• Interoperability
  • eHealthALIVE: Achieving national interoperability

    Interoperability’s (IoP) both essential and challenging. It has a huge range of issues stretching across priorities, levels, operational, affordability, pace of implementation and net benefits.

    At eHealthALIVE2016 in Johannesburg on 6 and 7 September, Matthew Chetty, from South Africa’s Council for Scientific and Industrial Research (CSIR), is part of an expert panel leading a two-part Interoperability Masterclass. It’ll provide delegates the practical tools and insights they need to develop and implement strong IoP strategies. In an article for eHealthALIVE, he sets out how he sees IoP for South Africa’s health system.

    At CSIR, he’s Competency Area Manager. It includes dealing with integrated systems, platforms and technologies and building ICT solutions. Over the last five years, he’s dealt with IoP for the National Department of Health (NDoH). It’s a priority identified by the Minister of Health and highlighted in the eHealth Strategy. It’s needed to integrate eHealth data where systems are fragmented, and where they’re automated too

    The first objective was establishing a set of standards for how eHealth transfers information. It was published in April 2014 as the Health Normative Standards Framework for Interoperability in eHealth (HNSF), a major milestone towards eHealth IoP. It includes a set of technical standards cutting across several categories, such as content, messaging, coding, security and general ICT standards. Complying with them creates a foundation for sharing information. It’s not the solution. Other functions need establishing too.

    One is how existing national eHealth services can achieve IoP with each other. The first step was assessing the systems already deployed in the primary healthcare environment to determine to what extent they comply with the HNSF. We completed that evaluation last year and soon after the results were presented to the National Health Council.

    Plans are underway at CSIR to establish an IoP lab by the end of 2016. It’ll be where people can test whether their systems interact or exhibit IoP with each other. Testing tools will help users understand the extent of technical compliance with the standards and where changes or improvements are needed. We’re aiming to have that facility up and running by the end of 2016.

    IoP’s seen as financially beneficial for the health system. Sharing eHealth data can help to avoid repeated tests at different facilities, costly and wasteful activities. It’ll address data fragmentation too, leading to greater automation in the health system. This leads on to health system efficiencies that benefit patients, health workers, managers and government.

    Achieving these needs barriers removing. ICT infrastructure has to be in place to enable IoP information exchange. Different IoP levels need to be in place, including organisational level, regulatory and policy. Vendors need encouragement and incentivises to so they’re willing to share information in their systems. All these need achieving by securing patients’ privacy.

    You’ll learn much more at eHealthALIVE. Tickets are available online.

  • eHealth has five big knock-downs

    As a new technology, eHealth’s ICT components are still maturing and evolving. It’s far from perfect, and may never be. Vince Lombardi, the USA footballer, had a less demanding, more realistic goal when he said “Perfection is not attainable, but if we chase perfection we can catch excellence.” In a blog on the site of the Healthcare Information and Management Systems Society (HIMSS), some USA doctors have set out five eHealth challenges and how to fix them. They fit eHealth in Africa.

    1: Navigation

    Issue: information isn’t organised to support clinical workflow and the way clinicians think.

    Why it persists: clinician workflows are complex, nonlinear, and dependent on a variety of sources, all of which differ significantly between specialties and individual providers, but eHealth’s designed for generic tasks and steps that impose new workflows that don’t support decision making

    How to fix it: observe and record workflows in a structured publicly available form to allow the industry to understand commonalities and best practices without recreating them and offer clinicians flexibility to customise task sequences to fit their work habits and quicken accurate decision making.

    2: Data entry

    Issue: consulting with a patient in an office visit needs numerous tasks, including eye contact with a patient, listening, processing nonverbal cues, keeping laboratories, allergies, and medication lists in mind, formulating a range of diagnoses, documenting granularly for ICD-10 codes, entering hundreds of items of structured data to comply with multiple quality and value programmes, and avoiding malpractice.

    Why it persists: data entry’s assigned to the busiest, highest trained members of the healthcare team, the front-line clinicians, and the increased cognitive load and decreased situational awareness impairs their focus, comprehension and potential to solve a patient’s problems.

