Tuesday, June 13, 2017

I Wonder Does This Work From The US Cover What We Need In A Strategic Interoperability Framework For Digital Health.

This article appeared a few days ago.

NQF maps out measures for interoperability

The National Quality Forum is set to finalize a framework that can measure health data interoperability and identify gaps in progress.
June 08, 2017 04:02 PM
The National Quality Forum moved closer to finalizing a framework for measuring interoperability. NQF said the framework will help identify in the nation’s progress to enable widespread health data exchange. 
The agency’s initiative comes as hospitals and electronic health records vendors are struggling with interoperability and the Office of the National Coordinator for Health IT is working to advance standards that enable information sharing. 
“Interoperability is more than EHR to EHR, and all sources of data should be taken into consideration,” NQF said. “All critical data elements should be included in the analysis of measures as interoperability increases access to information.” 
To that end, NQF based its work on ONC’s shared nationwide interoperability roadmap to measure information exchange happening in four domains: disparate systems, data to facilitate information sharing, interoperability to enable decision making and, broadly, the impact interoperability can have on healthcare outcomes. 
NQF was charged by the Department of Health and Human Services to identify a set of measures around interoperability that would help gauge performance. The goal is to help the healthcare industry improve care management, preventative care and population health management.
More here:
I decided to follow this up and what I found was this.

Interoperability Project 2016-2017

NQF will conduct a multistakeholder review of the current issues and barriers to interoperability and identify a set of proposed measure concepts around interoperability. A conceptual framework will be created to analyze, prioritize, and make recommendations for those concepts to be developed into performance measures. 

The Opportunity

Interoperability is defined as the extent to which systems and devices can exchange data, and interpret that shared data. One of the goals in using health information technology is to provide comprehensive information on patients at the point of care, as well as integrating information across different sources and sites, so that the provider can evaluate the most appropriate options for patients based on the effectiveness of treatments, including factors such as quality, risk, benefit and costs. Currently the promulgation of common data messaging standards and clinical vocabularies have increased interoperability, but they are not as effective as they could be for the seamless exchange and use of data to derive the maximum benefits of health IT. For two systems to be interoperable, they must be able to exchange data and subsequently present that data such that it can be understood by a user.
Over the last few years, there has been an increased awareness by both private and public sectors of the ability to improve the quality and safety of healthcare with interoperable health information technology (HIT) systems. These technologies include electronic health records, personal health records, health information exchanges, and medical devices. As healthcare systems are increasing in their adoption of health IT, a growing amount of data are being gathered.  In order for the healthcare industry to move towards better care management for patients, preventative care and population health management, there is need for usable clinical information to flow freely across networks and between hospitals and physicians. For this reason, healthcare organizations need interoperability, an efficient and secure means for hospital computer-based systems and applications to communicate and exchange patient data. However, true interoperability is a significant challenge to healthcare organizations for a number of reasons: lack of a common, standard framework that reconciles the differences in data as well as the varying data types; difficulties in product and system compatibility with existing infrastructures within hospitals; and consistent and persistent struggles internally to disclose the appropriate data within a hospital and with partners in their community. The result is health data that cannot be effectively used across the facility or system levels and that disrupts continuity of care at the patient level.

Objectives

National Quality Forum (NQF) will conduct a multistakeholder review of the current issues and barriers to interoperability and identify a set of proposed measure concepts around interoperability. A conceptual framework will be created to analyze, prioritize, and make recommendations for those concepts to be developed into performance measures.

NQF Process

Over a 12-month period of performance, NQF will complete an environmental scan and key informant interviews; and convene an expert, multistakeholder panel to provide input and help guide the creation of a framework to organize the information in a logical and efficient manner. Throughout this project, NQF will solicit input from NQF’s multistakeholder audience, including NQF membership and public stakeholders at key points throughout the project. NQF will produce a final report, which will include core principles and guidance on how to fill current gaps in measurement of interoperability as well as recommendations for future opportunities for work in the interoperability field.
Here is the link:
The final report draft, which is out for comment until the end of the month, is found here:
To me the executive summary says pretty much is all.

