Most agree the future of digital health largely rests on making joined-up data available. Integrated data is also going to play a vital role in propelling tech innovations forward. And, as we are hearing and experiencing from all corners of the industry, we need to leverage AI to unlock its full potential. The consensus is getting effective data foundations firmly in place is a prerequisite to support these types of innovations, while recognising there are some barriers to work through first.

NHS England shares the same views. The Operational Planning Guidance released in April places a key emphasis on implementing strong digital foundations. Just weeks before that it agreed to increase productivity in return for an additional £3.4bn investment for digital transformation in the spring Budget.

Traditionally, to risk stratify a patient, health professionals rely on hundreds of transposed data sources. This is an incredibly complex undertaking which is costly, time consuming, and difficult to scale up. I have experienced the complexity while being a chief information officer (CIO) and I have big reservations that continuing with the same approaches will undoubtedly delay progress, despite it being imperative that the NHS expediates digital programmes to relieve current pressures. It’s time for a new approach using architectures that are built differently to solve the mounting capacity issues.

A citizen-led approach that benefits everyone

openEHR enables healthcare systems to move away from organising records around systems to data that is centred around the person. The powerful architectural concept accelerates digital transformation by securely separating patient data without the frictions of disparate data silos. The result is one consistent longitudinal patient record that improves care coordination, outcomes, and population health.

Health and social care systems are realising that the longitudinal record or digital twin is the key to getting healthcare right for the individual and the population. The development of the NHS App has encouraged citizens to start thinking in this way, too. They expect to have access to their data, and they want to receive it in a unified way.

Evergreen growth and standards co-exist

openEHR is the best standard for data persistence and provides a platform for evergreen growth.  What is recorded today will be data that health and social care professionals can still use in 10 or 100 years to risk stratify and manage long-term conditions through a person’s lifetime.

My observations as a CIO were that systems weren’t evergreen because the data was hardcoded. With every new application, we had to start again with the data or rescue bits and put in a new data layer, causing huge frictions and costs to the trust’s overheads. openEHR is far more cost-effective because it is additive and can accommodate future technologies, but underneath, the data will remain valid and useful.

There are many data standards in use across healthcare and they must work together to provide a functional system. I used them together as an information practitioner, such as FHIR, SNOWMED, and OMOP. I feel quite passionate about this area, and we’ve been doing lots of work to make improvements. For instance, openEHR International has been working closely with HL7 on a number of FHIR projects including connecting smart FHIR and openEHR data sources together to surface in patient/clinician-facing apps. In a recent joint announcement with Chuck Jaffe, CEO of HL7, we signalled our ambition to align some of our standards and specifications for the global good. We hope this will enhance the choice and power of available software. In the spirit of the two open communities, we’re looking forward to the discussion this signalling of intent will bring.

Supporting advanced healthcare systems in Europe

Europe is leading the way with the use of openEHR. The interesting theme is that advanced healthcare systems are adopting the open approach because they are able to separate their data more easily and leverage it.

Catalonia is a flagship example of a bi-directional regional unified record. The region has taken a semi-academic approach looking at the target architecture and how they should use it. Academics from around the world collaborated to review the outcomes and openEHR was chosen as the data layer. Now there are future plans to implement openEHR in other Spanish regions as well. It’s been a rigorous process, but rather than a reflection on the pain of fragmented systems and data, it’s a reflection on what suitable architecture should be, and it’s been a pleasure to be part of it.

In the Nordics, there is a long tradition of openEHR, which is growing with lots of vendors. Seven regions in Sweden are using it, and the Karolinska University Hospital has published a framework with an open approach. It’s steeped in the country but with a variety of approaches and other regions are set to embark on their own transformation journey with openEHR.

Slovenia has been using openEHR for nearly 13 years, and the most recent country to follow suit is Greece, which has signed an agreement to implement a shared care record for the entire country.

openEHR in practice across the UK

Closer to home, we’ve been able to facilitate integrated care through read/write care coordination across OneLondon using the Better openEHR-based digital health platform. It amounts to a footprint covering approximately 10 million people, 5 Integrated Care Systems, 1400 general practices, over 40 NHS Trusts, and 33 local authorities.

There are some really exciting things happening in Scotland and Wales too, where they are using openEHR for various use cases at a national level. Certainly in the UK, we are seeing an increase in people moving towards openEHR and hearing more senior people within the NHS talking about architectural patterns for openEHR and the advantages based on experience.

