80:20 David Ingram and ChatGPT, 26 November 2025
Preliminaries
This essay took shape in my mind over recent months and was written in the past few days in partnership with ChatGPT: I provided the conceptual architecture and substance; ChatGPT helped refine and focus it for a general audience. I was impressed!
Its scope is historical, personal, and philosophical. It builds on the extensive context developed in my 2023 peer-reviewed open-access book, Health Care in the Information Society. The book follows my career across the foundational decades of health informatics and the envisioning, birth, and maturation of openEHR from the early 1990s onward. It included a chapter which traced the intellectual and organisational foundations of the movement. One of my aims there was to acknowledge and bring together people, ideas, and events of lasting significance. Readers may wish to refer to it for background.
My purpose in supplementing and updating the coverage there is to capture what seems a pivotal moment in the growth of the openEHR movement and comment on what has, for me, been its defining character and hence value.
Finally, I also maintain an extensive personal archive documenting the often anarchic and combative years during which openEHR emerged as a self-governing global initiative. If opportunity presents, I will upload this archive to an LLM and invite it to generate its own narrative of the era and events it spans—an experiment that might sit interestingly alongside the many already written human histories of those times.
I. Introduction: Living with a Question
For more than thirty years, I have lived with a very important and consequential question: How might we describe and communicate, with fidelity and humility, the purposes and meanings of health care? This question lay at the heart of the European Advanced Informatics in Medicine initiative, beginning in the late 1980’s, which led over the following decade to the birth of openEHR. What began as a technical inquiry into ‘computerisation’ revealed itself as a human one—a search for forms and structures capable of honouring the complexity of clinical practice and the often fragile and urgent needs of those who depend on it. I have come to see that healthcare information is not a technical artefact but a moral endeavour: an attempt to preserve meaning across the manifold human encounters that define care.
openEHR grew into a movement: a global community now spanning more than a hundred countries, committed to creating an open, durable, and ethically grounded semantic foundation for care records. Over time it developed governance, openly shared intellectual property, national affiliates, and partnerships across industries, organisations, and professional and patient communities.
This essay revisits a series of conceptual triads—“trifectas”—that helped me articulate the purpose and trajectory of the movement as it evolved. They serve as thematic anchors marking the development of ideas and commitments across three decades of collaboration.
My reflections are also personal. My wife’s and my own recent cancer care placed me not only as an architect and developer of information systems but as one who relies heavily upon them. In the interplay of advanced machinery, intricate data flows, and human touch, I have found renewed clarity about the meaning and limits of information in the life of care. For care is a human-centred and thus living endeavour. And the information systems that support it must be regarded and treated as akin to living entities—capable of growth, adaptation and response to local requirements and changing science, technology and practice. These systems must, in turn, come together, dynamically, to form something I have called a care information utility: an infrastructure as essential, and as life-supporting, as the water and power utilities that underpin everyday life. I use the term utility more than just platform or ecosystem as it is a service and may subsume different platforms and ecosystems. Whitehead, an eminent mathematician and philosopher, coined the term organic philosophy, justifying this with an example from knowledge of human physiology and health care, showing how meaning is intimately related to living context.
II. The Movement Emerges: Early Dimensions and Commitments
1. Clinical – Technical – Organisational
From the outset, it was clear that reimagining the foundations of care records required balancing three inseparable dimensions, comprising the first trifecta. The clinical domain provided purpose—the semantics of care and the reasoning of clinicians. The technical domain provided the means—formal models and computational structures capable of carrying meaning across languages, systems, and decades. The organisational domain provided the context—the governance, incentives, and workflows that determine whether innovation survives contact with reality.
openEHR grew by treating these domains as mutually shaping. None could stand alone.
Essence
- Clinical: the meaning and purpose of care
- Technical: the formal and computational expression of that meaning
- Organisational: environment, team and governance whereby meaning shapes practice
One-sentence refinement
Clinical purpose, technical precision, and organisational reality must move together if healthcare information is to serve care safely and meaningfully.
