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Interoperability
Computers need to interoperate so they can store and act on data from other computers in a reliable
and beneficial way without human intervention and translation.
[ Marshall Ruffin, M.D., M.P.H., M.B.A., F.A.C.P.E., Accenture ]
W
hat does interoperability mean? Imagine you have
traveled to London from the United States and arrive
in the morning after an overnight flight; you fall
asleep in your hotel to overcome jet lag and awake in the midafternoon somewhat revived and eager to clean up and get something to eat. You shower and prepare to use your corded electric
razor only to discover that the electrical outlet in England does
not receive the electrical plug of your American razor. You suffer
from a failure of mechanical interoperability — the plug doesn’t
match the wall jack. So you ring up the front desk and you ask
for an adapter. A member of the hotel staff brings the adapter
quickly and you plug it into the wall socket. Now your razor can
interoperate with the electrical system in England, right? Not
necessarily. When you turn on the razor nothing happens. The
electrical standards in England, the voltage and amperage, are
different than they are in electrical systems in the U.S. So while
you have mechanical interoperability with the converter given to
you, you do not have electrical interoperability. For your electric
razor designed for the U.S. to work in England, you need both an
adapter for mechanical interoperability (plug-to-jack interoperability) and a transformer for electrical interoperability, which
changes the voltage and amperage to what your razor requires.
At this point either you ask the hotel staff if they have a transformer, or you ask the hotel staff to sell you a manual razor and
shaving cream. The electrical appliance you brought from the
United States does not interoperate with the electrical system in
the U.K. on two levels because mechanical standards and electrical
standards do not match.
Similarly, imagine that after you shave with the manual razor
you dress and leave your hotel hoping to find an appealing restaurant. Looking about you do not see one, so you approach the near-
est person to ask directions. That person happens to be a visitor
from Germany who speaks little English and does not know
the city at all, having just arrived the day before from Berlin.
Here again you face a failure of interoperability. That person
does not speak your language well enough to converse with
you. You turn to another person walking by dressed in a tweed
jacket and kilts and ask him about restaurants in the neighborhood and he replies in exemplary English that he is a visitor to
London from Inverness, Scotland, and cannot recommend any
restaurant. You have interoperated in language but not in content
knowledge. The third person walking by is Asian and smiles agreeably so you ask your question with little hope of interoperating.
To your surprise and delight she answers in a British accent
with a “cheers” and a question about what type of restaurant
you would like. She is second-generation English and her parents
are on the faculty of University College London. With her you can
interoperate with language and content.
Now think of interoperability as it relates to computers. The
computers must connect together in some way, over some network, in order to interoperate — meaning they must physically
connect to the network in the same way with the same sort of
plugs, such as ethernet plugs. They also need to share operating
systems and network protocols in order to connect one to another, so one computer recognizes the other computer on the network. Anyone who has tried to add a computer to a network
knows the bewildering complexity of protocols, switches, IP
addresses, authentication and identification, and other facts
needed to achieve interconnectivity between PC and network.
Interconnecting a PC to a network is the first step, but not the
only step, to interoperability. Once the PC, whether wired or
wireless, connects to the network it will not give its user access
Marshall Ruffin, M.D., M.P.H., M.B.A., F.A.C.P.E., is a partner of Strategy and Business Architecture for the Health & Life Sciences practice
of Accenture. He recently served as the initial clinical director of the National Care Records Service for the National Health Service in the
United Kingdom. Dr. Ruffin currently is the executive director of the Interoperability Consortium (Accenture, Cisco, CSC, HP, IBM, Intel,
Microsoft, Oracle) that is developing the technical reference architecture for the regional health information organizations in California.
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Achieving Interoperability & Collaboration
to an application, such as an electronic medical record (EMR),
without proper authentication by ID, password, retinal scan, voice
print or other means of reliably identifying the user and determining that he or she may access the contents of the EMR application.
Once the PC has connected to the network and the user has
been given access to the EMR application, the user may be able to
access the content of patients’ records. A human can interpret the
language on the screen and make sense of it, provided the coded
numbers for diagnoses and laboratory results and pharmaceuticals and procedures are accompanied by their translations in
English. A computer cannot do these things. A computer needs
codes it expects, otherwise it will not understand the content of a
message it receives from another computer. A human who understands English can see an ICD-9CM code and, if the English translation accompanies the code, understand the meaning of the code.
A human can do the same with a SNOMED-CT code; that is, understand it, as long as the English translation of the code accompanies the code. A computer cannot understand, so to speak, an ICD9CM code if it is expecting a SNOMED-CT code, and vice versa.
Interoperability requires standardized language (terminologies,
data, information models and document structures) and
messages so the integrity of the content of the information
exchanged is preserved. Without interoperability, there can be
no useful exchange of information.