Executive Summary

The definition of interoperability with respect to health IT means health information technology that (1) enables secure exchange and use of electronic health information without special effort by the user; (2) allows for complete access, exchange, and use of all electronically accessible health information for authorized use; and (3) does not constitute information blocking.1 For two systems to be interoperable, they must be able to exchange data in an agreed-upon format according to a standard and subsequently present that data in a way that a user can understand and use.
In concordance with that definition, ONC developed the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap as well as national standards as part of its certified electronic health record (EHR) technology, which provided nationwide standards for interoperability, both in the exchange of information and in its use. This provided a foundation on which disparate systems could use the appropriate formats and mechanisms to exchange data to assist providers, patients, and other stakeholders. However, true interoperability is a significant challenge to healthcare organizations for various reasons, including the lack of a common, standard framework that reconciles the differences in data as well as the varying data types. Additionally, healthcare organizations maintain incompatible products and systems, which are unable to disclose the appropriate data within the organization and with partners in its community.
As the nation moves towards increased interoperability, a measurement framework would be useful to assess its impact. At the request of the Department of Health and Human Services (HHS), the National Quality Forum (NQF) has taken on a project to develop a measurement framework and measure concepts, which can serve as a foundation for addressing the current gaps in the measurement of interoperability. As a first step towards achieving these goals, NQF conducted an environmental scan and key informant interviews and published the results in the interoperability Environmental Scan Report and the interoperability Key Informant Interview Summary Report. Additionally, NQF convened an expert, multistakeholder Interoperability Committee to provide input and guide the creation of a framework. Throughout this project, NQF solicited input from a multistakeholder audience, including NQF membership and public stakeholders.
The Committee developed the following set of guiding principles that define the key criteria when considering the measure concepts to guide their development into performance measures.
·         Interoperability is more than EHR to EHR, and all sources of data should be taken into consideration.
·         Various stakeholders with diverse needs are involved in the exchange and use of data, and the use of this framework and measure concepts will differ based on stakeholder perspectives
·         The term “electronically exchanged information” should be used instead of “outside data” to completely fulfill the definition of interoperability.
·         Interoperability needs will differ depending on the care setting.
·         All critical data elements should be included in the analysis of measures as interoperability increases access to information.
The measurement framework contains essential categories (domains) and subcategories (subdomains) needed to ensure comprehensive performance measurement of interoperability. The Committee determined the following domains and subdomains that most accurately measure interoperability and its impact on health outcomes:
Domain
Subdomain
Exchange of Electronic Health Information
·         Availability of Electronic Health Information
·         Quality of Data Content
·         Method of Exchange
Usability of Exchanged Electronic Health Information
·         Relevance
·         Comprehensibility
Application of Exchanged Electronic Health Information
·         Human Use
·         Computable
Impact of Interoperability
·         Patient Safety
·         Cost Savings
·         Productivity
·         Care Coordination
·         Improved Healthcare Processes and Health Outcomes
·         Patient/Caregiver Engagement
·         Patient/Caregiver Experience
Using these domains and subdomains, NQF worked with the Interoperability Committee to examine and develop measure concepts based on information gathered through the literature, the key informant interviews, and the individual knowledge of each of the Committee members. Additionally, NQF examined a large group of quality measures from topics gathered through the literature to identify those that are “interoperability-sensitive” measures, which are quality-of-care metrics designed for reporting from an EHR that are potentially influenced by increased interoperability between EHRs. This framework contains two distinct sections that identify both the measure concepts and measures.
Appendix A includes identified measure concepts aligned with the appropriate domains and subdomains within the report along with a timeline. The estimated timeframe states whether (1) the concepts are useful in the short-term (0-3 years); (2) the concepts will be useful in the mid-term (3-5 years); or (3) the concepts are potentially implementable in the long-term (5+ years). Appendix B shows existing measures as illustrative examples of the measure concepts created by the Committee.”
This seems to define the scope of interoperability and makes it clear it is more like a year’s work – not 5 weeks.
The ADHA might save a lot of time if they read really carefully. Looks pretty good to me.
This from NEHTA in 2012 might also have a few ideas. See here:
I wonder why no references to all this work. Was it that useless?
David.

22 comments:

Anonymous said...

It takes a level of understanding to profile these works and others, they do not even reference the Australian standard IF. I question if the two running this would no what the deliverables would even represent or understand them, I am sure both have nothing to contribute.

Anonymous said...

The eHealth Interoperability Framework is fine, could do we some minor updates but even that is not as easy as it sounds, what would be good is addressing legal interoperability, especially as we enter an age where research and use of datasets is becoming more common. Now that would be a useful undertaking IMHO.

Anonymous said...

Happy for them to read it David. However, this sort of work is something that requires community collaboration and open national dialogue, to do a 'thing' in iscolation and behind closed doors in a short period of time will result in shelfware, a a lost opportunity for us all to gain a better and shared understanding or what interoperability is and what it means for our health system and where we might want to prioritise investments. Interoperability is about sets of layered agreements and understanding where agreements cannot be met, and over time any number of systems (not just computer) can come and go from partnerships, form new relationships and belong to any number of systems. As with all business negotiations there are specific constraints such as business and operating models, policy and legislation, agreed standards as so forth.
Why the ADHA removed people who had a clue about this at a time they are probably most needed is beyond me, seems Tim may have missed a golden opportunity to engage is robust conversations with experts who cared about the long term state of the nation and sort to ensure an open and level playing field for all.

