I only noticed this a few days ago and felt it was worth a mention.
How does Australian interoperability become reality?
March 21, 2019
How do we take our current and somewhat vaguely expressed desire for improvement in interoperability in Australia, and turn it into something real? Fast Interoperability Healthcare Resource (FHIR) founder, Grahame Grieve, has some ideas.
By Grahame Grieve
Interoperability is a hard problem; it’s important to understand that it’s about information management, and it’s about people.
It’s not actually a technology problem – even though people use the word ‘technology’ a lot in respect to solving the issues we face around interoperability. But it’s not a technology problem, it’s a people problem, and an information management problem. Technology comes and goes. Information management is where the hard stuff is.
In my role as FHIR product director, I talk about interoperability a lot, and about FHIR. I realise that a lot of people misunderstand what Fast Healthcare Interoperability Resource (FHIR) is – yes, it’s got technology in it, but it’s not so much about technology. FHIR is really two important things – a community of people, and a set of agreements about information management and exchange.
The really valuable thing FHIR has is people and the culture that it helps people build. It’s a culture of sharing and openness and it’s starting to transform healthcare IT around the world.
The FHIR standard and the FHIR community don’t exist to deliver solutions to any real world problems, they exist to enable other people to do it. Our job is to get IT out of the way. The challenge then, and the biggest challenge by far, is developing the right story, the right solutions and actually deploying this stuff.
When I set out on the FHIR journey I had three goals in mind:
- To disrupt and force change on healthcare IT standards – that’s mostly in the bag.
- To disrupt and force change on healthcare IT- that’s on going.
- To disrupt and force change on health itself- that’s starting.
There are three stages to the journey that we’re on.
The first is getting the basic capabilities into international standards. These are platform standards that we can build solutions on.
But there are all sorts of solutions- informatics, theory, international collaboration. And they can all be used differently, so…
The second stage is to take those standards and say “this is what we’re going to do with them here in this context.”
This is a set of agreements that we can run, in our smaller local communities where we have much more to agree about (as compared to what everyone in the world can agree on collectively). We need to work with how our systems work and work together as a group of people to figure out what these local guidelines or rules should be, test them, and integrate that process into a standards cycle that is sustainable.
The third phase is to actually turn those local agreements into operating software, operating market agreements – things that actually work and are available to our providers. That can transform how we do health.
Around the world FHIR is scoring goals in the first and second stages, but it’s the third stage that’s the hardest stage, by a long shot. And the challenge, for me, is that each of these stages means different people, different culture, different processes, and the handover between stages causes a lot of noise and potential disconnect. Getting continuity to try and run the process to the ground in each local community is the hard part, and it’s increasingly our focus.
I’m afraid I believe that in Australia, we’re starting at the back of the pack:
We’ve had a working standards process in the past, but we don’t currently.
We’ve had some consensus in the community in times gone past, but we don’t now (or, at least we don’t have it well enough established again).
We’ve launched this interoperability journey repeatedly for a number of years (maybe we missed a year here and there).
What we need is belief that we collectively can get it properly moving and solved.
If you look at the history of interoperability, the great interoperability technology and techniques tend to be invented primarily in four countries – USA, Russia, China, and Australia. In health, in fact, Australia has dominated the creation of interoperability technologies and techniques for decades (e.g. openEHR then FHIR).
But if you look around the world at countries that have actually taken those assets and made them work, they’re small countries. They’re the ones that can work together to drive the technology home into working solutions. Despite what some people say, it’s not actually about size. It’s about culture.
There is vastly more found here:
This whole article is worth a careful read.
I would be interested to hear how others see the perspectives offered.
Certainly when Grahame says all this is ‘very hard’ I find myself in furious agreement!
David.
4 comments:
Hi David and colleagues,
I am in full agreement with Grahame - as far as he goes, but we need to be a lot more prescriptive of the steps we need to take to get secure messaging working properly - other forms of interoperability also need serious effort. But it is time that we got down to tin tacks on day to day clinical messaging.
