Sunday, March 27, 2011

Some Further Views on HL7 V3, A New Compliance and Testing Tool Offered and More!

A few days ago I had an e-Mail from Professor Barry Smith letting me know about a new post on his HL7 Watch Blog.

I was pleased to see our recent discussions and comments got a substantial airing.

Saturday, March 26, 2011

An Australian View on HL7 Version 3

The Australian Health Information Technology blog has posted here a valuable discussion of the item headed Cries for Help published earlier in these pages. This discussion is interesting not least because of the large number of contributions it contains which -- unusually -- are signed by their authors. It seems that, in Australia at least, there are individuals who are willing to commit themselves publicly to a critical position as concerns the HL7 project (where the vast majority of my US informants are willing to have their views communicated only anonymously).

As David More points out in his introduction to the discussion, the implementation success of V3 thus far (and this means after some 14 years of development work) "has been somewhat patchy, with at least some proponents scaling back their enthusiasm for full adoption of the V3 Standard as some see it is lacking the necessary robustness and internal consistency for ongoing use." Dr More goes on to point out that, "While I am not sufficiently across the details of some of this to be able to form a trustworthy opinion a number of very smart people I have chatted with have expressed similar concerns."

In a comment, Grahame Grieve writes on behalf of HL7:

There's no reason for anyone to be afraid to comment. HL7 is not a police state, and there's an endless list of people who criticise and carp. They can expect a vigorous in kind response, but nothing more.

v3/RIM is not perfect. But it's not intended to be an ontology of everything. If only Barry would understand. It's just a model that has some use for interoperability. It's got some go-down-with-the ship type supporters, of course.

As does v2 (and all the other standards - they all have the folks who are going to go down with the ship). It's not enough to say it's simpler. There's more to it than that. The discussion is being had elsewhere, and here is not the place for it. HL7 continues to produce v2 (v2.7 is coming) but the community that is HL7 is switching to v3 because of it's power.

v3 itself does have a patchy record. I'm on record as saying that there won't be another full v3 implementation. People will cherry pick the parts that work - like CDA - and use them as they want.

I've got more to say but it's starting to rain and I'm out in the bush camping. Have a good weekend."

Lots more here:

A correspondent on the blog offered all sorts of interesting and provocative comments that followed on from the initial excerpt I have provided and makes some interesting points that are well worth browsing.

As I was digesting all this I noticed that Dr Eric Browne has also been busy.

Inching towards standardised pathology messages

2011-March-27 | 06:18 By: Filed in: exchange formatspathologyterminology

Fortunately, I’m now almost old enough to have forgotten the christmas pudding ritual – helping my father cut up the suet, spread out on sheets of newspaper on the dining room table. In those days, I was then already tall enough to also be able to peer down into the saucepan my mother used to boil clean the threepences and sixpences. And then when the pudding was finally mixed, it boiled away for hours and hours. The whole pudding making ritual seemed to take forever. All that effort for a minute morsel of pudding, that eventually arrived at the very end of an endless christmas lunch!

About this time last week, whilst reviewing the Australian Standards for pathology messaging, the smell of suet returned, reminding me of those yules of yesteryear. If, like me, your brain addles when presented with hundreds of acronyms squirming out from reams of paper, you may have some understanding of my state of mind. I really struggle when presented with bowls of suet that look something like this:-

PID|||QP-110||Norman^Harvey||19401009|M|||200^^E.ST ALBANS^^3021|ORC|SC||51205041^TGH|

(Apologies for the truncations!)

I thought that there had to be a better way for humans to deal with this – some easier way to interpret each arcane piece of HL7 v2 in context. I looked around, but could find nothing that met my requirements. So I have spent the past week writing an online message validator for Australian pathology messages. It is available at , and may be of some use to anyone dealing with pathology messaging, whether in the standards arena, or even if merely wanting to understand what some of the issues might be. There are a number of sample messages that can be explored. The validator also includes checking against LOINC and SNOMED terminologies.

