The HIMSS 2013 Definition of Interoperability says,
In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged.1 Data exchange schema and standards should permit data to be shared across clinicians, lab, hospital, pharmacy, and patient regardless of the application or application vendor.2 Interoperability means the ability of health information systems to work together within and across organizational boundaries in order to advance the health status of, and the effective delivery of healthcare for, individuals and communities.3
There are three levels of health information technology interoperability: 4
1) Foundational;
2) Structural; and
3) Semantic.
1. “Foundational” interoperability allows data exchange from one information technology system to be received by another and does not require the ability for the receiving information technology system to interpret the data.
2. “Structural” interoperability is an intermediate level that defines the structure or format of data exchange (i.e., the message format standards) where there is uniform movement of health data from one system to another such that the clinical or operational purpose and meaning of the data is reserved and unaltered. Structural interoperability defines the syntax of the data exchange. It ensures that data exchanges between information technology systems can be interpreted at the data field level.
3. “Semantic” interoperability provides interoperability at the highest level, which is the ability of two or more systems or elements to exchange information and to use the information that has been exchanged.5 Semantic interoperability takes advantage of both the structuring of the data exchange and the codification of the data including vocabulary so that the receiving information technology systems can interpret the data. This level of interoperability supports the electronic exchange of health-related financial data, patient-created wellness data, and patient summary information among caregivers and other authorized parties. This level of interoperability is possible via potentially disparate electronic health record (EHR) systems, business-related information systems, medical devices, mobile technologies, and other systems to improve wellness, as well as the quality, safety, cost-effectiveness, and access to healthcare delivery.
Why A Need for Standards?
The healthcare delivery system today employs many different information systems from different vendors, both within a single organization and across multiple organizations. For example, a hospital may have a laboratory system from one vendor, a pharmacy system from another vendor, and a patient care documentation system from a third vendor. Physicians affiliated with the hospital also have different systems in their offices, yet need access to data from the hospital on their patients.
In healthcare, standards provide a common language and set of expectations that enable interoperability between systems and/or devices. Ideally, data exchange schema and standards should permit data to be shared between clinician, lab, hospital, pharmacy, and patient regardless of application or application vendor in order to improve healthcare delivery.
Categories of standards in health informatics include:
·Data exchange standards
·Vocabulary standards
Data exchange standards
These are the standards that help to share medical summaries, prescription and the structured electronic documents)
1. HL7 Clinical Document Architecture (CDA) is an XML-based mark-up standard developed by the organization Health Level 7 International (HL7) to help define the structure of clinical documents. A CDA document contains Radiology reports, Patient summary, Discharge summary, Referrals, Claims attachments, Infectious Disease Reports etc. that means it can include text, images, sounds, and other multimedia content. The CDA document exists independently outside a transferring message and can also be sent inside an HL7 message.
2. HL7 v2.x is one of the most widely implemented standards for healthcare information in the world. This messaging standard allows the exchange of clinical data between systems. It provides a framework for the exchange, integration, sharing, and retrieval of electronic health information. HL7 v2.x has allowed for the interoperability between electronic Patient Administration Systems (PAS), Electronic Practice Management (EPM) systems, Laboratory Information Systems (LIS), Dietary, Pharmacy and Billing systems as well as Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems.
3.Continuity of Care Record (CCR Continuity of Care Record (CCR) is a health record standard specification developed jointly by ASTM International, the Massachusetts Medical Society (MMS), the Healthcare Information and Management Systems Society (HIMSS), the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), and other health informatics vendors. CCR is designed to be a summary of everything that has happened to a patient till now. It is a core data set of patient demographics, insurance and health care provider information, medication lists, allergies and recent medical procedures. It helps the healthcare provider or application system in aggregating all the relevant data about a particular patient and sharing it with the other thus supporting the continuity of care. The Security Standards and the Privacy Standards must be established such that it allows only authenticated and authorized access to the CCR document, also maintaining the confidentiality of the data.
4. Digital Imaging and Communications in Medicine (DICOM) is standard in the health informatics that facilitates the exchange of digital information (medical images, waveforms and related information) between medical imaging equipment and other systems allowing interoperability. DICOM now uses upper layer protocol (ULP) over TCP/IP as the lower-layer transport protocol. The standard was developed jointly by ACR (the American College of Radiology) and NEMA (the National Electrical Manufacturers Association) after the ACR-NEMA standard (image exchange standard) showed no success despite being revised several times.
