Interoperability & standards

Interoperability and
Standards
Healthcare Scenario 1
Admitting Orders from a Clinic
to a Hospital
J. Don M. Soriano, MD MBA

Healthcare Scenario 1
Dr. Santos (Internal Medicine) uses
an EMR called ClinicSys. He uses it
for SOAP notes, clinical abstracts,
referral letters and admitting notes.
He is a consultant at Reyes General
Hospital (RGH). RGH has a Hospital
Information System (HIS) called
HospitalSys. Dr. Santos wants to
send a patient for admission (with
admitting orders) to RGH. Dr. Santos
wants to get notice that patient has
been admitted.
• I chose Scenario 1 because
it is the one I am most
familiar with and can relate
to. My discussion though is
limited by my current
knowledge of IT applications
and terminologies.
• I tried to deconstruct the
problem, seen from the
perspective of a hospital
administrator faced with an
issue, looking for solutions.
Research notes were
included to supplement my
answers.

Points to Consider
• Interoperability is “the ability of different information technology
systems and software applications to communicate, to exchange data
accurately, effectively, and consistently, and to use the information that
has been exchanged.”
• There are two parts to that definition - the exchange of data and the
use of that data that has been exchanged. Interoperability issues can
arise from any part of this equation.
• “Data has to move between two or more systems – the exchange of
information. The receiving system and users must be able to process
and use the data. To “use” the data we need to ensure that it’s
delivered in a way that can be easily understood by the receiving
system and users so it can be applied. That’s where semantic
interoperability enters the picture.” - Dennis Giokas

• In my previous blogs, I discussed the issues with regard to
people, processes, technology and financial resources. Looking
at it from another perspective, these factors can be seen in the
Ishikawa Fishbone diagram for root cause analysis.
• Modifying this a bit to fit the context of the discussion, we can
come up with these diagrams:
People Process
Technology Content
Interoperability
Issues

Interoperability
Issues
People Process
No clear strategic direction for
evolutionary changes in overalll
technology environment of HIS
Limited IT knowledge of
medical staff
Limited IT knowledge of
admitting section staff
EHR may need upgrade
or replacement
HIS may need upgrade
or replacement
Poor integration
between components of
HIS
Poor quality of information -
lack of consistency, duplication,
out-of-date information
Poor Database Design -
table of data elements
may need normalization
Technology Content
We then use this diagram
to determine project goals

What entities are involved?
• Dr. Santos
• Doctor’s EMR (ClinicSys)
• Reyes General Hospital HIS
(HospitalSys)
• Admitting Section, Reyes General
Hospital
Information System 1
(EMR ClinicSys) creates
admitting order, sends
admitting order to
(HospitalSys)
(HospitalSys) receives
admitting order, sends
notice when patient is
admitted to Information
System 1 (ClinicSys)
Assumption: Notice of patient admission
is sent once the patient has a room

What applications need
to talk to each other?
• Doctor’s EMR (ClinicSys)
• Reyes General Hospital
HIS (HospitalSys)
• Integrated components of
HIS:
1. Databases - Patient
Registry and Medical Staff
with admitting privileges
2. Room Management
System
Patient
Registry
Directory
Medical Staff
Room
Management
System

Project goals for making applications
talk to each other
• Evaluate cause and effect factors by
reviewing Fishbone diagram
• Create an IT support group for medical
staff
• Form a technical working group which
includes medical staff, hospital
management, IT support group to discuss
ways to integrate disparate doctors’
systems and hospital system
• Determine standards needed such as
data content standard, data exchange
standard
• Identify and prevent data level conflicts
• Re-train hospital staff regarding data
collection and coding
“ Data level conflicts are differences in data which can
be caused by multiple representations and
interpretations of similar data.
Examples of data level conflicts are data-value
conflicts, data representation conflicts, data-unit
conflicts, and data precision conflicts.
Data-value conflicts are conflicts in data values. Data
values may mean different things depending on their
relationships to other factors.
Data representation conflicts happen when the same
data is represented in different ways (dates can be
represented as 9/17/2006, 17-9-2006 and/or
September 17, 2006).
Data-unit conflicts are those where the same values are
represented in different units – feet, yards, meters, etc.
Data precision conflicts happen when the same type of
data is represented in ways that differ conceptually.” -
From System Interoperability by Jennifer Macaulay

