openEHR and Clinical Knowledge Manager

A reader recently commented about something called openEHR. Maybe I was a little swayed by anything that says open since open source has used the term open so much. The idea of an open EHR sounded really interesting to me. I’m still not sure I completely understand the plan of openEHR, but I was put in contact with a fine lady named Heather Leslie who is working with openEHR on a product called Clinical Knowledge Manager (CKM).

I must admit that when I read the various information on clinical knowledge manager’s attempt to create clinical archetypes I was pretty lost. Maybe I’m just dumb or maybe across the pond (the project started in the UK) they are just using different terminology. Possibly it’s a little of both.

When I got this email about clinical knowledge manager the concept of creating clinical archetypes was new to me. I could be wrong, but reading it now they should have just said their creating standards for clinical data. That’s a concept I can understand and appreciate.

From what I can tell, it seems like CKM is essentially a wiki-like platform for displaying and improving these clinical standards (or archetypes if you prefer). I really think that the power of the crowd is the only way clinical standards are going to be defined, so the idea of a wiki-like website where people can collaborate around clinical standards sounds exciting. My only fear with it all is that if I’m having trouble cutting through much of the technical jargon, I wonder how many doctors will want to participate in this discussion. This seems like a really noble goal, but I can help but question if CKM and openEHR are not keeping EHR interoperability simple.

Time will tell how many EHR choose to adopt the clinical archetypes that openEHR creates. That will be the true measure of how valuable CKM will be to healthcare. I will be interested to see how this rolls out and if they can garner enough EHR interest and participation to make it a viable standard.

The following is an email about participating in clinical knowledge manager and more information on how it works:

I’d like to invite and encourage all clinicians to register for theopenEHR Foundation’s new Clinical Knowledge Manager (CKM) -found online at?

CKM is an international repository for?openEHR archetypes and has two primary purposes – that of archetype publication and archetype governance. It is a real opportunity for clinicians to collaborate and agree on clinical content definitions for publication and use in our electronic health records.

openEHR archetypes are open source, computable specifications that define clinical information about a single and discrete clinical concept. For example there are separate archetypes defining a ‘symptom’, ‘diagnosis’, ‘blood pressure’, ‘medication order’, and ‘risk of disease based on family history’. As structured and standardised definitions of clinical content, archetypes are increasingly being recognised as fundamental building blocks of electronic health records, especially when integrated with clinical terminologies such as SNOMED CT. If we all start to record information based on the same archetype, then we can meaningfully and unambiguously share health information between systems, and we can start to query that information across systems.

A primary goal of CKM is to encourage a broad range of clinician input to make sure that the clinical content in each archetype is correct. Absolutely no openEHR experience is necessary to participate in CKM, although we anticipate you will learn about?openEHR as part of the journey.All participation is purely on a volunteer basis, and you can opt out at any point.

Whilst CKM is still in its relatively early days, we are already seeing the benefits that contributions by grassroots clinicians are bringing to the archetypes currently undergoing team review. Technically oriented openEHR experts support the review process to provide guidance on design and implementation issues, so there are no unrealistic expectations of the clinicians. Contributions of clinical and technical nature are equally and gratefully received;-)

By design, each archetype contains all the relevant information about the specific clinical concept – a maximal dataset which can be used in all clinical scenarios.?? So, for each archetype we are seeking a range of views from a variety of:

  • professions – including every type of clinical expert;
  • geographical locations-to make sure we can capture diverse clinical and cultural practice; and
  • knowledge domains – from general healthcare to all specialist areas.

Please actively ‘adopt’ the archetypes that you would like to be involved in. This will ensure that you will be invited to participate in the review of archetypes that are of interest to you. At other times you may also be invited to participate in a review where we consider that your expertise might provide balance out the current team of reviewers.

While we will strive to achieve maximal datasets for each archetype, we are pragmatic and know that we won’t get it 100% right – certainly not at first try. However, I suggest that a small group of 3-4 clinicians with complementary skills and appropriate expertise can create and develop a draft archetype to approximately 80-85% complete. Further review within CKM by a team of clinicians from a range of professions, countries, institutions, research and health domains will contribute and refine the archetype further – maybe this still will only get it to 90% complete; but maybe much more. Our experience to date shows that maximal datasets are much easier to agree on than minimal datasets!! Over time it will be interesting to see how the models evolve – no doubt a good research topic!

Obtaining agreement on clinical content within archetypes in this manner is a significant achievement, even if in retrospect we find they are not 100% complete at the start. The flow-on benefits that come from sharing a standardised set of clinical specifications for EHRs can potentially transform some eHealth initiatives and is a necessary foundation for the truly sharable electronic health record.