2. Rigour – Engagement – Trust
Methodologically, openEHR advanced by holding three practices in tension: intellectual rigour, engagement with care practitioners and patients, and the continuous earning of trust. This trifecta became the movement’s ethical centre, enabling a global collaboration that produced something neither proprietary nor accidental, but deliberately built and broadly trusted.
Rigour sought to ensure clarity; engagement to ensure relevance; trust had to be earned through sustained stewardship over time—crucial in an international ecosystem.
Essence
- Rigour: disciplined methods and transparent reasoning
- Engagement: genuine participation across roles and communities
- Trust: the ethical foundation that emerges from the first two
One-sentence refinement
Rigour in method, engagement in community, and trust in shared stewardship formed the ethical backbone of the openEHR movement.
3. Implementation – Implementation – Implementation
The real discipline, and the humility with which we approached the mission, were captured in a simple refrain: implementation, implementation, implementation. Not as a slogan, nor as an impatient demand for deployment at scale, but as a philosophy—an acknowledgement that understanding grows only through lived practice.
Standards cannot be designed from a distance. They must be tested in the wild: in outpatient clinics, emergency departments, community services, research settings, and national programmes.
Every implementation served as a form of inquiry (e.g. considering medication reconciliation, obstetric care workflows, chronic-care pathways). Each one revealed new corner cases, overlooked complexities, and tensions between the elegant generality of a model and the messy particularity of real practice.
These encounters shaped openEHR far more deeply than any committee process could. Healthcare is too complex, human, and context-bound for speculative standards. What mattered was not how compelling an idea appeared on paper, but how faithfully it could serve clinicians and patients when it met the unpredictable, high-stakes, deeply varied world of real care.
Essence
- Implementation as reality’s testing ground
- Implementation as the discipline of iterative improvement
- Implementation as the source of truth
One-sentence refinement
Implementation—repeated, grounded, and iterative—kept the work honest, ensuring ideas survived contact with the real world of care.
4. Balance – Continuity – Governance
This trifecta came to me as I thought and wrote about the forces necessitating both reform and reinvention of care services in today’s world, in Part Three of my book. It applies equally to how the care information utility must be conceived, to help support judgement about the balance of diverse community and stakeholder perspectives and priorities, the continuity of the services and communities that depend on this, and governance that is transparent, trusted, and resistant to commercial capture.
In context of the growth of the openEHR mission, adherence to these principles was made possible by the progressive emergence of a genuinely open semantic commons for the clinical content of records. This paralleled the rigorous specifications of a generic technical platform infrastructure, to enable these data to move freely and carry their meaning across all levels and purposes of care. These two levels of the architecture are held in trust for the global community.
Essence
- Balance: harmonising diverse needs and priorities
- Continuity: sustaining coherence and stewardship
- Governance: providing stable, transparent oversight
One-sentence refinement
Balance, continuity, and governance expressed the ambition for a coherent care information utility to support the reform and reinvention of care services and enable their realisation.
5. Commitment to Openness
Making the openEHR methodology openly and freely accessible was a foundational principle—sometimes contested in its scope, but never abandoned. It defined the identity of openEHR and drew together and enabled its global ecosystem of contributors, implementers, and users.
I championed and enabled open-source reference implementations of the openEHR specifications and encouraged my team to take our work into the standardisation arenas of CEN and ISO. openEHR remained firmly committed to supporting all efforts to bring its methodology to the wider world. Market competition between members of the community, as well as beyond, was inevitable and a good thing.
Openness has many connotations, and I sought to assemble and interpret them in the context of the care information utility concept explored in Part Three of my book. In the context of openEHR, this emphasis is proving strategically effective, as well as an ethical choice.
Essence
- Community-wide co-authorship
- Open access for shared benefit
- Commercial neutrality
One-sentence refinement
Community authorship, open access, and commercial neutrality ensured that the movement could both claim and be seen to serve the global public good.
III. A Historical Arc: Adventure, Anarchy, Reform
I have found much relevant intellectual grounding in Alfred North Whitehead’s book, Adventures of Ideas, published nearly a century ago. Drawing on millennia of philosophy, mathematics, logic, science, and technology, Whitehead’s work suggested a sequential framework for my book, that resonates with the history of health information and openEHR: adventure of ideas, anarchy of transition, and programme for reform.
