Healthcare interoperability:

deceptively difficult Tim Benson

R-Outcomes Ltdtim.benson@r-outcomes.com

@timbensonwww.r-outcomes.com

Presentation to Digital Health Oxford (DHOx), 19 September 2016

Hope, hype and harm and digital health

These issues are not newIncentives and leadershipScalability, complexity and fitness for purpose

Benson T. Why GPs use computers and hospital doctors do not. BMJ 2002

1990s NHS successfully developedLab GP messages and procedures eDischarge summaries (Kettering)MIQUEST data extractionGP2GP record transfer

Wachter Report Sept 201639 mentions of interoperabilityPrinciple 5

Interoperability should be built in from the start

Recommendation 9Ensure interoperability as a core characteristic of the NHS digital ecosystem

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/550866/Wachter_Review_Accessible.pdf

Understanding interop• Definition

• The ability of systems to exchange and use electronic healthcare information from other systems without special effort on the part of the user

• Plug ‘n play

• Technical interop• Commodity service (Internet, WiFi, Web)

• Semantic Interop• Data types, structures and identifiers

• Process Interop• How people work (the benefits)

www.springer.com/gp/book/9783319303680

Barriers to interopTechnical

Standards not fit for purpose

CommercialIncentives to lock-inTechnical obsolescence

ProfessionalAlienation and fear of change

PoliticalLack of informed leadershipPrivacy and security

US Health IT Policy Committee Report to Congress (Dec 2015) Challenges and barriers to interoperability1. Measures for patients and payers

(PROMs not just activity)2. Measures of developer interop

performance (in vivo)3. Payment incentives for interop4. Multi-stakeholder action

https://www.healthit.gov/facas/sites/faca/files/HITPC_Final_ITF_Report_2015-12-16%20v3.pdf

StandardsExact specifications

Precise compliance requiredNo ambiguity

Quality standardsMinimum acceptable quality

Both need conformance testing

A standard is a document, established by consensus and approved by a recognized body, that provides, for common and repeated use, rules, guidelines or characteristics for activities or their results, aimed at the achievement of the optimum degree of order in a given context. (ISO)

Benefits of interop standards

What’s wrong with existing standards?Constraint model

Model the universe (HL7 RIM, SNOMED CT Concept model)Each specific application is constraint on the universal model

ProblemsComplexity, such as mood codes (HL7 V3) and post-coordination (SNOMED CT)Depends on full knowledge and correct use of the overarching modelMajor educational challengeDepends on the Universal model not changing

CaveatA great deal of very good work has been done in standards; learn from this.

Two ProposalsProvide codes and identifiers

Need agreed identifiers forcarersclinic slotsbedssurvey questions etc

Streamline SNOMED CT14 years oldPost-coordination is too complexFast issue of codes (takes 6-9 months today), should be as fast as domain name changes

Adopt FHIRFast Healthcare Interoperability ResourcesHL7 V2, V3 are not fit for purposeWeb technologies (RESTful, JSON)Suitable for mobile appsCheaper to implementCore plus extensions

FHIRFHIR Manifesto

Focus on implementersTarget support for common scenariosLeverage cross-industry web technologiesRequire human readability as base level of interoperabilitySupport multiple paradigms and architectures

Logical FHIR architecture

ConclusionsDigital is digital

cannot tolerate ambiguity

Wachter is excellent (read it) but it lacks detailThe devil is in the detailInteroperability is “deceptively difficult”

Need incentives for interop, and penalties for lock inAdopt FHIRSimplify and reform SNOMED CT content and proceduresEducation about healthcare interop needed