More here:

I think it is important that such a piece of altruism gets due publicity.

Last we had a ‘Cri du Coeur’ from an obvious expert lamenting the difficulties of the implementation of messaging standards (among other things) most especially in the Lab sector - and just how much pain and effort this was costing all involved.

Why is ‘IT’ all so hard in Pathology?

At the heart of a modern Pathology laboratory is a complex set of Information Technology (IT) systems that are critical to its operation. Users are often frustrated and disappointed at the difficulties they experience when systems fail, when requesting changes or seeking new IT functionality. Having worked in a number of industries before coming to Healthcare four years ago, I have tried to make some sense of why IT is so hard in Pathology.

We’re talking normal, run of the mill Pathology, not bio-informatics databases, leading edge cell imaging or shiny, ground breaking test developments. So why is it so hard to get some seemingly simple functionality from your IT Department? Why do all those small things that would make life a bit easier turn into long, drawn out projects that are around so long they become part of the family?

I'm sitting here at my desk massaging my temples. As the IT Manager, I've been handed the unenviable task of replacing the Laboratory Information Management System (LIMS), a job that will earn me no awards, applause or praise. We already know from past experience that it will be a difficult and traumatic project for my team as well as the whole organisation. We will grapple with new technology, interfacing and new ways of performing old processes. And for all that, we are not even expecting new functionality. We are not alone in this dilemma. At this time the IT managers of major Pathology providers in NSW, VIC, SA and WA are actively investigating replacing their LIMS. Some to modernise and consolidate, others, like ourselves, as a result of a pullout from the Australian market by a significant LIMS vendor. None will get any major new functionality. It may be easier to maintain, interface or get better reports, but it is unlikely that any new pathology breakthroughs will come as a direct result of these efforts.

Pages more here:

We are now over $350 Million and six years into the NEHTA experiment and still all this basic infrastructure messaging is not even agreed let alone actually implemented and operational in the way NEHTA is suggesting is vital.

Now I make no claims to fully understand what has and is going on here, but one has to suspect the award of a ‘gold star and Koala stamp’ for good behaviour to those involved is very unlikely.

Again we all know it is not beyond the wit of man to sort this out. What it is beyond is a National E-Health Governance Framework that is deeply dysfunctional and simply a fiasco.

To be clear the lack of leadership, governance and pursuit of an agreed strategy is just killing us!

We need to sort all that out and then with good will the rest can be sorted. This simply won’t happen in the present environment.

I recently had an e-mail from a colleague analysing the current motivators of the various actors. It was put this way:

  • DoHA – politics and money
  • NeHTA – power and self-preservation
  • SAI – cost mitigation
  • IT14 members (volunteers) – compromise, consensus, stubbornness

Until we have a break out of common sense and rationality the current situation will persist I fear!



Anonymous said...

It is a pity that more people don't know about AHML

Anonymous said...

Plenty of people know about AHML. That isn't the problem.

The big issue is "HOW to make AHML both relevant and effective?"

Grahame Grieve said...

The real question is how to make message certification relevant and effective. AHML is doing good work, both in testing and even more in behind the scenes advocacy. But the industry - *and* the purchasers - seem mightily reluctant to leverage it. The new MSIA messaging profile that reaches much further into the content may help with certification by making it actually useful

Anonymous said...

Well, if the industry and the purchasers seem mightily reluctant to leverage it you are back to where we started. Unless some form of market influencer (mechanism) is introduced to change the behaviour of the purchasers and the industry nothing will change. It is as simple as that. It matters not one iota how good AHML might be - it can be world best or even better than that - but that will not change anything. There needs to be a force at work that will make change happen. There is no such force today - so there is no change - the status quo remains forever fixated in one place and going nowhere.

Grahame Grieve said...

But if the market doesn't want it, perhaps the outcomes of trying to influence the market wouldn't be what is expected? Why doesn't the market want it?

Eric Browne said...

