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Co-creating Value in Healthcare with Interoperability

August 18, 2010  10:01 AM

Future Health Information Exchange (HIE)

Posted by: Nirpath
HIE, Interoperability and health information exchange

Technologies such as file folders, paper-and-pencil entries, tape recordings, and x-ray films are both physically limited and very restrictive in terms of keeping secure, accessible, portable and available records about the patients, but they are still practiced by care providers, who may be practicing in different hospitals and clinics associated with an HMO.

These traditional recording methods are limited because the captured data and information can only be kept largely in a “Physical” form and not easily accessible, transportable or available “virtually” or “digitally” to other expert clinicians, who may decide to travel to another country seeking a second opinion. New forms and modes of HIE technology such as wearable devices and embedded chips promise to give you the ability to access such recorded information that has been accumulated over the years both conveniently and surely at anytime, anywhere.

In the foreseeable future, you will also be able to control and access your own personal health records stored online and contributed by all of your care providers. As amazing as new technologies can be, it is important to first understand the basic function of HIE technologies that currently exist and how these technologies will likely evolve due to increased globalization, continuous healthcare reforms, the corporatization of medicine, and other major trends.

The emerging trends such as – the emergence of satellite based, wireless, user-friendly portables; the proliferation of cellular networks; implementation of various powerful network-based systems e.g. sensor networks and internet-based data warehouses are now pressurizing senior healthcare executives and managers to become seriously interested in understanding and endorsing cost-beneficial and interoperable HIE solutions.

The future HIE should have at least 5 major components:
1. Expandable and vendor/technology independent Data/Information/Knowledge component
2. Flexible Hardware/software/network component
3. Adaptive Process/task/system component
4. Integration/interoperability component for advanced (micro) devices.
5. Configurable User/Administrative/management component

It will be challenging for a CIO / CMO not just to create an HIE but a vision about lots of external factors, which may drive for next generation HIE very soon not by government regulations, but by market forces.

August 18, 2010  7:07 AM

Using interoperability for Disease Prevention in Modern way

Posted by: Nirpath

The growth of chronic diseases across aging population as well as young, middle-aged population due to lifestyle changes throws us to a challenging situation for a preventive strategy. The explosion of healthcare costs jeopardizes the sustainability of healthcare systems and adds urgency towards prevention as highest priority instead of last minute care.

But, the recent advances in communication technology and internet access opens up opportunities for innovative prevention and services around prevention in a cost effective way not only avoiding the costly hospital visits, but also giving better health.

These services can be started initially from Home and slowly penetrating to work places, but the challenge seems to be integration of heterogeneous systems and services with intuitive user interfaces to take care of different type of users from various age groups.

The young and middle-aged people could also benefit from ICT enabled health information, consulting and monitoring services as a prevention mechanism and should stay fit and healthy with lots of decision support systems around their health habits and correcting them at right time. Majority of citizens has broadband connections and feature rich communications and consumer electronics equipment, but only very limited access to e-health services. The few existing healthcare service platforms are limited to special medical conditions and proprietary devices.

The reasons for the lack of prevention and healthcare services in home networking are mainly related to technical and organizational issues. On the technical level, the integration of heterogeneous services and devices via a home platform has not yet been fully achieved. On an organization level, there is a lack of coordination between the major stakeholders in home-based prevention and healthcare service scenarios.
To implement successful service model feasibility depends on many factors like technology, standardization, interoperability as well as privacy, security and user acceptance.

Integration of technologies and devices:
This is another level of challenge that we face with lack of standards with home based devices used for prevention. The manufacturers should develop and promote open standards and guidelines that enable interoperability of health monitoring devices from different suppliers.

Standardizations in the field of e-health are not yet mature. The stakeholders should solve this by rejecting non-standard service providers.

The preventive model will largely depend on interchange of data across systems and interoperable electronic health records (EHRs) will play major role in its success.

