INTEROPERABILITY

#FHIR Important Concepts, Terms and Definitions by Manish Sharma, @msharmas

FHIR is the latest interoperability standard based on a RESTful API architecture published by HL7. HL7 has been working for over 25 years in publishing standards for Healthcare data interoperability. The move from the earlier HL7’s 2.x standards evolved to the Development of the RIM v3 and then to FHIR, has now allowed a paradigm shift to leverage web standards. The purpose of this article is to get the reader to understand the difference between the earlier versions of HL7 interoperability standards and then present the important concepts that will help you to understand FHIR concepts, terms and definitions.

Health Systems for a New India: eObjects Building Blocks by Dr. Pankaj Gupta, @pankajguptadr

Dr Pankaj Gupta

Here is a sequence of events over the last 8-10 years that lead to the eObjects. India has been majorly a paper-based Healthcare System. However, there have been pockets of success in transforming paper-based processes to electronic systems.

Making HL7 #FHIR work for India by Kumar Satyam, @kr_satyam

Kumar Satyam FHIR for INDIA

“Can I see your blood test reports from last month” – the doctor asked me. “I have it on my mobile” – I told him. I showed him the pdf report the lab had mail me on my email id. “Do you have earlier reports?”– he asked. I started searching my mailbox for previous reports but was unable to locate them. I asked him “Sir, if I give you my hospital Id, can you fetch it from your system. some tests were done in another branch of your hospital”.

The National Collaborative Initiative for Interoperability By Aniruddha Nene, NCII

NCII

Current Status in India

Indian healthcare informatics is at the point of inflection,with the government finally taking firm steps, towards becoming an active regulator and payor. The policy maker is finally in the process of becoming a facilitator for collaborative efforts for this massive exercise.

Immersive #HealthTech Ecosystem Showcase in “The Pavilion of the Future” during CAHOTECH 2019 by Manick Rajendran, @manicknj

Not only did the work involve a creative attitude, it involved the dedication of sharp minded attention to detail mindset. It was back-breaking work rising up to a crescendo of sleepless nights towards the finish line during CAHOTECH2019

How Healthcare is becoming B2C with the help of Interoperability by Ritika Jain @ritikajain192 and Vakku Chethalan

I joined the interoperability team at Philips Healthcare in my senior year of college. At that point of time, with a novice approach to software engineering and a look at real world problems with my rose-tinted glasses, interoperability seemed a bit dull. Until, one day I fell off the stairs and had to go through X-rays and six weeks of physiotherapy on my way to recovery. This is when I had a first-hand glance at hospital operations.

What does the Health Stack mean for you? Part 3 by Anukriti Chaudhari, @anukritichaudh2

The National Health Stack is a set of foundational building blocks which will be built as shared digital infrastructure, usable by both public sector and private sector players. In our third post on the Health Stack (the first two can be found here and here), we explain how it can be leveraged to build solutions that benefit different stakeholders in the ecosystem.   Healthcare Providers

India’s Health Leapfrog – Towards A Holistic Healthcare Ecosystem Part 1 by Anukriti Chaudhari @AnukritiChaudh2 – @Product_Nation

The leapfrog we envision is that of public, precision healthcare. This means that not only would every citizen have access to affordable healthcare, but the care delivered would be holistic (as opposed to symptomatic) and preventive (and not just curative) in nature.

Benefits of an Integrated Health Information Platform #IHIP by @msharmas

We have seen the benefits of Aadhar and how a public data repository can be used for public good. Population Health based clinical data repositories too can play a similar pivotal role in providing potentially great benefits


The use of Healthcare IT in the Indian context is picking up with most of the corporate hospitals going for the #EHRs and HIMS solutions. And these are present mostly in the Tier I cities and urban areas. There is a move now to get these solutions to the Tier 2 and Tier 3 centers as well. I would be looking to review reports that highlight percentage of IT enablement in Healthcare facilities, as part of follow up articles to this one.

The Center for Healthcare Informatics has rolled out an RFI detailing the requirements of an Integrated Healthcare Information Platform (IHIP). You can also visit the dedicated website to review the details of the IHIP RFI:
In this article I would like to highlight the benefits that will accrue from implementing such a solution in India. With no historic data of past implementations of such a system in India, I have reviewed the information available in journals and public domain regarding similar implementations across the world and what are the benefits and barriers in implementing an Healthcare Information Highway of patient healthcare data.



