Manager of Architecture and Standards at GE Healthcare, Charles Parisot, shares his insights into developing an interoperability (IOP) strategy and the role IHE can play in stimulating organisational and national interoperability strategies.  

Charles will be hosting a two-part Interoperability Masterclass at eHealthALIVE2016 to give delegates the practical tools they need to develop and implement strong IOP strategies. Click here to get your tickets.

 You’re renowned as a leading expert in Interoperability with decades of experience. Tell us a bit about your background.

 I started my career in networking and interoperability building corporate networks for large companies such as the French power company setting up their national network architecture. In the mid-80s I moved to the Boeing Company during an initiative whereby they were collaborating with other manufacturers and competitors in the building of the components of planes. They were collaborating because they felt that teaming up with their competitors was a way to influence the vendors that were providing IT solutions to them. I did that for four years and at the same time, I was involved in the early adoption of the Intranet in the late 80’s as it formed a large part of their strategy.

In 1990 I moved to GE, or GE Medical System as it was called at the time, where they were mostly focussing on imaging and acquiring imaging. That is when I worked with our competitors such as Siemens, Phillips, Agfa and Kodak, to create the Digital Imaging and Communications in Medicine (DICOM) standard. Since then, the DICOM standard has been very successfully adopted and deployed throughout healthcare, and is now used worldwide and supported by all vendors in radiology, cardiology, and now pathology.

So in a sense, I’ve been part of the birth of interoperability and understand interoperability from the trenches of the hospitals to regional and national level and more recently, at multinational level while working on the European Cross Border Project to move information across borders and nations. In the last decade I’ve worked with a number of clinician groups, governments and ministries from around the world including Europe, the US and the Middle East. And now my work is focused on Africa.

Why is interoperability so important to a modern health service?  

Interoperability impacts all stakeholders but first and foremost, it is important in terms of patient access. If patients need contact with the health service via mobile phones and applications, how can they access the system which itself is not connected? Think of the nightmare it would be for a citizen to connect to their local clinic if they travel north or south from where they live. Patients don’t have a map of the world of healthcare, they hope to see through their mobile devices and be able to consistently interact with it digitally. Therefore, if you don’t standardise this, it won’t happen.

Likewise, interoperability has numerous benefits for healthcare professionals, allowing them to collaborate with their colleagues, access decision support, refer patients to specialists or hospitals, and share patient information to enable continuity of care, etc. particularly for those working in remote areas.

Interoperability also underpins the broader IT programme and investment in IT systems used to support healthcare processes, delivery, tracking and other functions. The challenge Africa faces is deciding whether to include interoperability as part of the deployment plan, or deploy the IT systems and think about connecting them later. But the latter has been proven to be expensive, slow and painful in Europe, the US and Asia, so I don’t think it’s a wise thing to do when deploying new IT systems.

Lastly, interoperability plays a key role in population health data and management. Government and decision makers are impeded by the lack of information to guide decision making. Authorities have very little visibility of their health system – relying on paper-based or manually entered web questionnaires and retrospective tracking of services delivered in order to get a view of population health, where the quality needs to be improved, where to invest, where to place professionals or make more services available. This has a knock on effect across the board and means the service is largely reactive, as opposed to proactive and preventive.

A National eHealth Standards Board hasn’t yet been established in South Africa and this for many is a barrier to moving forward. How can stakeholders still make strides towards interoperability, if at all?  

It’s true that the clinician would like more interoperability but they’re not an IT specialist, so how do they know what decisions are needed to improve the system? Those who buy systems say that they’re not interoperability specialists, so how do they procure systems that are going to talk to each other? Vendors are saying that they’re just one vendor among many others in the country so how can they drive a national strategy?

Without a guiding national body, stakeholders feel distanced from the end goal and therefore, not responsible for the overall complexity of delivering interoperability. But this is where a change of culture is necessary whereby all of those stakeholders each own a piece of the problem and they simply need to be brought into a collaborative process with the understanding that no one group will drive the process, but rather contribute to the process in an organised way. I believe that this is where governments have a role to play but not in an autocratic way. You can’t dictate interoperability in a field as complex as healthcare. The government must be the orchestrator and this is critical to making interoperability happen.

The process won’t be without disruptions – the clinician might say that this is not how they work; the vendor might say they need to adapt and align their product, etc. so you can expect a reaction but the process must continue. If everyone looks at where we could be in healthcare with a better, more organised approach to interoperability and shares that vision we’d get much further, much faster.  Interoperability can’t be achieved without a strong commitment to collaboration from everybody and a road that must be walked together.