How can we make disparate systems and
applications talk to each other?
• Database translation
approach
“ The database translation approach is a
point-to-point solution based on direct
data mappings between pairs of
information systems. The mappings are
used to resolve data discrepancies
among the systems. The database
translation approach is most appropriate
for a small-scale information-processing
environment with a reduced number of
participants. The number of translators
grows with the square of the number of
components in the integrated system.
The corresponding translators must be
placed between the information
systems.”
Information in IS1 is represented by vertical lines, while the information in
IS2 is shown as horizontal lines representing a disparate system.

• Federated systems
approach
“Federated systems consist of a set of
heterogeneous databases in which federation users
can access and manipulate data transparently
without knowledge of the data location. Each
federation database includes a federated schema
that incorporates the data exported by one or more
remote information systems. There are two types of
federations: A tightly coupled federation is based
on a global federated schema that combines all
participant schemas. The federated schema is
constructed and maintained by the federation
administrator. A loosely coupled federation includes
one or more federated schema that are created by
users or the local database administrator. The
federated schema incorporates a subset of the
schema available in the federation. This approach
becomes rapidly complex when the number of
translators required becomes large.
The federated system is made only of horizontal
and vertical lines that IS1 and IS2 want to
exchange.”

• Ontology approach
“ The ontology-based
interoperability approach uses
ontology to provide an explicit
conceptualization of the common
domain of a collection of information
systems. An ontology defines a
common vocabulary that can be
used by users from different
systems. The construction of an
ontology for a domain is a difficult
task and often requires merging
existing overlapping ontologies. The
interoperability solutions based on
ontology describe the semantics of
information rather than their
organization or their format.”

• Standardization approach
“ In the standardization approach, the
information sources use the same model or
standard for data representation and
communication. The use of a standard
metamodel reduces the number of
translators (this number grows linearly with
the number of components) to resolve
semantic differences. However, the
construction of a comprehensive
metamodel is difficult; the manipulation of
high-level languages is complex; and there
are no unified database interfaces.
A centralized information system can be
built to replace the original information
systems (IS1, IS2). The global centralized
schema is a combination of the data
(horizontal and vertical lines) contained in
IS1 and IS2.”

• Multi base approach
“ Language-based multibase systems
consist of a loosely connected
collection of databases in which a
common query language is used to
access the contents of the local and
remote databases. In this approach, in
contrast to the distributed and
federated systems, the burden of
creating the federated schema is
placed on the users, who must
discover and understand the
semantics of the remote databases.
This solution is well adapted for
information systems that are based on
the same family of data models and
do not require complex query
translators.”

• Mediation approach
“ The mediation approach is based on two
main components: mediator and wrapper.
The mediator is used to create and support
an integrated view of data over multiple
sources. It provides various services to
support query processing. For instance, a
mediator can cooperate with other
mediators to decompose a query into
subqueries and generates an execution
plan based on the resources of the
cooperating sites. The wrapper is used to
map the local databases into a common
federation data model. The wrapper
component provides the basic data access
functions. In the diagram, a translator,
which acts as a wrapper, is placed
between the conceptual representation of
the mediator and the local description of
each information source.”

• WS approach
“ As new data models are developed for Web-based
information systems, there is a need to extend
interoperability solutions to take into account
requirements and specifications of the new models.
The existing Web technologies are not initially intended
to address some of the issues involved in database
integration. For instance, the Web-browsing paradigm
is efficient for data lookup in a large environment, but it
is inadequate for database integration support. To use
this paradigm to locate and merge data requires costly
applications that are often tailored to specific
integration needs. New challenges have arisen from the
development of Web-based information systems. One
of the challenges is the need to develop Web-oriented
tools to support information integration and allow
access to local as well as remote information sources.
Recently, Web services (WS) have been proposed as a
method to address some of the challenges of Web-based
integrated systems. A Web service can be
viewed as a set of layers contained in a stack. The
layers are dynamically defined following user needs
and are called through a set of Internet protocols.”