Benefits of Implementing an HIE

  1. Benefits of Implementing HIEs:
HIEs that have been implemented in the US have conclusively shown emergency departments gaining efficiency in patient visits with the use of HIE based solutions.
HIEs have shown to reduce the length of patient stay, readmission risk, and number of doctors involved in patient visits [1].
HLNY ER Dept Infographic_HIEGains.png
  1. Discharge Planning
One of the examples of benefits of an HIE, is the ability to generate alerts 24-hour to 48-hour prior to the patient’s’ discharge to Transportation services, Pharmacies at the patient’s location and alerts to help patient identify long term care and home care facilities. [2]
  1. Transfer of Radiology Images:
Currently the process of exchanging patient radiology images either does not exist or at best is time consuming with problems faced by the patients and providers treating the patients.
The ability to access and view radiology images is important for an accurate and timely patient diagnosis and treatment. Historically, the process of image exchange has happened via CDs with an understanding the receiving and reviewing physician will have the ability to view the PACS images leading to high costs and long time to diagnosis.
Enabling a Transfer to PACS capability helped in cutting these lacunae in the image sharing workflow, enabling providers to quickly share images with each other. [3]
  1. Vaccination and Immunisation details:
HIEs are now moving towards incorporating the exchange of patient immunisation details. Thereby enabling patient centered technology implementations.
  1. Disease Surveillance and Immunisation Records
IHIP will provide increased view of disease outbreaks and allow the governments at the state and national levels to deploy resources effectively and efficiently. IHIP based identification and surveillance of disasters and outbreaks is a big benefit of implementing a platform such as IHIP. And additional areas that provide a fillip to the IHIP-initiative needs to be identified and those aspects of the IHIP needs to be implemented in the initial stages.
  1. Medication Information Sharing via HIEs:
The ability for the patient to build and maintain an electronic Drug Profile is important for the continued care for the patient. Presence of a Comprehensive Patient Drug profile has direct correlation to improved patient safety. Improved medication information processing has a direct correlation to the benefits of an HIE like the IHIP since it will be able to provide a more complete clinical picture of the patient. [4]
  1. Telemedicine service enabled by HIEs:
Telemonitors will be able to provide patients a way to measure and record their vital signs daily from home using a touchscreen tablet/ mobile/ PC. The information will be then wirelessly transmitted to nurses monitoring the information for changes, giving patients with, complex disease states such as heart and respiratory conditions, a sense of empowerment around their health. Telehealth has far reaching benefits for specialists providing their services to patients in the rural, underserved and non-tier I cities. With the presence of digital payment gateways and transactions, Telemedicine is fast becoming a viable business model for certain types of visits(e.g., follow-ups, referrals). [5]
  1. New Use Cases for an HIE:
When HIEs have been implemented, new use cases can emerge that extend the usefulness of HIEs. For example, HIEs have been able to send hospitals alerts and reminders when patient transitions occur, device to device data transport, sending and receiving of claims attachments, and exchanges of documents for referrals [6]
  1. Security of Patient Information (PHI):
The greatest benefit of an IHIP-like solution is the Implementations of Security protocols for transport and transfer of patient information between healthcare facilities and between patients and hospitals. This ensures creation of “Trust” centers of patient data.
  1. Improves the Trust in sources of information
One of the reasons a physician would order for a repeat test for a patient in case of a referral, would be “Trust” on the presence of a similar/ same test result available for the patient in an earlier visit. Enabling information sharing via IHIP in a standardised and secure format will enable “Trust” between healthcare facilities as trusted sources of information. [7]
  1. Strategies to avoid Information Blocking:
Information Blocking has been known to be a major cause of hindrance to the benefits brought out by an HIE. Information Blocking is healthcare facilities not sharing patient healthcare record information causing holes in the episodes of care of a patient’s longitudinal record. To avoid this from happening, “Increasing transparency of EHR vendor business practices and product performance, stronger financial incentives for providers to share information, and making information blocking illegal were perceived as the most effective policy remedies,” wrote researchers. [8]
  1. Paradigm Shift in HIE from 1.0 to 2.0:
HIE 1.0 was characterized by a focus on “the noun,” that is trying to address perceived market failures by solving a wide variety of rich use cases through comprehensive interoperability.
By contrast, HIE 2.0 focuses on the verb that is trying to meet market needs most pressing to participating providers; HIE 2.0 has fewer legal challenges because it is trying to tackle less complex use cases and in many instances has the ability to marshal financial, technical and organizational resources. Tripathi also pointed out that HIE 2.0 comes in many shapes and sizes including point-to-patient; point-to-point; vendor-specific; transaction-specific national level; enterprise-level HIE organizations; State-level and regional collaborative HIE organizations and National level collaborative HIE organizations.
Three areas identified to spur innovation and move towards HIE2.0 were: Lab data transmission, Lightweight directed query of patient information, eCPOE and measures.

Problems Implementing HIE: A review of Global HIE Experiences

  1. Unspecified Interoperability Standards:
Barriers to HIE relate to incomplete and unspecific interoperability standards and the cost of interfacing the EHR with the HIE.  The lack of mature, agreed standards around interfaces, patient consent and patient identification are significant barriers to success.
  1. Accurate patient identification is not only a data management and data quality issue, it’s also a patient safety issue
  2. Clinical Information Generator and Vendor relations
In the India context, healthcare facilities like hospitals, laboratories, pharmacies deploy systems that are proprietary in nature and not necessarily standards based. In the event of strained relations between healthcare facilities and respective vendors, there is a need to consider addressing the need to have the patient related information to be relayed to the patient in a HIE readeable format. This information can then be uploaded by the patient thereby ensuring the continuity of care records are maintained in the IHIP, specific to the patient.
In this scenario, there could be a loss of updates to the public health based registries and the hospital based registries and it should be incumbant on the hospital to ensure the data is transmitted before the changeover of systems happens.
  1. Identifying ROI for various Stakeholders
A study needs to be enabled by the government at the national and state levels that will study the benefits of implementing interfaces that will share information between the Healthcare facilities and the IHIP. Potential savings can be quantified based on cost and projected savings in improved efficiencies enabled by the implementation IHIP towards patient safety and care coordination for the stakeholders.
Additionally, its important to quantify the cost of implementing HIE-based interfaces by the various healthcare entities (like Hospitals, Laboratories, Diagnostic centers, pharmacies, etc). It will be important to identify the Revenue Streams to sustain IHIP data sharing, and how can it be sustained by the stakeholders.
  1. Breach of Security of Data contained in IHIP or connected interfaces
We have seen various types of hacks that have breached the security of patient records stored in hospital systems. Enabling security at various levels needs to be ensured before any of the Stakeholders connect with the IHIP. Security guidelines will have to be defined and adhered to and reported on a regular basis as a regulatory requirement.
Security is also necessary at the IHIP level which has been defined as a main requirement for developing the IHIP infrastructure.
In the US Architecturally, RHIOs employ either the CHMIS approach of a centralized database, the CHIN model of federated independent databases, or some combination of the two, hybrid model.
  1. Usability & Access to Information Ok, so the data about a patient has been stored in the Data Repository for all to access and review at the time of emergencies, for enabling a continuity of care record for the patient and for generating population health management analysis. But, what if the data is not easily accessible, the functionality to access the care information of the patient, requires multiple access requests and clicks and permissions. What if, the data has now been stored in the public data repository, who can access it? Who can view it? Can there be an unauthorised data access by persons not connected to the health care of the patient? [25]
  2. Information Blocking:
For-profit EHR vendors have a natural vested interest in increasing revenue by limiting the flow of data.
“The specific forms of and perceived motivations for information blocking were harder to predict a priori,” Adler-Milstein & Pfeifer explain. “What we found in relation to specific forms is that EHR vendors appear to most often engage in information-blocking behaviors that directly maximize short-term revenue. Our respondents reported that EHR vendors deploy products with limited interoperability and charge providers high fees unrelated to the actual cost to deliver those capabilities or refuse to support information exchange with specific EHRs and HIEs.”
Hospitals and health systems likewise utilize information blocking as a means to prevent clients from seeking services elsewhere to keep from losing out to the competition.
“In our results, the most commonly reported forms of information blocking among hospitals and health systems point to their interest in strengthening their competitive position in the market by controlling patient flow, which has been reported in other studies,” they wrote.

