UNIT 4 - Health Care Vertical Open Standards
1. Introduction to Industry Vertical Open Standards
Broadly two types of standards are notable, generic and specific standards. Generic also called horizontal or technical standards
apply to almost all organizations, because they do not give any information on underlying business processes. For example XML is
a generic standard. Generic open standards facilitate competition, if we follow SQL standard (ISO 90750) we can easily swap
databases as we want.
In contrast to horizontal IT standards, which is concerned with the characteristics of IT products and applies to users in many
industries, Vertical IT standards focus on data structures & definitions, document formats, business processes and addresses
business problems unique to a particular industry. Vertical IT standards (also called specific or Semantic) are designed to promote
communication and coordination among the organizations comprising a particular industry sector and to promote interoperability.
For example HR-XML is vertical standard for the Human Resources industry to meet the common messaging needed to enable
communication between all the disparate and legacy systems. Similarly XBRL (eXtensible Business Reporting Language) is a
standard for the electronic communication of business and financial data. There are XML schemas that define how information is
represented in electronic patient health care records, but we would not use those same schemas to build the XML messages that
are part of an automotive supply chain.
Vertical industry standards guide the integration of common systems components with industry-specific components, and guide the
creation of industry solutions for targeted customer problems within a particular industry. They should be developed and owned by
the users and not by vendors. Standardization in this area is necessary on semantic level as well.
Not all standards are applicable to many industries; vertical standards are needed to address business problems unique to particular
industries. For example, when the chemical industry began to expand its EDI (Electronic Data interchange) document standards for
e-commerce, standards developers took RosettaNet (XML-based) B2B protocol standards in the electronics industry to customize
them to unique chemical industry processes, such as the shipment of hazardous materials.
Vertical standards such as RosettaNet and CIDX (Chemical Industry Data exchange ) standards differ from horizontal standards,
not only in their narrower applicability, but also in their technical content.
IT product standards (Horizontal) focus on rudimentary levels of interconnection, such as telecommunications protocols, by
difference, vertical standards focus on data and business processes. Because vertical standards are not much concerned on
technology nuances, but, on how it is used.
The development and adoption of vertical standards exhibits very different characteristics than those of horizontal IT standards.
Normally technology firms and governments are the leaders in horizontal standardization; their role in vertical standardization efforts
is likely to depend on such things as, degree of adoption of IT in a particular sector and the extent of regulation in the industry.
2. Health Care Vertical
Hippocrates started a revolution in healthcare, by calling for the cautious collection and recording of evidence about patients and
their illnesses. This introduced sharing of data among physicians to provide the best possible care for patients and established a
foundation for the evolution of modern healthcare. Although 25 centuries have passed since Hippocrates suggestion, we have not
yet attained true evidence-based healthcare. Huge quantities of data about wellness and illness continue to be dropped, rather than
collected and utilized to optimize patient care.
We now stand at the brink of a potential revolution in data-centric healthcare, aided by advances in information & communication
technology. This promises to improve the quality of healthcare by cutting costs, and enabling physicians to do the very best with
available resources. In fact this supports the oath that all physicians make when they solemnly raise their hand and recite the
Hippocratic oath upon receipt of their medical degree.
Paper-based records have been in existence for centuries and their gradual replacement by computer-based records has been
slowly underway for over twenty years in western healthcare systems. Computerized information systems have not achieved the
same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail
industries. Further, deployments have varied greatly from country to country and from specialty to specialty and in many cases have
revolved around local systems designed for local use.
Today, health care industry is one of the world's largest and fastest-growing industries consuming over 10 percent of gross domestic
product (GDP) of most developed nations, health care can form an enormous part of a country's economy also health care is
becoming the fastest growing Vertical in IT. The need for health care IT gets more urgent as the population of people aged 55 and
over grows and records move from paper to electronic. Meanwhile, spending on wireless connectivity by health care enterprises will
increase by about 12 percent. Also spending on wireless will be fueled by a large market for wireless health-monitoring devices,
according to a recent study. [Source: http://www.eweek.com Health care IT news]
3. Health Information Technology (HIT)
HIT consists of an enormously diverse set of technologies for transmitting and managing health information for use by consumers,
providers, payers, insurers, and other groups with an interest in health and health care. In general it includes the capture, storage,
use and/or transmission of health information through electronic processes.
3.1 Components of HIT
These are the ―programs‖ that are used to perform HIT functions. These applications include but are not limited to: Patient
Registries, Accounting/Practice Management Systems (PMS), CPOE/CDS (Computerized Physician Order Entry with Clinical
Decision Support), ePrescribing, Electronic Medical Records (EMRs), Electronic Health Records (EHRs), Patient Health Records
(PHRs), Results Reporting, Electronic Documentation, Appointment Scheduling, Patient Kiosks, Telemedicine, Interface Engines.