What’s next?
• “Health Level-7 or HL7 refers to a set of
international standards for transfer of clinical and
administrative data between Hospital information
systems. These standards focus on the application
layer, which is "layer 7" in the OSI model.” - HL7.org
• “SNOMED CT or SNOMED Clinical Terms is a
systematically organized computer processable
collection of medical terms providing codes, terms,
synonyms and definitions used in clinical
documentation and reporting. It is considered to be
the most comprehensive, multilingual clinical
healthcare terminology in the world. The primary
purpose of SNOMED CT is to encode the meanings
that are used in health information and to support
the effective clinical recording of data with the aim
of improving patient care. SNOMED CT provides
the core general terminology for electronic health
records. Its comprehensive coverage includes:
clinical findings, symptoms, diagnoses,
procedures, body structures, organisms and other
etiologies, substances, pharmaceuticals, devices
and specimen.” - ihtsdo.org
SNOMED

Proposed solutions
• Option - Check if an upgrade for
both Information Systems would
resolve the problem
• Option - Upgrade the Hospital
Information System, find out
which Clinic Systems are
interoperable then inform doctors
of these systems, have them
switch
• Option - Replace present Hospital
Information System with another
having a strategic intent of
interoperability with other systems
• Option - Use Database
translation approach if only
the ClinicSys of Dr. Santos is
to be considered
• Option - Use Standardization
approach if several other
doctors have their own
disparate information systems
• Option - Consider a Web-based
platform information
system for everyone to use

Data elements
• Date
• Doctor’s name
• Specialty
• Status (category of doctor’s Hospital
Admitting Privileges eg. Active Rotating,
Visiting Staff with admitting privileges
etc.)
• Patient’s name
• Patient Hospital ID number
• Patient’s birthday
• Account number (number which serves
as unique identifier for present
admission)
“Data elements are the smallest named item of data that
conveys meaningful information or condenses lengthy
description into a short code. It is called data field in the
structure of a database.”
“The data that is stored in tables is organized in a logical
manner based on a particular purpose to help minimize
duplication, reduce data anomalies, and reinforce data
integrity. The process by which data is logically
organized is called normalization; it not only simplifies the
way data is defined, but it also regulates its structure.”
“Stored data is manipulated using a programming
language called Structured Query Language, or SQL.
Many varieties of SQL exist, but most are based on set
theory relational operators such as and, or, not, and in, all
of which are used to perform operations on the data. The
operations that can be used in relational databases
include insert, select, update, and delete privileges.
Since the early 2010s, the relational database
management system (RDBMS), is the most commonly
used database format.”- wisegeek.org/what is a relational
database

Trigger events
• At what point (activity or
event) in the process should
the transfer of information
happen? The trigger event
could be the creation of the
admitting orders.
• At what point in the
application/software process
should the transfer of
information happen? The
trigger event could be the
transmission of the admitting
order.
“In a digital health care system,
applications create HL7 messages
because of a real-world event. The HL7
organization has written the HL7 standard
based on the assumption that an event in
the real world of health care creates the
need for data to flow among applications,
even when these applications span
heterogeneous systems. The HL7 standard
calls this real-world event a trigger event.
An automated system must systematically
recognize the trigger event.
Trigger events always result in the creation
of one or more messages that trigger an
action in the application that processes the
message.” - msdn.microsoft.com

Reference
• http://what-when-how.com/
information-science-and-technology/
interoperability-of-information-
systems/
“Standards are enablers.
Interoperable systems are what
support the business
and clinical requirements in a
typical e-health agenda.”
Dennis Giokas
Emerging Technology Group

Interoperability & standards

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