This document summarizes a presentation on healthcare interoperability. It discusses how interoperability is deceptively difficult to achieve due to technical, commercial, professional and political barriers. It recommends adopting Fast Healthcare Interoperability Resources (FHIR) and streamlining SNOMED CT as two proposals to help address issues with existing standards. Incentives are also needed to encourage interoperability and discourage data locking. The overall message is that while digital health holds promise, achieving true interoperability will require overcoming significant challenges.

1. Healthcare interoperability:
deceptively difficult
Tim Benson
R-Outcomes Ltd
tim.benson@r-outcomes.com
@timbenson
www.r-outcomes.com
Presentation to Digital Health Oxford (DHOx), 19 September 2016

2. Hope, hype and harm and digital health
These issues are not new
Incentives and leadership
Scalability, complexity and fitness
for purpose
Benson T. Why GPs use computers and
hospital doctors do not. BMJ 2002
1990s NHS successfully developed
Lab GP messages and procedures
eDischarge summaries (Kettering)
MIQUEST data extraction
GP2GP record transfer

3. Wachter Report Sept 2016
39 mentions of interoperability
Principle 5
Interoperability should be built in
from the start
Recommendation 9
Ensure interoperability as a core
characteristic of the NHS digital
ecosystem
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/550866/Wachter_Review_Accessible.pdf

4. Understanding interop
• Definition
• The ability of systems to exchange and
use electronic healthcare information
from other systems without special effort
on the part of the user
• Plug ‘n play
• Technical interop
• Commodity service (Internet, WiFi, Web)
• Semantic Interop
• Data types, structures and identifiers
• Process Interop
• How people work (the benefits)
www.springer.com/gp/book/9783319303680

5. Barriers to interop
Technical
Standards not fit for purpose
Commercial
Incentives to lock-in
Technical obsolescence
Professional
Alienation and fear of change
Political
Lack of informed leadership
Privacy and security
US Health IT Policy Committee Report to
Congress (Dec 2015) Challenges and
barriers to interoperability
1. Measures for patients and payers
(PROMs not just activity)
2. Measures of developer interop
performance (in vivo)
3. Payment incentives for interop
4. Multi-stakeholder action
https://www.healthit.gov/facas/sites/faca/files/HITPC_Final_ITF_Rep
ort_2015-12-16%20v3.pdf

6. Standards
Exact specifications
Precise compliance required
No ambiguity
Quality standards
Minimum acceptable quality
Both need conformance testing
A standard is a document, established
by consensus and approved by a
recognized body, that provides, for
common and repeated use, rules,
guidelines or characteristics for
activities or their results, aimed at the
achievement of the optimum degree of
order in a given context. (ISO)

7. Benefits of interop standards
!

8. What’s wrong with existing standards?
Constraint model
Model the universe (HL7 RIM, SNOMED CT Concept model)
Each specific application is constraint on the universal model
Problems
Complexity, such as mood codes (HL7 V3) and post-coordination (SNOMED CT)
Depends on full knowledge and correct use of the overarching model
Major educational challenge
Depends on the Universal model not changing
Caveat
A great deal of very good work has been done in standards; learn from this.

9. Two Proposals
Provide codes and identifiers
Need agreed identifiers for
carers
clinic slots
beds
survey questions etc
Streamline SNOMED CT
14 years old
Post-coordination is too complex
Fast issue of codes (takes 6-9 months
today), should be as fast as domain
name changes
Adopt FHIR
Fast Healthcare Interoperability
Resources
HL7 V2, V3 are not fit for purpose
Web technologies (RESTful, JSON)
Suitable for mobile apps
Cheaper to implement
Core plus extensions

10. FHIR
FHIR Manifesto
Focus on implementers
Target support for common
scenarios
Leverage cross-industry web
technologies
Require human readability as base
level of interoperability
Support multiple paradigms and
architectures
Logical FHIR architecture

11. Conclusions
Digital is digital
cannot tolerate ambiguity
Wachter is excellent (read it) but it lacks detail
The devil is in the detail
Interoperability is “deceptively difficult”
Need incentives for interop, and penalties for lock in
Adopt FHIR
Simplify and reform SNOMED CT content and procedures
Education about healthcare interop needed