Without interoperability of clinical content between computers,
one must print paper records from one computer, a human must
interpret the information content on the paper and then that
human must type into the second computer the information in
a format the second computer will store reliably. This happens
in the hospital pharmacy when a fancy physician order entry
system used by doctors on the inpatient care units is not integrated with the pharmacy information system, so the fancy
CPOE system, unbeknownst to all those hospital employees and
doctors proud of the new CPOE system, prints its orders in the
pharmacy on paper and a pharmacist types the order into the
pharmacy information system. In most exchanges of healthcare
information between providers, between providers and payers,
between doctors and pharmacies and durable medical equipment
A scanned document, unless formatted carefully and passed
through an optical character reader software application, is an
image in the recipient information system, available for viewing but
not for extraction of data for entry into a database.
Computers are not as facile with English and data as we humans.
To store, communicate and act on information they need data carefully formatted, with codes they expect, properly formatted and in
messages in the right order. To interoperate, computers need a
carefully defined structure of messages, using standards such as
Health Level 7 (HL7); and information, using a reference information model (RIM) such as HL7 RIM, and documents; using common
document formats such as HL7 clinical document architecture
(CDA). Without these standards, computers cannot reliably
exchange the information content of laboratory results, operative
reports, radiology interpretations, diagnosis codes, discharge summaries, prescriptions and lists of allergies without human intervention and translation. Without these standards, the computers
cannot interoperate — though they may be on the same network.
So why is interoperability important? It permits the automatic
exchange of clinical data from one computer to another while
maintaining the integrity of the information content, so diagnosis
codes sent from one computer are interpreted and stored as diagnosis codes by the recipient computer, and allergy data sent by
one computer are received by another computer as allergy data.
The network is essential but not sufficient for interoperability.
vendors and between physicians and hospitals, the translation
function takes place by people interpreting paper records printed
from one computer before entering by hand the content into the
second computer.
Think of all the claims that pass from doctors’ offices to insurers on paper, having been created in the doctors’ office computers
and printed to paper for mailing to the insurers, and the legions
of clerks who take the paper records and type their contents into
the insurers’ claims processing systems. Think of all the paper
prescriptions hand written or computer generated by physicians
and typed into pharmacy information systems by pharmacists or
clerks. Think of all the paper reports from consulting physicians
and reference laboratories and diagnostic radiology groups
received by doctors’ offices and either scanned or typed into
those physicians’ office practice electronic medical records.
A scanned document, unless formatted carefully and passed
through an optical character reader software application, is an
image in the recipient information system, available for viewing
but not for extraction of data for entry into a database. Scanned
documents generally do not contribute content to databases.
Interoperability of content with standardized terms and messages,
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Interoperability
and data and information models permits computers to exchange
coded data and to interact on the data exchanged, so that an
electronic medical record can alert a physician when it receives
an abnormal laboratory result from a laboratory system, such as
from a blood gas measurement in an intensive care unit that can
trigger changes in oxygen concentration, or ventilator rate per
minute or tidal volume of the ventilator oxygenating a patient.
Computers need to interoperate so they can store and act on
data from other computers in a reliable and beneficial way without human intervention and translation. The velocity of actions
speeds up and treatment decisions can occur more quickly than
they can with human intervention for translation.
The economic benefits of interoperability are enormous.
Imagine you had to speak with an operator every time you wanted to make a cellular telephone connection because the various
cellular networks did not interoperate. You use Sprint. Your friend
uses AT&T. You would need to call a
Sprint operator, who would call an
AT&T operator, who would dial your
friend’s telephone number before
establishing a circuit for you and
your friend to speak before both
operators can hang up. For this
model to work, almost the entire
population of the U.S. would have to
become operators in order to facilitate the number of telephone calls
we Americans take for granted
every day. All the telephone companies in the U.S. have adopted interoperable standards for dialing and
connecting telephone calls so that
computers can switch calls and set
up connections without expensive
and slow intervention by human
operators. The cellular and landline
telephone networks interoperate, and so our society enjoys enormous productivity benefits.
So too with the Internet and the World Wide Web — the standards permit interoperability insofar as Web pages on a server
attached to the Internet anywhere can be viewed by computers
with Web browsers anywhere. Through a Web browser you can
schedule a hotel room or a rental car or reserve an airline ticket,
all because your Web browser formats data in the way that the
computer systems of the hotel and rental car company and airline expect the data to be formatted. With this same technology
for interoperability, you can check the weather, the value of your
stocks or your medical record without another person having to
translate your request into the format of another computer.
The economic and political benefits of interoperability derive
from the automatic exchange of information between computers.
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Interoperability reduces labor costs and increases the velocity of
information exchange; it expedites and lowers the costs of commerce. Interoperability allows computers to exchange information
without human interference, assuring doctors that laboratory
their patients’ results will be available in their patients’ electronic
medical records as soon as the computerized laboratory equipment have calculated the results; it means a doctors’ staff can
instantly send claims for a day’s work to the patients’ various payers, and the doctors’ practice management system will receive
from the payers’ computers, just as quickly, results of claims adjudication and remittance advice for those claims found acceptable
by the payer. Delays with paper processing that may be on the
order of days and weeks in the interoperable digital world shrink
to seconds and minutes. Cash flow improves and clerical staff
work declines — provided the physician’s computer system has
been set up to interoperate with the computer systems of the payers used by his patients.