Interoperability in Healthcare: Some thoughts to share

Having followed the implementations in India for sometime now, I always wonder why interoperability is not a top priority or not implemented in most systems. They are HL7 compliant, but are they really interoperable? And I dont mean the part from HIMS to Lab or Rad equipment, that part is fairly well defined and documented. 

– But from the Patient to Hospital to Patient
– Patient to Insurance to Patient
– Patient to app to hospital to Patient

Take for instance most systems are able to share the discharge summaries as emails to patients, and a print out, even today. But on discharge can the patient “share” her discharge summary from an app or application to another practitioner who takes care of the patient rehab? Are for instance, the systems involved in the above use case, interoperable? 

Another point, how many Healthcare Apps (the production versions) have any data sharing via standards? They can however email PDFs of the recorded data. So what can be done to enable out-of-the-box interoperability in the Healthcare Apps? With the growing number of mHealth Apps, we will soon find ourselves in another new set of “Data-Silos” being created on a daily basis.

Recently we moved from Cash to Cashless to Less Cash scenarios … so is it right to say, in healthcare context, we are working from a Paper to Paperless to Less Paper scenario in Healthcare before going totally paperless? 

And if so: 

1. What will be the business case for interoperability and for sharing the discharge summary/ medications in a format that is easily exchangeable?

2. Can a Healthcare IT think tank, work on defining the standards of “workflow” of the data being generated in healthcare today? Starting from the Patient through the healthcare ecosystem and back to the Patient?


3. Can the Healthcare IT vendors form a group of HIMS, LIMS, Pharma Apps, HomeCare solutions that enable a “Patient Data Workflow” exchange group (a mini-IHIP) that actually enables the “Interoperability” of patient data as a great showcase. It could perhaps be tied to the IHIP effort or NDHA. It adds onto the work that is being planned in the Phase 1 of the IHIP project, by being able to provide feedback on issues, solutions, recommendations, pain points etc.

Its important to note, that a system like IHIP has a potential to solve the accessibility of patient care problem in India. My view is that there is a need to see interoperability from a Patient’s point of view rather than from the point of view of “Systems”. There is a need to map the flow of data from the Patient and back to the Patient, and this can help in enabling a radically different approach to interoperability in Indian Healthcare.

With Aadhar based solutions allowing for the consumer information to be securely transmitted and verified, it only behoves well if we were to adopt an “HIE of Patient” approach to IHIP wherein the Information is exchanged between various stakeholders in the Patient’s Care Continuum and that information finally rests with the Patient’s Electronic Health Record (PEHR). With the EHR standards mandating the Healthcare Information belongs to the patient, it will be extending that mandate to IHIP.

And here is a review by Mr. Rajendra Pratap Gupta, Policy Maker, Researcher, Author, TED Speaker, Economic & Political Strategies, Innovation, Healthcare) on how “India aims to be a Global Leader in Digital Health,

https://www.linkedin.com/pulse/india-aims-global-leader-digital-health-rajendra-pratap-gupta

References

  1. Cancer Care set for Digital Leap with the National Cancer Grid in India: http://health.economictimes.indiatimes.com/news/health-it/cancer-care-set-for-digital-leap/58758858
  2. NY Health Information Exchange Improves ED Quality, Efficiency
  1. HIE Partnership to improve Health Data Exchange of Imaging
  1. Health information exchange and patient safety
  1. Vermont HIE adds telehealth component
  1. DirectTrust HIE growth shows priority of Interoperability
  1. Health information exchange: persistent challenges and new strategies
  1. Health Information Exchanges report Information Blocking
  1. Maine Rural Veterans Health Access HIT Strategies
  1. The Value Of Health Care Information Exchange And Interoperability (a must read paper on how the costing for HIEs can be done)
  1. Health information exchange: persistent challenges and new strategies
  1. Information Blocking: Is It Occurring and What Policy Strategies Can Address It?:
  1. What is HIE?:
  1. Health Information Exchange?:
  1. HIE Benefits?:
  1. Guide to Evaluating Health Information Exchange Projects
  1. HIMSS Library for Information on HIEs
  1. Health Information Exchange – Overview
  1. 10 things to know about health information exchanges
  1. Selecting & Using a Health Information Exchange | AMA
  1. The Sequoia Project eHealth Exchange
  1. What is Health Information Exchange? | HIMSS
  1. IHIP, India
  1. Are Data repositories set to become data dumps? https://www.digitalhealth.net/2017/04/another-view-neil-paul-21/
  2. Powering the Patient Relationship with Blockchains: https://www.healthit.gov/sites/default/files/7-29-poweringthephysician-patientrelationshipwithblockchainhealthit.pdf
  3. Lessons from the UK | Healthcare IT News

 

Author
Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

Why Do We Want #Interoperability? by @Matt_R_Fisher

Interoperability, to a large degree, comes down to having a fully unified healthcare system where data is always available


A lot of time and attention has been put into the notion of interoperability by almost every stakeholder in the healthcare system. Those interested in the issue include patients, providers, vendors and the government. Why has interoperability received so much focus, though? It may be possible to answer that question by stating that interoperability contains a large element of the common good.