    How to fix it: standardise, simplify, automate, delegate, harmonise and decrease data entry requirements to focus only on the most meaningful data, so EHRs collect and populate appropriate quantitative data automatically, and expand capabilities to allocate tasks to other team members.

    3: Structured documentation

    Issue: documentation tools make it difficult to communicate complex details of patients’ care and nuanced clinical reasoning, and don’t incorporate complicated data into notes efficiently, track several high complexity problems or maintain continuity of medical decision making.

    How to fix it: documentation process needs to be re-envisioned and redesigned, such as sections of  medical records, such as allergies, medical history, and family history, change infrequently and don’t need repeating, so flexible specialty templates should emphasise the interval history, clinical reasoning, and recommendations most important to the current visit, with EHRs aggregating information pertinent to the problem at hand.

    4: Interoperability (IoP)

    The issue: disparate, non-integrative health ICT impedes care across the continuum, so manual reconciliation is persistent due to lack of IoP across vendors, increasing the risk of errors, gaps in care and delays

    Why it persists: differing platforms, clinical vocabularies, and information architecture make it difficult and expensive to achieve IoP or for clinicians to switch away from stand-alone EHRs, so rigorous research support is needed for innovative technologies that improve care across the continuum.

    5: Clinical Decision Support (CDS)

    The issue: many CDS tools are interruptive and fail to integrate key data needed in workflow, leading to alert fatigue and hindering decision-making with increased cognitive loads.

    Why it persists: clinical practice differences makes it extremely difficult to design tools that provide the right information to the right person in the right CDS format through the right channel at the right point in workflow.

    How to fix it: need to understand clinical workflows and clinician conceptual models better and have regulatory incentives for extensive formative, user-centred design testing to achieve better balance of clarity, scope, and prominence in CDS interventions.

    Some of these require daunting, but essential changes. Lombardi had something to say on this too. “It's not whether you get knocked down, it's whether you get up.” eHealth will, and Africa’s doctors have to take the lead to make sure it happens for their health systems.

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    Image from KevinMD.com

  • IoP across boundaries's still a struggle

    Sharing’s intrinsically worthwhile. J M Barrie, author of Peter Pan, said “Those who bring sunshine into the lives of others, cannot keep it from themselves.” This was before the pursuit of eHealth interoperability (IoP) became a worthy endeavour.

    Premier’s survey in its Economic Outlook 2016 shows that sharing health data with people in the same organisation seems quite good, but not so good at sharing data with doctors in other health organisations. This’s despite IoP being a priority, so it reveals that sharing across boundaries isn’t straightforward. 

    A summary of the survey results of USA healthcare’s CEOs CFOs and COOs is:

    68% say they’re successfully accessing ambulatory data from employed doctors networks 38% are successfully accessing the data from networks of affiliated doctors or doctors not employed 84% said ICT and telecommunications is their biggest investment category for the next year 48% said population health management goals has the biggest impact on their eHealth’s ability to deliver care 24% said staffing shortages are 13% said emerging technology is.

    It reveals a need for Africa’s health systems to balance their IoP plans for internal and external data sharing between doctors and other healthcare professionals in different health organisations and levels. Author Henry Miller, talking about books said “A book lying idle on a shelf is wasted ammunition.” Unshared health information’s wasted too.

  • The USA's ONC now has its IoP schedule

    Achieving a high level of interoperability’s (IoP) been a long journey for the USA’s Office of the National Coordinator for Health IT (ONC). It now reached its destination with the 2016 Interoperability Standards Advisory (ISA). It’s the ONC’s final version, building from its roadmap, reported on eHNA. 

    For Africa’s eHealth, perhaps the most important part is section one. It has numerous tables that list the best available vocabulary, code set, terminology, standards and implementation specifications for several healthcare contexts, such as aspects of allergies and medications. It’s essential reading for Africa’s informaticians and other eHealthers. 

    Unsurprisingly, the global IoP models, such as SNOMED-CT and HL7 are included. For each IoP healthcare setting, there’s a description of the standards limitations, dependencies, and preconditions that need consideration and understanding before they’re used. There’s also a comment on the applicable value sets, and in some cases, says that standards aren’t available for some types of granularity.

