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According to Healthcare Information and Management Systems Society (HIMSS), a not for profit organization focused on improving Healthcare through the use of Information Technology, “interoperability is the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. Data exchange schema and standards should permit data to be shared across clinicians, lab, hospital, pharmacy, and patient regardless of the application or application vendor. Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the health status of, and the effective delivery of healthcare for individuals and communities”.
Interoperability in Healthcare Information Systems is important for delivering quality healthcare and reducing healthcare costs. Although achieving interoperability is quite a challenge both because there are competing standards and clinical information itself is very complex, there have been a number of successful industry initiatives such as Integrating the Healthcare Enterprise (IHE) Profiles, and the epSOS initiative for sharing Electronic Health Records and ePrescriptions in Europe.
There are three levels of health information technology interoperability: 1) Foundational; 2) Structural; and 3) Semantic.
We shall try to define these terms in simple words in order for the reader to be able to understand not only the differences between them, but also to understand the complexity that lies in Healthcare Information Systems.
Technical Interoperability is usually associated with hardware/software components, systems and platforms that enable machine-to-machine communication to take place. In this kind of interoperability we are mostly interested in communication protocols and the infrastructure needed for those protocols to operate and not about the interpretation of data moved from on system to another.
Structural – or syntactical – Interoperability is usually associated with data formats. Certainly, the messages transferred by communication protocols need to have a well-defined syntax and encoding. This way it is ensured that data exchanges between information technology systems can be interpreted at the data field level.
Semantic Interoperability is usually associated with the meaning of content and concerns the human rather than machine interpretation of the content. We are talking about interoperability at the highest level, the ability of computer systems to transmit data with clear, shared meaning. Thus, interoperability on this level means that there is a common understanding between people of the meaning of the information being exchanged.
Most widely used contemporary Interoperability standards in Healthcare
In Europe, Technical committee 251 (TC 251) of the European Committee for Standardization, holds the responsibility for the standardization of Healthcare IT messages. The goal is to achieve compatibility and interoperability between independent systems and to enable modularity in Electronic Health Record systems. Various workgroups establish requirements for health information structure in order to support clinical and administrative procedures, technical methods to support interoperable systems. In addition they establish requirements regarding safety, security and quality.
In the United States HL7 committee is a not-for-profit, ANSI-accredited standards developing organization dedicated to providing a comprehensive framework and related standards for the exchange, integration, sharing, and retrieval of electronic health information. HL7’s 2,300+ members include approximately 500 corporate members who represent more than 90% of the information systems vendors serving healthcare.
In parallel with HL7, the ACR-NEMA committee established the DICOM standard (Digital Communications in Medicine) that is today the most widespread standard for the format of the pictures that medical equipments produce. DICOM enables the transfer of medical images in a multi-vendor environment and facilitates the development and expansion of picture archiving and communication systems. DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving system (PACS). The different devices come with DICOM conformance statements which clearly state which DICOM classes they support.
During the last years an initiative is in progress from IHE (Integrating the Healthcare Enterprise) in order to “improve the way computer systems in healthcare share information. IHE promotes the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. Systems developed in accordance with IHE communicate with one another better, are easier to implement, and enable care providers to use information more effectively”. Systems that adopt the IHE Integration profiles collaborate in a more standard way, are easier to be implemented and help Healthcare providers to use information more efficient with the aim of providing better care.
IHE facilitates users and developers of healthcare information technology to come together through an annually recurring four-step process:
- Clinical and technical experts define critical needs for information sharing (use cases).
- Technical experts create detailed specifications for communication among systems to address these use cases, selecting and optimizing established standards.
- Industry implements these specifications called IHE Profiles in HIT systems.
- IHE tests vendors’ systems at carefully planned and supervised events called “Connectathons”.
All IHE Profiles are publicly available and free of charge in IHE’s website. Until today more than a hundred companies are accredited by IHE having materialized at least one profile.
The IHE Process
The existence of so many standards creates challenges difficult to address. Their usage is not always well known, interoperability between applications using different standards is often not documented and some of them conflict. The market for interoperability standards is maturing, even though slowly. The third version of the HL7 standard is progressively being adopted by the health industry, and convergence with Europe’s CEN/TC 251 standardization work is under way. The IHE initiative is producing useful use cases that standardize communication between various health information system components.
In the future, the World Health Organization’s eHealth Standardization Coordination Group can also be expected to play a more prominent role in developing ICT standards for the health sector.