The preventive system should also consider its mobile capabilities so that it can be used seamlessly when the patient is on move especially for patients with chronic diseases needing permanent monitoring of vital functions. The monitoring data should be collected and processed via the system platform, in order to trigger certain actions e.g. medication reminders or doctor alerts, if critical values are reached.

I hope the latest developments in EHR and HIE will open up another set of opportunities for the citizens to improve upon the service infrastructure and provide better care to new generation.

July 26, 2010  4:39 AM

Creating Value at Imaging Centers through Interoperability:

Posted by: Nirpath

Using technology to improve productivity and using standards for interoperability can help an imaging center to improve the service delivery.

This creates enormous opportunity for the imaging center to reuse the technology and with internal and external workflow changes, can help more customers at the same time at reduced cost, making progress towards the realization of the EHR (Electronic Health Record) with increased profit.

In the past, radiology workflow has been dictated by its applications and manual processes were developed as suitable to the old working style and limited technology. Today, the outsourcing culture, better technology has forced the entities to become competitive using technology and exploring optimal workflow models.

The imaging centers today can automate the information exchange with referring physicians electronically through interfaces from system applications or EMRs. Through HL7 interfaces, patient demographics and order information can be sent directly to RIS. When the results are ready, the RIS can send the report directly to the physician’s EMR establishing a smooth 2 way asynchronous communication, eliminating routine manual efforts.

Apart from the above integration, the workflow at RIS can be made filmless using PACS solution. The PACS solution in-turn integrates multiple applications and helps radiologists and clinicians to interact with different people with ease looking at the images and supporting documents displayed right at their finger-tips without juggling through heap of papers.

Another business process that can be automated is the billing and coding process. The entire manual billing process can be reduced to a few manual steps of reviewing of irregular records automating the complicated coding, querying process with payors. This will reward the company with decreased reimbursement cycle, increased accuracy and increased customer satisfaction.

The positive impact of the use of advanced technology and automation of manual business processes by workflow automation are far reaching, few of them being:
 – Improving the delivery of care many fold
 – Increasing productivity
 – Greater patient satisfaction
 – Adapt to expanding referral community
 – Increased volume of business
 – Facilitating integration with EHRs

July 26, 2010  2:41 AM

CCD – Clinical Document Exchange standard in EHR:

Posted by: Nirpath
CCD, CCR, CDA, Interoperability and health information exchange

We still come across the standards such as CDA (Clinical Document Architecture), CCR (Continuity of Care Record) and CCD (Continuity of Care Document), but which one should we use for an EHR implementation.

CCD has come up in 2007, prior to which CDA and CCR were used for sharing clinical summary information about patients to referring physicians, pharmacies, EMR systems and other providers. A system using CCR is not compaitble with the same using CDA. So, buyers should know and enquire about – what kind of standard is being used by the EMR.

To solve the issues of incompatibility, CCD is created as an hybrid standard solution – using CDA elements, the data being defined by CCR.

As part of the new critera from CCHIT – 2008, all ambulatory and inpatient EHRs should be CCD compatible – which means the participating systems to send and receieve clinical documents in CCD format. CCHIT’s endorsement of CCD as part of their certification process is very good indicator for creating interoperable solution from different ISVs, paving the way for better communicating EHRs and Health exchange.

Real-world implementation of CCD is still at early stages. Labs, Clinics, imaging centers are exploring many ways on using CCD to stream line their manual processes and improving their return on investments. Few examples could be –
1. A patient performing a test at a Lab, which generates an HL7 “ORU” message and transmits to the referring physician’s office / EMR system. The EMR then generates CCD from the HL7 lab result message. This CCD can be part of the comprehensive Health Record, maintaining interoperability with other providers sharing patient information and test results in an accurate manner cutting down lots of manual work flow processes.
2. A physician can use CCD to enter free-form text about a patient visit in the standardized format, which is not possible in CCR. This specific narrative text could be very important for continued care of the patient at another provider’s place or hospital.

