Interoperability - The juggernaut of information exchange. Consumer-based interoperability exists practically everywhere in our digital world.
From social media to the automobile industry, home automation and personal finance, all responding to a consumer-based need to represent relevant and real-time information directly to the consumer's application of choice. Global technology industries pursue this product demand, willingly or hesitantly, to uncouple services for a more flexible approach to providing consumers what they need, where they need it, and when they need it. This is not a new concept for the manufacturing industry. What has changed is the broad availability and greater quantity of technology solutions across a greater market of consumers. Thomas L. Friedman identified the paradigm shift in how business is and will be conducted, nearly 10 years ago in his 2005 book "The World Is Flat". An important component of Friedman's observations is that this flattening not only represents a globalization of products, services and technologies, but also associated standards. We see evidence of these standards rapidly changing as consumer-driven needs define interoperability requirements. Products such as data analytics, web services, and mobile devices all require effective and standardize methods of communicating with one another. And, the challenge with standards adoption is implementation ahead of the rapid consumer demand.
It's no surprise to say that Healthcare technology has been slow to mature. Influencers aside, we are experiencing the evolution of a technologically delivered consumer-based product. This same evolution can also be identified across many other technical markets and consolidated into 5 iterative eras:
1. The Invention Era – Technology is applied to a need
2. The Adoption Era –Technology becomes a standard
3. The Integration Era –Technology becomes a component of workflow
4. The Interoperability Era – Technology provides data liquidity
5. The Unification Era – Technology presents an optimized and seamless environment
The challenge with using this model as a holistic approach is the understanding that many components of the overall healthcare product are at varied stages of need, discovery, use, and adoption. And a unified healthcare system must not only account for a consumer base of general population users, but also each user type interacting with a multitude of interconnected systems. The healthcare industry has many years of work ahead to fully achieve and implement a unified product line to meet all consumer demands. However, using healthcare imaging as an example we can see a how a major component of healthcare services is contributing to the overall evolution.
The Invention Era – In the very late 1800's through 1913, experiments led to the birth of nuclear chemistry and resulted in the invention of the hot cathode tube. These developments led to early attempts to visualize cancer.
The Adoption Era – Immediately following the Invention Era and extending up through the 1960's, the birth of the Western Roentgen Society, general use of radiographic films, and further development of the emerging industry's components signaled standardized use and need for imaging technologies.
The Integration Era – Although invention and adoption rapidly continued in many areas, the birth of the PACS (Picture Archiving and Communication System) in 1985 crossed a major milestone in the industry. The result of this milestone meant that the radiology industry could now consolidate its data into a single platform for managing workflow. This consolidation meant that previously isolated systems must communicate with a central platform and exchange information. Achieving this integration required a standard for modalities and systems to communicate, thus producing the DICOM standard that same year.
The Integration Era continued to evolve rapidly over the following 30+ years with implementation of integrated workflow and information management (RIS), system to system communication, tele communications, integrated voice recognition, electronic health records and medical records (EHR and EMR), and the birth of Healthcare Information Exchanges (HIE). Healthcare Information Technology (HIT) development continued at a torrid pace. Standards were created, revised, and deprecated rapidly while evolution of storage methodologies and advanced transport protocols began establishing a baseline for performance, reliability and standardization.
The Integration Era crossed the threshold between consolidated system platforms with a shift to a stratified model for system architecture. The result of this deconstruction and stratification created silos of technology. Each silo requiring complex integration methodologies with varying results in the information each system could share with another. Custom interfacing was commonplace in order to overcome non-existent or inefficient standards. It became clear that true standards-driven interoperability was required.
The Interoperability Era – While the Integration Era continued to experience infusion of new technologies and a race to keep up with demand, healthcare technologies began to struggle with large-scale implementation. The Interoperability Era represents our current period and one which focuses on system providers deploying capabilities designed for not only one-to-one integration, but one-to-many interoperability. This need has become increasingly evident over the past five years. Indicators of this shift in focus to interoperability can be identified with previously well-respected companies beginning to suffer from government policies and political backlash. Current government requirements dictate the utmost interoperability and delivery based on their initiatives and definitions of interoperability. An example of this scrutiny was seen in early 2014 with sustained criticism of Epic Systems' interoperability. And not only is this a requirement dictated by government entities, the emerging demand for a consumer-based service requires that a multitude of systems must interconnect to display a longitudinal service line of care. These requirements clearly dictate the rising demand for interoperability based standards.