Defining interoperability can be challenging, but a definition adopted by HIMSS in 2013 offers a good, comprehensive version: “the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.” Putting that into even plainer English, interoperability is the movement of data as expected and without hindrance. Ultimately, that likely expresses the expectation of many, individuals want data to be where it needs to be without a hassle.

Depending upon an individual’s role within the healthcare system, that individual may have a different perception as to the importance of interoperability. Patients want data moving without thought because patients expect seamless transitions in care. If a patient is traveling or goes from one provider to another, the medical data should be there. Other industries have mastered the ability to allow data to move around, but healthcare is still working on that issue. As such, the patient viewpoint on interoperability is that it should just exist.

Providers, much like patients, likely want to have all information about a patient available. For example, if a medication has been administered in one setting and a patient presents elsewhere, the subsequent provider wants and needs to know what has already been done in order to avoid a very easily preventable error. Additionally, providers want to know a patient’s full history, which may be more easily obtained from previous records than from the patient. The provider viewpoint on interoperability is that it forms a basis for good care and ensuring all data is available.

Electronic medical record and other HealthIT vendors may see interoperability as either a product challenge or potentially an impact on business. Clearly, the healthcare industry relies on vendors of products to build those products in a manner that permit interoperability. All the wishes for interoperability will go for naught if the tools being used are not set up to support it. That being said, are the right incentives in place? That question may be a bit unfair to the vendors because, optimistically, vendors are not necessarily trying to create public harms. Accordingly, the vendor viewpoint on interoperability may be a bit muddled, but at the end of the day should be favorable.

Given those potential viewpoints on interoperability, why is it so important? Interoperability is considered an essential element to succeeding with value-based care and/or population health, the government is turning its attention to the matter, and increasing patient demand. From the industry perspective, the value-based care and population health reasons are likely the most compelling drivers for wanting interoperability. 

Value-based care forms the basis for many alternative payment models, which is where the healthcare industry is quickly heading. If the right data are not available to understand how a provider is performing, then the likelihood of success decreases and in turn puts financial pressure on the provider. The government is also related to the push toward alternative payment models. 

The government, specifically the federal government through Medicare, is causing a seismic shift in the reimbursement system. The government wants these efforts to work, which means that all tools must be aligned. Rumblings have suggested that if interoperability is a problem, then the government may force the outcome it wants.

Ultimately, interoperability, to a large degree, comes down to having a fully unified healthcare system where data is always available. Thinking of the banking industry, this is true of account information because an individual can readily access it through an online account or at an ATM, for example, and then be able to access that money from almost everywhere too. Similar examples can readily be pulled from numerous other industries. The question continually comes back to why should healthcare be any different.

As suggested above, solving the interoperability conundrum comes down to a common good. Arguably everyone wants patients to be able to receive the best care possible. That means having data available and on hand.

Hopefully, this post results in an open dialogue about the issue of interoperability. I will be presenting at VITL Summit 16 on this same topic and welcome comments and thoughts that I can incorporate into my presentation. Please post in the comment section, email me, or engage on Twitter. If we can all focus on the issue and begin to reach a consensus understanding, that would be a good outcome.

Author
Matthew Fisher

I am the Chair of the Health Law Group and an associate with Mirick O’Connell. I am also a member of the firm’s Business Group. I focus my practice on health law and all areas of corporate transactions. My health law practice includes advising clients with regulatory, fraud, abuse, and compliance issues. With regard to regulatory matters, I advise clients to ensure that contracts, agreements and other business arrangements meet both federal and state statutory and regulatory requirements.

#Interoperability the Missing Link for #DigitalHealth Apps by @msharmas


In India we have 204.1 million smartphone users in 2016 [ http://www.statista.com/statistics/467163/forecast-of-smartphone-users-in-india/ ], it’s only natural to find startups using the mobile as the way to acquire customers by providing mobile Health based products and services.

While it is a great way to provide accessibility and affordability of healthcare services via mobile health solutions, it is also important to understand the need to ensure interoperability of the healthcare data being captured in these apps.


Today we have apps for Diabetes Management, Appointments Scheduling, Continuous Monitoring, Remote monitoring, Activity monitoring linked with wearables, women and child health, cardiology, telemedicine, secure messaging apps, etc. The list in the past couple of years has really grown exponentially. And that is great, since the mobile phone has become the centerpiece device for most people.

One aspect seems to be missing in the Go-to-Market rush,
>>  INTEROPERABILITY !!

It reminds me of the scenario in healthcare regarding medical devices, which traditionally were never developed for the purpose of sharing data with other systems or outside the location they were placed. It just sufficed that they were connected to the patients and displayed the readings the doctor viewed during her rounds.

And I find the same happening with the DigitalHealth Apps.

I have been following some of the DigitalHealth Startups that have developed apps that cater to one specialty or another, and I have come across most of these mHealth apps to be trying to build in the feature-set, i.e., to be a patient’s one stop shop for healthcare related data. In doing this they are duplicating the patient health record and there is a speciality-specific personal health record in each mHealth App (just like the medical device).

Since, each of the mHealth apps’ provides a feature for the patient to upload and store their records, soon we will have more “silos of information” than ever before. Multiply that with the number of apps a single user might have on her phone for capturing one or the other healthcare related parameter, the problem compounds.

The problem of solving the interoperability of patient information will continue to be an area of concern.

