Interoperability - according to the Healthcare Information and Management Systems Society (HIMSS), it is “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.” Practically, it is the “ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of healthcare for individuals and communities.”
To illustrate, let’s say a patient was admitted to PGH for renal cell carcinoma (a kind of kidney cancer). The doctor considers a nephrectomy (removal of the kidney) as a possible treatment. It turns out that the patient was a kidney donor, having it removed in NKTI. If none of the health care workers in PGH asked about it and no physical or laboratory tests were done to detect it (a major oversight I know, but just go with it for now), and the doctor continues with the procedure, the patient would have no more kidneys and die. If the doctor had an electronic record of the patient which included information from NKTI, she would have known that the patient had only one kidney left and thought of another course of action.
Interoperability of all health systems and applications used throughout the entire country is a massive undertaking. The following are just three of many issues that have to be tackled to achieve interoperability. As I discussed of HIE, just like humans sharing a common language, in order for different systems to be interoperable, certain rules and standards have to be followed. However, each system and application needs different information, so many standards have to be made to fit them all.
Another problem is transforming all the current data into the standardized format that can be used by all the systems. There are still many healthcare institutions in the country that use written health records. Those include years of records of thousands of patients. Turning all that into a digital format will require a lot of time and effort.
Lastly, with all these systems sending and receiving data through a network, there is a high probability of some people illegally accessing information and using it not for their intended purpose. Stories of hackers, frauds, and corporate espionage cause concern of individuals, IT developers, and healthcare providers in many countries. While individuals in the country are not as aware of this concept yet (based on stories of people sharing health information online publicly), we should not let the issues of privacy and security be forgotten, only for it to cause major problems later on.
The health system in general includes many stakeholders. Each of these stakeholders have important roles in achieving interoperability of electronic health systems. Some have more responsibilities than others, some share roles, but each of them are important in the grand scheme of things.
The government’s main role is mediator and overseer. They are involved in creating groups, such as the NHDC who are in charge of developing rules and guidelines. These include standards in data format, the semantics of health-related terms, what data ownership, and how data is protected during storage and transfer. There are already existing rules and guidelines made by international organizations, such as the WHO and HL7, and this group can chose which ones to adopt and modify.
Another group formed should be concerned on how to implement these rules and guidelines. This group looks at how not just the resources of the government, but all other stakeholders can be used to bring about interoperability. Their responsibilities include disseminating all the rules and guidelines decided on by the previous group to stakeholders developing health-related electronic systems or applications as well as end-users; creating the infrastructure necessary for communication and data transfer; creating accreditation groups that will certify electronic systems or applications developed to be used specifically for health institutions or to go on sale. A third group can be assigned to monitoring and reporting progress of implementation.
NGO’s are important in providing resources and advocacy. Some international standards are made by NGO’s, like HL7 (HL7 International) and LOINC (Regenstrief Institute). The implementation group formed by the government can ask for assistance from NGO’s in implementation. NGO’s have the ability to provide funding for equipment and training, and hire personnel (more manpower and specialists). NGO’s that help individuals with certain diseases can promote certified systems and applications used to address said diseases to individuals and health care providers, increasing awareness and use. NGO’s can also be certification groups.
The private sector consists of private health care institutions and systems and applications vendors or developers. They have a similar role as NGO’s, as well as taking part in the groups formed by the government for setting rules and guidelines and implementation. For the rules and guidelines group, they can provide insight on what data private organizations find useful, what data they are willing to share to other corporations and the government, how to maintain competition between corporations despite sharing data, among other things. For the implementation group, private sector stakeholders can provide their own resources for inter operability-related projects or know other companies that can provide these resources. They also increase the business-mindedness of the group, to maximize results at the minimum amount of resources.
Healthcare providers are end-users of the interoperable systems and applications developed. They may be members of the other groups mentioned above. As such, it is important to have providers as contributors in setting rules and guidelines, implementation and monitoring. In contrast to the private sector, providers provide insight in improving the quality of healthcare. For providers that are not a part of these groups, it is important for them to become aware of the changes in systems caused by these new rules and guidelines and put into practice the parts that involve the healthcare provider. This includes inputting data into systems in the recommended way, following protocols on how to send data to another healthcare provider or health institution, informing their patients about what data they will record and which ones the individual and other people can access. They also need to provide feedback to the monitoring group for them to report needs for adjustments.
Similar to healthcare providers, individuals are end-users abased on my post on PHR’s. Individuals can be members of any of the other groups, but for those that are not, they have similar roles to healthcare providers. It is important for them to know the rules and guidelines that apply to them when using health-related apps and systems. Which information is recorded about them, what their security information is, what data do they have access to, who else can access it, who is responsible for their data (in case they have to fie lawsuits), who should they report to if something is wrong with their records? All these questions are important in improving their health while still keeping their information safe and private.
Planning a national strategy for healthcare interoperability is a very complex and arduous process. However, PGH can serve as a microcosm for the national situation. Some strategies may not work at a more complex level, but the basic steps remain the same. In PGH, the different departments and sections have their own systems, some are electronic, such as surgery, labs, and radiology, while some still written. If the entire hospital is to have an interoperable system, a lot of changes have to happened.
For the first year, the main focus is on setting up an organization and the infrastructure to prepare for interoperability. First, a group for developing rules and guidelines as described above has to be formed. This consists of the administration (serving the government role), and representatives from the different departments and sections. Since there are existing electronic health systems, they should be taken into account when deciding to follow or customize international standards and setting rules.
The second group focused on implementation should also be formed at the starting period. While the rules and guidelines are still not finalized, the task of this group is making an inventory of available resources for implementation. How many electronic devices does each department have? How many personnel are there? How much funds is available? What means of communication do we have between departments? When the rules and guidelines are first released, they can determine what is lacking and where the budget has to go.
The rest of the first year will be spent on the early steps of implementation. For departments or sections with no electronic system, they have to hire developers to make a custom system (private or from the academe) or buy one pre-made from a vendor. These systems have to follow the standards decided on. On the other hand, the departments with existing electronic systems have to be changed to suit the agreed on standards if they do not at the present. In a year’s time, the new or modified system might not be finished; but if it is, most of the remaining time will be spent on inputing old records to the new system.
Along with this, new equipment have to be purchased and installed to support all the systems and communication between them. Computers have to be added to work stations so healthcare providers can input data (and some that already have computers might need more, since all providers will be required to record electronically). All departments have to be connected in a network through wired or wireless means. Only when all these are in place can systems can be put into use and begin sharing data.
By the end of the first year, the main goals should be: all standards, rules, and guidelines on electronic health systems have to be decided on (a first version), at least 70% of all departments have electronic records systems ready for use, and at least 60% of equipment for inputting, transporting, and storing data have to be installed. I think that a goal like that is already pretty lofty.
In the end, the idea of interoperability is amazing. There is great potential in sharing information between people and institutions in a swift, efficient manner to improve decision-making related to our health. However, getting to that point will require a lot of hard work and cooperation.
Sources:
- About HL7 International. Accessed from HL7 website: http://www.hl7.org/.
- About LOINC. Accessed from LOINC website: https://loinc.org/background.
- What is Interoperability?. Accessed from the Health Information and Management Systems Society website: http://www.himss.org/library/interoperability-standards/what-is-interoperability.
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