Interoperability (50)

At eHealth’s high peak sits Interoperability (IOp). Reaching the summit’s a test of preparation and endurance. The view from the top might be breath-taking, but the ascent’s a continuing challenge.

A report from the US Government Accountability Office (GAO) has identified some of these. They’re essential lessons for Africa’s health ministries and systems. ELECTRONIC HEALTH RECORDS HHS Needs to Improve Planning and Evaluation of Its Efforts to Increase Information Exchange in Post-Acute Care Settings sets out five important findings from stakeholders about the US IOp project:

  1. Cost:
  • Facilities often have limited financial resources for the initial costs of EHRs
  • Additional costs may be incurred for exchanging information and maintenance
  1. Implementing standards: concerns are:
  • Variability in implementing health data standards
  • Difficulty finding health information relevant to post-acute care providers when this information’s exchanged
  1. Workflow disruptions: implementing EHRs needs post-acute facilities to change their daily work activities or processes, which can be disruptive
  2. Technology challenges: such as EHRs that can’t exchange health information electronically
  3. Staffing: a lack of staff with expertise to manage EHRs and high staff turnover result in a constant user training.

There are other challenges too. The Department of Health and Human Services (HHS) hasn’t measured the effectiveness of its efforts to promote EHRs. It also lacks a comprehensive plan to meet its goal to increase the proportion of post-acute care providers exchange electronically. These gaps are seen as inconsistent with leading principles of sound planning.

Current planning excludes key external factors and risks that may affect its efforts adversely. Without a comprehensive plan to address these, risks of not achieving goals. Consequently, HHS cannot determine if its efforts contribute to its goal, or if they need modifying.

The Office of the National Coordinator for Health Information Technology (ONC) plans to survey providers in post-acute settings to collect baseline data on EHR adoption rates and activities to

demonstrate ways to exchange health information electronically. Currently, they don’t extend to assessing HHR’s effectiveness in promoting EHRs use. In addition, most of the key efforts lack specific plans for evaluating their progress.

HHS accepts the findings. It plans to improve its tracking of EHRs use in post-acute care if resources become available. The constructive dialogue reveals the way that Africa’s programmes for EHRs should proceed up the mountain, one step at a time, where each step adds to the ascent.

Africa has a very long history of mathematics, especially fractal geometry. Ron Eglash and Toluwalogo B Odumosu describe it in Fractals, Complexity, and Connectivity in Africa, a chapter in What Mathematics from Africa? Polimetrica International Scientific Publisher. It can be replicated in Africa’s long eHealth Interoperability (IOp) journey.

The US National Governors Association (NGA) has released its IOp road map for states to improve their health information flows between providers, Getting the Right Information to the Right Health Care Providers at the Right Time. It offers Africa’s provinces and healthcare entities an approach they can adopt in parallel to national health ministries’ IOp initiatives. Two benefits are:

  1. IOp’s enormous and interminable, so national governments can’t do it all alone
  2. Local IOp priorities may not be national priorities.

The NGA set out five core principles and two IOp strategies:

  1. Five principles:                  
  • Assemble a core team                                     
  • Conduct legal and market analyses
  • Determine primary barriers                        
  • Select strategies
  • Implement and evaluate
  1. Two strategies to overcome legal and market barriers.

These aim to overcome numerous inhibitors that restrict the exchange of clinical information between providers. Currently, it either doesn’t happen or it doesn’t enable meaningful data use to support optimal patient care.

The legal strategy aims to:

  1. Develop eHealth’s legal and regulatory aspects
  2. Create standardised consent forms for patient permission for sharing information
  3. Provide guidance and education for legal and regulatory requirements and misconceptions

Strategies to address market barriers include:

  1. Creating economic interests that encourage Health Information Exchange (HIE) and penalise the lack of it
  2. Using legislative, regulatory and contracting to bolster HIE and prohibit information blocking
  3. Setting the vision and holding people accountable
  4. Setting a vision for IOp HIE and elevating best practices and placing pressure on laggards
  5. Bringing key stakeholders together to work towards HIE IOp.

Some of these are specific to US states that have legislative powers that Africa’s healthcare entities don’t have. Despite this, the NGA initiative reveals how Africa’s healthcare entities can move their own IOp initiatives on as a sub-set of their countries national IOp plans.

The road map helps states evaluate and implement changes to achieve better health and healthcare and lower costs by increasing clinical healthcare information flows between providers. It protects patient privacy too. Both are steps towards national IOp, a valuable opportunity for Africa’s healthcare entities. As Eglash and Odumosu conclude, “Ideas can be powerful, and we are convinced that the fractal heritage of Africa holds great promise for its future.” Can it work for widespread eHealth IOp across Africa?