The first ten years were principally an adventure; the second ten years, as openEHR opened up to and started to challenge the real world of health care IT, were chaotic times. And ten years later, it has stabilised its governance, with new funding and connectivity with cognate missions such as SNOMED, FHIR and OMOP, leading to a reformation of the delivery of its mission.
This quotation from Whitehead resonates with me.
“In every age of well-marked transition there is the pattern of habitual dumb practice and emotion which is passing, and there is the oncoming of a new complex habit. Between the two lies a zone of anarchy […].”
– Alfred North Whitehead, Adventures of Ideas, 1933 (p. 14)
openEHR’s middle years exemplified exactly this zone of creative turbulence! Concerns about declining social cohesion in the information age were unknown to Whitehead. But the truth of his general observation and concern lives with us with great urgency today
Adventure of Ideas
The earliest stages of the Information Age were consumed with exploring and refining imaginative possibilities—how computers might be built, operated, and used. These were speculative years, animated by curiosity and the courage to challenge prevailing assumptions.
Anarchy of Transition
As ideas moved into practice, turbulence followed. Competing standards, incompatible agendas, and institutional resistance created uncertainty. Yet this period also fostered improvement: machines and methods matured, communities expanded, and commitments to shared and open approaches deepened.
Programme for Reform
More recently, we have entered a phase of consolidation. Benefits now depend on industrial capacity and capability, formal standardisation, effective governance, stable specifications, and coherent healthcare processes.
What was once experimental has become a recognised global framework for semantic interoperability. The programme for reform continues, but its foundations are strong.
Essence
- Adventure: creative expansion
- Anarchy: turbulence and contestation
- Reform: disciplined consolidation
One-sentence refinement
The history of health information reflects Whitehead’s cycle: the adventure of new ideas, the anarchy of transition, and the deliberate programme of reform.
IV. Rethinking Healthcare: Curative, Preventive, and Lived Care
This trifecta captures how care services are often grouped—and too often treated as distinct silos. Healthcare is typically framed as a balance between curative and preventive services. Modern life, however, demands recognition of a third mode: the supportive, relational care involved for those living with illness, disability, or deprivation.
Care records and openEHR’s archetype approach, must reflect lived experience, not only clinical interventions. They must capture the story of care in its fullness, encompassing the social, relational, and contextual dimensions of health.
The future of openEHR lies in representing and supporting this broader landscape. It is doing this by championing a unifying patient-centred care record as the ultimate source of truth about care, and by refining and sustaining a generic collaborative approach to its standardisation, now in the context of partnering with artificial intelligence oversight.
By embedding lived experience alongside curative and preventive care, openEHR can support clinicians, patients, and communities in ways that respect complexity, context, and human values. This vision positions health information systems not merely as record-keeping tools but as active participants in creating more humane and responsive care ecosystems.
V. A Living Information Utility: The openCare Vision
This vision positioned information systems not as rigid structures but as ecosystems that grow, adapt, and nourish the people and communities they serve. It focussed on enabling and supporting the balance and continuity of person-centred care, across different care journeys and joined up across organisations.
The idea was no doubt strongly influenced by my childhood experience of social care, living in a residential children’s home and later working as a volunteer in local community housing organisations. My parents devoted their lives to child care.
Such ecosystems must evolve and respond to diverse contexts. Many engaged in the openEHR movement and related endeavours are already advancing this path.
The immense cost and harm caused by fragmented information systems demand a new kind of infrastructure. One that supports care rather than bureaucracy, evolves rather than calcifies, and reflects the dynamic nature of human health and well-being of individual citizens.
In Part Three and Chapter Nine of my book, I explored the framing of an organic information utility – one that, for example, enables and supports continuity of care for an end stage breast cancer patient across oncology, primary care, hospice, and community nursing at home.
- What does it mean for such a utility to grow?
- How does it govern and sustain itself?
- What does it nourish?