Electronic Medical Record: ―An electronic record of health-related information on an individual that can be created, gathered,
managed, and consulted by authorized clinicians and staff within one health care organization.‖
Electronic Health Record: ―An electronic record of health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across
more than one health care organization.
Personal Health Record: ―An electronic record of health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled
by the individual.
Health Information Exchange: ―The electronic movement of health-related information among organizations according to
nationally recognized standards.‖
Health Information Organization: ―An organization that oversees and governs the exchange of health-related information
among organizations according to nationally recognized standards.‖
Regional Health Information Organization: ―A health information organization that brings together health care stakeholders
within a defined geographic area and governs health information exchange among them for the purpose of improving health and
care in that community.‖
3.1.2 Communications Standards
These are the various sets of standards that are necessary in order for HIT systems to communicate with each other in a uniform
manner. These standards encompass
HL7, ADT, NCPDP, X12, DICOM, UB92, HCFA, ASTM, EDIFACT, etc.
Messaging standards are the form and structure that is required for the information to move and be tracked from one system to
LOINC, ICD-9, CPT, NDC, RxNorm, Snomed CT, etc.
Coding standards are the form and structure of the procedure codes that are necessary to communicate what procedure was
performed for a particular patient during a visit.
These are the actual steps necessary to obtain, retrieve, send, and receive data from one computer to another, from one system to
another and from many systems in an integrated fashion.
MPI (Message Passing Interface) – these interfaces guide the transfer of the message from one system to another
HIE (Health Information Exchanges) – there has been recent debate as to whether HIE is a verb or a noun i.e. is it a process or
an entity? There are organizations that are called health information exchanges at the present time who provide the backbone
systems and hardware that allows and facilitates the process of health information exchange, however, as per current definitions
as referenced above HIE is a process
RHIOs (Regional Health Information Organizations) – although RHIOs are indeed entities that provide similar functions to the
HIE a RHIO usually has a much larger governance role in a specific area than does an HIE. Even this is changing as RHIOs no
longer only cover small geographic areas. RHIOs now cross state lines and provide services in multi states. This is a reason that
the ―Alliance‖ added a category and definition for Health Information Organizations (HIO) taking out ―regional‖.
This plays an important role in all exchange of health information using HIT. Healthcare providers, institutions and vendors must
comply with HIPAA in any and all exchange of personal health information (PHI). There is also much debate at the present time with
regard to HIPAA being or not being stringent enough to protect privacy in an all HIT world. A balance will need to be developed that
allows for health care information to be exchanged in order to provide improved quality of care for the patient and still maintain
These are the various hardware components that make HIT work and include such things as: Desktops, Laptops, Tablet PCs,
Servers, Mice, Pens, Bar Coding devices and more. As HIT continues to develop and we continue to exchange information with our
providers we will see in-home devices such as blood pressure monitors and scales have the ability to transmit data directly to our
provider for him/her to review and monitor our care. This is available and is occurring now.
In today’s healthcare industry, goal is to exchange patient data freely across various systems in the industry. Health IT standards
provide the necessary foundation for institutional data sharing and integration of this data with home care. Security, privacy and
regulatory issues need to be addressed while ensuring end to end delivery and accessibility. Healthcare is an information intensive
industry and persistent information losses are costly, economically, as well, in terms of human life.
The purpose of using standards in health information systems is to facilitate the integration of component parts and support
interoperability, for example, by making data generated in one part of a system accessible, meaningful and reusable where different
technology may be in use.
In health informatics, standards development is concentrated in such areas as data exchange, medical terminologies, documents,
p<>To address the standards in health IT, today there are various SDO’s and SIG’s already in existence.
The US National Committee on Vital and Health Statistics describes three levels of interoperability:
Basic interoperability—allowing a message from one computer to be received by another, but not requiring the receiving
computer to be able to interpret the data.
Functional interoperability—an intermediate level defining the format of messages. This ensures messages between computers
can be interpreted at the level of data fields, so that data can pass from a structured field in one system to a comparably
structured field in another. Neither system, however, has understanding of the meaning of the data within the field(s).
Semantic interoperability—provides common interpretability, that is, information within the data fields can be used intelligently.