    IoP for clinical eHealth’s classified into three groups:

    Semantics, which is vocabulary, code sets and terminology Syntax, which is content and structure Services, which are the infrastructure components deployed and used to fulfil specific IoP needs.

    ISA has at least three purposes:

    Provide healthcare and health ICT vendors with a single, public list of the standards and implementation specifications that can be used to meet specific clinical health information IoP needs Reflect the results of a continuing ongoing dialogue, debate, and consensus among healthcare and ICT vendor stakeholders when more there’s more than one standard or implementation specification as the best available Document known limitations, preconditions, dependencies and security patterns among referenced standards and implementation specifications when they’re used for specific clinical IoP needs. 

    Africa’s eHealth leaders and technocrats can save a considerable amount of time and energy by adopting ISA too. The USA’s ONC’s put in an enormous shift for ISA. It’s a vital and valuable contribution to Africa’s eHealth too, as eHealth leaders look to eHealth to improve the health of Africans.

  • IOp's not easy

    The limits of ICT’s expansion seem to have no insurmountable boundaries. As eHealth creeps on, interoperability (IOp) becomes more challenging. Stan Augarten, the prolific author on computing, said “Computers are composed of nothing more than logic gates stretched out to the horizon in a vast numerical irrigation system.” As the horizon moves further away, IOp becomes more important and more challenging.

    If eHealth’s interoperability’s (IOp) such an obvious requirement, why is it such an issue? The obvious answer’s that it’s very challenging and stretches right across eHealth, especially into mHealth and into healthcare planning and finance. eHNA’s posted on many IOp aspects, and these combine into a profile that African countries can use to set a context for their IOp initiatives.

    Across IOp’s three levels of technical, syntax and semantic, it’s in semantic where the big challenges sit. Semantic IOP links can be a across a grid of data, so the links aren’t always in a linear sequence. They often have large, complex spider's web of linkages, which is why IOp's a big, long-term project. At its highest and most complete level, it results in data that’s sharable and seamless in a context. 

    At its highest level, teams of very skilled informatics experts are needed to set it up. With the increased transactions, expanded ICT capacity’s needed too. These bring considerable connectivity and affordability requirements for Africa’s health systems. 

    Advancing IOp isn’t a solitary activity for experts. It needs:

    Effective engagement with all stakeholders Developing successful semantic IOp solutions Using them successfully Successful organisational change and re-engineering of healthcare’s demand side to realise the benefits Creating the financing models for population health management and research entities to contribute to semantic IOp’s costs Ensuring affordability Mitigating semantic IOp’s risks effectively Constant, routine data management.

    These need sustained effort and resources. eHNA’s posted about the USA’s has a ten year road for IOp. For Africa’s health systems, it’s a long horizon, but one that’s needed to stretch into IOp’s benefits. For Africa, it highlights the need for explicit IOp priorities that need to be in place. Integrating mHealth data into eHealth’s one, as posted on eHNA.

    Experience shows that good IOp on its own doesn’t avoid the informatics scourge of duplicate patient records. An eHNA post shows that without resources for routine data management, informaticians’ time’s diverted to cleaning up duplicate records, reducing their time for advancing IOp. Without extra resources, benefits are diminished. 

    As eHealth’s tentacles creep into more health and healthcare activities, IOp’s challenges expand with them. Two examples are mHealth and South Africa’s National Health Insurance (NHI) programme. Research in mHealth IOp’s underway, but has plenty to do as mHealth expands. As countries adopt more responsive healthcare financing models, such as Diagnosis Related Groups (DRG) it’s important that ICD-10 andDRG groupers are prominent in IOp plans, as eHNA identified. Switching from conventional financing to DRG reimbursement carries endemic risks, so it’s vital that IOp’s in place to support it.

    With IOp such an enormous endeavour, the only way to move it on is to adopt a sustainable strategy suggested by one of Augarten’s books. It’s Bit by Bit.