The shift to the Interoperability Era is also evident with the underlying push for iterations of standards such as HL7 FHIR (Fast Healthcare Interoperability Resources) which addresses a methodology change from solving 20% of exceptions to meeting 80% of system use cases. This change is evidence that creating consistency and streamlining data exchange is a key component of interoperability. Not only is system data exchange methodology undergoing standardization, so is the exchange of image objects. Now that multitudes of imaging systems are required to interconnect and synchronize changes in real-time, the birth of transport and change control standards such as IOCM (Image Object Change Management) are being developed. However and in the case of both examples, all interconnected systems must adhere to the finalized standard for it to be implemented successfully. This means each system provider must begin accounting for the applicable standards and rapidly develop capabilities to implement them as they are finalized. Although these are only two ongoing standards, many other standards continue to iterate, emerge, or repurpose. For instance, existing web standards have recently been adopted as an efficient method for image transport, access, and display. Medical image viewing providers are breaking away from proprietary software applications and cumbersome transport protocols and have begun utilizing existing web-based standards. This combination allows image distribution to function with consumer based products such as commercial browsers and mobile technologies, resulting in flexible low-overhead applications.
The Unification Era – As we round out the interoperability era in the upcoming years, we can continue to expect larger amounts of systems to operate cohesively. This cohesion will provide a collaborative and unified approach to presenting data in a single interface of the user's preference, regardless of the origin and format. In fact, we already see some of this taking place with the big data initiatives and aforementioned EMR (Electronic Medical Record) systems. These systems attempt to aggregate multiple sources of data and present them with in a single and normalized user interface. VNA (Vendor Neutral Archives) have existed for a period of time, but are now gaining traction as organization understand the need to consolidate imaging data in a single platform. At one point, we considered imaging data to be radiology-specific and DICOM only. We now appreciate imaging data as an aggregation of all types medical imaging collected within (or outside of) a healthcare organization, regardless of type. This includes cardiology, pathology, dermatology, wound care and any other sources and service lines where images are acquired.
Unfortunately, the consolidation of contextual data (EMR) and image data (VNA) still requires mutually exclusive interfaces for visualization. Much the same as we saw with reconsideration of medical imaging types, the expectation that contextual data should be considered an image when "visualized" will shift in how we perceive it should be handled. This means all "data" will be considered an image when visualized by the consumer. Inversely, it also implies that all image-type data be considered "data" when utilized for analytics. Over time and during the unification era, consumer demand to visualize both contextual and image data within a single interface will drive providers to rethink how they approach managing data.
The Holy Grail and The Source of Truth
Ultimately, this era of unification will not only account for a consolidation and reconsideration for how we manage data (image, contextual, or otherwise), but also visualization and manipulation of this data within a single interface of the consumer's needs or choice. This dramatically changes what we consider the "source of truth" in respect for presenting data. Historically, consumers have utilized applications directly connected to the native source of the data they wish to view. The "source of truth" was almost always the native repository and provided a myopic view of available data. Multiple interfaces were required to view multiple sources of truth, which limited the ability to aggregate and calculate correlation and causality of information. The advent of unification, consolidation and innovation will allow healthcare information technology to assemble multiple "source of truth" sources into a single interface for consumer access. Depending on the consumers need, an application may aggregate many different sources of truth to the user, manipulated and visualized in very different ways from application to application. From a user's perspective, the specific applications will become a virtual or proxy "source of truth" in which data is handled and presented according to the requirements of the application.
As we apply these 5 eras of technological evolution to the healthcare system, we begin to see the timeline of a consumer-based product unfold. Although many components will continue to emerge and iterate through these 5 eras, it is clear that we are in the midst of an age of interoperability. The success of Unification Era, and the product as a whole, depends greatly upon the outcome of interoperability. Although the Unification Era is inevitable and failures simply delay evolution, the industry must continue the path towards interoperability and standards to sustain an environment of highly collaborative technology.
Dave Whitney is a Senior Consultant at Ascendian Healthcare Consulting and a frequent contributor to the subject of Health Information Technology. You may contact him directly at dwhitney@ascendian.com or visit the Ascendian website for more information at www.ascendian.com.
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