In addition to the standard methods for systems to communicate (chiefly Health Level 7 [HL7]) and those required for submission of
claims (Current Procedural Terminology [CPT]-4, International Classification of Diseases, Ninth Revision, Clinical Modification [ICD9-CM], and X12N), there are several other available standards that are clinically useful and can greatly improve the ability to access
and exchange patient information. Major advances in the Unified Medical Language System of the National Library of Medicine have
made the patient medical record information standards (Systematized Nomenclature of Medicine [SNOMED], Logical Observation
Identifiers, Names, and Codes [LOINC], RxNorm) easily accessible. Detailed knowledge of the arcana associated with the technical
aspects of the standards is not needed (or desired) by clinicians to use standards-based systems. However, some knowledge about
the commonly used standards is helpful in choosing an EDIS, interfacing the EDIS with the other hospital information systems,
extending or upgrading systems, and adopting decision support technologies.
Electronic Medical Records, Electronic Health Records ...
The replacement of healthcare systems reliant on paper-based medical records or generally localised clinical information systems
by very large scale health information infrastructures centred on interoperable electronic patient record systems (and/or electronic
heath cards) is now underway in many countries. Some countries are well-advanced in the implementation of electronic patient
records and national network infrastructures - particularly the Scandinavian countries of Denmark, Finland, Norway and Sweden.
But most aren't. However, governments in France, Canada, Australia, England, New Zealand and the USA, for example, have now
committed to deliver national electronic networks and medical record systems to support healthcare delivery for their populations,
typically by the end of the current decade.
These national programmes, all established within the last few years, are so extensive they constitute a healthcare technology
revolution in each country where they have been announced. In Europe, the European Commission took a lead in publishing in
2004 an action plan for a European e-Health Area. The plan specifies a sequential set of actions to be taken by EU member states
over the period 2004-2010. The investment committed in one case - NHS England on its wholly publicly funded Connecting for
Health programme - is unprecedented. Some other countries, including France, are also funding their programmes exclusively with
public money. Other governments, including the USA, Australia and Canada, are promoting collaborations between the private and
public sectors. Finland's FinnWell programme is focusing on promoting healthcare technology development to create opportunities
for Finnish business and research, while at the same time aiming to improve the Finnish healthcare system.
Interest in implementing e-Health technologies is not limited to the most highly developed countries of the world. In Asia, countries
such as Hong Kong, Singapore, South Korea, Thailand and Taiwan are developing and implementing e-Health policies. e-Health
projects focusing on telemedicine in particular are running in many of the countries of Central and South America and the
Caribbean. Some countries in Africa are starting to develop e-Health policies and strategies and are receiving impetus and support
from various global and regional organisations from the United Nations, the World Health Organisation, UNESCO to the recently
inaugurated Digital Solidarity Fund (which aims to support implementation of ICT - including e-Health - in Africa) and NEPAD (the
New Partnership for Africa’s Development). . National penetration of EMRs may have reached over 90% in primary care practices in
Norway, Sweden and Denmark (2003), but has been limited to 17% of physician office practices in the USA (2001-2003) [HHS,
2005]. Those EMR systems that have been implemented however have been used mainly for administrative rather than clinical
Electronic medical record systems lie at the center of any computerized health information system. Without them other modern
technologies such as decision support systems cannot be effectively integrated into routine clinical workflow. The paperless,
interoperable, multi-provider, multi-specialty, multi-discipline computerized medical record, which has been a goal for many
researchers, healthcare professionals, administrators and politicians for the past 20+ years, is however about to become reality in
many western countries.
Over the past decade, the political impetus for change in almost all western countries has become stronger and stronger.
Incontrovertible evidence has increasingly shown that current systems are not delivering sufficiently safe, high quality, efficient and
cost effective healthcare (see Public Reports section on OpenClinical), and that computerization, with the EMR at the centre, is
effectively the only way forward. As Tony Abott (Australian Minister for Heath and Ageing) said in August 2005: "Better use of IT is
no panacea, but there's scarcely a problem in the health system it can't improve". For the first time, the responses have been
national and co-ordinated. Governments in Australia, Canada, Denmark, Finland, France, New Zealand, the UK, the USA and other
countries have announced - and are implementing - plans to build integrated computer-based national healthcare infrastructures
based around the deployment of interoperable electronic medical record systems. And many of these countries aim to have EMR
systems deployed for their populations within the next 10 years.
Terms used in the field include electronic medical record (EMR), electronic patient record (EPR), electronic health record (EHR),
computer-based patient record (CPR) etc. These terms can be used interchangeably or generically but some specific differences
have been identified. For example, an Electronic Patient Record has been defined as encapsulating a record of care provided by a
single site, in contrast to an Electronic Health Record which provides a longitudinal record of a patient’s care carried out across
different institutions and sectors. But such differentiations are not consistently observed.
The 1997 Institute of Medicine report: The Computer-Based Patient Record: An Essential Technology for Health Care, provides the
following more extensive definition: "A patient record system is a type of clinical information system, which is dedicated to collecting,
storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such
systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical
information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information
pertinent to patient care (e.g., computer-based patient record systems)." [IOM, 1997]
The three essential capabilities of an electronic health record as follows:
To capture data at the point of care
To integrate data from multiple internal and external sources
To support caregiver decision making.