It’s encouraging to see this shift in conversation at a time when the NHS is nearing breaking point and services need rapid transformation. openEHR is the fastest approach to achieve it and put digital health on the path to a sustainable and promising future.

By Rachel Dunscombe, CEO of openEHR International

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The procurement marks the latest advancement of the trust’s bid to move to a new data-centric model with openEHR standards at its core. The strategy involves modernising systems from a previous siloed-state where data is locked within applications to a data archetype model which facilitates a patient-centric approach.

The Christie is Europe’s largest single-site cancer centre. It serves a population of over 3.2m people, treats 60,000 patients each year. It is a research-intensive institution and, as such, the integrity of, and access to, timely data is critical. This, in combination with the drive for all trusts to implement ePMA meant that adoption of an ePMA solution is a key priority.

Alistair Reid-Pearson, Chief Information Officer at The Christie, said: “Digitally enabling clinical services is the primary mission in our Digital Strategy. We needed a module that could level up our core capabilities whilst also plugging into our openEHR data platform. The data-centric approach to continuously improve clinical outcomes is pivotal to the strategy.”

Vanessa Clay, Clinical Director for Acute & Support Services at The Christie, said: “Having a system that is easy to use and lowers the training requirements was a central objective of the selection process. Implementing an intuitive web-based system, that makes it as easy as possible for clinicians, is going to be a key principle of the project going forwards and from the outset.”

Damian Child, Chief Pharmacist at The Christie, said: “We selected Better Meds as we wanted a system that provided core prescribing capabilities, but careful consideration was also given to future capabilities. One example includes secondary care Electronic Prescription Service (EPS) connectivity which allows prescriptions to be sent digitally to community pharmacists.”

The Better Meds solution is built on the Better openEHR platform which underpins the trust’s in-house electronic health record (EHR). It will facilitate a seamless embedded user interface with clinical staff able to access the medications from within the EHR providing a better user experience and increased efficiency.

The project also plans to integrate the trust’s chemotherapy prescribing system into the Better digital health platform. iQHealthTech, the supplier of iQemo, have committed to move to openEHR storage standards for key clinical data items. This will facilitate a single source of truth for allergies, height, weight and prescribing data, which aims to give clinicians a complete patient overview and enable sharing between modules.

The Christie contract is the latest in a series of contact wins for Better, with Better Meds now live in seven NHS trusts featuring rapid implementations for the Better Team, and their implementation partners. South Tees, Oxford Health, South London & Maudsley, and North Cumbria have all gone live within the last six-months.

Adrian Aggett, Client Director, Better UK & Ireland, said: “We are delighted to have been chosen by The Christie to provide our award-winning Better Meds ePMA solution. This latest contract will enable us to support The Christie as it continues to progress its openEHR digital strategy which will provide multiple benefits including better access to data and information, faster decision-making, and more efficient management. Through our ePMA solution, we are committed to supporting The Christie to safely digitise its prescription processes whilst also providing improved access to data via the Better Meds integration with the trust’s in-house EPR and other systems.”

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The future of healthcare systems lies in open standards that free data from traditional, stand-alone silos and make it available to the many applications that need it. But how are we going to reach that future?

Realistically, we have two options: open Electronic Health Record, better known as openEHR and Fast Healthcare Interoperability Resources, or FHIR. I’m not going to argue that one is better than the other. They both have advantages and disadvantages and they will both have a role to play in the digitisation of the NHS.

However, it sometimes feels like openEHR has become the focus of attention in the UK and I’d like to see more debate about the role of FHIR and open platform architectures that use FHIR to natively extract, store and re-export data to applications.

This is the model that Alcidion uses in its Miya Precision platform, and I assert that it has some benefits for innovative suppliers, trusts and Integrated Care Systems.

OpenEHR and FHIR

OpenEHR and FHIR both aim to address a long-standing problem in healthcare, which is that conventional healthcare systems tend not to share information – to interoperate – with each other.

Conceptually the most important difference between them is that openEHR uses multi-level modelling while FHIR adopts an 80/20 rule. In other words, openEHR operates with a stable reference information model, that sets out to capture every use case for data in the medical world and archetypes and templates that enable it to be used and re-used in the real-world.