So, all clinicians are welcome to get involved in CKM – we will certainly set you to work very quickly! We expect that by contributing domain expertise and insights, clinicians will also benefit personally by gradually developing openEHR understanding and expertise as part of the experience.

And then of course, there is also the contribution to the good of mankind… 😉

[Instructions for registering can be found]

About the author

John Lynn

John Lynn

John Lynn is the Founder of the, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • There is some confusion in the purpose of archetypes in the author’s introduction.

    Archetypes represent constraints on a reference model that is implemented in software. If the EHR doesn’t include this reference model then the archetypes are not useful.

  • Tim,
    There’s no doubt I’m still getting my head around archetypes. However, I did say ” I will be interested to see how this rolls out and if they can garner enough EHR interest and participation to make it a viable standard.” I think that goes to your point that if no EHR vendors choose the archetypes, then they are useless.

  • Let me say first that your blog is my best source of information and perspective about EHR. Let me then say that at points, you come close to creating a straw man and them turning around and making him your everyman. It is true that standards for Treatment, Payment and Operations are rather like clotheslines on which practitioners hang their work in whatever way suits them. They certainly don’t think with them. This makes EHRs that push this data around a sorry thing to contemplate. However, coherence in reporting labs would in my estimation provide something of a floor to the other data and that that rising tide might raise all boats. This causes me to be optimistic about the results of the HITECH Act initiative. On the other hand, what is needed to bring integration of clinical efforts are standards people can think with. That is what you have with openEHR. Because it is a kind of “Being John Malkovich” for the clinical mind, walking around in it is a rather disorienting experience. However, if we are going to begin to think with standards rather than look for the nearest curb to kick them to, that is where we need to go. Now, it seems to me entirely misplaced to say that these standards are useless unless adopted by EHR vendors. It might better be said that EHRs, as a means to get all the clinical imaginations involved in a patient’s care on the same page, will be ineffectual for that purpose until they use standards like openEHR whose natural resting place is the mind and not the curb.

  • Chareles,
    Thanks for the kind words. I didn’t quite get the straw man example, but I’ll focus on the first comment you made.

    I have to agree that labs would be a great place to start. In fact, as I’m thinking about it now, we already have all of that info standardized pretty well using HL7. We’re sending results between our lab and EHR like crazy. Would be simple enough to send those results to someone else. Would be a great place to start and then build from there.

    I still don’t think it’s misplaced to say that a standard is useless if EHR vendors don’t use it. The reality is that a ton of standards will be adopted by EHR vendors. Let’s just hope it’s the very best standards and that the standards are shared by the majority of EHR vendors. Unfortunately, my realism makes me think we’re going to end up with a number of standards. Let’s hope I’m wrong.

  • The current healthcare system and its players have been drafted by HITECH into a war they never imagined would be waged. We are starting as did the Union army in the Civil War with officers who bought their commissions. They will do badly and others will take their place. Obama is in the position of Lincoln when he reads how bad his ‘generals’ are. They both focus on the war to be won and not on how bad the present marshaling of forces is. In that sense, saying that EHR as it is now and its standards process are not up to task is a misplacement of focus – a straw man. The question is, how can they be challenged to become equal to the task? When I say that openEHR like standards have to be in the hands of the troops in order to win, I don’t mean the present EHR troops. To say that the present forces are the measure of success is to my mind to take the straw man of present inadequacy and make him the sine qua non, the everyman, of the entire effort. That would redouble the misplacement of emphasis. In brief, these guys aren’t going to be around at the finish, so why go on about them? We need to cull these forces for those who will be around at the end and that could well be openEHR. That is what Lincoln had to do and that is what Obama will have to do. Significance plays no favorites between the past and the present. These present struggles are significant and they will have their own kind of casualties.

  • Interesting comparison of the battle of healthcare with the civil war. I’m going to have to think about the comparison a bit more, because I think the challenge facing the president could very well be similar. A president making decisions about something for which he has limited information as one example of the similarity.

    Let me ask you one question, is Obama currently defending freedom or slavery in the healthcare system?

  • Well, here goes. In 1819 the Supreme Court ruled that giving states the power to tax an arm of the Federal government could not be allowed, because “the power to tax involves the power to destroy”. But as “the government of the Union, though limited in its power, is supreme within its sphere of action” , it cannot be so circumscribed. This position derives from the first Article of the Constitution. The President swears “to preserve, protect and defend the Constitution of the United States”. For any President, preserving the Union trumps all other concerns. In Lincolns time, many private individuals and leaders of different stripe were wont to say that freedom was the causative factor of the conflict and others freedom ‘to be let alone’ in the practice of slavery was paramount. In present times, individuals can see present initiatives in healthcare as government intruding where it doesn’t belong or as the government providing what the private sector seemingly cannot. For Obama, his healthcare initiatives are about only one thing; that healthcare, if left to itself, will so reduce the realm of action of constitutional government as to make it subordinate to the license of unregulated commerce, placing the union in jeopardy. As President, he cannot allow that.