Grahame Grieve said...
"But if the market doesn't want it, perhaps the outcomes of trying to influence the market wouldn't be what is expected? Why doesn't the market want it?"

Presumably because there would be cost but little benefit, either to senders or receivers, and hence Anonymous (Monday, March 28, 2011 5:29:00 PM)'s assertion that " There needs to be a force at work that will make change happen". I agree. But I would suggest that a set of forces is necessary. The standards need to be improved. The barriers to adopting and supporting the standards need to be lowered. These barriers are currently HUGE! The conformance, compliance and accreditation regimes need to be strengthened. Financial sticks/carrots need to exist. All this requires strategy; a comprehensive, publicly articulated, funded and resourced plan; appropriate governance and some leadership. Ergo, nothing will change in the foreseeable future!

Anonymous said...

"Why doesn't the market want it?" you ask. Good question.

As a purchaser? I don't understand that stuff, I am a busy provider of health services, I am not a technical person, we look at what systems are available, we try to assess their functionality and which system seems to do the job best and meet our needs. If the sales person says it complies with the recommended standards how would we know whether he is telling the truth or not? We are just simple users and we purchase what seems to work often based on the reassurances of our colleagues.

As a vendor? We run our business and try to make a profit. We sell what we've got. If something better comes along that we can use we will put it into our system as and when we can afford to do so. We don't chase rainbows and we don't have starry eyes. We try to survive in a tough market doing what we know best and we try to avoid falling down the rabbit holes and running up endless drain pipes. If we don't have to do something and it is not essential for business survival then we don't do it.

I hope that answers your question.

Grahame Grieve said...

hi Eric

> Presumably because there would be cost but little benefit

Well, if there's cost but little benefit, why should we try to make it happen? "Cost with little benefit" seems like a catch cry about some other government health IT program at the moment...

As for anonymous: ahh, we should all trust the sakes guys huh? How on earth could that go wrong ;-)


Anonymous said...

Exactly, there has to be a market. The reason PIT has survived so long, and is now even inserted into HL7 messages, is that it is simple, easily understood and implemented, and confers a benefit to all users.

Andrew McIntyre said...

Its not that hard to do, but the players need motivation to do it and motivation to train people to acquire the knowledge of how to do it. Medical-Objects has had AHML accreditation since 2004, so it was doable > 6 years ago.

Most of the interoperability issues are not due to poor standards but poor adherance to standards, often due to ignorance. Many vendors just thumb their noses at standards and say we are big enough for everyone else to produce messages that are not standard, but work with our broken non-compliant system.

Eric wants semantic interoperability, and so do I but before we can even think about that we need basic compliance with message construction and consumption. In the years since we obtained AHML accreditation we have proven that V2 can carry highly semantic data and leverage SNOMED-CT for decision support, but the general standard in the community remains much as it was 6 years ago (With a few exceptions).

What concerns me most is that vendors just do not care about poor messages and non compliance. In other industires marketing a product with the potential to kill someone and not complying with standards would not happen, why is health IT an exception??

It appears that the problem is a lack of governance, no worse than that, bad governance as its governance that makes people care about standards.

The vendors know that standards are not being enforced and as they do little to actually help them market the product, they ignore them. Many in the industry want governance, but "The Hollowmen" are in control. It is doable, we just need governance to say do it.

Eric Browne said...

"Presumably because there would be cost but little benefit"

I said "to ether senders or receivers". The benefits are expected to accrue to patients, as a result of sharing of information amongst providers. Patients have no buying power in an e-health market. Our health system works, and works pretty well by international standards, predominantly by not being market driven. Why should we expect market forces to be the sole mechanism for e-health reform?

Grahame Grieve said...

Hi Andrew

> Most of the interoperability issues are not due
> to poor standards but poor adherance to standards

uh? If I look through the issues that lead to the MSIA profile that is in process, there *is* one issue that is literally non-compliance with the standards. There's a few that are bad documentation in the standards (HL7 and Australian). But most is simply that the standard doesn't resolve what is needed for actual interoperability. And therefore conformance testing on that wouldn't help either.