Advantages of CCD:
1. Shares summary of information about the patient very easily with other vital information as secondary information. The summary information may clarify some missing data about the patient, helping the other physician understandig the patient better and giving better patient care.
2. High level of compatibility and wider adaptibility makes it a better choice for the providers.
3. It’s easily understandable by Human unlike other standards like HL7 which are more of machine friendly.
4. Xml format, beign easy with machines to do faster processing and compatibility with other systems designed with Xml.

CCD’s developments make both CDA and CCR less favorable in specialized situations encouraging migrations to a single standard – making one step closer for interoperability. The end result is better – more efficient care for patients.

July 9, 2010  8:49 AM

HIE Building Blocks:

Posted by: Nirpath
EMPI, HIE, Interoperability and health information exchange

HIE is a central repository or exchanging place, where clinical and administrative information is shared among institutions for clinical care, research or process improvement. It will be successful by participation of all the stakeholders in this process.

To implement an HIE, one should focus on below important subsystems –

  1. EMPI (Enterprise master patient Index) / Patient Index (PIX) Service: This is the Patient Identifying service at each participating system. Due to lack of standard practice, the “PatientID”, which was supposed to be unique, is different for each service, or for each hospital or for each physician. This service has different techniques to collate and give a near exact match of a patient.
  2. Provider Index / Provider data Query (PDQ) Service: Although it is not that complex like its peer Patient, “ProviderID” also has got different “unique identifier”. This service takes care of identifying a near exact match of a provider.
  3. Record Locator Service / XDS Registry: XDS Registry works along with both the above services but, is primarily responsible for managing the search result.
  4. Security Services: This service includes the following items –
    • Authenticating and authorizing each request coming from stranger services and ensuring that it has got the right access.
    • Communication layer security takes care of creating the proper channel e.g. intranet, internet, VPN tunnel or any explicit hand shaking mechanism.
    • Data encryption service takes care of encrypting to the right level before the data is transferred across network in compliance with various federal regulations.
    • Auditing service to give fool proof mechanism to track back in case some spoofing activity being detected or for the sake of just reporting for early detection of any unusual activity.
  5. Standards Protocol (HITSP, IHE, HL7 etc…): As this has to be the smartest to talk to all stakeholders, it has to follow standards on how to talk to different HIEs and any other subsystem. There are different standard bodies, who publish the guidelines to be followed by similar systems.
  6. Messaging Gateway: To collate the patient date from different communities / hospitals, HIE has to follow a standard of “polling” and the connected systems responding to the “polling request”, in a specific standard format, if they have the patient data. IHE developed Cross-Community Access Gateway, or XCA. Using XCA gateways, one can access records from other communities that a given patient may have visited.

Although, it is very complex system, I have tried my best to give a concise view of it.

July 2, 2010  8:33 AM

Interface Engine for Interoperability

Posted by: Nirpath
Interface Engine, Interoperability and health information exchange

Clinics, Physician’s offices, laboratories, imaging centers etc… are facing daunting tasks of integrating with each other creating a collaborative environment that provides the satisfying service to the patient.

There are a lots of legacy application written in Visual Basic 6 that integrate with very few selected partners as part of their communication strategy. These applications are designed prioritizing “performance” instead of “flexibility” and most of them follow “point-to-point” interfacing strategy, integrating different application vendors such as Electronic Medical Record (EMR), PACS,  Laboratory Information System (LIS), Hospital Information System (HIS), Radiology Information System (RIS), Transcription etc..

Instead of “Point-to-Point”, the vendors should at least go for “Spoke-Hub” model and implement a centralized solution. The “hub-and-spoke” integration model is a system of connections arranged like a chariot wheel, in which all traffic moves along spokes connected to the hub at the center through the “hub” instead of direct communication to individual partners. The model is commonly used in industries such as  “transport”, “telecommunications” and “freight”. This mode drastically reduces the number of interface points required. A more sophisticated approach to this is Service Oriented Architecture (SOA), but the earlier is sufficient and can be developed with simpler logic and affordable 3rd party utilities, unlike costly Enterprise Service Bus (ESB).