  • Let me clarify. I think Obama’s intentions are good. Your assumption is that “healthcare, if left to itself, will so reduce the realm of action of constitutional government as to make it subordinate to the license of unregulated commerce.”

    Only time can really tell if Obama’s policies will help or hinder the healthcare situation. I think the jury’s still out on this one.

  • The discussion has surfaced an analytical result and I believe in the power of analytical results. We hope that set of all outcomes that increase quality of care overlaps partially with the set of healthcare systems that no longer distort all other economic transactions. It is the second set that Obama must bring into being. As it stands now, the path from where we are now in evolving healthcare to where Obama must have it arrive as in balance with the rest of the society is not in view. He will not choose another goal; he cannot. I am sure he hopes that in the effort to examine healthcare in the light of pervasive EHR, some ideas may come into view that will allow healthcare to come back into balance with the rest of the society. He’s only primed the pump. He will achieve a healthcare system in balance and whoever can give it to him. He cannot allow civil society to go to hell for the sake of any private institution. Constitutional scholar that he is, he is sure that that is the test of his Presidency. From this point of view, stoking up expectations that naysaying on these matters from within in the industry will have any effect on his resolve will prove to be a colossal waste of everyone’s time.

  • openEHR has published the implementable specification of a European EHR standard that is also an ISO standard (EN13606)

    EN13606 is about documentation of care provided by clinicians in an EHR. When implemented in systems it is possible:
    – to define what needs to be documented, archive, exchanged and re-used without any changes to the database
    – all health data is stored in a standardised (non vendor determined) way)
    – healthcare is in control of the content of EHR-systems
    – no longer database conversions
    – a real life long record
    – an infrastructure (like that for the iPhone) where small companies write software using a standardised repository
    – each clinical decision support application (when conformant to the openEHR specification) works plug and play in the same way without any programming
    – it is multi-lingual
    – can be used along message standards like HL7, Dicom, etc
    – it is the only standard that is based on an ISO document “Requirements for EHR Architectures”. This ISO standard contains quality related aspects like: patient safety, legal and ethics.

    Gerard Freriks, MD
    former chairman of CEN/tc251 wg1

  • I refer you to the Semantic Health Report published in Jan 2009 from the European Union – especially p16 –
    It identifies “Current attempts to standardise the capture, representation and communication of clinical (EHR) data reply upon three layers of artefact to represent meaning:
    1. Generic reference models for representing clinical (EHR) data, e.g. ISO/EN 13606 Part 1, HL7 CDA Release 2, the openEHR Reference Model
    2. Agreed clinical data structure definitions, e.g. openEHR archetypes, ISO/EN 13606 Part 2, HL7 templates, generic templates and data sets
    3. Clinical terminology systems, e.g., LOINC and SNOMED CT

    The openEHR archetypes are the computable content definitions as described in the second point. An openEHR archetype is a specification for a single, discrete clinical concept, based upon the openEHR reference model. It is intended to be a maximal data set for a universal use case for each of these clinical concepts.

    The Clinical Knowledge Manager (CKM) mentioned above is a effectively library of these archetypes, with the dual purpose of faciliating clinician review and agreement of these knowledge artefacts, and of archetype governance.

    Agreed archetypes can then be aggregated and constrained for use in specific clinical scenarios within openEHR templates such as a Discharge Summary or Clinical consultation. For example, an antenatal visit template may contain components of up to 80 archetypes – not the maximal data set of each archetype but the only data elements required for the specific situation, including context appropriate bindings to terminology subsets where needed.

    Using agreed archetypes as the content definition, and the openEHR templates as the mechanism to aggregate and constrain them so that they are ‘fit for purpose’ depending on each clinical scenario, we have the foundations of semantic interoperability – exchanging data that has been captured, stored and transmitted based on shared and agreed content definitions.

    As openEHR is the basis for CEN/ISO 13606 standard there has been most initial momentum and interest in and around Europe. This is gradually spreading as more national programs seek pragmatic approaches to defining and specifying their clinical content. And the ability to engage grassroot, non-technical clinicians in collaborating in the defining of the archetypes is also garnering some significant interest.

    There are 2 open source archetype editors, and some commercial tools supporting templating, terminology management and openEHR EHR platforms. Many universities around the world doing openEHR based research. The openEHR community has over 1500 members from over 85 countries. More information is available on the openEHR Foundation website –

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