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Thursday, October 29, 2015

"Interoperability? We don't need no steenkin' definition."

That's what I would say. But, consider this, from THCB:
Defining Interoperability: An Interview with Grahame Grieve
by Leonard Kish

Grahame Grieve is a long-time leader within HL7 and one of the key drivers behind FHIR. He chats with Leonard Kish about what’s been happening and what’s ahead for interoperability...

LK: There’s a lot of talk in congress about the lack of interoperability and everyone probably has their own definition. Do you have a working definition of interoperability or is there a good definition you like for interoperability?

G: The IEEE definition to get data from one place to another and use it correctly is pretty widely used.  I guess when you’re living and breathing interoperability you’re kind of beyond asking about definitions...

It’s actually relatively easy to move data around. What you’ve got to do is consider the costs of moving it, the fragility of the solution, and whether the solution meets the user’s needs around appropriateness, availability, security, and consent.  Given the complexity of healthcare and business policy, it’s pretty hard to get a handle on those things. One thing that is key is that interoperability of data is neither here nor there in the end because if providers continue with their current work practices, the availability of data is basically irrelevant, because they treat themselves as an island. They don’t know how depend on each other...

I think of standards as a precondition. If they can exchange data correctly then they can start asking themselves whether they want to.  Whereas if they can’t exchange data correctly and usefully then they don’t even get to ask the questions.  So standards is just a precondition to asking “How do we have patient focused care without having to build specific institutions around a particular process?”...

LK: Can you tell us a little bit about how SMART On FHIR enhances FHIR and are there going to be other things on FHIR as we go forward with different enabling bodies working together?

G: FHIR is a base API for all sorts of usages.  One of the most common usages is going to be exchanging healthcare information between EHR’s and within an EHR in its internal extensibility environment.  And that’s where SMART On FHIR fits in and provides a really neat solution for what EHR’s need to do.  So personally I think most data exchange using FHIR will use SMART on FHIR because the driving need is in the EHR space.  And I think Smart On FHIR is a great extension to FHIR around that. I think there’ll be other extensions that are more in the corporate backbone space and more knowledge-based service, things that are not so user specific. Those aren’t formed yet and SMART On FHIR is the one we’re throwing all our weight behind because it meets the immediate needs...
"when you’re living and breathing interoperability you’re kind of beyond asking about definitions."

I must have missed that day in science class. BTW: I've had my say about APIs, and HL7/FHIR, e.g., here, here, and here.

Let's recall the IEEE definition:
interoperability: Ability of a system or a product to work with other systems or products without special effort on the part of the customer. Interoperability is made possible by the implementation of standards.
"without special effort on the part of the customer."

It looks to me like we're going to "define interoperability down" by eliminating (at least implicitly) that clause of the IEEE definition.

Look at ONC's take:
Defining the Difference between Health Information Exchange and Interoperability
Because exchange is a prerequisite for interoperability, here at ONC we’ve focused a lot of attention on it...

But we must always remember that exchange is only part of the puzzle. If I send an email from one computer to another computer, I have exchanged information between those two systems. But if I write my message in French, (and you can only speak English), there is no way for you to automatically use the information that has been exchanged without risking losing something in translation...I may have exchanged information, but I won’t be able to seamlessly use the information in the new system to alert the provider automatically of a new drug allergy, for example. So to get to health information interoperability, we need more than just transport standards:  we must also use standards for vocabularies and terminologies (to help standardize the meaning of the words that we use), standards for structure (so computers know how to break a message into the appropriate information chunks), and potentially other kinds of standards...
I had run at the "French-to-English" thing back during November 2013 while covering the NYeC Conference in NYC.

I have some lingering Interop questions. One goes to the humorous phrase proffered by one of the presenters:

"Smiling Almighty Jesus."

