The Interoperability Imperative

This article originally appeared in Healthcare Information Management & Communications Management magazine:

Call me a “fan boy” but I couldn’t wait to get my hands on Apple’s iPhone 6. Having written about the disruptive potential of digital health platforms, I was eager to play with apps designed for the new HealthKit platform (and that took advantage of the iPhone 6’s many built-in sensors). Even before I began to explore the functionality of the first HealthKit enabled app that I installed, I was struck by how it easyit is to share data among these apps. I simply indicated during the installation process which data elements I wanted to read from and write to the HealthKit repository and I was done. If only the sharing of my personal health data across the various health IT systems in which it is stored was so easy!

Interoperability, like innovation, is one of those words that has become so overused that it risks oblivion in buzzword hell. Equally concerning, it is a term that few people outside the health IT community use and care very little about. Yet, interoperability (or, perhaps, more correctly, lack of interoperability) has proven to be a major impediment to realizing the full potential of health IT.

Karen DeSalvo, Director of the Office National Coordinator for Health Information Technology (often referred to as the ONC) in the United States, has made impassioned pleas about the interoperability imperative at various events since she was appointed less than a year ago. At the annual HIMSS conference, held this year in Orlando, Ms. DeSalvo told attendees:

“We have made impressive progress on our infrastructure, but we have not reached our shared vision of having this interoperable system where data can be exchanged and meaningfully used to improve care.”

A similar situation exists in Canada. In a brochure advertising an interoperability workshop scheduled to take place in October 2014 (before this article is published), ITAC Health offers the following summary:

“For years the Health ICT industry in Canada has struggled with the challenge of interoperability. Application developers are faced with a dizzying array of standards, jurisdictional requirements and legacy environments.”

At the annual American Health Information Management Association (AHIMA) conference held this year in San Diego, Ms. DeSalvo observed that healthcare data “must be plug-and-play. It’s not helpful if it just sits there idle.”

I was intrigued by Ms. DeSalvo’s choice of words. To be useful, Ms. DeSalvo contends, healthcare data must be able to move to where it is needed. This notion of data liquidity, which the Institute of Medicine defines as “the rapid, seamless, secure exchange of useful, standards- based information among authorized individual and institutional senders and recipients”, captures the essence of what we are trying to achieve when we talk about interoperability.

So, how do we achieve data liquidity? Dr. Doug Fridsma, Chief Scientist at the ONC (and soon to be President and Chief Executive Officer for the American Medial Informatics Association (AMIA)), contends that tackling this challenge “from the top down isn’t going to work.”

In a HealthITBuzz (the ONC’s blog) post earlier this year, Dr. Fridsma offered insights on how to achieve interoperability on a large scale. These insights were gleaned from a Software Engineering Institute report entitled “Ultra-Large Scale Systems: The Software Challenge of the Future.” He notes that the characteristics of ultra-large-scale systems described in the SEI report have “an eerie similarity to the challenges we face in the overall health IT industry.”

“Ultra-large scale systems are not about a single software application, or a couple of applications working together, but rather an ‘ecosystem’ of interacting software systems,” notes Dr. Fridsma. These systems “cannot be managed ‘top down’ in a monolithic way, but will require a coordinated, decentralized way of meeting local needs, while keeping all of the systems working together.”

This notion of ecosystem is reflected in the ONC’s 10-year vision for an interoperable health IT infrastructure. This vision is based on what the ONC refers to as “five critical building blocks”

1. Core technical standards and functions
2. Certification to support adoption and optimization of health IT products and services
3. Privacy and security protections for health information
4. Supportive business, clinical, cultural, and regulatory environments
5. Rules of engagement and governance

These building blocks are similar to the key enablers that Canada Health Infoway lists in its Pan-Canadian Digital Health Strategic Plan.

Ken Stevens, VP, Healthcare Solutions, Intelliware Development
Inc. and Co-Chair of the ITAC Health Interoperability and Standards Committee, offers what I think is perhaps the best summary of the interoperability imperative. Commenting on one of my posts on the eHealth Musings blog, Ken writes:

“Interoperability and data mobility have a huge impact on whether innovation is even possible …. Wherever valuable data is accessible through simple open standards, innovation will flourish.”

