My View: Standards and interoperability – problems and solutions

VIEW - Peter Jordan, chair HL7 New Zealand & affiliate director HL7 International

Does New Zealand’s health sector really want interoperability and is it prepared to make the necessary sacrifices? Peter Jordan explores this crucial question.

We all agree that standards are a good thing – if not I’d suggest skipping to the next article or joining your local anarchist group – and localised versions were a key part of everyday life well before the digital age, The NZ Road Code is one obvious example.

The advent of distributed technology – notably the Internet – has been predicated on the development and use of international standards; our everyday use of e-mail and web browsers is totally dependent on the universal adoption of strictly specified, standardised protocols.

All well and good – so why has it proved to be so difficult to develop and implement standards relating to healthcare information?   The ‘Holy Grail’ of interoperability – whereby information can be passed seamlessly between applications and facilities without loss of meaning – remains a seemingly distant goal. 

The Global Digital Health Partnership recently made the rather obvious statement that “interoperability is made possible by the use of standards.” I would go a step further and declare that it is an impossible goal to reach without the conformant use of international standards.

So, what is the underlying issue here – is it a lack of standards themselves? This line has been fed to me on numerous occasions over the past 3 decades and I believe that it has worn threadbare thin by now. In fact, at NZ Digital Health Week in 2019, HL7 New Zealand presented an award for 25 years of local HL7® Standards Implementation!

Certainly, back in the day, these standards were not always easy to use or fit for all the multitude of purposes required for health information exchange. However, the suite of modern, international standards now available for implementers, e.g., HL7® FHIR®, SNOMED CT®, LOINC®, openEHR®, etc provide options for all but the most obscure edge cases.

This might suggest that we have solved the ‘technology problem’. Certainly, the conformant implementation of international standards would take us a long way towards interoperability.

Unfortunately, technology is only one part of the solution and it seems that we have a long way to go in resolving the ‘people problem’ and, to a large extent, that is dependent on cultural change.

In fact, this problem is so fundamental that it raises the question as to whether our Sector really wants interoperability and is prepared to make the necessary sacrifices. Alternatively, is interoperability just a buzzword or akin to a New Years’ Fitness Resolution that fails to survive January because of unwillingness to make the necessary lifestyle changes on a long-term basis?

One of the most significant of the requisite cultural shifts was articulated in a recent presentation made by Rachel Dunscombe (CEO NHS Digital Academy) …

“Data is for life, not just one system. If we consider that as a principle, we will design and procure systems differently.”

We must consider that all clinical data entered in electronic healthcare systems has multiple uses by a variety of people in numerous settings. Consequently, a mind-shift is required whereby clinicians are not viewed as data entry clerks, but as clinical record authors alongside engaged patients with the right to curate and augment their own records.

The development of these systems needs to be raised above the level of a software engineering task, open to anyone able to program a computer, to co-design between clinicians and qualified informaticians and implementers. Unfortunately, many of our current systems have been created by those with no formal training or qualifications in health informatics or standards, with dire outcomes for interoperability.

Creating consistent and conformant implementations of standards also requires a great deal of time-consuming and costly consensus processes among all stakeholders. In the words of HL7 FHIR Product Director Grahame Grieve…

“Healthcare software – Cheap, Flexible, Interoperable – you can have any two.”

As with the building of the core standards themselves, this involves building communities, rather than the top-down approaches favoured in the past.

A fresh approach is also required among implementers away from their natural desire to develop and self-test their own solutions. We need to mature beyond the “not invented here” syndrome to the use of standardised software components and the independent, on-line, testing platforms facilitated by modern standards, notably FHIR.

The role of governance and regulation is a moot point. New Zealand has always been well-served in terms of the endorsement of international standards by HISO, although attempts to create interoperability via statutory dictate might be a culture step too far. Nevertheless, maybe our national regulators might mandate that digital health application providers who declare standards-conformant capability can back those assertions with independent evidence – rather than the tick box, self-attestations that have been a dysfunctional feature of many a procurement process? Applying a recent statement from Apple CEO, Tim Cooke to this context…

“…and we’re here today because the path of least resistance is rarely the path of wisdom.”

In conclusion, where might all these cultural changes lead? Hopefully, to resolution of the single greatest barrier to interoperability – the quality of data in our endpoint systems. Several months ago, I was able to obtain an electronic copy of my own primary care record in GP2GP format and, to be frank, I was horrified. Sections of data relating to conditions, pathology results and other key health indicators – created from several different software products – were unusable beyond free text descriptions. Without fixing this problem, plans for national healthcare information exchange platforms will be defeated by that oft-cited maxim - “culture eats strategy for breakfast”.

Disclaimer: The opinions expressed in this article are purely personal and do not represent the views of my clients, HL7 New Zealand or HL7 International.