  • Elusive IOp on the move with Sequoia

    Interoperability (IOp) in eHealth seems like a horizon. As you walk towards it, it never seems closer. Maybe it’s recently taken a big step to shrinking the distance. The Sequoia Project has released the details of its Carequality Interoperability Framework (CIF). It enables eHealth vendors to participate in integrated IOp programmes across its components that include:

    Governance Legal terms Policy requirements Previous frameworks, including Sequoia’s Carequality Principles of Trust Technical specifications.

    Organisations that adopt CIF can leverage existing networks and business relationships to set up data sharing partnerships quickly and uniformly. Without it, each Health Information Exchange (HIE) project needed their specific legal agreements between the data sharing partners, involving lengthy and costly negotiation and inconsistent experiences of the quality and quantity of exchanged data.

    Five major health ICT vendors have committed to CIF:

    athenahealth eClinicalWorks Epic Systems NextGen Healthcare Surescripts. 

    As a step forward for IOp, health systems can expect more to follow. As Africa’s health systems look to procure EHRs from big global suppliers, they may expect them to participate in Sequoia’s projects. If responses aren’t positive, health systems can reasonably ask how bidding suppliers will offer at least an equivalent service and development path without Sequoia.

    Sequoia’s non-profit entity. It’s important for Africa’s health systems to track its activities and contributions to shrinking IOp’s horizons.

  • Can mHealth advance IOp?

    A research team at the University of Technology Sydney, Australian has identified a valuable role for mHealth. Valerie Gay and Peter Leijdekkers say limiting the negative effects of health data silos, mHealth can offer a better holistic view of health and fitness data, which can then be analysed to provide better and more personalised advice and care. It has important implications for Africa’s ehealth strategies. 

    The study, published in the Journal of Medical Internet Research (JMIR), sets out to demonstrate that a mobile app can be used to aggregate health and fitness data and enable Interoperability (IOp) for health and healthcare data. It aims to overcome the limitation of a lack of real integration of fitness-related data and data in EHRs. Overcoming IOp constraints and the dominance of data silos that prevent users and health professionals compiling an integrated view of health and fitness data is essential in their quest. Succeeding needs solutions to technical IOp challenges of integrating data in one place.

    Their results include confirmation that myFitnessCompanion can aggregate their data in one place. The challenges that the team encountered include:

    Different wireless protocols and standards used to communicate with wireless devices Diversity of security and authorisation protocols used to exchange data with servers Lack of standards usage, such as Health Level Seven, for medical information exchange.

    The app integrates data into EHRs and connects to back-end servers, devices and systems, including:

    Fitbit Google Fit iHealth Jawbone Microsoft HealthVault Several EHRs.

    The findings show the need for Africa’s eHealth strategies to integrate their mHealth plans and EHR initiatives. It may be that the links are falling into place.

  • IOp needs more information

    Duran Duran, a 1990s pop group recorded “Too much Information.” It wasn’t about Interoperability (IOp). Stakeholders want more. 

    South Africa’s IOp, posted on eHNA a few days age, highlighted the step forward. IOp experiences of many countries are that as the steps are taken, IOp becomes a bit more complicated. Recent correspondence in the USA has shown this. A report by Fierce EMR says the American Hospital Association (AHA) has written to the National Coordinator for Health IT, Karen DeSalvo, about the 2016 draft Interoperability Standards Advisory, which identifies and assesses the best standards and implementation specifications that support IOp, saying it doesn't provide enough information.

    The AHA’s letter asks for more detail about the characteristics and metrics used to assess the standards identified as the best available, a core requirement. It sets out six characteristics of the best available: 

    Standards process maturity Implementation maturity Adoption level Regulated Cost Test tool availability.

    As South Africa moves its IOp ahead, it can expect stakeholders, users and provinces to want to know similar details. As other African countries move ahead, they can build in the details in the earlier stages to engage stakeholders in a valuable constructive dialogue. 

    The European Commission’s (EC) study on Semantic Interoperability for Health Network has identified the need “to invite industry more specifically to comment, towards the end of the project, on the understandings arrived at within SemanticHealthNet about semantic interoperability, what the principal challenges are, how they should be prioritized and addressed, and what kinds of action now needs to be taken by different stakeholders.”