Its therefore very important for the startups developing mHealth apps, to start the app development process by incorporating the Interoperability Standards in healthcare. I think this should be the first step in the app development process and in fact patients and the healthcare VCs, investors should demand the app to have the ability to generate interoperable medical records out-of-the-box. The question that one should ask before downloading and using an app should be, “Will I be able to share my medical data between apps, in a Standard and interoperable form?”

Quality & Interoperability

Just as there is no compromise on quality, there should be no compromise on interoperability

Take for instance the medical devices, no one insisted on interoperability, or the cost of enabling interoperability was perhaps higher than the cost of the machine, that no one went for it. It was perhaps thought, its OK, anyways the doctor goes on her rounds she will see the information

Similarly, today if we take a ‘share-it via app way’ out to interoperability, we will not have demanded for the “right way” of doing things, we would simply have been taking the same approach as before.

Interoperability should be a plug’n’play option and not a separate service that the vendor chooses to provide, if paid for. It should not be a “Optional”, or paid add-on.

Last i checked there were 100,000+ “medical apps” on the various app stores. How many of these are interoperable? If earlier we had to contend with medical devices that were not plug’n’play interoperable, today we have siloed data being created by mHealth apps.

Solutions to the Problem

The EHRs should have the ability to “add” apps data to the patient EHR allowing for incorporating the mHealth App Data into the patient’s longitudinal record.

The app developers should consult doctors and capture “contextual” healthcare data of the patient. The app should have the ability to share this data via the HL7 certified, interoperable document.


Additionally, when a mobile user deletes a mHealth app from her device, any data stored for the patient should automatically be sent to the patient’s registered email as a HL7 enabled document. Providing a summary and detailed medical record information of the patient. These should be downloadable into any EHR or another app. 

And there you go, its fairly simple and we look forward to you sharing your experiences with our community of readers. We appreciate you considering sharing your knowledge via The HCITExpert Blog
Team @HCITExperts [Updated: 29th May 2016]
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Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

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Workflow and Interoperability approach to National eHealth Authority (NeHA) in India

Author: Manish Sharma

24 April 2016, Bangalore, India


The Ministry of Health and Family Affairs in India recently published a Concept note on the National eHealth Authority and called for comments and feedback on the formation of NEHA, India. All comments and suggestions can be emailed to jitendra.arora@gov.in on or before 20th April 2016.

NEHA is envisioned to be, to quote from the concept note, “a promotional, regulatory and standards setting organisation to guide and support India’s journey in eHealth and consequent realisation of benefits of ICT intervention in Health Sector in an orderly way”

Workflow Optimisation

While considering the implementation of DigitalHealth Solutions in India, its is very important to understand the “Workflow” of the patients and understand the Information requirements within the Identified workflows.

Since Healthcare has always been considered to be the “last bastion” to be Digitised for many years, the approach to Digitize Healthcare Workflows has always taken the “Traditional” approach, i.e., Go to the hospital, Study their workflows, gather all the current paper being generated and Digitize IT. And hence we came up with the “Paperless Hospital” approach.

But the flaw in the paperless approach, in my opinion is the approach that caused the creation of Information silos. We Digitised the Paper, and not the workflow.

Take for instance the workflow of a Doctor in a hospital. She is inundated with information which her training is able to Streamline as a workflow, but give the doctor a system, she is faced with a daunting task of having to “feed” the system with the information, because the system is not designed to help her streamline her workflow in her specialty.

The problem in the usecase of the doctor is that we have Digitised the feeding the information part, but not the workflow of the doctor-patient relationship and by that extention the care provider-doctor-patient relationships.

There have been many recorded and unrecorded cases of HIT implementations wherein the Clinical workflows are the last to be IT-enabled and at times not even enabled, due to this very reason.

World over the learnings of other National eHealth Implementations are definitely pointing towards the absence of patient and healthcare professional workflows being digitised, leading to dissatisfaction with the current Digital Health solutions.

Suggestion 1: 

NEHA should consider “Workflow Digitisation” in a Healthcare Facility as the driving force instead of Data Generation or Data Capture. It is important to identify and define the workflows across the healthcare organisation considering each care providers role and responsibilities. And to endeavour incorporating these workflows into the HIMS of the future.

Major and Minor workflows need to be identified and incorporated within the ambit of the pragmatic workflow optimisation, to ensure the relationship model between the care providers and the patients are well documented.

The Interoperability Red-herring

Most often than not, the main premise of setting up a National Level eHealth Authority in most countries has been to provide for “Interoperability” of information between the “Silos of Information” within and outside of the hospital.

As the report points out, Lack of Interoperability leads to “Ineffective Results”. 

In the discussion about Interoperability, I would like to for the need of discussion define “Exchange of Information” to be subcategorised as two specific areas

  INTRA-operability:  between Digital Health systems within the Hospital. Most vendors are contracted with the hospital and hence there is more control for the hospital management in this particular aspect, from a solutioning point of view.

INTER-operability: between Digital Health systems within the Hospital and “External” Digital Health systems that could be government bodies, patients, Digital Health Apps, etc. 

The above sub-categorisation can help in identifying areas of information flow and help the NEHA define the standards for each of the presenting usecases.

Consider the various Digital Health solutions within a Healthcare Organisation and you will realise the presence of “Standards” that each are specific to the type of Digital Health solution

For instance, 

  • a Laboratory equipment exchanges information via the RS232 port or RJ45 port in a ASTM format. 
  • A Radiology imaging platform deals with DICOM standards. 
  • The Patient Monitoring system in the hospital is a fortress of information, “Designed” to “Lock-in” the information that is “Proprietary” to the vendor that has supplied the system.

Just take the above three scenarios, and try and get a quote from a vendor to build you a system that “Integrates” all these three data streams (or information silos) into a patient’s EHR. It will be considerable. I would guesstimate 10-20% of the cost of ownership of a enterprise Digital Health solution.