I see nothing in that RFT except another example of wasted tax payer money and wasted opportunity. Not just regarding the fee for the proposed work.

Makes one wonder the shallowness of some to grab a spotlight in the beaming radiance of a now dimming ADHA.

Anonymous said...

Thank you for bringing these interesting documents to our notice David. As I read them I was conscious of the significant differences between the US and Australian health systems. Whilst the fundamentals of interoperability are the same the world over the focus of these documents seemed to be on inter- and intra- hospital communications and health information exchange. The primary care practitioners and various specialists outside of the hospital environment did not seem to rate a mention It was almost as though they didn't exist which is quite different from what we have in Australia. Perhaps that is a reflection of the US health system or maybe I have missed something.

Bernard Robertson-Dunn said...

"The Committee determined the following domains and subdomains that most accurately measure interoperability and its impact on health outcomes:"

All these measures are either implicitly or explicitly measures of benefit.

There are no measures of costs or risks.

Rather like the government's promotion of MyHR - all claimed (and often unjustified) benefits - not a mention of cost/risks/downsides.

I saw my GP yesterday to arrange for a cholesterol test. He spent most of his time staring at his computer screen and not hearing the things I was asking/telling him. I know he wasn't listening because he'd ask me something I'd just told him.

GP's are in danger of becoming glorified call-centre operators with many of their patients.

Peter said...

Interoperability, in the IT sense, is much more than just the ability to share data. It is the difference between 'speaking the same language' (integratable) and 'working well together' (interoperable). The first is straightforward (if not simple) and off-the-shelf translation or mediation layers are common in most multi-system IT environments. The second is more about carefully matching capabilities and system design. It is a much more complex, and more nebulous, concept.
I am reminded of one definition of 'architecture': "Things work better when they work together - on purpose". It is the role of an architect to handle the "on purpose" bit.
Unfortunately there don't get the impression there are many professional IT architects within the ADHA.

More on topic - the US solution looks like an reasonable approach to a limited aspect of the problem but we already have a lot of the key pieces already available here. There is a common information model and (some) integration standards defined. But we still have situations where even hospital systems - installed by the same management - don't work well together. Let alone including allied health or external partner systems (such as GP clinics).
This is where I think the ADHA Interoperability framework could add value - providing a platform for delegation of functionality and responsibility as well as just data. Hence allowing disparate applications to collaborate if possible or operate independently where necessary.

Anonymous said...

The RFT is a scam, it will either be used to inform the board there are no suitable tenders and they need to extend the timeframes and bring in one of the big international firms who will need to at least end of 2018. I am sure those they bring in will have links to certain high ranking ADHA people.

Time will tell but something smells dishonest here, much like a lot from ADHA of late.

Anonymous said...

7:56 AM I think you are being a little generous in regards to their creativity. It is more IMHO a look at what to expect from the ADHA, once the foundational work they inherited dries up. Everything happening at present was long in the making by others. It will be another 6-12 months before we see ADHA specific undertaking happen.

Anonymous said...

ANON June 17, 2017 8:36 AM, reluctantly I have to admit I agree with your sentiments. Looking internationally this really is a bit below par, well more than a bit, probably closer to not even in the same ball park. The ADHA is simply the MyHR operations and Marketing Division , it is the eHealth Branch under another name. This will suit many just fine.

Anonymous said...

@9.00 AM You rightly reiterate what I have been saying for a long time “The ADHA is simply the ……. eHealth Branch under another name.”

Consequently Paul Madden and the Department’s eHealth Branch do, and will continue to, call the tune. Tim Kelsey’s ADHA “is simply the MyHR operations and Marketing Division”.

Because Tim lacks insight, experience and understanding into the ‘dimensions and complexities of the health system' he can quite boldly and in all naivety actively undertake all the marketing communications and promotion required by the Department, in order to continue pushing the MyHR without having to be concerned at all about any of the consequences of his actions.

Anonymous said...

Oh now I understand why people have referred to it as ADOHA, and GovHR

Anonymous said...

So we ended up with all that was bland and obstructing from the past, not solely the eHealth branch but also those parts of NEHTA that represented its worst side. Oh well hopefully the next 12 months will prove its as simple as opting everyone in so they can control their own healthcare and who sees what about them. Wish them luck.

Anonymous said...

Australia I am afraid will never recover from this. I hear ADHA has lost all but a few who can do eHealth at a national level. Even HL7 Australia is only a handful of people. A case in point is recent updates to an HL7 Australian Standard, no public announcement, no call for community comment, just happened, undertaken probably at the command of ADHA. Even the pathology work they just published, which standard are we suppose to use? HL7 or Standards Australia. The process by which standards are created was the value of a standard, that no longer exist and therefore not worth the paper it is written on. National disgraces the lot of em.