What are your thoughts on the interoperability imperative? How can we achieve data liquidity? What needs to change?

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Did the eHealth Ontario 2015 Blueprint See Its Shadow Today?

Since I often leave for work before the sun rises in the winter, I didn’t hear whether the groundhog saw his shadow today until after I sat at my desk. In fact, I didn’t hear about it so much as I read about it on twitter. Realizing that it was Feb 2nd, I pondered whether the eHealth Ontario 2015 blueprint document, like the groundhog, had made an appearance.  If it did it must have seen its shadow and scurried back in its burrow because I can’t seem to find it anywhere!

Last year I attended several public forums at which senior eHealth Ontario executives spoke about the new eHealth Ontario 2015 blueprint. The first event was an ITAC Health sponsored vendor forum at which Fariba Rawhani walked a packed room through a detailed overview of the blueprint; you can read my blog post on this event here. At the end of her presentation Ms. Rawhani promised that we would see a 100+ page detailed blueprint document “real soon”.

In early October I co-chaired an OCRI sponsored one-day eHealth partnership and innovation forum in Ottawa at which Ms. Rawhani once again spoke about the blueprint and once again promised a more detailed document would be released “real soon”. Thinking that perhaps the delay was imposed by events outside Ms. Rawhani’s control, I publicly asked Greg Reed when the blueprint document might be released when he spoke at an eHealthAchieve breakfast in early November. His initial answer was – wait for it – “real soon!” He then qualified his answer with “by the end of the month”. Perhaps I should have asked him “which month?” or “what year?”.

So, now it is 2012 and Ican only find one reference to the blueprint on eHealth Ontario’s web site. It is a copy of a one-page blueprint diagram on the vendor relations page.

Unlike the proverbial groundhog, no one seems to know what has happened to the eHealth Ontario 2015 blueprint document.  Given that lack of a strategy beyond 2012 was a major criticism leveled by the Auditor General more than two years ago, I am left to wonder why there hasn’t been more urgency given to releasing the blueprint document.

Mike

eHealth Ontario – 2015 eHealth Blueprint – 1st look

I attended an ITAC Health hosted event this morning at which eHealth Ontario presented a 1st look at Ontario’s 2015 eHealth Blueprint.  I’ll comment on what I heard in a separate post but, for now, I thought that I’d share a copy of a handout provided to attendees entitled “The Foundation for Innovation and Action”.

Mike

Engaging health IT vendors

Although my viewpoint is probably somewhat biased given my day job with a heath IT vendor, I hold the firm conviction that the health IT vendors have an important and valuable role to play in helping shape local, regional, provincial, and national health IT plans.   The extent to which organizations across Canada consult with vendors outside the formal procurement process varies considerably, though I am noting a gradual trend towards more meaningful engagement.

A number of healthcare IT organizations including Canada Health Infoway, Manitoba eHealth, and the Chief Health Information Officer’s office at the  Nova Scotia Department of Health, for example, hold periodic briefing sessions.   In addition, ITAC Health works with organizations such as eHealth Ontario to organize vendor information sessions.

As I have mentioned in previous blog posts, one of the more innovative organizations with respect to vendor engagement is the South West LHIN.  Shortly after joining the organization, Glenn Lanteigne, the LHIN CIO, instituted what he calls “Vendor Fridays”.  These 2 to 3 hour sessions provide an opportunity for vendors to offer insight into how their products and services can help the LHIN achieve its strategic objectives.  Equally important, these sessions provide a forum for vendors to chat with LHIN IT staff and interested provider stakeholders about their needs.

Not content with the information flow that “Vendor Fridays” has engendered, the South West LHIN recently invited vendors to participate in a “Consumer eHealth Innovation Day”.   This “public – private sector” workshop is the first of five workshops designed, in Glenn’s words, to “address real-life LHIN issues and explore how these types of solutions can help and how“.   Other topic areas that will be addressed in future workshops align with the LHIN eHealth strategy.  These areas include Capacity Management, Decision Support, Quality, and the Electronic Health Record.

The Consumer eHealth Innovation workshop will take place on Thursday, June 30th, at the University of Western Ontario’s Research Park Convention Centre.  You can find more details here or by calling 519-640-2592 or emailing Jordan.lange@LHINS.ON.CA.