There are costs to interoperability in hardware, software and network access, and in standardization
of data and information
in clinical and financial transaction
systems that exchange data. However,
once the standards have been implemented and the computers can
interoperate, the velocity of commerce increases, the friction of
interaction between businesses
and their customers declines and
the costs of commerce decline. In
the short run, adoption of digital
communications and standardization of information exchange hurts
and costs money. It hurts because it
requires change in the ways business happens. It costs money
because hardware and software and network access cost money,
and because the language of work must change from free text to
coded information interpretable and storable by computers. In the
long run, the standardization reduces the costs of commerce and
reduces the costs of both producers and consumers, especially for
activities that require searching many sources of information, or
updating sources of information remotely.
Think of the friction of finding sources of information in paper
form on obscure topics, the publications of a little-known author
or the medications used to treat an unusual tropical disease. Visits
to libraries and searches through card files and stacks of journals
often take days or weeks. Now with a Web browser and the English
language, you can perform those searches in seconds with PubMed
or Google. How can a large multispecialty group practice using
paper medical records alert its patients taking Vioxx that the
Achieving Interoperability & Collaboration
medication has been recalled by the manufacturer and they should
contact their physicians to discuss other treatments? It will have to
alert all of its patients by mail, since it has no simple way to scan
paper charts for those patients who have received prescriptions for
Vioxx, and no way of knowing if those patients who responded to
the letter represented all of the patients taking Vioxx. On the other
hand, with an EMR and software for e-prescribing, the group practice can identify and contact only those patients who have received
prescriptions for Vioxx and make certain it reaches each and every
one of them directly, increasing the velocity and accuracy of care
and reducing the friction of information management.
What steps can a healthcare community of doctors, hospitals,
pharmacies, nursing homes, home health agencies, durable medical
How do interoperable EMRs form in communities? In some
countries with centralized healthcare systems, such as in England,
the government defines the interoperability standards. The National
Health Service (NHS) has defined the data and messaging standards
for a summary EMR for every person in England, and calls that
summary record the “National Spine.” Right now the computer systems used by all the providers of healthcare in England, including
dentists, home health nurses, nursing homes, diagnostic centers,
pharmacies, general practitioners, hospitals and consultants are
receiving new EMR software that will communicate with the
National Spine. England has one source of organization and funding for this gargantuan effort, the NHS, which is planning to spend
more than $20 billion over 10 years on the effort.
England has one source of organization and funding for this
gargantuan effort, the NHS, which is planning to spend more
than $20 billion over 10 years on the effort.
equipment vendors and dentists (to name a few of the providers of
care in a community) take to establish interoperable digital health
records which they can share? For providers, payers and patients
to share the myriad of standards for messaging and content of
medical records, they must share a complete technical reference
architecture for defining the documents and content to be
exchanged between participants on the network. A community will
have as much a political as a technical challenge to establish such
a reference architecture. When any two people or organizations
want to share data, they need only agree on standards among
themselves. When a company wants to exchange data in standard
format with all its customers or all its suppliers it faces a one-tomany challenge, and needs to establish the standards for communication and convey them to all those with which it wishes to communicate electronically. However, in healthcare, a patient may have
many providers of care and a provider will have many patients,
with many forms of insurance and many pharmacies of choice.
A community sharing medical records electronically produces
a many-to-many challenge that requires some third party to define
the standards for the community — either the government or the
community itself in the form of a shared organization. The community needs a trusted broker to establish the shared standards for
all participants in the exchange of EMRs. In the paper world, the
analog are the carriers of paper — the U.S. Postal Service, FedEx and
UPS. In the digital world, for interoperability, every computer needs
to connect to a shared network and share messaging and format
and content standards in order to exchange medical information
reliably. No aggregation of individual point-to-point exchanges
will serve the purpose, at least not economically.
In the U.S., with our pluralistic and fragmented industry and
dislike of big national government programs, we are moving
toward a model for interoperable EMRs that promotes standards
for interoperability and gives providers of care and payers for
care economic incentives to modify their information systems
to send and receive patients’ data according to those standards.
The standards will be defined by consortia of private sector
organizations such as the Interoperability Consortium (started
by Accenture, Cisco, Computer Sciences Corporation, HewlettPackard, IBM, Intel, Microsoft and Oracle) and endorsed by the
federal government through the Office of the National Coordinator
for Health Information Technology.
HHS and other payers now are expressing their strong interest
in the widespread adoption of interoperable EHRs and are formulating the government grants and contracts to initiate development of regional health information organizations (RHIOs) that
will establish communication-based interoperability, data security
and privacy standards for all providers and payers and others
who would exchange healthcare data in digital form. Because
the costs of interoperable electronic health and medical records
will be lower than those costs for maintaining and communicating paper records, the federal government believes that after
catalyzing the conversion from paper to EMRs in some communities — with grants — the business case for EMRs will become
obvious to most medical communities, and regional health
information organizations (RHIOs) will appear spontaneously,
adopting the interoperability standards that the first governmentfunded RHIOs will adopt, based largely on the Federal Health
Architecture that already exists. ■
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