And yes I don't like it and yes I am off to join another industry.

Anonymous said...

3:01, sorry to hear you feel like that. What exactly will Australia never recover from? We listened and it was clear NEHTA, Standards and specification were surplus to requirement and that industry driven by customers needs would do the job that had failed constantly for the past ten years. I think some would see this as recovering from a deep meaningless sleep. Banking and Airlines are years ahead of health, I citizens just want realtime health information streamed to them. We need to be able to put to task the medical professionals who treat us and frankly cost the nation quite a large portion of the budget, a budget taking us further into debt. Technology is a major way of curbing waste, costs and having me make better choices.

Andrew McIntyre said...

3:01 pm should join HL7 Australia and attend the teleconferences on the standard and make comments. There was a comment call and comments were resolved. Certainly not perfect but an attempt to resurrect the standards process and progress the standards that are in widespread use.

Anonymous said...

Might be a poor choice of words Andrew - . Certainly not perfect but an attempt to resurrect the standards process.

As 3:01 I think was trying to raise, it is the process by which Standards are created and maintained that lends them weight. This is a long tradition and well documented principle led processes. Either they are followed to the letter or they are not followed. I understand HL7 Aus is not the power house it once was. I do to some extent support its 'resurgence' but this does smell a little like Munchausen at Work.
Perhaps we should simply defer everything back to HL7 International who has the community infrastructures and processes in place and supported. We are no longer a technology island, many of the more significant digital implementations are undertaken by international consortium. Perhaps the effort is better spent resurrecting a better discipline around the profiling of standards in partnership with ADHA through its co-design mantra and developer community, or even invest in IHE which is more implementation experience focused. Project Argonaut or Join-up/IHE are good examples of how the international players can cut through localised BS, MyHR is another great example.

These are only alternative thoughts and I would like to see an Australian standards community again, but perhaps it is better those efforts are invested in ensure Australian interests are tabled at an international level. Might help Australian companies be more attractive internationally

Anonymous said...

Will have another look at the value of joining in the new year. If thought and business leadership can be resurrected as you say HL7 Australia is attempting to do then in might be money worth handing over. A long way to go though.

Anonymous said...

17 June 3:01 - Technology is a major way of curbing waste, costs and having me make better choices.

Maybe we should hand Parliament over to AI, probably see the biggest positive result

Andrew McIntyre said...

The lack of perfection in the HL7 Australia process for standards is around publishing quality and stakeholder engagement. The process is standard, for a standard. The issues are being addressed, but stakeholder engagement is the critical factor. Some sort of compliance requirement is the way to address that. In reality all vendors should be very engaged, as they have to implement or consume the messages.

Anonymous said...

Would it not be simpler just to license ADHA as the standards and publishing entity? After all they seem to be the ones facilitating the clinical, business and consumer agreements, through the RFT and such gaining additional technical agreements. The nice chap in charge of design and innovation seemed to be setting up an impressive developer platform, the ADHA pretty much directly or indirectly fund standards work and provide a hell of a lot of intellectual input. The also own and operate the MyHR, secure messaging etc...

Just curious why we bother having extra bodies involved it getting things done?

Anonymous said...

June 18, 2017 4:50 PM. I think that is very reasonable and probably a good path to go down. I would argue that the ADHA is to wed to a specific technology however, that could be said of many involved in standards development. It is rumoured this will be the case going forward and the ADHA is actively working through particulars to create an SDO like division. Seems sensiable as you point out the ADHA directly and indirectly funds a majority of it anyway and it is clear all roads lead to MYHR which is CDA and will be sprinkled with FHIR, both have strong international adoption and significant clinical and technical communities working together.

Grahame Grieve said...

"Perhaps we should simply defer everything back to HL7 International who has the community infrastructures and processes in place and supported"

Australians are fairly active in international standards processes, though we should be more active, sa formal government program around standards engagement would be useful; our lack of that demonstrates that the government has no long term strategy around standards. Perhaps this rft will help formulate one, and then the government will have a framework in which to have an standards engagement strategy.

But HL7 international has no interest, energy or authority to define Australian standards of the 4700.x ilk, nor should we want it to. We need a working Australian ehealth standards process, and it's pretty awful that we don't have one. HL7 Australia is trying to set one up, but that's taking time. The key problem is that while the process is pretty well described, the central authority in the standards process has to be able to engender trust in all the participants. It seems to me that not everyone is convinced that HL7 Australia is able to this, and particularly that it can remain the trusted authority in an ongoing fashion. But there's no other candidate t this time, so we better all hope that we can build this trust.

"We are no longer a technology island, many of the more significant digital implementations are undertaken by international consortium"

As long as we are a policy island, we'll need local health standards. I don't think that anyone is holding their breath for this to change.