John Meredith, Lead Application Design Architect
NHS Wales Informatics Service
Clinical information requirements are integral to the development of digital solutions across NHS Wales and may be used as part of the patient electronic health record (EHR). However, there is no standard to how this activity is conducted, nor a clear ability to reuse data definitions for a variety of different clinical areas.
Translating health and social care concepts into the digital domain, and maintaining the clinical voice requires tools that are accessible by both technical and clinical partners. The resulting models must be clear to all potential users.
Clinical care data is complex and constantly evolving. openEHR is a technology used across the world to support digital records. The ability to create and reuse clinical models known as archetypes is part of national programmes worldwide. It uses the Clinical Knowledge Manager (CKM) tool.
This project sought to establish if the underlying principles of openEHR could support the work of the Wales Cardiac Network (WCN) in defining a digital model of the acute coronary syndrome (ACS).
Clinical care is an expensive resource and it is vital that time is spent effectively in the development of software and applications. openEHR supports the virtual curation of clinical models, providing a governance wrapper around how they are developed and subsequently requiring clinical sign off. The potential to support clinical staff to carry out this work without invoking resources to hold physical workshops and arrange transportation could provide an additional level of agility during the development of digital systems.
The ability to work in a way that fits the patterns of clinicians across the Health Service was an important attribute.
Reusing models developed by others and subsequently sharing those produced by the project demonstrates a means to reduce variation in this process whilst sharing the burden of governance.
Engaging with an interested clinical group.
The project was seen by some to produce working software although there was no scope (or budget) to do so. The WCN saw the development and agreement of data definitions as a specific issue that has affected them historically. They became an effective stakeholder to support the project aims.
Securing clinical time to hold an initial training workshop proved difficult. The nature of clinical modelling is complex although the openEHR tooling alleviates some of the more technical aspects, training is still required to support understanding of the techniques and processes involved.
Curation of the ACS pathway lead to the development of two new archetypes for Crusade Bleeding Risk and GRACE ACS Risk scores. Most of the model development comprised of archetypes already available, or those needing minor modification. However, the proportion of reusability was significant.
The nature of the ACS pathway involves perspectives from different stakeholders, and describes key processes such as referral, clinical history, risk assessment and investigations.
It therefore represents a complex clinical model that required decomposition into key components. Curating a model in this way made it more digestible with the stakeholder modelling team, leading to the creation of two “templates” for ACS Referral and ACS Pathway Outcome.
To support learning, the training workshop employed a “handholding” approach, using concepts that were well understood by cardiologists and working with pre-developed models. As the modelling progressed, the aim then became to tail off support as understanding of the process became embedded. New archetypes were reviewed with the group using the internet based digital tools over a two-week timeframe.
The resulting models have been published on the UK CKM, with new models submitted to the international CKM for consideration by the wider community.
Following the successful development of the ACS pathway models, a governance review will be conducted by the WCN. This will be analysed before the curation of the remaining three pathways that are a deliverable of the Cardiac Informatics roadmap.
The publication of ACS models will facilitate further work to assess the efficacy of openEHR tooling for NHS Wales clinicians. The nature of publication on the CKM will invite collaboration with other openEHR communities across the world.
These templates represent readily deployable clinical data structures for use within any openEHR compatible system, supported by electronic forms for rapid application development.
“grateful for the development of my Bevan peer network that has forged links with new friends and colleagues – it’s been very valuable to me!” John Meredith
Part of cohort Bevan Exemplar Projects 2018-19