Now, lets say you have been able to take up the implementation of such an “integrated” system, it took you a good year to stabilise your system with “INTERoperable” solution. And after the year of stability, you need to start sharing all this Information with the new app that has become famous with the patients.

Lets assume, that the new app is built on a standard that is different version (or perhaps proprietary) from the one that you have implemented during the past year. The entire process begins again to now “INTERoperate” with the new app.

Suggestion 2: 

I would suggest that the NeHA identify Digital Health information sources and fix the VERSION of messaging formats for each of these Digital Health Information sources for a period of 7 years so that all the sources of Digital Health Information are talking the same language without the need to constantly keep changing the standards of information exchange.

There should be a clear roadmap for version upgrades within the NEHA framework to allow for newer usecases but avoid changing the messaging format altogether year on year.

Streamline and standardise the INTERoperability and INTRAoperability standards for Digital Health Information sources.

As an additional step, it is important to mandate the implementation of common Digital Health Standards in all the Medical Devices that is OPEN and can be easily extracted from existing and new Medical Device implementations. 

Ideally, solutions, EHR products, medical devices and any other patient information generation device or software solution should adhere to a fixed set of standards, that allow for easy exchange of information.

Finally, NEHA can provide an Infrastructure to provide Open and Secure Digital Health Exchange Services/ APIs”. This will definitely remove the cost barrier to interoperability of Digital Health information.

I would suggest the use of “a Pragmatic approach to Interoperability” that helps NeHA identify and enable Interoperability of Digital Health information that provides the context in patient care. Physicians, Specialists and Chronic and palliative care experts should be consulted to define the usecases for patients need of Digital Health information. 

Questions to consider for Patient Information Inter / Intra Operability : 

  • Does the Doctor really need the “Womb to Tomb” record of a patient
  • What percent of patients need a “Womb to Tomb” record? 
  • Is it really possible to have such a record available, if one version of the HIMS is different than the other?
  • What percent of Patient’s benefit from Digital Health Interoperability?

To remove the boundaries between information silos in a Hospital workflow are the key aspects that should be identified and addressed in a pragmatic interoperability approach for an optimised workflow approach rather than a paperless or less paper approach

Author

Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur.

Additional Articles by the Author:

  1. Health ID as Patient IDs unifier in India  by Manish Sharma  
  2. 5 Steps towards an Integrated Digital Health Experience in Indian Healthcare in 2016 
  3. Top Healthcare & Digital Health Predictions for 2016
  4. Zen Clinicals: An Activity & Workflow based solution (1 of 3)
  5. RFID in Healthcare: Usecases from Hospitals
  6. 10 Solutions for the Healthcare IT Fringes

Suggested Reading:

  1. CHIME Calls for More Transparent, Uniform Interoperability Standards for Medical Devices
  2. The future of depends upon the secure exchange of electronic data – Deloitte Healthcare
  3. Pragmatic interoperability: Interoperability’s missing workflow layer | Health Standards – Dr. Charles Webster ( @wareflo on Twitter)

Health ID as Patient IDs unifier in India

Health ID as Patient IDs unifier

06.Feb.2016, Bangalore, India


Overview
The post discusses how a Health ID can be linked to Aadhar Number


Unique Identifiers, Health ID & Aadhar Number

A unique identifier from a database technology standpoint, is the ability to create a primary key and link all the data in the database using a primary key (parent record) & foreign key (child records) concept.
Keeping this concept in mind using Aadhar Number as a Health ID offers a very compelling opportunity to uniquely identify a patient across multiple episodes and visits, in a single facility or across multiple facilities (that may be located in same geographical location or multiple geographic locations)
In most Health Information systems, the records of a patient are tied to a Unique Patient Identifier, a Patient ID or a UHID.
Let’s consider what are the various use cases of the Aadhar Number and a Patient ID.

Aadhar Number

The Aadhar Number has been planned to be used by the government for various welfare and direct benefit transfer schemes. There have been many instances that the Information that has been recorded in the Aadhar ID may or may not have the latest information of the person carrying the Aadhar Card. The purpose for which the Aadhar Card has been created is to identify a person for various government schemes and also has been deemed to be used to be provided at the time of opening of a bank account. Hence there are quite many financial transactions that might be linked to the Aadhar Card.

Patient ID or UHID Number

The Patient ID in various Healthcare information systems, is generally used to uniquely identify a patient so as to deliver various services for the patient at the right place and the right time and to the right person. And also link all the healthcare information about the patient to this unique identifier.
Keeping in mind the need to uniquely identify a patient and to avoid duplicates becomes a very important factor in the Hospital Information Systems.
In a specific system ( and these obviously vary from one HIMS to the other) the Patient ID is utilised to keep track of various types of patient related information or healthcare events. In addition to the Patient ID, there is the Episode ID and the Visit ID information that is used to store specific visit related and diagnosis based information in the Health Information System. In these systems, the Episode ID and the Visit ID are used as the child records of the Patient ID.
Most Health IT systems employ an algorithm to identify patient duplicates based on various data points creating a complex key.

Using Aadhar as a Health ID

In various countries around the world, the use of a single identifier as a universal identifier has never been successful due to the complexity & security concerns of the various use cases.
Take for example the case of the SSN (Social Security Number) in the US. The SSN is recorded for the patients in the Healthcare Information Systems but is never utilised to uniquely identify a patient due to the issues of Security and Identity theft. There are a lot of instances in which the SSN has been stolen and leads to the person suffering from stolen identity.
Healthcare Information systems have been hacking targets and currently the losses estimated in every hacking incident runs into millions of dollars.
Now take the example of Aadhar ID as a Health ID. We might land up having similar issues of the healthcare information system at a hospital/ clinic being hacked into and the Aadhar information being misused by the hackers.
Obviously, the security levels of an IT infrastructure at a hospital or clinic will not be as superior as the competent authorities security and IT infrastructure.
The government agency will be able to ensure the security of the Aadhar number, by providing robust and secure systems, but the same may or may not be expected of the Hospital Information System vendor or the hospital or a clinic that has implemented the solution or for that matter a Health Information Exchange authority. 
Suggestion
  1. Use Aadhar to validate the Identity of the Patient, Only