Africa’s eHealth interoperability (IOp) challenge is different to rich countries. An article in Digital Health Legal by Acfee’s Tom Jones describes some of the differences. If US healthcare, with its huge resources, finds IOp challenging, it is not surprising that it’s challenging for Africa’s health systems. Put alongside this, the long-standing eHealth challenges and socio-economic characteristics of Africans and African countries, Africa’s IOp’s a mountain.

Rwanda and South Africa’s approach to IOp show how different Africa is to developed countries.

IOp risks and vulnerabilities now being identi?ed by countries like the US need balancing against the affordable eHealth investments needed to achieve Universal Health Coverage (UHC) for a huge health burden and insufficient healthcare, and Sustainable Development Goals (SDG) in Africa. With constrained resources for eHealth, African countries have to deploy their scarce resources to improving these. It reduces the resources available for high levels and extended reach of semantic IOp.

While effective, appropriate IOp has considerable and essential benefits, it also has a cost. It’s important that Africa’s health systems consider both together and the extent to which IOp’s needed for strategies such as UHC and SDGs. Extra spending on IOp can reduce net benefits unless they contribute directly to benefits or provide a foundation for future benefits. These are complex decisions that, like all eHealth, involve considerable risks. Doing nothing isn't a good idea.

For Africa, IOp risks and vulnerabilities now being identi?ed by countries like the US need balancing against the affordable eHealth investments needed to achieve UHC, SDGs and other health strategies in Africa. The challenges are:

  1. How much IOp do we need in the short term
  2. How much can we deal with successfully?

While countries like the US and other developed countries can show a way ahead for IOp, Africa needs to find its own way. Like all eHealth investments, IOp needs to help each country achieve its health and healthcare aspirations and objectives, and lead to healthier Africans.

Dealing with interoperability (IOp) challenges might seem more like grappling with “infinity and beyond.” Buzz Lightyear can’t help much, but Open Minds might. It proposes themes for success:

  1. Determine the care networks and the connections to them
  2. Identify and prioritise
  3. Determine if networks and connections need expanding
  4. Start a dialogue and plan
  5. Start the wheels in motion towards semantic IOp.

These emerged from a session, Standing Apart – Interoperability’s Strategic Role In Advancing Behavioral Healthcare Transformation, a 2016 OPEN MINDS Technology and Informatics Institute seminar. It was sponsored by Qualifacts Systems.

It defined IOp as “Orchestration of health care data between healthcare systems so that all individuals, their families and health care providers can send, receive, find and use electronic health information to support the health and wellness of individuals through informed, shared decision-making.” It runs across the three IOp levels of foundational, structural, and semantic.

  1. Foundational allows data to be sent or received, but needs people to read and import it
  2. Structural means sharing of data where systems understand key phrases, but not everything
  3. Semantic’s seamless exchange and interpretation of data and information where people aren’t needed to translate it.

Semantic IOp’s seen as not yet been achieved in healthcare. The current position’s described as “Somewhere between levels one and two – with some organizations making more progress than others.” This sets the challenge of reaching semantic IOp.

A five-step process can help organisations plan for interoperability:

  1. Identify the information needed about patients and communities across the care networks for decisions
  2. Identify priorities for exchanging information needed for clinical outcomes, staff satisfaction, and administration, rate how hard it will be to achieve them and validate them with stakeholders
  3. See if care networks and connections need expanding and find the gaps
  4. Start the dialogue and build a plan
  5. Implement the IOp plan, the most difficult challenge.

IOp’s road’s seldom smooth. In healthcare, total IOp’s a holy grail. Instead, starting and moving ahead’s more important. Progress in achievable steps towards IOp’s destination should be the objective. This seems a more practical approach for Africa’s eHealth than aspiring to a big step up.

Exchanging health and healthcare information and Interoperability (IOp) is an important eHealth benefit. It needs extensive levels of IOp to make it work, but how much is enough and sensible to minimise cyber-security risks?                                                                                                                                

It’s a scenario described by the US Federal CIO Tony Scott at the College of Healthcare Information Management Executives (CHIME) 2016 CIO Fall Forum, and reported in Healthcare IT News.

One of his two special addresses identified the inherent threat posed by the technical paradigm of maximum IOp. The other dealt with the digitisation process.