The point was miscommunication resulting from information garble over time between people. The above refers to a dx of "Spinal meningitis," which the elderly fictional patient in the slide got wrong. As it goes to HIE, this aligns with my chronic rant about a data dictionary standard. As I have observed by way of analogy:
True interoperability requires a comprehensive data dictionary standard. Without it, information can become “garbled.” That is, altered during sequential transmissions. For example, what if you took these sentences and ran them through Google Translate from one language to another — say, [1] from English to Spanish, [2] then from Spanish to French, [3] then from French to German, [4] then from German to Greek, [5] then from Greek to Swedish, [6] then from Swedish to Portuguese, and [7] then back to English?
  1. Verdadero interoperabilidad requiere un amplio diccionario de datos estándar. Sin ella, la información puede llegar a ser "confusa". Esto es, alterado durante las transmisiones secuenciales. Por ejemplo, ¿qué pasa si usted tomó estas frases y las pasó por Google traducir de un idioma a otro - por ejemplo, del Inglés al Español, a continuación, del español al francés, después del francés al alemán, después del alemán al griego, luego del griego al sueco, luego del sueco al portugués, y luego de nuevo a Inglés?
  2. Véritable interopérabilité requiert une vaste série de dictionnaire de données. Sans elle, l'information peut devenir "confus". C'est, séquentielle modifié pendant la transmission. Par exemple, si vous avez pris ces mots et a traversé Google traduire d'une langue à l'autre - par exemple, de l'anglais à l'espagnol, puis l'espagnol vers le français, puis du français en allemand, puis de l'allemand vers grec , puis du grec au Suédois Suédois Portugais après, puis revenir à l’anglais?
  3. Echte Interoperabilität erfordert eine breite Palette von Data-Dictionary. Ohne sie können die Informationen zu "verwirrt". Dies wird sequenziell während der Übertragung verändert. Zum Beispiel, wenn Sie mir das Wort und ging durch Google übersetzen von einer Sprache in die andere - zum Beispiel aus dem Englischen ins Spanische und Spanisch in Französisch und von Französisch ins Deutsche und Deutsch auf Griechisch, dann aus dem Griechischen ins Schwedisch Portugiesisch nach dann wieder auf Englisch?
  4. True διαλειτουργικότητα απαιτεί ένα ευρύ φάσμα του λεξικού δεδομένων. Χωρίς αυτά τα στοιχεία για να "σύγχυση". Αυτό είναι διαδοχικά αλλαχτούν κατά τη μεταφορά. Για παράδειγμα, αν η λέξη και μου περπάτησε μέσα από το Google μετάφραση από τη μία γλώσσα στην άλλη - για παράδειγμα, από τα αγγλικά στα ισπανικά και ισπανικά στα γαλλικά και από Γαλλικά σε Γερμανικά και Γερμανικά σε Ελληνικά, στη συνέχεια, από τα ελληνικά στα Σουηδικά Πορτογαλικά σε συνέχεια πίσω στα Αγγλικά;
  5. Verklig driftskompatibilitet kräver ett brett spektrum av data dictionary. Utan denna information till "förvirring." Detta successivt förändras under transporten. Till exempel, om ordet och promenerade mig genom Google översättning från ett språk till ett annat - till exempel från engelska till spanska och spanska till franska och från franska till tyska och tyska till grekiska, sedan från grekiska till Svenska Portugisiska in sedan tillbaka till engelska?
  6. Plena interoperabilidade exige uma ampla gama de dicionário de dados. Sem esta informação a "confusão". Isso mudou gradualmente em trânsito. Por exemplo, se a palavra e me atravessou tradução do Google a partir de uma língua para outra - por exemplo, de Inglês para Espanhol e Espanhol para Francês e de Francês para Alemão e Alemão para o grego, depois do grego para o Português Sueco em seguida, de volta para Inglês?
  7. Full interoperability requires a broad range of data dictionary. Without this information to "confusion." This gradually changed in transit. For example, if the word and I went through Google translation from one language to another - for example, from English to Spanish and Spanish to French and from French to German and German to Greek, then from Greek to Portuguese Swedish in then back to English?

Pull up Google Translate, try it yourself. Pick additional languages. The results can often be quite amusing.

Senate HELP Committee Chairman Lamar Alexander (R-TN) is running around with his hair on fire these days advocating a delay in implementing Meaningful Use Stage 3 -- the core of his gripe being the lack of progress on "interoperability."

Had we required "Type-O" EHR data at (or close on the heels of) the MU outset, this might by now be a relatively minor issue.

I reflect back a decade to when I first came to Health IT, during the "DOQ-IT" era. HIE/Interop were not even on the radar, but intra-clinic HIT "integration" vs "interfacing" was a hot topic, given that "Practice Management Systems" (PMS) were already fairly common -- Front Office/Back Office apps used for scheduling and patient demographics input and management and claims billing. Given that a lot of clinics had substantial sunk costs in their PMS software, a thriving coding industry arose via which to build and install PMS-to-EMR "mid-office interfaces," in lieu of expensively migrating to fully integrated Front/Mid/Back Office EHRs that are pretty much the norm nowadays (at least in the ambulatory settings). Interface deployments back then comprised a constant source of tech support firefighting.

One can only hope that history will not repeat itself on the interop front. I continue to have my concerns.

Speaking of MU Stage 3 news,
I'm incredibly disappointed we even have a Stage 3. It's just a mistake. It's just prolonging the program. We should have claimed victory, frankly after Stage 1, but clearly after Stage 2, and stopped the program. There's no real additional benefit.
- Former ONC Health IT Policy Committee member, Intermountain Healthcare CIO Marc Probst

The release of the Stage 3 Final Rule broke while I was down in Santa Clara covering Health 2.0 2015. All the "real" press dudes were buzzing about it. I didn't even bother looking into it. I'll get around to the PDF eventually, but, it's a relatively low priority.

More to come...

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