The eight core capabilities that EHRs should possess are:
Health information and data.
Having immediate access to key information - such as patients' diagnoses, allergies, lab test results, and medications - would
improve caregivers' ability to make sound clinical decisions in a timely manner.
The ability for all providers participating in the care of a patient in multiple settings to quickly access new and past test results would
increase patient safety and the effectiveness of care.
The ability to enter and store orders for prescriptions, tests, and other services in a computer-based system should enhance
legibility, reduce duplication, and improve the speed with which orders are executed.
Using reminders, prompts, and alerts, computerized decision-support systems would help improve compliance with best clinical
practices, ensure regular screenings and other preventive practices, identify possible drug interactions, and facilitate diagnoses and
Electronic communication and connectivity.
Efficient, secure, and readily accessible communication among providers and patients would improve the continuity of care,
increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events.
Tools that give patients access to their health records, provide interactive patient education, and help them carry out homemonitoring and self-testing can improve control of chronic conditions, such as diabetes.
Computerized administrative tools, such as scheduling systems, would greatly improve hospitals' and clinics' efficiency and provide
more timely service to patients.
Electronic data storage that employs uniform data standards will enable health care organizations to respond more quickly to
federal, state, and private reporting requirements, including those that support patient safety and disease surveillance."
This list of key capabilities will be used by Health Level Seven (HL7) ... to devise a common industry standard for EHR functionality
that will guide the efforts of software developers.
Benefits of EMRs
Replace paper-based medical records which can be incomplete, fragmented (different parts in different locations), hard to read
and (sometimes) hard to find. Provide a single, shareable, up to date, accurate, rapidly retrieveable source of information,
potentially available anywhere at any time. Require less space and administrative resources.
Potential for automating, structuring and streamlining clinical workflow.
Provide integrated support for a wide range of discrete care activities including decision support, monitoring, electronic
prescribing, electronic referrals radiology, laboratory ordering and results display.
Maintain a data and information trail that can be readily analysed for medical audit, research and quality assurance,
epidemiological monitoring, disease surveillance .... Support for continuing medical education.
Widespread implementation of EMRs has been hampered by many perceived barriers including:
Technical matters (uncertain quality, functionality, ease of use, lack of integration with other applications,
Financial matters - particularly applicable to non-publicly funded health service systems (initial costs for hardware and software,
maintenance, upgrades, replacement, ROI ...)
Resources issues, training and re-training; resistance by potential users; implied changes in working practices.
Certification, security, ethical matters; privacy and confidentiality issues Doubts on clinical usefulness
Incompatibility between systems (user interface, system architecture and functionality can vary significantly between suppliers'
Integrated systems require consistent use of standards in e.g. medical terminologies and high quality data to support information
sharing across wide networks
Ethical, legal and technical issues linked to accuracy, security confidentiality and access rights are set to increase as national
EMR systems come online. These issues become more pressing with the current movement to promoting consumer
empowerment and information ownership, championed by the European Commission for example, which is leading towards
patient records accessible by patients (Personal Health Records).
Common record architectures, structures
Clinical information standards and communications protocols
Security and confidentiality of information
Patient data quality; data sets, data dictionaries.
Interoperability aims to support :
Data transfer and sharing on much more than a local or enterprise-wide scale Knowledge transfer and integration
Medical terminology transfer, mapping and integration
Integration with clinical and non-clinical applications
EMR / EHR-related standards
Health information exchange (HIE) is the transmission of healthcare-related data among facilities, health information organizations
(HIO) and government agencies according to national standards. HIE is an integral component of the health information technology
(HIT) infrastructure under development in the United States and the associated National Health Information Network (NHIN).
To meet requirements, HIE technology must enable reliable and secure transfer of data among diverse systems and also facilitate
access and retrieval data. The purpose of HIE development is to improve healthcare delivery and information gathering.
Syntatic interoperability is a prerequisite for semantic interoperability. Syntatic interoperability refers to the packaging and
transmission mechanisms for data. In healthcare, HL7 has been in use for over thirty years (which predates the internet and web
technology), and uses the unix pipe (|) as a data delimiter. The current internet standard for document markup is XML, which uses
"< >" as a data delimiter. The data delimiters convey no meaning to the data other than to structure the data. Without a data
dictionary to translate the contents of the delimiters, the data remains meaningless. While there are many attempts at creating data
dictionaries and information models to associate with these data packaging mechanisms, none have been practical to implement.
This has only perpetuated the ongoing "babelization" of data and inability to exchange of data with meaning
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