1. Interoperability: Issues, Challenges, Solutions Bill Lober, MD MS Associate Professor, Health Informatics and Global Health Schools of Medicine, Nursing, and Public Health University of Washington Director of Informatics International Training and Education Center for Health

2. Overview Why start with Interoperability? What is Interoperability? – Definition, Types, Assumptions Principles – Software engineering – National Institutes of Health Barriers (Non-technical) – Canada – Europe

3. Session Theme Why Start With Interoperability? Interoperability, Standards, and Architecture Interoperability Standards-based Interoperability Architecture to Support Standards-based Interoperability HIV PMIS HIV VCT HL7 messages HL Referral Summaries PMIS VCT LabPharm HL7 messaging Provincial/District Reporting National Reporting Supply Chain/Stock Mgt Surveillance/Case Reporting National Patient Index Billing/Utilization/Insurance Commercial Ordering SDMX-HD HL7 X.12? EDIFACT? HL7 CDA

4. Definition “Interoperability” means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data so the clinical or operational purpose and meaning of the data are preserved and unaltered.

5. Definition “Interoperability” means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data so the clinical or operational purpose and meaning of the data are preserved and unaltered. Like going to the Moon… Definition from US Presidential Executive Order 2006-Aug-22, “Majority of Americans shall have access to electronic health records by 2014”

6. Challenges “Interoperability” means the ability to communicate and exchange data accurately, effectively, securely, and consistently with different information technology systems, software applications, and networks in various settings, and exchange data so the clinical or operational purpose and meaning of the data are preserved and unaltered. Like going to the Moon… Definition from US Presidential Executive Order 2006-Aug-22, “Majority of Americans shall have access to electronic health records by 2014”

7. 5 Types of Interoperability * Priority areas for achieving interoperability – Unique person identifier – Meaning (semantics) – Structure/format (syntax) – Core data sets – Data quality and use *Hammond WE, Bailey C, Boucher P, Spohr M, Whitaker P. Connecting Information To Improve Health. Health Affairs. 2010;29(2):284 -288.

8. Underlying Assumptions Supporting Health Interoperability* Interoperability is preferable to large integrated systems – Apparent simplicity brings risk, creates barriers – Interoperability can bring flexibility, innovation, ownership Record data only once, but allow it to be reused in other systems. * Bailey C, Boucher P, Kibbe D, et al. Interoperability Standards for Health Information Systems. 2008. Available at: http://www.dbmotion.com/multimedia/upl_doc/ doc_281008_174695.pdf. Accessed March 15, 2011.http://www.dbmotion.com/multimedia/upl_doc/ doc_281008_174695.pdf

9. Assumptions About “Other Systems” (and Architecture) All information systems operate like they are at the center of the architecture To connect them (scalable interoperability) – All systems have to be well described, in functional requirements – The business processes that require data interactions should be well described in use cases – The standards used to support those data interactions, and the specific ways those standards are to be used, should be integrated with the use cases as interoperability profiles. For Example: EMR supports certain business rules Doctors review old records Doctors see labs and medicines Reporting to hospital administration Lab has other business rules quality, test kit inventory, supply chain, analyzer interfaces …if an EMR designer adds a lab module, it will add the functions to serve the EMR… … if a Lab designer builds a system, it will serve the needs of the lab … the goal is for systems to support their own business areas, and exchange the information they need.

10. Assumptions About “Other Systems” (and Architecture) All information systems operate like they are at the center of the architecture To connect them (scalable interoperability) – All systems have to be well described, in functional requirements – The business processes that require data interactions should be well described in use cases – The standards used to support those data interactions, and the specific ways those standards are to be used, should be integrated with the use cases as interoperability profiles.

11. Software Engineering Principles of Interoperability No Clear Distinction Between Systems and Systems of Systems Interoperability Problems Domain Independent Solutions Cannot Rely on Complete Information No One-Time Solution Is Possible – Incremental Development is needed. Networks of Interoperability Demonstrate Emergent (New) Properties * Dennis B. Smith. Guiding Principles for Interoperability. Carnegie Mellon Software Engineering Institute; 2004. Available at: http://www.sei.cmu.edu/library/abstracts/ news-at-sei/eyeonintegration20042.cfm. Accessed March 27, 2011.http://www.sei.cmu.edu/library/abstracts/ news-at-sei/eyeonintegration20042.cfm

12. US National Institutes of Health Integration Principles Loosely Coupled Interfaces Publish Integration Points Platform Independent, Open Standards Reusable, Shared Services Integration Change Management Minimize Application Impact * NIH Enterprise Architecture - Integration Principles. 2004. Available at: http://enterprisearchitecture.nih.gov/ArchLib/AT/IA/Integration/IntegrationPrinciples. htm. Accessed March 27, 2011.. http://enterprisearchitecture.nih.gov/ArchLib/AT/IA/Integration/IntegrationPrinciples

13. Political, Social, Policy Barriers to Interoperability in Canada Political – distributed control and funding mechanisms Social – distributing knowledge promotes equality and erodes boundaries Policy – – diverse policies set at province level – financial incentives can limit information sharing – expectations change faster than policies * Juzwishin DWM. Political, policy and social barriers to health system interoperability: emerging opportunities of Web 2.0 and 3.0. Healthc Manage Forum. 2009;22(4):6-16.

14. European Commission ICT Standards in the Health Sector Political barriers: Different national and regional health system standardisation approaches. Standards Development Organisations (SDO) barriers:...hindered by competition between different SDOs. Company barriers: ICT firms seek positive returns,...conflicting standards can be good for business of companies. ICT user barriers:...expensive to identify the best standards, convert existing data. * The European e-Business Market Watch - Studies. Available at: http://www.ebusiness-watch.org/studies/special_topics/2007/eHealthStandards.htm. Accessed March 28, 2011. http://www.ebusiness-watch.org/studies/special_topics/2007/eHealthStandards.htm

15. Syntax, semantics, and…?