EPSOS (European Patients Smart Open Services)
A very interesting and ambitious EU initiative that falls under the Interoperability domain is epSOS. The project “aims to design, build and evaluate a service infrastructure that demonstrates cross-border interoperability between electronic health record systems in Europe”.
EpSOS attempts to offer seamless healthcare to European citizens. Key goals are to improve the quality and safety of healthcare for citizens when travelling to another European country. Moreover, one other goal is the development of a practical eHealth framework and ICT infrastructure that enables secure access to patient health information among different European healthcare systems. epSOS can make a significant contribution to patient safety by reducing the frequency of medical errors and by providing quick access to documentation as well as by increasing accessibility of one’s prescribed medicine also abroad. In emergency situations, this documentationprovides the medical personnel with information and reduces the repetition of diagnostic procedures. epSOS aims at building and evaluating a service infrastructure demonstrating cross-border interoperability between Electronic Health Record Systems in Europe. Sometimes called a large-scale European implementation, epSOS is driven forward by many European member states, the first European eHealth project gathering such a large number of countries in practical cooperation.
Interoperability in Greece Healthcare Informatics
In the next pages, we will try to investigate the introduction of Interoperability in ICT systems in the Greek Health sector.
Until the dawn of the century in the Healthcare IT arena in Greece, emphasis was given in Enterprises Resources Planning (ERP) applications with the aim to better monitor financial data and streamline supply chain planning. The biggest from the Public Sector hospitals have incorporated some Information systems in this area, that were manufactured by “E government for Social Security” (IDIKA), a government organization with the mission to supply IT applications in Hospitals and Social Security organizations. Private hospitals were more advanced and the biggest of them have started implementing more integrated systems, some of them international, like YGEIA hospital or MITERA obstetric clinic that implemented SAP ERP. These applications were built in a monolithic way, and the various modules were tightly connected together. Hospital Information Systems (HIS) and Laboratory Information Systems (LIS) were in their infancy and each Healthcare provider was acting as a silo. Hence the need for Interoperability was not considered crucial.
The need for interoperability among the disparate systems within a hospital and among the hospitals of the same region was firstly introduced as a need in the Integrated Information Systems projects that were carried out in the Healthcare Regions and were funded by the Operational Programme “Information Society” of the 3rd CSF. The design of these projects started in 2001 and the first one was tendered in 2003. The purpose of those projects was the infusion of IT technology in the management of the Healthcare organizations, in order to support the changes in the organization of the Healthcare System in Greece – that was moving towards regionalization – and the upgrade of the services towards patients.
In these projects the need for Interoperability was expressed in the following four aspects:
- Interoperability within a hospital with applications and systems already in place.
- Interoperability among the sub systems that would be provided in the scope of the tenders for each hospital, wherever necessary (ERP, HIS, LIS etc)
- Interoperability with future systems, which were not part of the projects, like RIS and PACS.
- Interoperability among the different regional Health Authorities and Ministry of Health systems (mostly future ones) like Blood Bank, the National Center for Emergency Help (ΕΚΑΒ) etc.
The standard that was selected in order to ensure a common messaging standard was HL7 ver 2.x.
All these projects finally materialized after several years of delays, with different level of success between Regions but also between hospitals inside the same region. The reasons for the rather poor results in interoperability are many and we will try to illustrate the main barriers. At this point we should note that there is official data in the form of a study of the current status of interoperability in Healthcare.
- Poor technical specifications for the interoperability aimed to be achieved. The standard (HL7) selected was adequate and mature, but detailed specifications were missing.
- There were no national codifications that could facilitate the set up of the systems
- The institutional framework was not clear and the obligations derived were not documented
- The maturity and openness of the solutions that were implemented varied a lot
- The applications in place could not interoperate through HL7, so this aspect could not be accomplished
- There was no strategy and specifications for the national EHR for the implementations to be benchmarked against.
As a conclusion someone could say that despite that results were not as expected, it was the first time that interoperability in Healthcare was ever mentioned and required as a mandate. Several use cases were implemented and a step towards openness has been achieved. Many lessons were learned and the evolution of HC ICT will definitely incorporate Interoperability as an integral part.
In recent years interoperable eHealth in Europe or even on an international scale is a fact. The European Commission is supporting collaboration initiatives through its policy initiatives and funding instruments and the World Health Organization (WHO) is promoting worldwide eHealth through its Global Observatory for eHealth.
 HIMSS, Definition of Interoperability. Approved by the HIMSS Board of Directors, April 5, 2013
 American College of Radiology (ACR), National Electrical manufacturers Association (NEMA).
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