Vocabulary Standards
These are the standardized nomenclatures and code sets used to describe clinical problems and procedures, medications, and allergies. This is to be achieved through the substantial use of Controlled Medical Vocabularies (CMV) that is detailed as follows:
1. Logical Observation Identifiers Names and Codes (LOINC®): It is a universal code system for identifying laboratory and clinical observations. It helps in exchange of clinical results for clinical care. The Regenstrief Institute Inc., an internationally renowned healthcare and informatics research organization, maintains the LOINC database and supporting documentation, and the RELMA mapping program.
2. International Classification of Diseases (ICD10): The ICD is the international standard diagnostic classification for all general epidemiological, health management and clinical purposes. It is used to keep track on the incidence and prevalence of diseases and other health problems.
3. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT): is a standardized, multilingual vocabulary of medical terminology that is used by physicians and other health care providers for the electronic exchange of clinical health information. SNOMED CT provides a standard by which medical conditions and symptoms can be referred by using the numbers that represents the medical concepts. This will help eliminate the confusion resulting from the use of colloquial terms. It is originally created by the College of American Pathologists (CAP) and owned, maintained, and distributed by the International Health Terminology Standards Development Organization (IHTSDO), a non-for-profit association in Denmark.
4. Current Procedural Terminology, 4th Edition (CPT 4): The CPT-4 is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by entities such as physicians, health insurance companies and accreditation organizations.
5. RxNorm: RxNorm, produced by the National Library of Medicine (NLM) provides normali
zed names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software, including those of First Databank, Micromedex, MediSpan, Gold Standard Alchemy, and Multum. By providing links between these vocabularies, RxNorm can mediate messages between systems not using the same software and vocabulary.
6. ATC – Anatomic Therapeutic Chemical Classification of Drugs: is used for the classification of drugs. It is controlled by the WHO Collaborating Centre for Drug Statistics Methodology (WHOCC), and was first published in 1976. This pharmaceutical coding system divides drugs into different groups according to the organ or system on which they act and/or their therapeutic and chemical characteristics. Each bottom-level ATC code stands for a pharmaceutically used substance in a single indication (or use). This means that one drug can have more than one code: acetylsalicylic acid (aspirin), for example, has A01AD05 as a drug for local oral treatment, B01AC06 as a platelet inhibitor, and N02BA01 as an analgesic and antipyretic. On the other hand, several different brands share the same code if they have the same active substance and indications.
According to the “Recommendations on Electronic Medical Records Standards in India” -FICCI Health Services here goes the Healthcare IT Standards that are recommended for India.
Recommended Healthcare IT Standards (for India)
Chapter8
Data Privacy and Security
The Data Privacy and Security Standards are interlinked. Safeguard is required for any health record system to confirm that the data is present in the system whenever if it is needed and that the data is not inappropriately used or accessed. As data security and privacy standards are interconnected to each other they work together to establish controls and protections. Health sector entities which are required should comply with both security as well as privacy standards.
There are several factors that the organization must consider for adapting security measures. The organization must keep in mind its capabilities, software and hardware security capabilities, technical infrastructure while deciding adoption of security measures.
The healthcare providers should comply with the security standards for implementing reasonable and appropriate administrative and technical safeguards.
Purpose of the Security Standards
The healthcare providers are required by Security Standards to implement appropriate administrative, physical and technical safeguards:
·To ensure that the e-PHI that is created is confidential, integrated and is available or not.
·To protect data against threats to the security of their e-PHI.
·To protect the e-PHI against uses which are not permissible under the privacy standards.
·It is to make sure that only the individuals who have authorization have access to the information.
·It is also to make sure that the individuals who have authorization to access the information keep the information secure and safe.
·To ensure whether the e-PHI is accountable or not.
Advantages of present age Health Information Systems
Present age Hospital Information Systems like SaaS applications definitely have a serious advantage over the traditional medical practice and the hospital management.
Reduces cost: An application with which hospitals plug in & subscribe to services on per transaction basis. It is built on shared infrastructure and resources. You pay as much as you use. Offline mode should be possible. It provides EMR, telemedicine platform, integrated wallet card technology, PC kiosk based and mobile-based technology. Most players have one or two, but not all of the above solutions. It upgrades are at source and the business will have access to them as soon as the application is accessed. Hospitals are not required to buy, build, secure & maintain their servers. Patches and updates are not required to be bought.
