Norwegian national governance of archetypes Silje Ljosland Bakke RN

Information architect, National ICT Norway

Norwegian public hospital system

The Norwegian public hospital system consists of

four Regional Health Authorities (RHAs), with a

total of 24 Hospital Trusts, each of which have

one or more hospitals. 100% of the hospitals

have adopted EHRs. Two vendors dominate

the hospital EHR market; Siemens (Central

Norway) and DIPS (the three

remaining regions). One

common health trust, National

ICT (Norwegian: “Nasjonal

IKT”), acts as a strategic

coordinating unit for the

hospital sector’s common ICT

commitments.

openEHR in Norway

As of yet, only Oslo University Hospital is using an

openEHR based system in a production

environment. DIPS is finalising its implementation of

openEHR, and their solution is being tested in

hospitals around the country. Several other vendors

are either in the process of or are looking into

implementing openEHR as part of their products.

National ICT has developed and deployed a scheme

for the national governance of archetypes. The goals

of the governance scheme is ensuring a high quality

of archetypes as well as enabling semantic

interoperability between systems through the use of

identical archetypes. The governance scheme is

heavily dependent on a common tool for both

collaborative development and sharing of

archetypes and templates. For this purpose,

National ICT has chosen the Clinical

Knowledge Manager (CKM) from

Ocean Informatics.

The governance model

The governance model has three

main phases; development, review

and approval.

Development

Development of archetypes is based

on a so-called “do-ocracy”, where

those who actually spend time and

resources doing something decide what gets done

and in which fashion. Whoever wants to influence

decisions can do so, but only by participating

actively in the development process. This has the

advantage that as long as someone is willing to

spend the resources to do something, it will get

done whether or not anyone else is interested in

participating. To ensure a real possibility of

participation in new initiatives, this model also

requires a very open and transparent development

process, something the CKM does very well.

The actual archetype development is done in a

geographically distributed manner, using the CKM as

a collaborative tool. Requirements are defined by

the originating initiative, alternatively in

collaboration with vendors

and other participants. Re-use of

archetypes already developed internationally is

encouraged, but these must be translated into

Norwegian and then put through the same review

process as locally developed archetypes no matter

their approval status at their origin.

During this process, the local initiatives can get

archetype design assistance from their Regional

Resource Group.

Review

When a development initiative is satisfied with a

developed archetype, they can submit it for review.

The National Editorial Committee will then initiate a

review of the archetype in question, and define the

requirements of the review, the most important

being which professions and specialties should be

represented among the reviewers. The Regional

Resource Groups in each of the four regions then

recruit suitable reviewers, and the archetype is

iteratively reviewed and improved until there is

consensus among the reviewers that the archetype

is acceptable for clinical use.

Approval

Once there is consensus on an archetype among the

reviewers, the National Editorial Committee

assesses the quality of the review, using parameters

such as

number of

reviewers,

geographical and professional spread of reviewers,

and if any other stated requirements for the review

are met. If the review is considered to be of

acceptable quality, the archetype is approved for

clinical use. Once approved, the archetype is given a

new status “Published” in the CKM, which marks it

as stable and suitable for actual clinical use.

Deployment

The governance model was formally approved in

October 2013, and the governance model including

online tools at http://arketyper.no were deployed in

January 2014. The National Editorial Committee was

formed with members from each of the four RHAs

as well as from the Directorate of Health. The

National Design Committee is temporarily

considered to be part of the Editorial Committee.

Two full time positions were created to coordinate

the work of the Editorial Committee. As of August

2015, only the South-Eastern RHA has been able to

get a Regional Resource Group up and running. For

the remaining four RHAs, the coordinators for the

Editorial Committee are filling this gap until the

regional groups can be put in place.

Experiences & results

The first year of operation was mainly spent getting

the governance structure up and running, including

the recruitment of large numbers of clinicians for

review participation. Only 6 archetypes were

published during 2014, with the total number rising

to 20 by August 2015. All but one are translations of

archetypes adopted from the international

openEHR.org CKM (http://openehr.org/ckm).

Success factors

The greatest success factor identified is the

participation of clinicians. The limiting factor that

led to the approval of only 6 archetypes

during 2014 were the lack of clinicians

for review participation. Once this

number reached a certain critical level

(around 150-200), the rate of review

increased significantly, and 5 of the 6

archetypes were published in

December 2014. Other major

success factors are:

good tooling; not having to rely

on distributing documents with UML

diagrams for clinician review

resourcing for coordinators to do the practical

work, and for training clinicians and others

collaboration with the sizable international

community, which saves a lot of development and

review time by providing both a large number of

models as well as experienced modellers.

Pitfalls Translation has proved to be tougher than

anticipated, since not many clinicians are bilingually

trained in their clinical professions. Project

management practices not taking into account time

for designing and reviewing information models has

also been a challenge, leading to many models not

being approved in time for the appropriate project

milestone. As mentioned, regional resource groups

have been hard to get going, which means the work

of recruiting clinicians and supporting initiatives has

fallen on the coordinators and regional

representatives.

National ICT

National EditorialCommittee

National Design Committee

Define review requirements

Approve reviews

National coordinators

Edit archetypes Organise reviews

Administer arketyper.no

Make sure archetypes are technically sound

Conformity w/ other standards/formalisms

Regional representatives

Regional resource groups

Clinicians

Participate in reviews

Start local initiatives

Represent the RHAs in the Editorial Committee

Recruit clinicians

Support local initiatives

Vendors

Implement archetypes in software Supplement requirements

What are archetypes?

Archetypes are formalised information models

based on the openEHR specification

An archetype is a collection of information ele-

ments relating to a single clinical concept

Archetypes are defined by domain experts, and

exist independently of vendors and solutions

Archetypes are made to be maximum datasets,

and can be grown over time

Archetypes are not complete data sets, user

interfaces or terminologies