These questions reinforce a central theme across openEHR: the need to address, in parallel, global coherence and local agency. It is an ecology—continuously evolving, shaped by community and context, never complete. Those in our community who combine front-line care participation with contributions to the evolving openEHR methodology are taking crucial steps toward moving the movement to the centre of societal efforts to reform health and social care for the information society of tomorrow.
VI. Personal Experience: Technology, Measurement, and Humanity
My cancer treatment brought back memories of the pioneers of computerised radiotherapy treatment planning and systems I helped shape sixty years ago. Today, I experienced—and was shown—the inner workings of highly automated machines and the planning of my treatment. This is now near to an end-to-end AI-supported process, yet people are still essential to explain, guide, and support patients throughout.
Each session began with a preliminary CT scan to ensure alignment of updated organ positions with the plan, optimising target dose while reducing risk to surrounding organs—echoing the Nobel Prize-winning CAT scan work I first encountered in the 1970’s. The linear accelerator delivered radiation with varying intensity along arcs—a striking contrast to that delivered along three or four separate axes from the unshuttered cobalt sources of my early career.
In the 1960’s I had observed the developing technology of the linear accelerator, watching prototypes being built and tested in huge aircraft hangars, with only partially protective concrete block walls! A reminder of the risks borne by those who pioneered the science and technology of these machines.
Now, I witnessed precision technologies, intricate data flows, and met fellow patients—anxious and experiencing accumulating side effects—and radiographers whose care, skill, and humanity grounded the experience.
I was reminded that information is not a central theme of care; it is its servant.
VII. Philosophy for a Time of Radical Uncertainty
We live amid noisy political upheaval, technological acceleration, ecological stress, and the rise of AI. Emerson warned of echo chambers of human words. People not listening to one another but talking across one another – essentially listening to their own words.
“By having a real other respond to me, I am spared one thing only – the worst cumulative effect of my own echo chamber of words.”
– Ralph Waldo Emerson, 1803–1882, essayist and poet
We might now best be wary of echo chambers of machine reasoning and communication.
In like manner, Whitehead emphasised the importance of preservation of symbolic insight as we seek to enhance society and make it more resilient. He feared that rapid and radical change risks losing much of symbolic value that has been distilled over time:
“It is the first step in sociological wisdom, to recognize that the major advances in civilization are processes which all but wreck the societies in which they occur […]. Those societies which cannot combine reverence to their symbols with freedom of revision, must ultimately decay either from anarchy, or from the slow atrophy of a life stifled by useless shadows.”
– Alfred North Whitehead, Symbolism, Its Meaning and Effect, 1927 (p.88)
These philosophies speak to needs that openEHR encounters and addresses – coherence and sustainability in knowledge, record and communication that must live over life times and through periods of rapid and overwhelming change. openEHR helps prevent this harmful loss of symbolic meaning (e.g., through durable semantic formalism, federated community modelling, preservation of context).
These considerations highlight openEHR mission as in part a societal undertaking: a way of preserving meaning, coordination, and human agency under accelerating change. The quotations remind us that even advanced technology cannot replace careful stewardship of values, symbols, and human judgments.
VIII. Conclusion: What Endures
openEHR’s principal strength lies not in its specifications but in its distributed stewardship. Its community is carrying the movement through adventure, anarchy, and reform. My recent experience of illness clarified what the movement has always known: information matters only insofar as it supports one human being meeting another at a moment of need.
Leadership of such radical change is measured not by what one achieves but by what one enables. As Lao Tzu wrote:
“A leader is best when people barely know he exists, when his work is done, his aim fulfilled, they will say: we did it ourselves.”
– Lao Tzu, sixth century BCE Chinese philosopher
The future of this movement is not a fixed programme but a living promise—of openness, rigour, and the continual pursuit of meaning in the service of care. It is guided by the same question that opened these reflections: how we might preserve and communicate the purposes and meanings of care with fidelity and humility. That question remains as vital today as when the journey began.
Endnote
After drafting and refining this reflection, I asked ChatGPT to offer its view on the future role of artificial intelligence in the openEHR movement. I will include its interesting and thought provoking perspective as an additional discussion piece; I am no longer familiar enough with the field to offer it as an evidenced position.
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