Special Report: Interoperability
Writing the future
Over the past year, there has been an explosion of frameworks, declarations and charters supporting interoperability.
But are they promoting the right things? Is action happening fast enough? Do they have the levers to engage suppliers? And are trusts asking the right questions? Daloni Carlisle asks the experts.
Interoperability used to be the territory of the techie. Now it’s a buzzword bandied about by everyone who is anyone in health policy and clinical leadership; not least because the last 12 months have seen an unprecedented flurry of activity.
A year is a long time in interoperability
A year ago, in March 2015, a new GPSoC framework specified that principal system suppliers must provide interface mechanisms to allow suppliers of subsidiary services to integrate with them.
Come the summer, and techUK launched an interoperability charter with more than 80 suppliers signing up to share their APIs without charging exorbitant fees and, where relevant, use internationally recognised standards.
In November, Code4Health’s Interoperability Community adopted a new mission to “create a common and open set of APIs to support information sharing across health and care”. NHS England has now started running events on interoperability for the Five Year Forward Vanguard sites.
On the clinical leadership side, in September 2015 the CCIO Network developed the Newcastle Declaration calling for a radical step change on interoperability to enable truly joined up healthcare. CCIOs and health CIOs are now working with techUK to take this forward.
Come February 2016, and over the other side of the Atlantic, HIMSS16 saw the announcement of a commitment from the major US providers – who together provide 90% of electronic health records – to adopt federally mandated, national interoperability standards to allow information exchange.
Setting the world on FHIR
Cerner is one of the large suppliers to have taken on the interoperability challenge and open its APIs with good effect – particularly in the USA. Cerner is backing the Fast Healthcare Interoperability Resources messaging standard FHIR and SMART healthcare app open standards through Project Argonaut.
Justin Whatling, Cerner Europe’s vice president for population health, who was fresh back from HIMSS 2016 when he spoke to Digital Health, says: “We have developed information for open APIs and this year will be releasing them within a sandpit environment.”
His starting point is the US-based Meaningful Use Stage 3 workgroup recommendations that set out a roadmap for developing electronic health records. “I think it is a sensible place to start,” he says.
In the US, Cerner is already working with app developers on draft APIs and plans to adopt them as soon as they go live. “There is no reason why this should not happen in the UK and we are looking for a use case to start,” he says.
In the first instance, this would allow app developers to take information from the Cerner EHR and use it to – for example – develop a growth chart in their app. The clever bit, says Whatling, would involve mapping SMART onto FHIR and moving that data visualisation back into the EHR. “I think this is the way it will go,” he says.
This work is all US based, and while NHS England is co-operating with US counterparts through what is known as a memorandum of understanding, Dr Whatling sees a danger.
“My main concern is that we do not create another set of proprietary UK standards,” he says. “That’s what we did with the ITK [interoperability toolkit] so the US suppliers did not develop the interfaces.
“The background conversations are taking place about adopting meaningful use and FHIR standards without messing about with them.
“There is the opportunity here for a free gift for the NHS, because the US will already have developed the open APIs. It would be good for the US vendors in the UK and also UK vendors in the US.
“So I hope that after eight years of doing nothing much we can get something of practical utility across the pond.”
Just doing it
Orion Health’s business is firmly in the interoperability sphere and naturally the company is signed up both to the techUK Charter and the Code4Health Interoperability Community. Orion supports a standards-based approach including the adoption of FHIR.
Colin Henderson, managing director for UK and Ireland says: “It’s a bit like preaching to the converted.”
Groundwork being laid out now in this space is all about shared clinical records. “People are focusing on getting the fundamentals right,” he says. “That’s what they are talking to us about.”
Only with this in place will innovation follow – whether that’s through integrating apps that support self management or mobilising rich data flowing from projects such as Genomics England and the 100,000 Genomes Project.
But Orion recognises the need for clinical leadership and six months ago appointed its first part time CCIO, GP Amir Mehrkar. “There is a maturity of understanding now that tech projects do not deliver on their own,” he says. “My role is to remind everyone of the clinical reality.”
Over at InterSystems, another supplier whose bread and butter is interoperability, David Hancock also majors on the clinical aspects.
Yes, he says, NHS trusts must become intelligent buyers of IT and demand more in the way of open APIs and adoption of international standards. But that will only happen if interoperability can be seen to answer compelling clinical cases.
