• Interoperability
  • HIE and high-level interoperability's years away

    If you think that Health Information Exchange (HIE) and interoperability (IOp) are easy to do, Black Rock Resarch’s latest report’s for you. If you think they’re hard to do, you may not think it’s this hard in the USA.

    The findings are that HIE is persistently unpredictable. It’s the view of:

    86% of healthcare providers 69% of insurers 81% of ICT vendors.

    Doug Brown, Managing Partner at Black Book, says that “Fewer and more specifically defined interoperability objectives are needed to focus stakeholders to prevent the technology industry from backing further away from HIE initiatives.” Keeping projects limited with clear, explicit goals and requirements seems like sound advice for African countries. It implies that IOp isn’t an absolute state, but countries can reach it incrementally.

    In the USA, some simple healthcare information is exchanged between parallel EHR systems in small communities. The vast majority of users, 94%, of providers, healthcare agencies, patients and payers aren’t connected yet. Perhaps even worse, 5% of providers are dropping HIE as a priority where it operates outside their EHRs. The main causes seem to be complicated and weak HIE business models.

    This changing disillusionment hasn’t changed the long-term view. More than 90% of payers and providers believe that the USA will achieve a robust, meaningful national HIE by 2025, a ten year horizon broadly consistent with the ONC’s plan.

    There are numerous vendors in the USA. Black Rock found a top four popularity rating by users of:

    Cerner –Electronic Health Record-based HIE Orion Health– Government Payer and Commercial Insurer Centric HIEs Aetna Medicity – Core Private Enterprise HIE Solutions Intersystems –Core Public HIEs Systems.

    Other high-scoring vendors scored specific HIE content were:

    Alere Wellogic Availity Caradigm CTG dbMotion Allscripts Epic Systems Greenway GSI Healthcare HealthUnity ICA Infor (Lawson) McKesson RelayHealth Medecision Optuminsightt QSI Mirth NextGen Sandlot Siemens.

    Watching how the USA moves ahead is a good use of African’s time.

  • EHRs and HIEs have a few IOp holes

    “Everything in strategy is very simple, but that does not mean that everything is very easy.” That’s how the Prussian military strategist Carl von Clausewitz sees it. Semantic Interoperability (SIOp) might be similar. A strategy for SIOp is unavoidable, but it doesn’t always convert into practice. A very important review by a team of eleven researchers of EHRs’ and HIEs’ SIOp, in the Journal of the American Medical Informatics Association (JAMIA), found eleven holes.

    They’re summarised in a table as:

    Omissions or misuse of Logical Observation Identifiers Names and Codes (LOINC) in results or vital signs Omission or misuse of Systematized Nomenclature of Medicine (SNOMED) in problems Excess precision in timestamps Omission or misuse of Unified Code for Units of Measure (UCUM) in medications, results or vitals in a Consolidated Clinical Document Architecture (C-CDA) for document exchange Omission or misuse of RxNorm, the USA’s catalogue of standard names for clinical drugs and drug delivery devices, in allergies and medications Omission or misuse of dose quantity Omission or misuse of allergic reaction Omission or misuse of allergic severity Omission of dose frequency Omission of results interpretation Omission of results reference range.

    The researchers classify each item as an error, heterogeneity in C-CDA documents or both. These errors limit semantic interoperability. They also provide a schedule of work needed to improve C-CDA document quality and exchange.

    The study shows the challenges of effective accreditation and certification, and the precision needed to achieve SIOp. It’s extremely valuable to all healthcare organisations already dealing with SIOp in their EHRs and HIEs, and for ones about to embark on their SIOp endeavour.

    As African countries develop their eHealth regulations, the study’s findings show a way ahead for some of the content and detail needed for the accreditation of eHealth suppliers. The precision that the study used transfers from accreditation to the detailed assessment of suppliers’ EHRs and HIEs needed for procurements, then onto successful SIOp.

    Clausewitz also thought that “Part of strategic success lies in timely preparation for a tactical success.”The study shows that even certification isn’t enough for a successful SIOp strategy. The study’s findings are part of the solution.