Complacency may prevail in IOp max where specifications and manufacturing are so good, it's assumed that everything will work. The next step’s addressing a set of crucial missing questions from a cyber-security perspective. They include:

  1. Who should interoperate?
  2. Are connections reliable?
  3. Are all entities what they portend to be, or are some masquerading
  4. Is IOp working as it should?

Currently, investment’s in place to answer these questions and configure and operate solutions. Support for better ICT security’s on place too. These should help to minimise increased cyber-security risks.

Other questions include:

  1. What extra vulnerabilities are created by IOp max?
  2. Are the technical solutions enough to mitigate them?
  3. How much IOp’s really needed, less than IOp max?
  4. How much IOp’s affordable?

Answers to all these questions are vital for Africa’s eHealth programmes. Affordability’s a permanent constraint.

Access to secondary data and using it effectively’s essential for initiatives to improve health and healthcare quality, research, implementation, surveillance and M&E. The Quality, Research and Public Health  (QRPH) Technical Committee of Integrating the Healthcare Enterprise (IHE) has published a new white paper, Using IHE Profiles for Healthcare - Secondary Data Access. It’s the fourth in a series of white papers. The other three are:

  1. Knowledge Representation in Chronic Care Management: Example of Diabetes Care Management
  2. Newborn Screening (NBS)
  3. Performance Measure Data Element Structured for EHR Extraction.

The new white paper describes how to allow secondary data communities to have standard, reliable and secure data access from another health community, especially clinical. It also provides guidance on respecting patients’ privacy and access to data if a secondary data community isn’t allowed to know patients’ identifiers used by the other community.

Before using the white paper, it’s important to have a working knowledge of five IHE standards:

  1. Cross-Enterprise Document Sharing (XDS)
  2. Patient Identifier Cross-Referencing (PIX)
  3. Cross-Community Access (XCA)
  4. Patient Demographic Query (PDQ)
  5. Cross-Community Document Reliable Interchange (XCDR)
  6. Query for Existing Data (QED).

Other relevant standards are:

  1. Redaction Services (RSP)
  2. Data Element Exchange (DEX)
  3. Clinical Research Process Content (CRPC)
  4. Retrieve Protocol for Execution (RPE)
  5. Aggregate Data Exchange (ADX).

There are two use cases:

  1. Epidemiology, with data available from research to the clinical community
  2. Case Report Forms (CRF) retrieval for clinical purposes, with data available in both directions between research and clinical communities.

IHE has a standing invitation to public health professionals to join its collaborative efforts between the public health and HIT vendor communities. It guides the development of IHE Integration Profiles for Interoperability (IOp) among and between EHR and Public Health Systems (PHS). The profiles facilitate the linkages, standardisation and integration of health data between clinical care and public health to create robust, overarching Health Information Exchanges (HIE). These are becoming increasingly important for Africa’s eHealth.

These days, healthcare professionals need reliable, available clinical data. At eHealth ALIVE’s masterclasses, Shelly Lipon, from the International Health Terminology Standards Development Organisation (IHTSDO) and the Systematized Nomenclature of Medicine–Clinical Terms (SNOMED-CT) initiative, unpacked Interoperability (IOp) and profiling terminologies.

SNOMED-CT’s the world’s most comprehensive multilingual clinical terminology. It contains scientifically validated clinical content and maps to other international standards. In eHealth, it supports high quality clinical content in EHRs and has an increasing number of tools and implementations. It’s not surprising it’s used in more than 50 countries.

Its clinical terms are comprehensive as a SNOMED concept. A comprehensive clinical scope reduces need for several coding systems, that also enables queries that span across numerous multiple disciplines and clinical areas, such as test results, diagnosis, medication, devices, procedures and organisms. It’s multilingual to, so can localise national, regional and dialect use. This’s matched by a facility that links different ways of saying the same thing by a common code.

The common reference terminology facilitates integration of clinical data from many sources that use different code systems or free text. It means that it can provide consistent representations of meaning for retrieval, processing and communication. Computable definitions of meaning allows meaning-based retrieval of clinical relevant facts that help to define relationships, support powerful querying, reporting and linking knowledge.

Using discharge summaries as an example, Shelly summarise the range of information needed. It includes diagnoses, procedures, medications, social circumstances and follow-up appointments. These are in a combined context of current problems, past medical histories and future contexts. The data can come from single or several systems.

A data model for discharge summaries includes the data’s form, and the form it’s transferred in. Data’s recorded in text and clinical terminology codes. Terminologies used are classifications of data recorded as summaries of episodes of care, or data used for real-time recording. It’s transferred  as message structures that can include coded data only, original text only or a mixture of coded and original text. An example of SNOMED-CT’s codes is:

Currently, SNOMED-CT isn’t used widely across Africa. Examples are in supporting HIV/AIDS services. As eHealth and IOp sophistication increases across the continent, it’ll become increasingly important in providing accessible, relevant information to clinicians and other health professionals to help manage and improve their clinical and working practices and integrate healthcare across organisational boundaries.