While FHIR is built from discrete resources that cover 80% of the data elements that are used in existing healthcare systems. This leaves the remaining 20% for specific use cases that can be customised, extended and handled by FHIR profiles.

The obvious attraction of openEHR is that it paves the way for disparate systems to operate to a pre-determined standard thus claiming ultimate interoperability. It also allows organisations to build a stable representation of their data and to use it to build and manage their own healthcare system from the ground-up.

However, openEHR requires a strong commitment from organisations and clinicians to maintain and extend the underlying model, while the need for the whole openEHR community to move forward together can make it difficult to implement localised changes.

FHIR is less grand in scope and is a lot easier to use. Indeed, FHIR resources were built to make it easy to integrate disparate systems. They are easy to understand and to transmit over well-understood network protocols and modern, web-based technologies.

This makes it easier for suppliers to build applications that can ‘plug and play’ with other systems and for trusts and ICS’s to adopt them to deliver the changes that matter most to them.

FHIR: not ‘just’ a messaging standard

So, why isn’t there more discussion of the role of FHIR in UK healthcare? I think one issue is that FHIR is often catalogued as a ‘messaging standard’ when it is far more than that.

FHIR resources represent generic clinical data models and templates containing data elements for different types of clinical and administrative functions in healthcare settings. There are approximately 150 FHIR resources for concepts such as ‘patients’, ‘encounters’, ‘observations’, ‘medicines’, ‘allergies’ and so on.

All of these are actively developed and nurtured by the HL7 Organisation, so they can be used as a model to store data as well as to exchange data. This means it is possible to use FHIR as the basis of an open platform architecture; one in which data is extracted, stored and re-exported as native FHIR messages.

Alcidion was an early adopter of FHIR and our Miya Precision platform is unique in using this model. In passing, it means we separate the data layer from the application layer, which is what the UK government, NHS England, and the transformation directorate that has absorbed NHSX, say they want to do.

Benefits of FHIR thinking

There are some significant benefits to adopting FHIR thinking. One is that it works well for the microservices architecture approach that Alcidion has also embraced for Miya Precision. Because FHIR supports RESTful architecture and modern web standards, it’s possible to create business-focused applications that can be deployed at speed, while remaining highly configurable.

Native FHIR data extract, storage and re-export also offers significant benefits when it is used to power an event bus that orchestrates communication between different micro-services and applications. The data store in the Miya Precision platform is constantly being updated with information and analysed in real-time for variations in a patient’s condition.

This enables alerts to be sent to Alcidion’s suite of mobile first applications to improve patient safety (Miya Observations) and operational efficiency (Miya Flow). In effect, it not only separates the data layer from the application layer but makes the data layer active and useful.

At the same time, the universal event bus makes it easier for new and innovative suppliers to join a trust ecosystem; without having to interact with the API layer or facade that traditional vendors put over their systems or adopt the entirety of the openEHR conceptual framework.

This last point should appeal to forward thinking trusts and ICSs. If you want to store information from disparate systems at an ICS level and to use it in new pathway apps and analysis, without going ‘full openEHR’, you should be thinking about doing it in FHIR native format, so you get mature interoperability from the outset.

Let’s FHIR up a debate

The NHS needs innovation and it needs to adopt approaches that will allow it to reach that open future in order to make the most of it. That means there’s a big market out there and plenty of scope for both openEHR and FHIR to demonstrate their value.

But it also means we shouldn’t let a single philosophy of open standards drive our product engineering. Instead, we should remain focused on what we all want to achieve, which is not just a longitudinal health record, but one that helps clinicians to focus on patient safety, patient care, and patient satisfaction.

I think that means we need to kindle that conversation about FHIR, because FHIR can lead us to the point at which, as a colleague of mine puts it, we’re doing ‘the cool stuff’ – faster.

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By their very nature, these systems throw up an array of inhibitive barriers which act as blockers to effective communication and secure data sharing. The result is a risk of error and delay which slows down access to treatment. For those in need of acute mental health care, this can be life-threatening.

To achieve the joined-up, patient-centred care called for by the Mental Health Act Reform Bill and to support the growing demand for acute care, overcoming these barriers and facilitating wider collaboration is paramount. We desperately need the tools to enable simpler, streamlined and more secure cross-service communication. The answer? In a single word: interoperability.

Why is interoperability so important?