Reduce time because installing, deploying & maintaining servers that are required in the legacy software is avoided in a SaaS application. Cost of implementing updated legacy software is five times the cost of the original license. Legacy software bought today gets obsolete in less than 3 years. Cost of obsolesce is triple of the original cost of purchase of legacy software.
Improves quality with the integrated Quality performance indicators as required by NABH.
The HIS should provide value additions to the patient’s hospital experience. It should bring in the WOW factor by providing the following: For example, Generating of a unique privilege card with a QR code for every patient, which embeds patient health records, Retrieving hospital reports and discharge summary by logging onto the hospital website, Voice message reminders for review and medicines, Online self Scheduling of appointments with consultants and obtaining second opinions by logging on to the hospital website, Pizza hut module for caller identification at the Front office, MMS messaging by the doctors to them and an integrated Tele medicine module.
Risks & barriers
Risks are hacking, vendor longevity, Downtime, Data ownership once contract is terminated. Barriers include Customer awareness of services, customer mindset not willing to accept shared resources, Security, Ecosystem maturity, Connectivity: all of which we have addressed.
Chapter9
Application specialist and trainer
As regards the hospital application is concerned there are application specialists who works in coordination with the software vendor performing the activities which are required in implementing the software. Besides this the trainers give training to the employees of the hospital.
For the role of application specialist, an application specialist should be well versed with the software that can approach professionally implementing the information system and also give the support facility. Besides implementation process the application specialist needs to give the training to the employees of the hospital about the usage application.
Application specialist has multi-tasking role which are as follows:
·Reviewing and analyzing organizational needs; contacts with the users to evaluate requirements, discuss solutions and develop plan of approach.
·The application specialist has to analyze the software and then design program logic, screen layouts, reports to support development of new or enhanced systems.
·The application specialist prepares a program document to support new or enhanced applications.
·Application specialist always participates in activities regarding system reviews and also provides support and training.
·Application specialist performs application maintenance and also reviews the application.
Chapter10
Systems administrator/Database administrator
The responsibility of systems administrator-cum-database administrator is to administrate systems and to handle all database backup and restoration activities.
As a database administrator, you have the responsibility for performing, integrating and securing a database. However, depending on the organization and your responsibility, the role can vary from inputting information through to total management of data. In hospitals for information management system, databases will record patient’s detailed information. This information is used to structure and organize the patient management system in hospitals.
Depending on the level of responsibility, typical tasks may include:
·Assisting in database design.
·Making changes and updating the existing database.
·Creating and testing new databases.
·Regularly monitoring efficiency of database.
·Maintaining the security and integrity of data.
·Creating complex query definitions for data to be extracted.
·To train colleagues to how to input and extract data.
Besides the database administrators the system administrators have a role to play. Their work is to maintain all the systems and check them in regular time interval.
Chapter11
Hardware and Network Engineers
> Maintenance of the hardware and network systems in the hospital is the responsibility of the hardware and networking engineers. The main aim of hardware and networking engineers is to troubleshoot the systems and keep them working and making the patient’s data available to the doctors and nurses.
In EHR’s overall performance it is necessary to choose the proper hardware system. To compare the present hardware and networking components always take the technology inventory as a part of your selection process.
·The IT hardware used should be in compliance and fulfill the optimal requirements required by the software used.
·The medical and IT hardware used must comply with the specifications given by BIS, NEMA, ISO apart from Medical and IT standards for the equipment.
·A backup or data storing device should be available. The capacity of storage device should be planned to meet the storage requirement as per the mandated rule.
·All the hardware devices should be checked regularly for correctness and completeness of operation expected from them.
·Planned and expected Capacity and Quality requirement of the organization should be met by the hardware used.
Networking and Connectivity
It is the work of the network engineer to select appropriate network media types for helping the data exchange and account accessing process. He is also responsible to select the related hardware devices that are required for the networking purposes.
·Should be able to resolve and or control any telecommunications-related connectivity issues like the Internet, LAN, WAN, WAP, CDMA, GSM or even Cloud Computing that will permit the various EMRs of an individual to be integrated into a single lifelong electronic health record.
·As far as practicality and affordability is concerned, the reliable connectivity medium should be chosen which should also be fast enough to sustain a secure data exchange for the period expected for transaction of records and data.
·It should be able to ensure that there is secure data exchange to ensure data validity.
·It must be ensured that data integrity is maintained at all times.
Chapter12
Security of SaaS