Supplements to Interoperability (IOp) standards for pharmaceutical services have been released by Integrating the Healthcare Enterprise (IHE) Pharmacy Technical Committee. The  Pharmacy Technical Framework Supplements deal with four aspects:

  1. Pharmacy Dispense (DIS)
  2. Medication Treatment Plan (MTP)
  3. Pharmacy Pharmaceutical Advice (PADV)
  4. Pharmacy Prescription (PRE).

There are three types of review. They started trial implementation on 21 October 2016. They’ll be tested at subsequent IHE Connectathons too. The third is by direct comments from individual users. Commenting online seems the most convenient way for Africa’s pharmacists and other healthcare professionals to contribute.

As eHealth expands and needs to transfer data from more parts to others, there’s no doubting the need for effective Interoperability (IOp). It seems there’s no doubt that it’s hard to achieve. A meeting of US hospital CIOs at the College of Healthcare Information Management Executives (CHIME), and reported by Fierce Healthcare, recognised that IOp’s a persistent challenge.  Observations and comments from the event offer salutary and realistic lessons for Africa’s eHealth. They included:

  1. Some progress has been made with help from the Office of the National Coordinator for Health IT (ONC), but there’s still a long way to go to be truly and semantically interoperable
  2. IOp’s not solved, and not even close
  3. Considerable effort and work’s still needed to ensure information is exchanged quickly and accurately between facilities
  4. “Behind the scenes, there’s a bunch of little mice on wheels that are taking the data from one system, manipulating it and sending it to another system. That’s a full-time job for a team, running these interfaces
  5. One organisation exchanged about 500,000 records in a quarter, but failed to connect roughly 150,000, about 30%, because it couldn’t match patient’s IDs.

These point to the realism that Africa’s health systems should adopt to their IOp plans and programmes. Two features of an effective approach are first, being clear and explicit about IOp’s benefits and how they’ll be delivered. Second, before starting, make sure that long-term sustainable finance and budgets are in place and reset the benefits to match affordability. These can help to avoid excessive IOp optimism.

In its eHealth Strategy stretching from 2012 to this year, Dr Aaron Motsoaledi, South Africa’s Minister of Health, was clear. “Historically, health information systems in South Africa have been characterised by fragmentation and lack of coordination, prevalence of manual systems and lack of automation, and where automation existed, there was a lack of interoperability between different systems.” In a masterclass at this year’s eHealth ALIVE conference, Matthew Chetty from South Africa’s Council for Scientific and Industrial Research (CSIR) set out the Interoperability (IOp) policies and governance as part of the solution.

Five levels are:

  1. Political context, with co-operating partners with compatible visions, aligned priorities and focused objectives
  2. Legal IOp, needing aligned legislation so exchanged data’s accorded proper legal weight
  3. Organisational IOp, needing co-ordinated processes so organisations achieve a previously agreed and mutually beneficial goal
  4. Semantic IOp alignment so precise meanings of exchanged information’s preserved and understood by all parties
  5. Technical IOp for interaction and transport so planning technical issues to link computer systems and services.

Four sequential steps are needed to achieve these. They’re:

  1. Analyse the landscape and assess Health Information Systems (HIS) to define the IOp problem
  2. Establish a set eHealth IOp standards, the National Health Normative Standards Framework for Interoperability in eHealth (HNSF)
  3. Establish a regime for IOp testing and certification, the National eHealth Interoperability Lab
  4. Establish the foundational ICT Infrastructure needed for IOp.

Recommending eHealth standards for South Africa isn’t developing eHealth standards from scratch. It’s selecting the most appropriate set of standards from the range available from international standards organisations to support South Africa’s health system. The HNSF includes a process of reviewing eHealth base standards and selecting a stack that fits South Africa’s health systems requirements and health functions. Seven selection criteria are scalability, implementability, testable, cost, maturity, extendibility and flexibility. Six IOp components fit into a template of:

  1. Process for functional group and functions
  2. Technical, for Integrating the Healthcare Enterprise (IHE) profiles, general ICT standards, transfer and messaging standards
  3. Semantic, for coding and terminology, content and structure and EHR standards
  4. Security standards.

Steady progress is underway. There’ll be much learning on route as standards are applied in eHealth investment decisions using the HNSF as a firm foundation