The Aadhar number must be used only and only to validate and authenticate the Identity of the person who has come to the hospital. Aadhar Authority could provide a service that could be called to authenticate a person.
  1. Use Health ID to be the Primary Key, Patient IDs to be the Secondary Key

In the absence of standards as to how the Patient information is to be stored within a Healthcare Information Management System or EHRs, it is more advisable to maintain the Health ID as a Primary Key, the ownership remains with the Health Authority. However, each visit that a patient makes into any healthcare facility, the HIMS/EHR/EMR vendor generates a care summary record (using Patient ID) as a “Secondary Key” information for the patient.
This is akin to how each bank might have different banking information systems, but the PAN number is a unifying information to understand how many bank accounts a tax payer might have (since PAN number is mandatory for every transaction done).
In this bank scenario, the PAN is the Primary Key, and every transaction done against the PAN card is the secondary key.
The authentication of the PAN is done by the competent authority who develops robust systems to safeguard the PAN card information of the PAN Card holder.
  1. Patient ID/ Health ID should be maintained by the Health Authority (e.g., the National Health Portal)

We propose the Health ID should be maintained by the Health Ministry in the government and the various aspects of Health Information should be defined by this authority. Since the Health Information of the patient needs to interoperate between the Hospitals/ clinics (which comes under the Health Ministry) and the Insurance Companies (which is another government department), maintaining a separate Health ID with its own security and interoperability guidelines is an appropriate approach.
The interoperability between the various government departments is more easier than any other third party vendor implementing such a interoperability system. The government therefore becomes an enabler of interoperability between various consumers of the healthcare information (in this case, the insurance companies and the Hospitals)
For instance, the Health ID could have a one-to-one relationship with the Aadhar Number. But the contents of the Health ID related information can be dictated by the Health Ministry or the National Health Portal Authority.

In Conclusion

  1. Health ID should be used to maintain a persons’ Health Record across the care continuum.
  2. Health ID can derive the Demographic information from the Aadhar ID and use the Aadhar ID for Identity matching, duplicate check and person authentication services.
  3. There should be a one-to-one relationship between Health ID and Aadhar ID.
  4. Each time a patient makes a visit to a healthcare facility, the Health ID information regarding the patient will be updated. Mechanism to be worked out if the current and latest information gathered from the patient regarding the demograhics should be updated back to the Aadhar Information.
  5. For Healthcare Related information, Healthcare Information Exchange purposes, Health Insurance purposes; the Health ID should be the unique and Primary Key.
  6. The Patient ID or UHID captured in each of the system should be treated as the Secondary key or the child records that will help put together the patient visit related information.
  7. We can now move to a National Level Health Information Exchange to store health data for the Patient’s clinical events across healthcare facilities, against a Health ID

References:

  1. Limiting the Use of the Social Security Number in Healthcare – http://library.ahima.org/doc?oid=104465#.Vz_5EJN95E4
  2. Patient Identification and Matching – Final Report – http://ow.ly/2ZAE300qT1Z
  3. National Patient ID System: Debate Stoked – InformationWeek – http://www.informationweek.com/administration-systems/national-patient-id-system-debate-stoked/d/d-id/1109314?
  4. HIMSS Asks Congress for Patient Identity System–Again – InformationWeek – http://www.informationweek.com/healthcare/patient-tools/himss-asks-congress-for-patient-identity-system–again/d/d-id/1106498?
  5. National Patient Identifiers | Practice Fusion  – http://ow.ly/XwfTj
  6. Identity Crisis: An Examination of the Costs and Benefits of a Unique Patient Identifier for the U.S. Health Care System | RAND – http://ow.ly/Xwg2I 
  7. Creating Unique Health ID Numbers Would Facilitate Improved Health Care Quality and Efficiency | RAND – http://ow.ly/Xwg6v 
  8. Patient Identification in Three Acts – http://ow.ly/Xwgab
  9. National patient identifier struggles for life | CIO – http://ow.ly/Xwgd5 
  10. White Paper on Unique Health Identifier for Individuals http://ow.ly/XwgfI
  11. The Imperative of a National Health Identifier | HL7 Standards – http://ow.ly/Y0KHz
  12. Are we ready for national patient IDs? | HIMSS Future Care – http://ow.ly/Y0KSn

    Suggested Reading

    1. Unique Identification Authority of India – https://uidai.gov.in/faq.html
    2. Aadhar: A number to facilitate the lives of the next billion | Dr. Pramod Varma | TEDxBangalore – YouTube http://ow.ly/pX4K300AsO8
    3. Linking Aadhar to better Healthcare – http://www.thehindu.com/news/cities/mumbai/news/linking-aadhaar-to-better-healthcare/article8288043.ece
    4. Authenticating Indian eHealth System through Aadhar: A unique identification – http://www.ijser.org/paper/Authenticating-Indian-E-Health-System-Through-Aadhaar-A-Unique-Identification.html
    5. A secured model for Indian eHealth System – http://www.softcomputing.net/ias27.pdf
    6. The Aadhar for mass health insurance – http://www.thehindubusinessline.com/opinion/the-aadhaar-of-mass-health-insurance/article4644193.ece

     

    Author: 

    Manish Sharma

    Founder HCITExperts.com, Digital Health Entrepreneur.