What do you think of the South West LHIN’s efforts to meaningful engage health IT vendors?  Do you have any suggestions for how healthcare organizations can meaningfully engage health IT vendors?

Mike

 

Health Canada Reconsidering Licensing of Patient Management Software

ITAC Health is advising its members that Health Canada will be issuing a revised definition for “Patient Management Software” with respect to medical device licensing.  According to ITAC Health, the new definition will be less restrictive than the definition contained in Health Canada’s 21 May 2010 notice on this subject.  An FAQ addressing this matter is expected from Health Canada before the end of November.

Mike

 

Greg Reed at ITAC Vendor Forum

Today I attended an ITAC Health vendor information session at which Greg Reed, the CEO of eHealth Ontario, provided an update on the agency’s plans and priorities.  While I had hoped that Mr. Reed would make a more definitive statement regarding the agency’s role and offer a clear articulation of the agency’s updated strategic plan, I did walk away with a better sense of the underlying philosophies influencing how the agency operates and the challenges that it faces in positioning itself in the complex Ontario health system.

Mr. Reed continues to demonstrate an unwavering commitment to “getting it right” and steadfastly refuses to assert his own views about the “right” direction for either the agency or eHealth in Ontario.  Instead, Mr. Reed insists that he needs to take the time necessary to consult with all stakeholders.

Mr. Reed spoke for just under an hour and then took questions.  He divided his presentations into four parts to cover the following topics:

• Update on various efforts to remediate eHealth Ontario
  
• Observations on what he has seen / heard during his visits across the province
  
• Update on strategic planning activities
  
• Musings on eHealth Ontario’s role
  

Mr. Reed structured his remarks on efforts to remediate problems at eHealth Ontario in terms of the four general areas of concern raised in the Auditor General’s report.  He noted that the agency’s analysis identified 84 root causes for the problems identified by the Auditor General. In terns of the four areas of concern, Mr. Reed offered the following update on efforts to address these concerns:

• Oversight / governance – The agency is “almost there” in addressing these concerns according to Mr. Reed.
  
• Procurement – The agency has overhauled the procurement process so that it is more open and transparent albeit more complicated.  According to Mr.  Reed, the agency is “just about done” addressing this area of concern.
  
• Project planning – The agency needs “outside help” and has engaged someone (wasn’t clear whether it was new hire or a consulting engagement) to lead remediation efforts in this area.  Mr.  Reed stated that he could not identify the person but that an announcement was forthcoming in the near future.
  
• Strategic planning – Mr. Reed had “hoped to have a plan by now” but that he was still talking to stakeholders to get feedback.  As part of this process Mr. Reed indicated that he wanted to engage the audience is a dialog during the question and answer portion of his presentation.
  

Mr. Reed offered additional insights regarding remediation efforts including:

• The eHelath Ontario leadership team has been “reinforced” with “8 or 9 new vice-presidents
  
• Significant staffing changes.  150 out of a total staff complement of “800 to 850” employees have left the agency and roughly 200 new employees have been hired.  Some of the new hires replace consultants.   According to Mr. Reed, there are now 118 consultants working at the agency.  This number represents about 12% of the eHealth Ontario workforce, a level that Mr. Reed feels is “about right”.
  
• Joint planning with Ontario government regarding network and data centre operations. The Ontario government is reusing portions of the eHealth Ontario network for other gov’t department traffic and there are discussions regarding use of an existing Ontario government data centre.
  
• Working to change the organization’s culture from “command and control” to “more open and transparent” where good ideas can come from anywhere, not just through the chain of command.
  

Mr. Reed explained that he had spent considerable time “in the field” talking to an “alphabet soup” of organizations. He noted that it quickly became apparent to him that the Ontario health sector was a complex environment which he categorized as “very heterogeneous” in many ways, from process to technology. This complexity will, according to Mr. Reed, make developing an interoperable electronic health record a “daunting task”.

When engaging various stakeholders, Mr. Reed explained that his approach has been “listen, learn, hypothesize ideas, and solicit feedback on these ideas”. It is this collaborative and iterative approach to developing a new strategic plan that is taking more time than expected but which is considered an important ingredient to arriving at the right strategy for Ontario.