On the general subject, I wish that we live in a world were conformance testing was both useful and widely adopted. But we don't. I think because:
* Vendors will do what it takes to get sales, and purchasers aren't asking for it (in general). This is because of the following reasons...
* conformance testing an instance of configurable software isn't that useful
* we can't afford to test configured software
* the standards aren't yet deep enough to ensure conformance
* the standards change too slowly to keep up with innovation - either you have innovation or conformance
* The net benefits of conformance accrue to the community as take up reaches a critical mass (like immunization), and not to individual implementations

Particularly for the last reason, imposing rules on the market place might be appropriate. (I guess I agree with Eric)

Andrew McIntyre said...

I wrote the list of areas to be covered for the MSIA document and I would disagree. They are compliance problems. It may be that the standard is not as well written as it could be, but anyone who was doing a proper implementation would realise what the issues were.

In many cases people are not doing proper implementaions, that would allow interoperability and as a result the quality suffers and the MSIA document really points out the obvious, like the fact that you need to escape reserved characters. Standards improve with real use and testing and the fact that the issues in the MSIA document have to be highlighted suggests many vendors are not taking the standards seriously. This includes large organizations. The pool of people with good HL7 knowledge has not increased, because standard compliance is not taken seriously.

It is up to governance to change this, and we have had several statememts in the past that Australia is going with V2, but there has been effort made to come up with any sticks or carrots and the donkey has not moved in a long time.

Anonymous said...

Dear Eric Browne for your comment on Monday, March 28, 2011 9:45:00 PM you enumerated the “set of forces” that are necessary. For that you go to the top of the class.

Dear Graham Grieve for your comment on Monday, March 28, 2011 10:33:00 PM you ask “if there's cost but little benefit, why should we try to make it happen?” – the answer is because it needs to be made to happen in order to take a fundamental step forward towards new horizons. As for trusting sales guys – they are trained to make you trust them. I don’t advocate trusting them but I don’t have the knowledge to know what is the truth and what is not.

So there you have it – a set of forces that must be exploited and deployed in an affordable way so that regardless of the almost non-existent cost-benefit the combined set of forces will influence the market and make the necessary change ‘happen’ whilst as Andrew McIntyre said on Tuesday, March 29, 2011 12:01:00 AM at the same time motivating the players to do it.

And oh yes, as Eric said on Tuesday, March 29, 2011 8:21:00 AM “the benefits are expected to accrue to patients, as a result of sharing of information amongst providers”. So, although Eric correctly observed “Patients have no buying power in an e-health market” we need to create an environment which empowers patients by availing them of the capacity to exercise their latent e-health buying power.

“You either have innovation or conformance” says Graham Grieve which earns him a few brownie points now that he is coming around to Eric’s way of thinking.

Summing this all up then, a vendor that is innovative and intent on conforming to standards which are reasonably mature, robust and reliable, and who develops a sales and marketing business model which empowers patients and embraces Eric’s “set of forces” will steadily advance towards the elusive e-health horizon whilst the donkeys lag behind.

Grahame Grieve said...

Hi Andrew

I said there was *one* example of non-compliance, and you proceeded to quote that one. Any others? I didn't think any of the others in the MSIA profile were that simple - simply due to bad conformance that you claim the other vendors don't care about.

Btw, for everyone else, the MSIA profile we are talking about is due to be published shortly, and I'll make sure to let David M know once it's published.

Andrew McIntyre said...

Hi Graham, I don't have the current version but here are the headings that I wrote initially.

1.How to escape and un-escape reserved characters
2.Reliable sending of rtf/pdf
3.Message addressing for delivery
4.What values have to be unique and how to do that reliably
5.Correct use of HD values e.g. to determine the sender and authoring organisation
6.Image and other advanced data type support
7.HL7 V2 standards based message signing and digital signatures
8.Determining clinical vs Pathology vs Radiology content & role of REF/ORU messages
9.Use of National identifiers in HL7 V2
10.Common display issues and the solutions
11.Proper identification of display segments and their rendering

Every one of these is covered in either the International standard, a local standard, handbook or Technical report.

