Monday, February 18, 2008


Health Care Interoperability Dilemma

I’m currently reading through Dave McComb’s book, “Semantics in business systems” and finding certain chapters particularly meaningful to my master’s degree final project. Especially interesting is the section dealing with ‘Strategies for coping with integration’ on page 229. This is something I have been dealing with in the health care arena for a long time when developing internal applications, or integrating new proprietary systems. McComb discusses five approaches to system integration which include; Manual, big database, direct connect, point to point and message based. I certainly understand the semantic limitations of implementing some of these strategies (manual, big database, direct connect, and point to point), although I’m perplexed at the direction of both organizational and enterprise interoperability in health care given the current proprietary environment.

My final project, involving two other extremely talented iSchool colleagues (Jill Blue Lin and Katherine Ahern), is attempting to build a multi-device, clinical note entry and retrieval system for hospitals. Our focus is on prototyping some new technology involving voice and text menus, along with refining the process for note capture and retrieval. In the past few weeks, as our needs assessment has progressed, we have discovered how many clinical systems are tied into the note collection process. First, you need to have access to all the clinical staff information to associate a physician to a particular note. Then, it’s important to have access to ADT (Admission, Discharge and Transfer) messages, or the patient master table to associate a particular note to a patient. Finally, notes are closely tied to the hospital scheduling system. Administrators will often look at both scheduling and registration to find those patients that never had a note entered while at an outpatient clinic.

Given that all this information is critical in developing an application that’s meaningful to clinical note entry and retrieval, what’s the best way to proceed with integration? The problem with pursuing the majority of solutions discussed by McComb is that you’re duplicating the information that’s already available in a different system. Even the message broker solution (which is accomplished by HL7 engines in health care) provides the same messages to various systems to be stored independently. In addition, some added or edited information might not trigger a message to be generated. For example, a resident finishes a rotation with a particular hospital and is inactivated from the system. Should this edit not trigger and HL7 message and dependent application are not notified, there could be a variety of negative impacts (incorrect billing, compliance issues, etc).

What’s the next step for better integration? How can this issue of repetitive storage and asynchronous information be solved? Will the major vendors within the industry (GE, McKesson, EPIC, Siemens, Cerner, etc.) provide a web service or API for other companies to add value to their platform?

To twist Hamlet a bit, "To duplicate, or not to duplicate, that is the question." Duplication of data is certainly easier but raises integrity and security issues. There is a highly relevant paper in the Document Engineering course syllabus coming up on 20080303 -- "Key Issues of Technical Interoperability Solutions in eHealth and the RIDE Project" -- be sure to read it carefully.
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