Again, instead of reinventing the wheel, there are already tools – “Interface Engines” available in the market that can be used in the “hub” for giving seamless integration, cutting down the development cost and time drastically.

A modest interface will facilitate communication between two healthcare applications may include –
–    An export endpoint for sending the HL7 or X12 files or content to the “Receiver”.
–    An import endpoint to collect / receive the HL7 or X12 files from the “Sender”.
–    A software application / logic to parse the content and move the data between the end points.
–    A mechanism for handling the queuing the messages – message based system.

The above steps becomes complex, when the number of standards involved are more. In HL7 itself we will have too many types, hard-and-fast rules and same for X12. One “Black Box” export interface will not meet the requirements of every application. Similarly, one “Green Box” import interface will not meet the requirements of every application.

From my personal experience, I recommend to use ready-made software such as JavaCAPS, Microsoft Biztalk Server and other small vendors, instead of trying to create the whole thing from scratch.

June 28, 2010  1:57 AM

Electronic Laboratory Result Exchange

Posted by: Nirpath
Interoperability and health information exchange, Lab Results, LIMS

Interoperability is increasingly recognized as necessary strategy for a high performing, effective health care system. State and national initiatives that use interoperability strategies have gained momentum with the passage of American Recovery and Reinvestment Act (ARRA) of 2009.

Some 70% to 80% of data contained in a medical record consists of Laboratory records and results and approximately 70% of clinical decision making is based on laboratory test results. Laboratory results are proving to be a critical data element for making Health Information Exchange (HIE) initiative successful, even though the policies guiding the result sharing creates its unique challenges.

The present way of Laboratory test result exchange: Physician writes down the tests to be carried on for the patient. Some write their NPI / UPIN or some notes miss the vita information. The patient searches for the nearest lab station and takes an appointment. The results are sent to the ordering doctor’s office by fax / mail. The results are scanned to the EMR and attached to the patient’s chart / documents for review. The test results discrete data items are keyed into the physician’s EMR manually.

The above business process has lots of disadvantages, not to mention data entry mistakes, patient care cycle. In electronic exchange form a lab requisition form is written by the provider on behalf of the patient and delivered (typically by the patient) to the lab draw station. The specimen is drawn and transported to the lab for analysis. The results will be transmitted electronically in HL7 standard to the ordering provider’s EHR system where they can be reviewed with the rest of the patient’s history, including past lab results. The discrete data can be directly sent to the EMR with the standard LOINC Codes and abnormal result alerts making it faster for a physician to prioritize the patient flow either manually or automating similar cases to the next level of alerting to the hospital staff electronically.

Similar data exchange process can be utilized to send data between multiple EMR systems or between a laboratory and a RHIO (Regional Health Information Organization) to give the patient the quality care and help in prioritizing patient flow in any hospital.

The implementation of such a system is very easy –

  • Coordinating the communication mechanism with the diagnosis lab IT system on figuring out data delivery channel and mandatory data items required to identify a patient and provider.
  • The Lab should have facility with interface engines to process the HL7 order messages and delivering HL7 result (ORU) messages – most of the time the results are either pushed or pulled by the EMRs using web services.

The EMRs parse the HL7 ORU message, LOINC codes then generate the PDF or report from the discrete result data and implementing the alert mechanism for different result types – normal, high, abnormal cases and mapping logics to the patient chart, document and other business processes.

From this simple automation, if we think on a larger scale – it not only automates physician’s process helping the patient receiving quality care, it also helps us getting one step closer to implement HIEs smoothly.

June 21, 2010  6:46 AM

Interoperability in other industries

Posted by: Nirpath
Interoperability and health information exchange

Recently, I came across an article of a digital camera vendor, who was trying to solve the interoperability problem between the latest cameras with that of the older cameras. And, it was part of their marketing campaign to win some market share creating USP (Unique selling point).