  • The USA plans for IOp over ten years

    Like fine wine, successful eHealth takes time to develop. The USA’s Office of the National Coordinator for Health Information Technology (ONC) has set out its ten-year vision for interoperability (IOp). Its goal is to have “a strong, flexible health IT ecosystem that can appropriately support transparency and decision-making, reduce redundancy, inform payment reform, and help to transform care into a model that enhances access and truly addresses health beyond the confines of the health care system.”

    It has a set of guiding principles:

    Build on the existing health ICT infrastructure One size doesn’t fit all Empower individuals Leverage the market Maintain modularity Consider the current environment and support multiple levels of advancement Focus on value Protect privacy and security in all aspects of IOp.

    By year three, ONC aims to send, receive, find, and use eHealth information to improve healthcare quality. It includes accelerating the use of Health Information Exchange (HIE).

    By year six, it aims to use information to improve healthcare quality and lower cost. Examples are:

    People regularly contributing information to their EHRs for use by members of their care team People integrating data from their EHRs into apps and tools so they can set and meet their own health goals Primary care providers and authorized researchers can understand how well controlled diabetic patient population’s glucose levels are and how often patients have been admitted to hospital based on standardised information from multiple sources Connect clinical settings and public health departments through bi-directional interfaces to produce seamless reports for public health departments, and seamless feedback and decision support from public health departments to clinical providers.

    Bi-directional feedback is quite complex. tinTree’s view is that it has a probability of realising net socio-economic benefits, but well beyond the six year timescale if risks are mitigated effectively. This is consistent for large-scale, complex eHealth, so not a constraint, just a phenomenon.

    By year ten, the ONC wants a learning health system. It includes:

    People manage information from their own electronic devices and share that information seamlessly across multiple electronic platforms Primary care providers can select effective medications for patients based on their genetic profiles and results of comparative effectiveness research People, healthcare providers, public health and researchers contribute information and learn from information shared across the health ICT ecosystem, with rapid advancement in methods for deriving meaning from data.

    As African countries build their IOp approaches, these types of global experiences areworth sharing.

    All this sounds exciting. With a ten-year horizon and its planned steps, it sounds realistic too. It’ll need rigorous risk mitigation measures to secure it.

  • WHO Forum on eHealth Standardization and Interoperability expands its access

    When resources are scarce, collaboration is invaluable. Charles Darwin, the 19th century naturalist and author of On the Origins of the Species, once said “In the long history of humankind (and animal kind, too) those who learned to collaborate and improvise most effectively have prevailed.”  This is especially important when facing new and complex challenges. eHealth standards and interoperability fit this well, since the WHO AFRO RC resolution on eHealth and the WHA 66.24 Resolution on eHealth Standardization and Interoperability were passed last month. The work of the WHO Forum on eHealth Standardization and Interoperability offers a good way to respond.

    WHO has supported and driven eHealth initiatives globally for many years and the Inter-Ministerial Policy Dialogue and 2nd WHO Forum on eHealth Standardization and Interoperability Forum has substantial support. The first event in December 2012 attracted over 200 people from 54 countries. Numerous other participants followed the event through live webcasting. The 2nd event takes place next year from 10 – 11 February at the WHO Headquarters in Geneva.

    The Forum’s primary objectives are to: facilitate a dialogue on the need for Policy and Governance mechanisms for adopting health data standards in countries; and to draft a policy and governance framework for full adoption of standards at national and sub-national levels. The Forum has six panels. Three panels meet on the first day to review key policy issues in eHealth standardization and interoperability, overcoming eHealth regulatory and administrative barriers in standards adoption, and the essentials of a good policy framework needed to adopt standards for interoperability. On the second day, the other three panels review the components of evidence-informed policy, statutory requirements, governance and stewardship.

    Like Darwin’s famous work, WHO’s Forum is a massive undertaking. The findings of these proceedings are an invaluable resource for African countries. Similar initiatives are needed to cover other challenging eHealth topics. Without these, eHealth evolution is more tortuous.

    For more information on the event email WHO at whofhdsi@who.int