There was a palpable change in the room when Mr. Reed shifted his presentation to an update on the strategic planning process. Many people reached for their notepads and could be seen scribbling furiously as Mr. Reed spoke. Mr. Reed opened his remarks regarding strategic planning by stating eHealth Ontario’s overarching goal: Whenever someone in Ontario touches the health system in the presence of a provider want that provider to have much information about the patient as possible, preferably in electronic form. Mr. Reed noted that keeping this information accurate and consistent while also assuring that it is securely protected is a major challenge given the high transaction rates that will have to be supported.

Mr. Reed talked at length about two strategic priorities:

1. Deliver on key commitments. Mr. Reed stated that it was imperative that the agency deliver on commitments that it makes in order to build credibility. He offered a quick status report on several key initiatives including the Diabetes Registry (a misnomer, according to Mr. Reed, as it really is an application), Drug Information System (procurement expected to start late this year, early next year), and foundation technologies such as registries (client, provider, location, etc which need to be “cleaned up” and turned into a resource that the provider community can use).
   

   Mr. Reed mused about the difference between local initiatives and cross-sectoral projects such as Chronic Disease Management systems that “feel like government work”. These cross-sectoral applications have no economic incentive for a single provider but offer significant benefits to the health system as a whole. Such projects, according to Mr. Reed, are likely best handled at a provincial rather than local or regional level. Since many eHealth projects have more local benefits, Mr. Reed believes that many solutions will come from the provider community working with vendors.
   

2. Drive meaningful use and adoption. According to Mr. Reed, the province is “awash in electronic health records” that range in sophistication and that have been designed to meet local needs. Most of these systems are not “controlled or owned by government”. The problem in driving an interoperable electronic health record is that these systems are not connected in any way and that we have, as a result, a plethora of “information silos”.
   

Mr. Reed introduced the concept of “natural referral areas” in which providers have an incentive to work together. According to Mr. Reed, there are 4 to 5 such areas in Ontario, most of which are larger than many provinces. Rather than a “big bang” approach that results in a single electronic health record system, Mr. Reed suggested that it makes more sense to develop an interoperable electronic health record within each referral area and link them at a later date. This multilateral approach respects local needs and priorities and potentially offers a way to get personal health records into patients’ hands sooner. By adhering to common standards and working towards a common goal, regional initiatives will eventually converge to create a provincial interoperable electronic health record while providing benefits at a faster pace than a unilateral, “big bang” approach.

To my disappointment, Mr. Reed did not offer a succinct and clear statement regarding eHealth Ontario’s role. Indeed, when asked during the question and answer session how the agency plans to work with the LHINs, Mr. Reed responded “I don’t know”. He did muse on the agency’s role, offering some thoughts, including:

• Need to collaboratively develop an overall architectural framework, with the agency making the “hard decisions when necessary”.
  
• Need to “draw people into the tent” rather than make pronouncements about how things should work.
  
• The agency will act as a “strategic investor” funding local and regional projects around the province.
  
• The leadership style is to be a “servant leader” that facilitates dialog and gets the right people in the room for this dialog
  

Overall, the presentation offered considerable insights into the philosophies and guiding principles but was a little short, I felt, on definitive statements of where to next and how we will get there. Perhaps Mr. Reed is right that more consultation is needed but I think that, at the very least, more definitive timelines as to when a new strategy will be in place and a succinct statement on the role of the agency are needed to set expectations and to drive discussions to a conclusion. What are your thoughts on what Mr. Reed shared today?

Mike

Upcoming Greg Reed Presentation

In case you weren’t aware, Greg Reed, the relatively new CEO at eHealth Ontario, will be presenting next week at an ITAC Health sponsored vendor information session.  From what I can tell this presentation will be one of Mr. Reed’s very few public appearances since assuming his new role.  Many people with whom I have spoken over the past few months have wondered why Mr. Reed has been so quiet.  They tell me that they still feel largely in the dark about eHealth Ontario’s role and the status of an updated strategic plan for eHealth Ontario that Mr. Reed has promised on more than one occasion.

