• Interoperability
  • US eHealth IOp should focus on big impacts

    Interoperability (IOp) in eHealth isn’t an absolute state. Measuring it isn’t either. Sir William Osler, a Canadian doctor and one of four founding professors of Johns Hopkins Hospital, didn’t need to bother with eHealth IOp, but hinted at it in strategy when he said “In seeking absolute truth we aim at the unattainable and must be content with broken portions.”

    Challenges are how much, and which IOp measurement will achieve contentment without breaking it. An article in Fierce Health provide some indication. It sets out responses from five US organisations to the Office of the National Coordinator (ONC) report in the Proposed Interoperability Standards Measurement Framework, reported by eHNA in May.

    It has two main themes.  One’s measuring standards implementation. The other’s how end users can refine and customise standards to meet their needs. Most groups expressed some trepidation that new standards would result in an undue burden for providers. They want the ONC to focus on measurement areas with the biggest impact. Their advice is directly relevant for Africa’s IOp plans.

    The American Medical Informatics Association (AIMIA) supported the ONC’s framework in its response. It also asked the ONC to target “high-value standards” that offer the biggest impact. Specific requirements are functionalities for accessing drug databases and transmitting laboratory data. It wants the measurement framework to be automated too, so easier reporting mechanisms translate to higher participation.

    A combination of support and caution was part of the Health Information Management and Systems Society (HIMSS) contribution. It offers three main themes: 

    Limiting undue burden by leveraging the use of existing reporting frameworksStandards as the means, with the standards measured aligned to use cases critical to advancing IOp and better information exchangeIncluding all relevant stakeholders, including the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC).

    A sub group of HIMSS, the Electronic Health Record Association (EHRA) suggested a combination of standardised approaches with non-standard methods. It’s a focus on use cases with the biggest impact. It emphasised the potential burdens too.

    The College for Health Information Management Executives (CHIME) highlighted patient matching as one of the biggest IOp barriers. It says measurement standards are premature, and wants the ONC to:

    Develop standards for seamless communication between ICT systemsEnsure that data exchange identifies patients with 100% certaintyMake data exchange usable for clinicians before tackling IOp standards.

    CHIME proposed that if the measurement framework’s implemented, the ONC should work with stakeholders to prioritise cases and develop a granular set of standards.

    Health IT Now, a coalition of patient groups, healthcare organisations, employers and payers, recognises that measuring IOP’s necessary, and said a narrow focus on successful data transmissions devalue improvements in using data to improve care and defer the capability of health systems to exchange information. It wants collaboration with patients and patient advocates and private sector organisations that can contribute to identifying, developing, and deploying IOp standards for better information systems.

    These perspectives can inform Africa’s eHealth development. IOp and its choices are seldom off the eHealth agenda.

  • Kenya’s setting up new mHealth legislation

    Africa’s eHealth legislation and regulation needs considerable developed. Kenya’s stepping it up, eHealth experts have welcomed proposed eHealth legislation, including the Health Act 2017 and the Kenya Standard and Guidelines for mHealth Systems. They see the legislation as facilitating Interoperability (IOp) between private and public healthcare, and as guidelines to move wider eHealth on says an article in ITWEB Africa.

    The Health Act 2017 says within three years of its operation, the Ministry of Health (MoH) will implement management information banks. They’ll include an IOp framework for data interchange and security to improve personal health information management.

    Tony Wood, Managing Director at My Dawa, an online service for ordering prescription and wellness products, said he welcomed legislation that builds the eHealth ecosystem. "With everything, as you look at the world, technology is moving faster than regulation, governments and policy. More can now be done on how these are implemented going forward. I hope they are going to be implemented through open consultation where the public and private sector are working together." This seems like the next step.

    The 66-page guidelines are wide ranging. They set out definitions and extend across mHealth implantation, standards, governance and policy. The proposed legislation’s scheduled for debate in the national assembly. It’s a crucial stepping stone implementing successful and sustainable mHealth and wider eHealth.

  • Semantics aren’t good enough on pagers

    Effective communication between people and information systems in eHealth relies on rigorous informatics such as semantic Interoperability (IOp) and data definitions. A US study of pagers’ messages content reported in the Journal of the American Medical Association (JAMA) Internal Medicine found limitations of both quality and safety. These points to initiatives that Africa’s health systems can set up.

    Even with the seemingly ubiquitous mobile communication technology, inpatient healthcare teams often use pagers to communicate using text. The study team say it’s inefficient, disruptive and has communication concerns. The study analysed the content of 575 text messages on pagers in an internal medicine service of an academic tertiary care hospital. The texts included messages sent or received by physicians, nurses, students and ancillary staff. They included texts about the care of 217 patients. 

    Most messages, 78%, were sent to doctors by healthcare workers who were not doctors. The analysis revealed three main deficiencies:

    No standardisation, including information on vital signsUnclear vocabulary on ranges of urgencyCommunication gaps arising from messaging practices.

    While the ranges of content and topics were quite narrow, the team saw wide variations in message clarity and structures. It’s possible that the limitations could reduce patient safety and other aspects of healthcare quality.

    A solution’s to develop guidelines for using text paging effectively, to ensure efficient communication among health care teams. They should extend across standardised, structured communication for high-frequency topics and structured urgency flags for text paging doctors. Africa’s health systems can start their own improvement projects as part of their IOp and data dictionary projects.  While the study dealt with pagers, are the findings likely to be replicated for text messages using mobile phones?