Interoperability between the old system and new system is relatively easy and straightforward, due to just one stake holder and multiple system versions with the proprietary technology. When it comes to thousands of stake holders, then the interoperability factors is left to individual companies’ decision to co-operate, create some standard and following it through some enforcing body. The products thus created serve a larger market creating value for all stake holders with a simpler or smarter solution.

The standard creation process is the most crucial step for interoperability. When there is a market leader, it will champion the cause and interoperate with smaller players, who may not be perceived as a threat – and this is what exactly happened in our health care industry. With too many vendors providing service to specific areas of the problems, there was no clear market leader in this industry. But, when the quality suffers, they all have to unite and start following some standard – either set by industry body or government and here we are!

But ever wondered how this happens in other industries! Off-course it is not a rocket science! This did happen in other industries.

If we look at a laptop, we will see hundreds of small components work seamlessly to give a collective output of problem solving. There are interoperability programs or policies in place for the vendors to supply components as per the specification and every component of a laptop goes through an “interoperability program” or “compliance program” and the successful vendors are listed in something called “integrators list”. A vendor producing laptop as an end product acts as an integrator and while sourcing the parts, it has to buy the parts from a “certified” vendor from “integrators list”. Similar processes are in place in other industry as well. Usually, the industry association takes the call and manages the campaign. And in health care industry as well, we are taking the baby steps now.

In health care industry also, industry bodies such as IHE, HITSP are created to ensure that vendors follow the policies defined by the standards and policies defined by IHE, HITSP and produce the software component, which becomes automatically interoperable.  Software vendors producing applications, other stake holders become member of these bodies and take part in formulating the policies for the whole industry.

On a regular basis, a huge group of physician’s offices, not having enough technical knowledge suffer from interoperability problems due to various technical problems. To solve this problem, the physician’s office should create another layer of professionals, who are technically sound enough to understand the software and interoperability challenges, for few years before the industry gets stabilized. This layer of professionals should act as CIOs / CMOs on behalf of the physicians. And, unlike other industries, in healthcare industry, the end users (CIOs / CMOs of Hospitals / anyone knowing about software and integration challenges) should also participate in the policy making process to make this process successful creating  “Interoperable vendors’ list”.

Once the industry gets certified products and vendors in the market place,  the health care industry will be able to take the challenge of HIE and other health care exchanges creating a seamless environment for transferring information among one another giving the best service to the end user – patients.

June 11, 2010  12:01 PM

Interoperability as the need in a complex system

Posted by: Nirpath
Interoperability and health information exchange


Life would have been simple, if there were few stake holders or for that matter just one stake holder in a system. But, as a social animal, we prefer to stay as a group, which also gives another advantage of staying ahead in the race for survival. As the group becomes bigger, the existing system approaches a breaking point where, the fibers of bonding need to be changed to balance the system. Management consultants call it as “Demand – Supply” rule or biotechnologists call as “Survival of the fittest”.  I prefer to call it as “Co-creating” value in the process of “Chaos – Control – Balance”.

There are a lot of examples in our daily life, where we co-create value for ourselves as well as for others. Some are so mundane tasks that we fail to observe them, like queuing up at a post office. Being in a queue, not only we create value for ourselves, but also creating value for others. Think about a situation, where everyone starts jumping the line. Even though, we may succeed to achieve our goal, the end result will not be satisfactory. This is the simplest example, where we “co-created” value.

For “Co-creating” value, we normally take help of standards or policies to be followed by all the stake holders, in other words, the stake holders become “interoperable” or cooperate / understand each other. Interoperability is simple enough as a concept: it requires competitors / stake holders to cooperate in order to provide choice and more efficient services to consumers, while still competing on quality and price.

From our past experiences, we have seen this in complex business scenarios in “telephone networks”, “Bank ATM networks”. The competitors co-create value for themselves with interoperability as well as giving better service to the end user. But, as I said earlier every system follows through “Chaos – Control – Balance” path, so will our “Healthcare system”.

Interoperability is the means, which all stake holders have to follow in a complex system not only to balance the system or give more efficient service to consumers, but also for the survival or co-creating value for each participant.





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