A Deep Dive Into The Clinical Knowledge Manager

In April 2009, the OpenEHR Foundation created an international repository of archetypes and templates that are being maintained and updated, when necessary, by an online group of health care and informatics professionals that is known as the openEHR Clinical Knowledge Manager (CKM). CKM enables re-purposing of clinical artefacts such as Archetypes ad Templates, suggest corrections, participate in discussions, and translate archetypes to other languages. The CKM has a robust governance system that supports the life cycle of archetypes, templates, and terminology. CKM has now become an active online community that is constantly working together to determine clinical definitions.

Instances of CKM

Since different healthcare systems pertaining to different countries may have different requirements, there are various instances of CKM, namely Norwegian CKM, Australian CKM, NHS England CKM, Shared UK CKM. These instances of CKM cater to the specific requirements of their respective regions.

Functions of CKM

The core functionalities of the CKM includes:

Search Archetypes, Templates and Termsets

CKM is the online repository of clinical artefacts such as Archetypes, Templates and Termsets (Terminology reference sets), allows the user to search for the aforementioned artefacts in the following ways:

Using the Quick Search widget on the CKM Dashboard

Search Using the Find Resources Tab in CKM

Using 'Resource' sub-tab is probably the most common method

Using 'Project' sub-tab and by selecting the desired “Sub-domain” and “Project/Incubator” from the dropdown menu

Using the 'All Resources' Pane: Search Using the “All Resources” Pane Using the Filter on the Resource Name

Using the 'All Resources' Pane: Search Using the “All Resources” Pane Restricting by Sub-domain or Project/Incubator

Search Using the 'Project' Accordion Heading: Select a “Project” from the dropdown and then select the displayed archetype/template/termset

View the clinical artefact within the CKM

Within the CKM the users will be able to select and view the desired artefact

Different classes of Archetypes are displayed within the CKM seen on the left side panel of the CKM dashboard

One can view the different sub-types of Archetypes by expanding the higher-level Archetypes seen as “Cluster”, “Composition”, “Entry” and “Section”.

In order to figure out the type of Archetypes that needs to be used for specific use cases depends on the understanding of the different types of Archetypes.

Understanding the different classes of Archetypes hosted by the CKM

The CKM hosts various classes of archetypes currently arranged in alphabetical order. The relationship amongst the various Archetypes can be depicted as below:

As evident from the figure, the highest level is the “Composition” which holds the Sections which in turn consists of Entries and their Elements within.

A brief understanding of the classes of Archetypes is as below:

There are 5 types of Entries 4 of which correspond to critical clinical processes. The 5th Entry type is “Admin” which captures non-clinical processes such as “Admission”, “Discharge” or “Triage”. A snapshot of the types of Entries is as given in the figures below:

The figure above depicts the different types of Entry Archetype: The first one is the “Observations” which include data that are observable or measurable, e.g data recorded for History, Examination or Test Results. The second one is Evaluation which is clinically interpreted findings that require clinicians to draw conclusions from the evidence gathered from the “Observations”, e.g Problem and diagnosis. Instructions and Actions then tend to go hand in hand. Instructions include initiation of a clinical workflow like placing a medication order and the corresponding Action includes the activities carried out to execute the order initiated in the Instruction, such as medication administration.

Different views of the clinical artefacts within CKM

One of the most interesting features of CKM is the way the information of the chosen archetype or template is shown on the CKM.

Archetype

CKM allows the user to experience different views of each archetype. Some of the views commonly used include:

Tabbed View:

This view enables the user to get detailed information on the archetype as depicted in the figure below:

Mind map view:

Template

Similar to Archetypes, CKM also provides different views of Templates as below:

Simple View:

Mind map:

Termset

Downloading the clinical artefacts from the CKM

Archetypes

Archetypes are required to be downloaded from CKM to be re-used in template building. CKM allows archetypes to be downloaded in the following formats:

Template

Termset

Archetype statuses available within CKM

 

The figure below depicts the various statuses that are available within CKM:

An archetype in its lifecycle goes through all the above statuses in CKM.

Once a need for a new archetype gets identified, it is created and uploaded into the CKM where a process of archetype review by the openEHR reviewing team will be made. Once the archetype is deemed fit by the reviewing editors of the CKM repository the archetype will be “Published” and allocated to the Release set for subsequent dissemination.

Archetype Lifecycle within the CKM

As evident from the figure above, “Initial” is the first stage of an Archetype within the CKM. From this stage the archetype goes into the “Draft” stage which in turn goes into the “Team Review”. All the three stages can get “Rejected”. From “Team Review” the archetype can go into a “Review Suspended” stage which in turn can also get “Rejected”. From “Team Review” stage the archetype will get “Published”. A “Published” status is generally considered to be stable. However, if a new clinical requirement is identified then this will trigger the need for a new revision cycle. A “Published” archetype can then be reassessed and go into the “Reassess (Draft)” stage which goes into the “Reassess (Team Review)” stage which can go into the “Reassess (Review Suspended)” stage. Again, all the “Published”, “Reassess (Draft)” and “Reassess (Team Review)” stages can get “Deprecated” along with the “Reassess (Review Suspended)” stage. Notice that only “Published” archetype can get deprecated. Resources that are yet to be published can only get “Rejected”.

Projects and Incubators within CKM

CKM Incubators

As mentioned earlier in addition to the International CKM, there are regional instances of CKM as well. If a new Archetype gets created within the regional CKM, the same can be inserted into the International CKM repository using the “Incubator” feature available within the CKM and making the information shareable with everybody. Incubators consists of Archetypes whose quality is unknown and/or at the initial stages of development.

CKM Projects

For larger organisations, the work of creating content standards is split and further organised as CKM “Projects”. A CKM Project is comprised of a nominated set of artefacts (Archetypes/Templates/Termsets) with its own process of artefact reviews. Although CKM projects typically concentrate on their own artefacts, users can ‘see’ and reference artefacts from other projects as well.

CKM Community

The CKM community primarily consists of Members, Editors, Clinical Knowledge Administrators performing the following functions:

Members:

• Contribute to the collaborative development and verification of the clinical artefacts through participating in content, terminology binding and translation reviews
• Submit candidate translations
• Join in discussion forums

Editors:

• Leadership role in the development and evolution of the clinical models by facilitating review rounds where members contribute feedback that is used to modify and enhance the content of the clinical models
• Determine precise technical representation of the clinical data
• Ensure appropriate terminology bindings
• Accurate translations of the models

Clinical Knowledge Administrators:

• Responsible for governance and maintenance of the CKM, the quality and integrity of the clinical artefacts
• Management of teams and user roles within the participating community

Clinical artefacts are managed within the CKM through a defined review and acceptance process till the same gets Published with the consensus of a combination of clinicians, health informatics experts, technical folks, and vendor representatives. The OpenEHR CKM has been growing consistently in size and quality due to ongoing submissions by user organizations. It has currently gathered an active community of interested and motivated individuals from around the world focused on furthering an open and international approach to clinical informatics moving the healthcare industry towards sharing health information between individuals, clinicians, and organizations, between applications, and across regional and national borders. The CKM provides the opportunity and means for users interested in modelling clinical content to participate in the creation and/or enhancement of archetypes, which have the potential to provide the foundation for interoperable Electronic Health Records.