Here is my suggested approach NB step 1 is borrowed from Grahame, step 2 from Andrew McIntyre.
I have offered to help ADHA with doing some of these things, in my new role as an independent consultant and as Deputy President of MSIA. For the record, I have offered my services on the basis that I will not charge any fee of this advice (after all, I am as much a cause of the problem as anyone has been!). I do however think I understand this challenging area well enough to make some very positive improvements.
Steps to sorting out messaging interoperability - Viewpoint from T Bowden
1. Updated specification of architecture, security & authentication. This includes determination of which message formats should be used in which parts of the sector. Achieving this should not hold up making immediate progress, but our overall architectural plan needs to be reviewed at this point including all relevant parties (including those which are disengaged). This is to give the parties confidence that achieving present day interoperability will be part of a long term investment (on everyone's part) and worth the effort.
2. Precise definition of message formats. Throughout the sector there is considerable variance in the way that supposed message standards are implemented. To have true interoperability, precise conformance is essential. Even small variances will prevent reliable messages exchange. All companies sending secure messages must ensure their outgoing messages are fully conformant with the agreed standards.
3. Ensuring ease of choice for users of messaging services. Currently clinicians choose messaging services in a somewhat ad-hoc manner, on the basis of whether or not they believe that their intended recipient also uses this same service.
4. Reviewing the viability of the current SMD interchange Model. I am not a big fan of it.
5. Ensuring all Secure Messaging system and electronic medical records (EMR) vendors are fully involved.
6. Establishment of acceptable service levels and practices. There must be agreements on service levels so that healthcare providers and patients can rely on a robust electronic messaging platform.
7. Consensus on messaging business models. While it is not right to direct how players in a competitive market should position service and price offers, it would be helpful if some important anomalies were addressed across the board.
I am looking forward to hearing from ADHA regarding my offer of help.
Kind regards,
Tom Bowden
Director - Cognoscenti Digital Health
Nicely put Tom and a generous offer. The last few years have seen a decline in access to people willing to challenge, model and seek long-term trajectories. My hope is that in the coming year(s) those who have been sidelined while the MyHR goal was pursued will again be brought back and form a proper think-tank that architectures can begin to be formed around so stakeholders can engineer new solutions to a given challenge (political, funding, clinical models, security/privacy interoperable, etc…).
I sense that ground hog day has dawned again and for a new generation it’s turning out that replacing a social construct with a computer program is difficult. The centralised database approach does on the surface address many regulatory and technical hurdles but not without consequence. This is something lacking at present- what are the consequences? What problem does any given solution introduce to the broader eco-system, or if you like what are the benefits/dis-benefits. If we cannot have insights and dialogue around the consequences of interoperability we will end up with the usual strategy - write hundreds of pages about how well you’ve done with the easy bits — and the hard bit’s coming some time in the astounding future.
Interoperability already exists in almost every other industry. Health is one of the last hold-outs trying to get by with an approach to technology which is frankly obsolete everywhere else.
Part of this is the nature of the industry and the way that change is (trying) applied. Health practitioners are, by nature, very independent and hence power is dispersed amongst a large number of individuals. Forcing, or even influencing, change from a central point is going to be very difficult. ADHA has set itself up to fail.
Learning from other industries where interoperability works - manufacturing and retail, or finance/banking/insurance. Collaboration is critical and power is somewhat concentrated (especially in the last few decades) so change is easier. But even there, standards grew out of operations - they were no imposed. Individuals and small groups work together and then the groups start interacting and cross-company communication is required. There is incremental growth of interaction which scales up to the whole industry.
The first step is getting individual doctors and clinics to work together, interoperability and standards come later.
Which is (I guess) essentially what this article is saying...
If the Australasian Diagnostic Error in Medicine Conference was anything to go by there is certainly a need for additional people with broader experience and subject matter expertise. The ADHA are a few roles short of a picnic lunch.
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