He says: “It’s is a three legged stool where IT providers, policy makers and NHS and social care providers all come together around a real world, compelling problem and try to solve it.”
He points to InterSystems’ work with the shared end of life care record Coordinate My Care as an exemplar.
This project, run out of The Royal Marsden NHS Foundation Trust, has provided opt-in urgent care plans for more than 20,000 patients in London and Surrey, with a focus on access by out-of-hours services.
“The ambition of being able to share an end of life care record across potentially 5,000 care providers in London alone, so that people who hit a crisis get the right care,” Hancock muses. “This is a compelling problem to solve.”
Technically, Coordinate My Care uses a standardised level 3 structured CDA for the clinical document architecture. “We have proven it works and people are adopting it,” Hancock says.
Louise Caney, maternity and nursing product manager at System C, says: “If you’ve just seen a woman who’s a complex case, and you would like a second opinion, you have to take the paper notes away from the clinical area to find that person, because they might be in theatre or in clinic.”
Push me, pull you
And yet, and yet. There are persistent voices from within the supplier community that things are not moving fast enough, and that NHS England’s Code4Health Interoperability Community risks becoming bogged down in NHS processes. It’s a charge that is robustly defended (see below).
Conversely, trusts and interested clinicians have expressed concern that there are not enough levers to force suppliers who do not want to move in this direction to do so.
Paul Cooper is director of research at IMS MAXIMS where “interoperability is our primary focus”. He is also vice chair of techUK and is as keen as anyone to see action from the suppliers who signed up to the charter.
“I think people are doing what they said they would,” he says. “One of the challenges we have had from NHS England is how do you ensure that suppliers conform to what they have signed up to? To be honest, we are a trade body and we are not able to police it.”
Rather, he says, it should be up to trusts to hold their suppliers to account on this. “One of the concerns we have is whether trusts have enough information or enough knowledge to ask the right questions of the suppliers,” he adds.
“Trusts need to be informed buyers. We will be speaking to CCIOs and CIOs to get advice about the types of questions they need to ask.”
TechUK’s membership also includes the smaller suppliers and the organisation is now talking to HSCIC about how to lower the compliance barrier and make it easier for SMEs to share NHS data. “We need compliance to be free and fair for SMEs to play alongside the bigger boys,” says Cooper.
Following the map
There’s a long way to go, the roadmap is clearer than it ever been, but traversing it will be challenging.
Hancock, who worked in a variety of industries before healthcare, says: “Healthcare is the most vendor centric industry I have been in and there are lots of reasons for that. We are coming at this from a long way back. But that is not a reason we should not be putting energy into it.”
Code4Health Interoperability Community
Inderjit Singh, NHS England’s head of enterprise architecture, mounts a robust defence of the pace at which the Code4 Health Community is moving, and the way in which it is developing.
“The community is about changing the dynamics. It is about working with the service to understand the key needs and with vendors to understand what approaches need to be taken and the standards we need to adopt,” he says.
“It is a fundamental shift from top down dictat to consulting with a wide community – and that, of its nature, takes time.”
That said, in just a few short months he can point to some concrete achievements. January 2016 saw the first AGM and decisions taken on key priorities, including through wider discussions with the CCIO and CIO networks.
The priorities include the ability to share key patient safety data, managing long term conditions and creating timelines that track when people come into contact with different parts of the system along patient pathways.
“We are really starting to get a level of granularity and to develop a set of standards and specifications,” says Singh.
In February, NHS England held the first face-to-face workshops on interoperability for organisations; pioneering GP Access and Five Year Forward View vanguard sites. Alongside this, the community board members were confirmed, bringing in representatives from techUK, CCIOs, CIOs, NHS England and HSCIC.
Singh adds: “We have already identified key priority APIs based on scenarios and draft information models and from March we will be releasing draft specifications on a two weekly basis.”
Indeed, Singh has a challenge of his own. “What would be welcome would be people being more proactive,” he says. “The whole point is to be a community. If vendors want to get together – or if geographies want to work together – that’s what we are encouraging. “
One way or another, he agrees that work has to progress quickly, and he is prepared to put some markers in the sand for where he hopes to be in a year’s time.
“I think we will have initial APIs out there,” he says. “I think vendors will have confirmed these and we will start to see the service really thinking about the clinical process change.”
It’s not enough to have the APIs and the ability to share information, says Singh. Clinicians are going to have to change the way they work. And that is a whole other challenge.