I will be attending the ITAC Health vendor session next week.  For those of you who don’t know me well, I am an independent consultant based in Ottawa and my trip to Toronto for the ITAC Health session will come out of my own pocket.  I am making the investment because I want to hear, firsthand, what I hope will be a presentation on Mr. Reed’s vision for the future of eHealth in Ontario and the agency’s role in making this vision a reality.

Many people have commented in various forums about the need for strong leadership and, whether he likes it or not, Mr. Reed is seen by these people as the Ontario eHealth leader.  An article in today’s Toronto Star marks Mr. Reed’s return to the public spotlight but is short on details on how eHealth Ontario will deliver tangible results.    I hope that I can share some more details on my blog next week after Mr. Reed’s presentation.

Unlike many eHealth Ontario critics, I believe that eHealth Ontario has an important role to play in realizing the many benefits of integrating IT into healthcare delivery processes and that we can, with the right plan, realize a return on the investments made to date.   I do wish, however, that Mr. Reed has been more open and transparent about the process to develop a new strategy so that we didn’t feel so in the dark about what has been going on at the agency for the past six months.

Mike

Regulating HIT Software in Canada and the US

I have been following the debate regarding Health Canada regulation of HIT software (including physician EMR software) and have written several blog posts on this topic.  While the Canadian debate seems to have taken place after the regulations were put in place and decisions made to actively enforce them, the US debate is taking place BEFORE decisions regarding how best to regulate health IT for patient safety are made.

As it does for many issues facing the health IT industry, HIMSS is seeking input from the community on how best “to foster a large scale dialogue on the issue”.   In a recent blog post (HIMSS actively engages its members and the broader community through blogs and other social media), HIMSS summarizes the current situation in the US and poses the question “What should be the role of the federal government in ensuring the patient safety of health IT products and the settings in which they are utilized?”

Do we need a similar debate in Canada or is the matter already decided?  I fear that much of the debate in Canada is taking place behind closed doors and that there is little opportunity for input from the broader stakeholder community.

Mike

Health Canada Medical Device Certification – Differing Views?

Just under two weeks agoI attended and blogged about a workshop on the Health Canada medical device regulations hosted by ITAC Health, MEDEC, and COACH. This workshop explored the applicability of these regulations to health IT software. Since that workshop I have learned that various stakeholders have different views on the extent to which the Health Canada regulations should apply to health IT software.

The HIT vendor community appears to support application of the Health Canada regulations to HIT software. On 7 September 2010 ITAC Health published a blog post summarizing their position on the Health Canada regulations.  This post states that “ITAC Health supports the application of Health Canada’s Medical Device Regulations (MDR) as they apply to patient management software defined in Health Canada’s Notice dated May 21, 2010.  This regulation is appropriate for patient management software products that manipulate and interpret clinical data, which require a high standard of quality.”

According to a comment posted by Brenda Seaton on the “Canadian EHR Professionals” LinkedIn group discussion forum, healthcare CIOs “have pushed back because of the very legitimate operational challenges, of which legacy systems are one“.    Based on what I am hearing from other sources,  these concerns are causing Health Canada to reconsider their definition of patient management software.

So, it appears that the community is divided on the application of the Health Canada regulations, with the vendors lining up in support of the regulations and the health IT user community working behind the scenes to lobby for additional changes to the regulations.  There is little public information available regarding these discussions and the views of the various stakeholders.  Does anyone have any additional insight that they can share?

Mike

HIT Adoption as a Performance Indicator

The OHA Board recently identified the strategic performance indicators for its new 2010-2013 strategic plan.  Of particular note, “Health Information Technology Adoption” was selected as one of the performance indicators.  The complete list of indicators includes:

• Number of Alternate Level of Care (ALC) Patients
• Patient Satisfaction
• Staff Engagement
• Patient Safety Composite
• Adoption of Governance Leading Practices
• Wait Times Composite
• Health Information Technology Adoption
• Cost per Capita

According to the OHA, the next steps with respect to use of these indicators include “a review of the eight indicators by selected industry experts and development of definitions, baselines and targets”.   I do hope that the Health IT industry has a role to plan in refining the indicator related to Health Information Technology Adoption.  ITAC Health, do you have a position on this matter?

Mike