The baseline maturity of systems and quality of accessible data is much lower in acute mental health care than in other areas. With standard practice for arranging patient care still largely paper-based, broader digital transformation is also yet to be widely adopted. Paper-based forms have to be manually transferred across geographical boundaries, risking both loss and delay. Meanwhile, existing digital systems are inherently siloed, meaning they are unable to effectively share information or data with one another.

Interoperable systems, on the other hand, are able to speak directly to other systems. Information can be shared safely and seamlessly, without the need for additional manual input or intermediary data translation. Simply put, they can bypass the obstacles presented by the current paper-based and siloed digital systems, all while strengthening security and compliance.

Arming mental health services with fully interoperable digital tools helps:

• Speed up access to treatment – by reducing admin time and speeding up the transfer of patient information;
• Reduce the risk of errors and delays – by enabling safer, more secure data sharing; and
• Provide more collaborative, joined-up care – by making it easier for services to communicate and share essential information

Using interoperable systems also gives us a clearer, more complete picture of care through improved access to data. This can help more accurately identify areas where improvement is needed, inform impactful policy change, and enable services to establish best practice by learning from one another.

How can we successfully introduce interoperable systems?

Making interoperability a priority is essential for ensuring that we’re heading towards the goals outlined by the Mental Health Act Reform Bill. As services begin to migrate from paper-based processes to new digital systems, the aim must be for interoperability to be made standard from the start.

So how can we put this into practice? While developing our platform for supporting care delivery under the Mental Health Act, my team at Thalamos have found the following steps crucial to achieving genuine interoperability:

Start small and simple

While widespread interoperability is the ultimate aim, we won’t achieve this overnight. Building any kind of interoperability, however small, into new and existing systems will have a huge payoff and positive impact on patient care. Making it easier for data to be shared at any stage of the care pathway will ultimately help reduce delays and speed up access to treatment.

Start by identifying the areas where these systems can most easily and effectively be introduced, and use these as a springboard for encouraging wider change.

Build broad communities

Interoperable systems make it easier and quicker for data to be shared, but they also require collective agreement on data standardisation. Any new systems introduced must be able to work together effectively while maintaining compliance and keeping patient data safe.

By building strong relationships with other services and providers, you can ensure that standards are agreed upon and instituted at every stage of system development.

Don’t reinvent the wheel

Most importantly, don’t feel as though you have to start from square one. Pre-existing standards for data creation and sharing, such as FHIR and Open EHR, and systems for data standardisation, like SNOMED, are a strong foundation on which to build safe, effective and compliant interoperability.

Lean on these to guide and inform each stage of system development. Then collaborate and share both your successes and failures with other services and providers. This will not only help encourage wider interoperable development, but will drive up standards across the board.

There’s no doubt that interoperability is the key to unlocking genuine mental health care reform. Without it, there are simply too many barriers to providing quicker, safer and more-joined up patient care. We will only overcome these barriers by introducing tools which enable the multitude of services involved in acute mental health care to work more closely together. Ultimately, interoperability is the essential foundation for making this large-scale collaboration a reality.

By Arden Tomison, Founder and CEO of Thalamos

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However, within healthcare, it has been a case of “Gradually, then Suddenly” — with little innovation or disruption for years, until COVID-19 came along and necessity became the mother of invention. Over the past 18 months, I have been directly involved in supporting a small part of the NHS’s response to COVID-19 through Kainos’ work on remote consultations and the services they delivered for COVID-19 Testing, Contact Tracing and Vaccinations. I have seen first-hand how innovation has been ignited, processes have been optimised, and hurdles have been safely removed. Things that used to take months were completed in weeks, sometimes days. There will be many elements to maintaining this innovative approach and there is one foundational piece that I believe will play a crucial role.

openEHR and healthcare  (Pronounced “open-air”)

More healthcare systems are turning to openEHR — from individual hospitals to regions to entire countries. I believe we are at a similar junction now with healthcare and openEHR as we were with software in 2011. But, just as with software then, we can see that the tide is turning, momentum is growing, and disruption is coming. Over the next ten years, I expect many more healthcare systems to separate their applications from their data, putting openEHR at the centre of their architecture. Doing so will allow them to establish entire ecosystems of disruptive and innovative services centred around the patient.

Why is this happening?

Because openEHR will make healthcare integration obsolete, accelerating digital transformation.