      5 Steps towards an Integrated Digital Health Experience in Indian Healthcare in 2016

      In 2016, we expect Interoperability, Move to the Cloud, Connectivity Data and Analytics Trifecta, Personalised Digital Health Services will dominate the Digital Health Landscape in India


      Introduction

      Fard Johnmar, describes 2016, as the “Age of Implementation”. Bringing the inflection point of providing services to customers of healthcare; by moving from treating the ‘patient’, to providing  services to the ‘customer’ across the continuum of care. In my opinion the Indian Healthcare Providers should be focussing on these areas in 2016

      Efficiency in Workflow, Speed in Communication will be the key implementation factor


      Interoperability

      Indian healthcare providers have implemented solutions that have the ability to capture the patient demographic, test results, clinical summaries and financial data. This data resides in the Hospital Information systems as silos and there is a need to implement interoperability solutions that allow for the exchange of the patient data between the healthcare information systems and Digital Health solutions like a patient CRM, mHealth solutions, medication reminders apps, appointment scheduling solutions, telehealth etc.

      Absence of interoperability between existing solutions in the hospital and other connected solutions required to enable an Integrated Digital Health experience for the patient, causes duplication of work, information silos and data information errors. Interoperability should become a de-facto feature provided by the vendors with APIs and interface capabilities using Standardised formats, i.e., HL7, CDA.

      Since the billing and insurance information is being captured by most of the providers, we believe there can be paperless electronic claims processing capabilities that can really drive the adoption for interoperability in Healthcare in India.

      Move to the Cloud

      More enterprises and specialty clinics will put into place strategic partnerships towards enabling a cloud infrastructure. The needs of each of the Healthcare providers is different and varies from specialty to specialty.

      With the need to orchestrate between multiple systems the Healthcare Providers will have to work on putting in place long term strategic partnerships with Solution Developers and system integrators.

      Such partnerships will allow for a continuous evolution of their Digital Health solutions that will enable the Healthcare Providers to Innovate in the “Agile” way, while delivering a personalised experience and always operating in the real time for service delivery requirements

      Connectivity, Data and Analytics Trifecta

      Digital Health solutions will be implemented providing connectivity to the customers with the range of services offered by the Healthcare Providers.

      With the availability of the Data, the Healthcare Providers will be able to personalise the offerings for each customer, since the requirements for a customer in need of a Health checkup is completely different from a patient in need of chemotherapy.

      With the availability of the data, the Healthcare Providers will be able to continuously improve the offerings to each segment of the customer by utilising actionable intelligence.

      Personalised Digital Health Services

      The patient of today wants faster access to services, personalised experiences, 24/7 access and connectivity and access to these services from a host of devices. To meet these expectations Hospital providers in India will start to engage the patient via multiple channels by implementing  Patient Engagement Services with a focus on a Multi-channel approach required to deliver alerts, messages, video visits, email.

      More and more hospitals have started having their presence on the Internet and Social Media. In 2016, the hospitals will leverage this presence and offer a real Integrated & personalised Digital Health experience to their customers.

      Integrated Digital Health platforms can provide specialised, focussed and personalised solutions for curative care and preventive care.

      Healthcare Apps

      Indian Healthcare providers will offer their services via Healthcare Apps to provide an integrated Digital Health experience to their customers. These apps will be used to provide medication reminders, personalised healthcare advice, appointment scheduling for doctors and services, telehealth for followup care. The Healthcare Providers will work towards implementing mHealth 3.0 services, the next level of mHealth capabilities.

      From Indian Experts

      Some of the experts too chimed in on their strategic opinions for Digital Health in 2016:

      Dr. Ruchi Dass @drruchibhatt, MD Healthcursor Consulting Group, stated her priority areas as, “Get “Healthcare delivery” – a fundamental reset. Brings a dash of frugality to medical innovations.”

      Dr. Supten Sarbadhikari,  ‏@supten  Project Director at the Center for Health Informatics of the National Health Portal, stated his priority areas as, ‘National eHealth Strategy / Policy for India; Health Informatics as a formal discipline; Capacity building’

      Dr. Vikram Venkateswaran ‏@drvikram   Healthcare Influencer & Marketing Leader, stated his priority areas as, ‘reduce #infantmortality introduce  #universalcare increase #preventivecare.’

      Dr. Sunita Maheswari, Chief Dreamer, RxDx and Teleradiology Solutions, in a recent article in Deccan Herald, opined the growth of the Home Health Services such as medicines, pathology, nurse & physiotherapy visits. She also has indicated the need for more funding in other aspects of Digital Health services.

      Dr. Pankaj Gupta, @pankajguptadr, Founder Taurus Glocal Consulting, stated his top three areas to focus in 2016 as SMAC, IoT and CRM

      Dr. Aniruddha Malpani, MD Malpani Infertility Clinic , stated his top three priorities as, prescribing information therapy for patients, productivity solutions for doctors and Indian Language content

      Srikrishna Seshadri, Healthcare IT Consultant, stated his top three areas to focus as telemedicine, IoT and Digital Health Platforms

      Dr. Suresh Munuswamy, Assistant Professor, Program Coordinator, Indian Institute of Public Health- Hyderabad is an academic arm of Public Health Foundation of India

      1. Standards and Structure- For digital health care to even start, India needs standardized treatment schedules, standardized documentation (as EHR), standardized job roles, standardized continuous education and standardized social networking procedures for health care. Lack of standards and structure will lead to poorly inter operable and overlapping systems and procedures.
      2. Digital Health needs reliable supporting infrastructure ecosystem.
      3. Digital Health should focus on developing innovative, smarter, smaller and usable devices that can deliver quality health care…with lesser emphasis on (big or small) data analytics.
      I would like to thank all the experts for sharing their opinions.

      To provide an Integrated Digital Health experience the Hospital Providers need to enable agility in innovation, create the infrastructure to ease the interoperability of patient information, establish connectivity with the patient and continuously engage with the customer in the care continuum.

      Please share your views with me on LinkedIn or Twitter @msharmas or via email: manish.sharma@hcitexpert.com

      The article was also featured on the February 2016 issue (pg.40-41) of Healthcare Radius

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