So yes the problem is non compliance, combined with standards that are perhaps not easy to read, but the information is there if you look.


Grahame Grieve said...

hi Andrew

Yep, that's the list, and there was only a few things additional to that

1 and 11 are definitely non-compliance. Though even #1, I'm a little bit sympathetic because we only really clarified this in v2.6.

4, 5, 6, and possibly 10 are sort of covered but the actual issues were hardly explicitly obvious.

3, 8, and 10 generated substantial discussion that wasn't solved by simply consulting the standards

7 is a Tech note, not a standard. 2 and 10 are new grounds in different ways

You have sought to portray the problems as simple lack of conpliance to clearly defined standards. But this is not true. It's some of that and more things on top. In fact the MSIA profile is not entirely consistent with the HB262 spec, and will be referred to Stds Australia IT14-6-5 for consideration.

Most of the vendors and providers are simply trying to keep their heads above the water in these matters. They can't all afford knowledgable insiders like you and me. It's not fair to say "Many vendors just thumb their noses at standards".

But you are right that governance is required to improve matters here. Does the MSIA profile count as governance?

Andrew McIntyre said...

Hi Graham,

I realise that vendors are trying to keep their head above water, but the quality of their messages is a critical safety issue and that is perhaps more obvious to me as I deal with all the problems. The issue is that the standards are not high on their priority list, and interoperability is not either. We need governments to change this and no action has been forthcoming. NEHTA do not get it.

I think technical reports ballotted by Standards Australia should carry weight locally. They were written to solve problems.

Solving these issues, when interoperability does not occur between 2 systems is our bread and butter, and it requires a lot of knowledge. When problems are pointed out there is little motivation to fix the issues at source, whereas vendors should be horrified by errors. Its this lack of motivation that frustrates and concerns me. It is the role of government to provide this motivation, but they do not know enough to do anything sensible, as recent annoucements so clearly demonstrate.

The MSIA document is an attempt at self regulation, but it lacks teeth, unless MSIA want to force a compliance agenda on their own members, which is politically difficult do do in a real way. The critical mass of vendors that know it needs to be done is growing, but really it should be taken up at a government level. I should not have to be critical of other vendors because of compliance issues (It's hardly politically correct) but I have given up waiting for the light to come on in the hollow men that are running the eHealth agenda.

I can tell you that vendors do thumb their noses at standards, certainly not all, but some do and in a many to many messaging environment it causes major issues. The pathology industry pandering to poor implementations has probably caused this, but we must undo this if we want to progess. This means we need mandatory compliance. Then vendors would shift the HL7 compliance problems up the priority list and things would improve. This has happened with html and javascript over 10 years. I do not think we have progressed much at all in the last 10 years wrt eHealth compliance and the cracks are becoming more obvious as connectivity is established.

Anonymous said...

Here's what I make of these conversations:
(a) The people who are commonly referred to as engineers or techies (often in a derogatory fashion) are the ones who are doing it all - identifying problems, solving them, urging change and improvement to the appalling state-of-the-art, AS WELL AS specifying what policy and governance mechanisms are needed to build, implement and sustain interoperable systems (b) Unless Eric Brown, Graham Greive and Andrew McIntyre (plus perhaps 3 or 4 other folk) are in the room, around the table, on the panel or committee, we might as well not bother having these conversations....
So where are the highly paid policy wonks? and what on earth are they doing? What value do they add? perhaps Andrew is correct... they are just "hollowmen"... who have just enough knowledge to be dangerous....

Anonymous said...

"perhaps Andrew is correct... they are just "hollowmen"... who have just enough knowledge to be dangerous...."

Always has been, always will be - which is why an entirely new way of thinking about how to approach and resolve the problems must be adopted. New thinking! What's that?