  • USA’s ONC updates its eHealth IOp plans

    eHealth’s Interoperability (IOp) just doesn’t stand still. The USA’s Office of the National Coordinator for Health Information Technology (ONC) has released a new IOp framework. Proposed Interoperability Standards Measurement Framework aims to identify the USA’s progress in implementing IOp standards in healthcare. It builds from the ONC’s IOp roadmap Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap, and deals with:

     The current state of measurementStandards implementation and useAn overview of the Proposed Measurement FrameworkImplementing IOp standards health ICT productsEnd users use of standards to meet specific Imp needsData collection sources and mechanisms.

    The report identifies significant variability across the health ICT ecosystem in capabilities to measure IOp standards vary significantly. It constitutes significant eHealth challenges. Most significantly, health ICT developers and exchange services exhibit variability in tracking the use of standards in Health Information Exchange (HIE). The main causes are attributed to differences in:

     ArchitectureDevelopment decisionsAccess to the dataVariability in standard implementation.

    Two vital proposals to enhance progress towards uniform implementation and use measures set out in the framework are:

    ·       Capturing progress on implementing standards in health ICT products by annual reporting on:

    o    Standards in development plans

    o   Standards implemented in health ICT products and services

    o   Product versions with standard implemented deployed to end users

    ·       End users using standards, including customisation, to meet their specific IOp needs

    o   Standards used by end users

    o   Volumes of transactions by standard

    o   Level of IOp standards conformance and customisation 

    There are three valuable lessons for Africa’s eHealth IOp. An IOp roadmap’s essential. It’s also essential to have a grip on the distance travelled and what’s needed to reach the destination.

  • IOp extends beyond healthcare entities

    Engaging patients, sharing information, analytics and using EHRs for research are examples of modern eHealth. This expansion from the 1990s vision of eHealth means that informatics issues, like Interoperability (IOp) have expanded too. A white paper from IDC Health Insights and sponsored by OpenText sets out a way to respond that can guide Africa’s eHealth approach.

    The Rocky Road to Information Sharing in the Health System says eHealth such as EHRs, operating in healthcare silos, business interests of health systems and health ICT system vendors and regulatory requirements for security have combined to inhibit information sharing complex and costly. The response is to improve IOp to enable better information sharing to help prevent unneeded and costly interventions such as repeat tests and procedures and create evidence-based care plans implemented by networks and in communities.

    Trends and realities of the new eHealth environment include direct messaging that needs IOp standards and protocols and secure data sharing for:

    Referrals between organisations and cliniciansDischarge summaries and test resultsCare transitionsSending data to public health organisationsInformation sharing with payers for authorisation of servicesSecure information sharing between patients and providers. 

    Direct messaging’s still in its infancy. An IDC survey of 179 healthcare organisations showed that paper, phones and faxes are still prevalent:







    Informal, such as phone calls



    Fax machine or fax service



    Scanning directly to recipients



    Standard or secure email



    Portal/system provided by a hospital



    Care/patient transition portal such as Curaspan



    Multiple portals or systems



    EMR or EHR integration



    Health information exchange (HIE)



    Electronic media such as CD/DVD/USB drive



    While direct messaging may be evolving, the consequences poor and incomplete information sharing remain in place. The survey revealed that over the past three years, organisations current methods of sending and receiving patient information resulted in:

    Loss of business               


    Decrease in operational efficiency


    Billing/medical coding errors


    Medical errors                   


    While business cases and their estimated costs and benefits need assessing before adopting direct messaging, the white paper’s clear that healthcare providers have much to gain and little to lose by extending IOp  across their networks and into their communities. It seems like a model for Africa’s eHealth.

  • IOp isn’t easy, it needs more planning and evaluation

    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:

    Cost:Facilities often have limited financial resources for the initial costs of EHRsAdditional costs may be incurred for exchanging information and maintenanceImplementing standards: concerns are:Variability in implementing health data standardsDifficulty finding health information relevant to post-acute care providers when this information’s exchangedWorkflow disruptions: implementing EHRs needs post-acute facilities to change their daily work activities or processes, which can be disruptiveTechnology challenges: such as EHRs that can’t exchange health information electronicallyStaffing: 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.

  • All Africa’s healthcare entities should tackle IOp

    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:

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

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

    Five principles:                  Assemble a core team                                     Conduct legal and market analysesDetermine primary barriers                        Select strategiesImplement and evaluateTwo 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:

    Develop eHealth’s legal and regulatory aspectsCreate standardised consent forms for patient permission for sharing informationProvide guidance and education for legal and regulatory requirements and misconceptions

    Strategies to address market barriers include:

    Creating economic interests that encourage Health Information Exchange (HIE) and penalise the lack of itUsing legislative, regulatory and contracting to bolster HIE and prohibit information blockingSetting the vision and holding people accountableSetting a vision for IOp HIE and elevating best practices and placing pressure on laggardsBringing 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?

  • IOp challenges in Africa are African

    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:

    How much IOp do we need in the short termHow 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.

  • Are five IOp themes enough for Africa’s eHealth?

    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:

    Determine the care networks and the connections to themIdentify and prioritiseDetermine if networks and connections need expandingStart a dialogue and planStart 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.

    Foundational allows data to be sent or received, but needs people to read and import itStructural means sharing of data where systems understand key phrases, but not everythingSemantic’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:

    Identify the information needed about patients and communities across the care networks for decisionsIdentify 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 stakeholdersSee if care networks and connections need expanding and find the gapsStart the dialogue and build a planImplement 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.

  • Is IOp max a cyber-security risk?

    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:

    Who should interoperate?Are connections reliable?Are all entities what they portend to be, or are some masqueradingIs 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:

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

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