Most software applications, including those in healthcare, have app-centric architectures, where the data for the app is stored as an integrated part of the application, each responsible for storing, protecting, auditing and sharing the data for their app. However, within any healthcare system there is never just one application. This means we typically end up with lots of data — often duplicated — stored across many applications, oftentimes in a closed, proprietary format.

The traditional approach to making all these applications speak to one another lies in what I believe is an overused buzzword.

Interoperability

Typically, people associate this term with API’s or ETL’s that move data between systems to support the needs of one or more applications. Healthcare organisations have been wrestling with this idea of interoperability for years, which is understandable — stitching together an entire healthcare system in this way with hundreds of applications is highly complex and challenging.

Why is openEHR different?

openEHR still enables a system to be “interoperable”, federated, and use standards-based API’s to interact with data, but it moves the entire landscape from an app-centric architecture to a data-centric one. In making this shift, it eliminates data silos, removes point-to-point integrations between applications and provides a composable architecture that accelerates development.

Healthcare organisations considering this shift will need to carefully evaluate how they will manage their data, especially if it will be at the centre of their architecture. First, they will be making a strategic, long-term decision, so they will not want to be tied to one vendor. Second, they will be working with complex healthcare data, so they will want something that embraces this complexity and allows information to be precisely defined. Finally, they will be establishing an ecosystem of applications around the data, so they will need a robust modelling framework that encourages agility and re-use.

openEHR addresses each of these considerations as a core part of its design. It has an open architecture, allowing patient-centric information to be stored in a vendor-neutral format that is long-lived, versioned, and easily computable. Second, it has a semantic architecture, allowing the meaning of health and care information to be precisely defined. Finally, it has a robust modelling framework, where domain models are created by domain experts (such as clinicians) and are separated from technical layers, leading to greater agility and re-use.

I believe this data-centric approach — implemented using openEHR — will allow an eco-system of intuitive, user-centred applications to emerge. It will also enable innovation in clinical research, digital therapeutics, disease prevention and population health management — leveraging complementary standards such as FHIR, OMOP CDM and patterns such as Data Mesh. I am not alone in believing openEHR will make a difference. There are many examples across the world of where it is being adopted.

Adoption of openEHR in healthcare

Perhaps the most recent and high-profile example of this is the Catalonia Health Service. They plan on using openEHR for its new platform for health records across the entire region of Catalonia. The announcement highlights that its current system for sharing information is a “barrier to the systematic use of health data”, with “semantic interoperability being probably the biggest problem”.

In London, a £3.1m contract was recently announced to provide a shared care planning solution for London. This solution will “Establish… a platform of persistent data with openEHR coupled with a low code environment for health and care professionals to dynamically evolve digital care planning services”.

In Wales, Digital Health and Care Wales (DHCW) has announced a contract to implement a clinical data repository that will form a “constituent part” of their national architecture and will “help to transform care and treatment for patients”.

Still, we face some challenges

First of all, there is a view from many CIO’s and healthcare leaders that there are no applications that run on top of openEHR. This is not true. There is an ever-growing ecosystem of applications, which I expect will accelerate over the next ten years.

I also believe we are entering the next generation of software development, where no-code/low-code applications will allow citizen developers to quickly build applications safely, using platforms developed and managed by programmers and platform engineers.

Secondly, there is rarely a “greenfield” opportunity where CIOs only need to think about their target state architecture without considering what they have now. The key message here is to re-use existing assets, not be limited by them. Where new applications are introduced, adopt a data-centric approach from the start. Where existing applications are in place, incrementally move towards a data-centric architecture leveraging tools such as API management to support an intermediate state of co-existence between your current state and target state architectures.

Finally, over the last number of years, there have been many headlines and much attention surrounding FHIR. Much of this has been well deserved, and I’m an advocate for FHIR, where it is used in the right way. However, the challenge emerges when people believe FHIR and openEHR are competitive standards that do the same thing. At best, this leads to confusion; at worst, it leads to bad design decisions impacting implementations. Nevertheless, I believe there is a place for both standards to be used in a complementary way.

The alternative option of standing still is — I believe — not an option. Instead of being held back by the scars of the past or perceived challenges of the future, let’s seek to understand the benefits of a new data-centric architecture. To quote Marc Andreesen, “That’s the big opportunity. I know where I’m putting my money”.

About the author

Alastair Allen, Chief Technology Officer at Better, is an experienced technology leader with a proven track record of leading the strategy, design and development of large transformational digital services and products.

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