Border control

Neil Versel

There are some who think that cross-European interoperability will promote high-quality, efficient care between institutions and across national frontiers. But other evidence and opinions suggest that it is only one step along a challenging path.

Nevertheless, the topic is gaining more and more attention – an interoperability showcase from the international Integrating the Healthcare Enterprise (IHE) project was a centrepiece of this month’s World of Health IT conference and exhibition in Geneva.

“I think the idea of having interoperability across borders in Europe is a noble one, but it’s light years away,” says Murray Bywater, managing director of Hampshire-based Silicon Bridge Research. “A lot of the perceived wisdoms in this area are just plain wrong. They’re just fantasy.”

“It’s a seriously, seriously difficult challenge. It’s not just a technical challenge, it’s an operational challenge.”

Standardisation in any large industry is a long process, perhaps 10 years or more, and healthcare tends to move more slowly than most. “The question is: What do you use in the meantime?” Bywater says.

There is an adage in the US: ‘Don’t let perfection be the enemy of progress.’ The phrase, often attributed to internationally known patient safety advocate Dr Donald Berwick and frequently invoked by former US national health IT co-ordinator Dr David Brailer, certainly can apply to many European health systems.

A more pragmatic approach than aiming for a comprehensive, pan-European health record would be to narrow the focus to specific health communities, such as a local population or a group of patients with diabetes, Bywater suggests.

Bywater says that international record-sharing might be feasible in the context of a bipartite agreement between countries, such as the one that provides care for British citizens who spend their winters in Spain. “We don’t have the availability of treatment across borders yet,” he says, “Interoperability is meaningless if there is no provision for care.”

And then there are the issues of confidentiality and security. “If I were living six months out of the year in Spain, I wouldn’t necessarily want to have my health records online,” Bywater says. “But I would want to have my medication list online.” It also would be helpful for a foreign doctor to have information on chronic diseases or allergies, he adds.

Care before records

In some areas, access to care is a greater issue than interoperability or even basic information technology, says Joan Dzenowagis, a project manager with the World Health Organisation. While Dzenowagis witnessed this phenomenon first-hand while touring India, she says that it could equally apply to some of the less-developed Central European members of the EU.

“Given the choice between ICT and access, people are going to choose access every time,” Dzenowagis says.

Even in a single, large system like Kaiser Permanente in the US, interoperability is proving elusive. Kaiser is trying to build a common electronic health record for its 8 million patients and 12,000 physicians scattered across nine operational regions.

At the Geneva conference, EHR programme director Bruce Turkstra reported that the largest population Kaiser can exchange full medical information for is about 1.5 million to 2 million people. The rest just get health summaries, many of which are derived from payment claims rather than actual clinical data.

Fragmentation is prevalent even in Denmark, which has a total population of just 5.3 million, says Henrik Bjerregaard Jensen, chief executive of MedCom, the Danish national healthcare data network. But MedCom is overcoming barriers by cutting off bite-sized pieces.

Discharge and referral letters can be automated by interoperable messaging systems, Jensen says, and MedCom has done just that by specifying a single electronic form for each type of letter.

Since 1999, about 4,000 health institutions across Denmark with at least 100 different IT systems have built electronic messaging links are linked electronically, he says. Today, 81 per cent of e-prescriptions, 84 per cent of discharge orders and 97 per cent of lab reports traverse the MedCom network in standard format.

“Start with the basic needs,” Jensen advises.

Identification management is just emerging on the national level in most of Western Europe, says Dr Ramin Tavakolian of the Berlin-based Central Research Institute of Ambulatory Health Care in Germany, so full-fledged international projects simply are unrealistic in the near term.

Language

Ilias Iakovidis, deputy head of e-health in the EC’s Directorate General for Information Society and Media, says that mobility of the population across the EU is the “biggest nightmare” to those planning international interoperability of health information. Language and semantic barriers are among the myriad hurdles.

“The best way to address these problems is using a concept-based lexicon engine built upon a common pool of standardized, codified medical concepts,” says Theo Bosma, vice president of global sales for US-based Health Language Inc., who was in Geneva to present a session on clinical terminology.

The EC essentially is requiring every member state and some membership candidates to develop national plans for interoperability, through a Turkish-led programme called A Roadmap for Interoperability of eHealth Systems (RIDE). Iakovidis likens it to an international translation box since the participants have determined that is unrealistic to have one clinical data model for all of Europe.

Work on integration is happening at a governmental level within Europe. The EC’s e-health office is about half-way through a two-year project to determine how healthcare providers can issue a basic patient summary for use across borders.

Furthermore, the European Health Telematics Association (EHTEL) is attacking a single component — namely e-prescribing — as part of its Interoperability of Identification Management in eHealth (i2 Health) project. Based on a workshop on this topic in Amsterdam last March, i2 Health recommended “running demonstrators to achieve and prove cross-border interoperability,” following accepted European regulatory processes.

Both projects represent small but important steps along the road to international transition.