    The need for this dialogue includes stakeholders working in several health systems with well-developed IOp information systems. Africa’s health systems have an opportunity to start the dialogue at an earlier stage.

  • ICD-10's resulted in lower productivity for US hospitals

    As African countries develop and apply their interoperability (IOp) plans, there’s a salutary lesson from USA hospital. A survey by Himagine Solutions, a coding company, says hospital productivity dropped after hospitals switched to WHO’s International Classification of Diseases and Related Health Problems Series 10 (ICD-10) the standard diagnostic tool for monitoring the incidence and prevalence of diseases and other health problems. It’s also an essential data source for Diagnosis Related Groups (DRG) and their derivatives.

    ICD-10’s a statistical tool requiring compliance with WHO’s definitions and rules. The data enables accurate, consistent and comprehensive capture of data for secondary purposes, including billing. It’s not designed for recording by clinicians at points of care. That’s Systematized Nomenclature of Medicine--Clinical Terms’ (SNOMED CT) role.

    Himagine’s survey and Benchmark Report says 75% of respondents predicted the adverse productivity impact from ICD-10 is more than 30%.

    Large hospitals, those with more than 250 beds, reported a productivity drop of 30 to 45% for inpatient services, and a 20 to 40% drop for outpatient services. Community hospitals, which have fewer than 250 beds, the inpatient productivity drop was 22 to 33%, and 35 to 40% for outpatients. 

    Large Hospitals (over 250 beds) are seeing a 30-45% reduction on the Inpatient side and a 20-40% reduction on the Outpatient side. When it comes to Community Hospitals (under 250 beds), the Inpatients reductions are much lower ranging in a productivity decline of 22-33% while the outpatient is higher on average hovering around 35-40%. Teaching hospitals reported an average 40% drop in inpatient productivity, with a 10 to 35% ranges for outpatients.

    It may be that part of the explanation may be an increased rejection of reimbursement claims due to incomplete supporting data, so a loss of income, rather than a productivity drop. Either way, it’s a considerable disruption to hospital’s operational and financial performance. Part of the solution may be better and more training for coders and billing teams and greater use of eHealth solutions. Another part is the low use of Computer Assisted Coding (CAC), about 56%. This could increase to 75% in a year’s time.

    As Africa’s health systems move their eHealth on and rely more on health insurance schemes, it’s important they don’t have a similar experience to the USA. eHealth can be disruptive. It’s a bad idea for hospitals to have strained productivity and income too.

  • IOp needs to do more to fulfil its promise

    WiFi’s a good example of comprehensive Interoperability (IOp). All WiFi-enabled devices are compatible with WiFi without having to worry about different specifications. It’s because the Institute of Electrical and Electronics Engineers (IEEE) standard 802.11 has been adapted as the universal standard. Prof Howard Po Hao Chen uses Wifi to show the limitation of healthcare’s IOp in his article in the American Journal of Managed Care (AJMC). It’s reassuring for Africa’s health systems that may be well behind the IOp curve.

    IOp healthcare’s much more complex. The links needed to long medical histories of patients create a challenge, especially at the semantic level that aims to integrate healthcare information systems using a common structure and a shared lexicon. IOp with the same proprietary solutions is one method of achieving this goal. Microsoft achieved IOp in the 1990s when Word.doc format became the de facto standard for document exchange simply because Microsoft Office had a huge percentage of users, creating a network effect. However, there are still limitations.

    Open standards offer another approach where vendors and developers agree specific ways of implementing services so that their data are compatible. The best open standards are unobtrusive and seamless, understating the monumental efforts needed to create them. Examples include IEEE 802.11 wireless standard, Hypertext Transfer Protocol (HTTP) and Hypertext Markup Language 5 (HTML5). These open standards for the Internet benefit all users. Prof Chen sees this as a goal for eHealth IOp.

    He says that “While proprietary solutions align powerful market forces with patient interest, the reality of healthcare's complexity will require all the major players to work together and agree on an open format.” Until they do, IOp will not fulfil its promise. Africa’s health systems seem to have time to catch up.