records, about 30% SNOMED encoded back in Turkey). So I know a little bit about SNOMED ūüėČ No I don’t like the way IHTSDO operates (even many of IHTSDO members will be surprised to hear SNOMED had been translated into Turkish back in mid-90’s and due to their agressive commercial direction¬†back then the Turkish editor who I worked very closely with sent all print material to recycle and destroyed electronic copies!) and current archaic structure and limitations of SNOMED but hey they are overwhelmingly successful – so they must be right! And I accept it – SNOMED is our best shot. GALEN is dead. Medcin never took off. VHS won over Betamax! once again!!! So will it be the case for FHIR and openEHR?

My current view: I know whether we get a Big vendor’s EHR or a local solution (code name: NZ Inc.) we need to define our national clinical information requirements. So this is a homework we ought to do whatever the solution might be. Now a bit Health Informatics 101 stuff but we health informaticians know by heart (at least my students!) there are several different layers for interoperability and thus building a decent EHR:


So what do we currently have in NZ?
1- Data layer: ticked, that’s bread and butter these days. Not a problem
2- Terminology layer: ticked? well effectively yes, we do have ICD10AM, LOINC (NZPOCS) and now SNOMED CT. That should be enough for a while. Need a terminology server and Patients First is working on it. Thanks to Peter Jordan.
3- Content Standards: Houston we have a problem! So I argue strongly there is currently no coherent group in NZ addressing this at a national level using best scientific and other evidence available. The standards group within the Ministry with limited resources¬†have been¬†putting together some information standards recently but I believe this should be done with more engagement from the Sector – especially¬†from¬†clinicians and consumers.¬†Keep in mind¬†this is the information level – or more formally: Information Modelling. That’s the business level – healthcare. So currently proposed Content standards for NZ EHR are all technical – where is the¬†clinicians’ and consumers’ voice? That is what openEHR delivers – non-technical people can directly contribute to content development (e.g. how to record a clinical diagnosis, lab result, prescription or even as simple as body weight) using mature high-level tools.¬†Ah but we have FHIR – right? read on…
So the question is: where is the source of truth for clinical information definition for Single EHR?

I must admit there is overlap, possibly significant, between the definition of clinical information (aka Content) within EHR and the content at¬†API. Truth is, FHIR is still in its infancy, don’t get me wrong, it is a working brilliant standard which I’ve been a strongly supporting… There are many real-world examples. But these are all health information exchange type of projects – mostly used to provide fast, innovative and predominantly mobile App extensions to Big Vendors’ big EMR.

Although its¬†uptake has not been rapid, openEHR in turn, has been in this space for almost two decades. Moreover, openEHR is the only standard, by way of a fit-for-purpose EHR Reference Model, that provides an architecture for EHR – that is a lifelong, longitudinal clinical record organisation that is capable of satisfying medico-legal, ethical and provenance requirements (that have explicitly been defined in ISO 18308 – Requirements for an electronic health record architecture).¬† We now have whole national programs (Norway, Brazil), regional projects (Australia, many EU countries, Russia, Middle-East and Asia) and specific products and projects. See this whitepaper for more details. We have around¬†1500 active users: expert clinicians, terminologists – lots of hard-hat health informaticians contributing, globally to defining these information models – called Archetypes (see¬†CKM and select Report>Statistics). Suprisingly so few from the US. I hope it will change (Well maybe¬†not with Trump ¬†ūüėČ

The point I’m making is: it is not a matter of FHIR or openEHR, I say why not FHIR and openEHR?¬†That seems to have been identified as the low risk option by many governments, regions and large projects (again refer to the whitepaper). Even HL7 itself is doing it (The Clinical Information Modelling Initiative uses Archetypes as source of truth to derive FHIR profiles). What’s so special about NZ? I believe there is a need for education and support – and I intend to do just that – with your help!

Reality is openEHR currently has many validated and mature information models which we can leverage to define our own EHR information requirements. It would be a breeze to create FHIR profiles and extensions and SNOMED RefSets once we know what information to collect and how. Trouble is FHIR currently does not have enough models and more importantly the tooling which clinicians can comprehend and create content. Yes my valued colleague and friend David Hay has been meticulously working on ClinFHIR tool – but I’m sorry it simply is not there yet for confronting clinicians. It took openEHR almost a decade and a handful of¬†full-time developers (kudos to Ocean Informatics) to create CKM (openEHR’s web based collaborative clinical model governance tool). But many national and regional programs have been using it successfully to quickly, cost effectively and relatively easily define clinical information requirements. I told¬†the analogy of building a real building to David yesterday at the airport over a couple beers: building an EHR is kind of similar to building a house: you start with a foundation, national MPI (NHI in NZ), health provider list, medicines list, formulary etc. we already have most of it in place – thanks to the NHITB. Then you assemble¬†the walls, floors, kitchen, bathroom etc.¬†and lastly you put the windows and doors and chimney – right? So, in my opinion,¬†we have the foundation (e.g. NHI, NZULM etc.) and bricks (terminology – ICD, SNOMED, LOINC) but we need to have the interior design to build walls, internal doors, kitchen, appliances etc. This is similar¬†to the definition of detailed clinical models for building a decent EHR. Once we get them right, only then, can we start putting windows and doors (APIs). I believe – strongly.

OK I’ll cut to the chase: Inspired from recent purchase of a private beach on behalf of the public via crowd-funding in NZ ¬†I suggest we, health informaticians and enthusiastic clinicians and consumers, pretty much everyone who can contribute, to support the government in the quest for EHR.¬†And I hope we can manage¬†to provide this at no¬†direct cost¬†to the government. Timeline is pretty tight – they are aiming to get it running by 2018 so we got a lot to do. I hope at least some¬†of you will join me.

So I’m thinking, this is beyond openEHR now, so probably a working group within HINZ might be a good platform – Health Information Working Group? I’d be interested in your feedback. Don’t forget, terminology and API are¬†already in good and capable hands (govt and HL7 NZ). Everyone’s input will be valuable to help define key terminology sets and information models/datasets required for NZ EHR. I’m sure a participatory and consensus based input from a much wider and informed¬†group will be very helpful for the standards group within Ministry of Health and HISO. Let’s do this! I’m sure if openEHR provides real value in this journey the government may¬†consider their decision again.

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