Where do we start in developing an interoperability plan, at an organisational level all the way up to a national level?  

In my opinion, a plan to develop interoperability has five pillars. In the first instance, you need to select priority use cases in a collaborative manner with clinicians. Ask yourself: what is the problem of health information exchange you want to solve which is sufficiently important or urgent enough to focus your efforts on? You may choose to focus on co-ordinating immunisation delivery and tracking, for example. You’ll come up with two or three problems to focus on and not add use cases until you’ve mastered the deployment of two out of the three because that is how you make progress. Some support may be needed for this first cycle, and leveraged to develop the expertise and collaborative skills needed to further advance on your own.

I think it’s important to remember that interoperability is not a problem that is eventually ‘solved.’ Just look at the internet which came about in pieces and is still evolving as we get new building blocks. The internet wasn’t designed to work on wireless connections but now, Wi-Fi is an integral to how many of us access the internet. It was built piece by piece and there are many examples of this.

The second pillar to devising an interoperability plan is to agree on national health information exchange policies including privacy and security, and a code of conduct. What happens if a patient chooses to block certain information? Is it allowed or not allowed? Can you do commercial research with public patient data? And so on.
Third pillar is to create a set of national interoperability specifications (including terminologies) for each use case by referencing profiles and standards. Those specifications need to be very precise because interoperability is something that is very breakable.

The good news is that countries need not write all elements of those interoperability specifications themselves, they can reference profiles such as IHE’s and standards that have already been defined, but they need to state unambiguously what the country’s interoperability specifications are and what the various systems that are going to talk to each other need to do. Some systems may be deployed by hospitals, some may be deployed by pharmacies, and some may be deployed by Ministries at a national level. Essentially, specs have to be simple, referencing reusable building blocks. This is critical – vague interoperability is useless. It never works.

But it’s still not enough to have good, clear specifications so the fourth pillar is to organise testing and conformity assessments against the national interoperability specifications. Because you can buy a product and ask all the right questions about whether the product meets specifications and all of the standards, and if the answer is yes, but in reality it doesn’t, nobody would know. So we need to do testing. Likewise, vendors who are committed to investing in their systems to make them interoperable and maximise the value to their customers will need a testing tool and conformity assessment process that validates their product against national interoperability specifications.

Lastly, we must educate clinicians, developers, health managers and authorities on the above four pillars relevant to their jobs and roles within the health delivery chain. I put this step last because it actually cuts across all of the previous four pillars. When you develop policies, you educate a different set people on policies, primarily patients and providers. When you talk about testing, you focus on software developers and product designers and buyers. When you’re promoting the use case – you are developing a strategy for the nation. You will need consensus from clinicians and all of the stakeholders that will need to invest to actually deploy interoperable systems that perform the exchange of information at a national level.

The challenge of interoperability is that it needs strong leadership, as well as it needs to be collaborative and we have to address all five of these pillars. If you miss one of them, you will either not move forward or will deliver a broken system that nobody understands, cannot use and thus, ignores.

What would you say to vendors about the monetary investment they’d need to make in interoperability?  

It’s important to recognise that the development of the local IT industry is critical but that the local market for any single African software company is most likely too small at any single country level. Interoperability should be a priority in your product strategy because if your system is not interoperable, it can be a barrier to export, just like it is a barrier to import.

The more countries set up interoperability strategies that are 95 – 99% consistent with those of other countries, the more they make positive choices for their national economies. This is very well understood by several countries in Europe. For instance, the Prime Minister of Luxembourg, a small country but very wealthy country, looked at Luxembourg’s IT strategy and knows he needs to buy in products from outside the country but he also needs to stimulate the local IT industry so that they’re competitive in the market. He knows that Luxembourg is not a big enough market for the local IT industry to thrive so they have to export. And getting export-ready means facing the competition early on in the development lifecycle.

He also had a strategic objective because Luxembourg has a lot of migrant workers from neighbouring countries and Portugal that regularly visit as well as would retire in their own country so they need to be able to exchange health information. He asked himself, ‘What is Portugal’s eHealth strategy? Can we align our countries?’ Africa would benefit from a similar approach and reiterates the value of reusing existing specifications, policies, testing tools not only to achieve interoperability but to reduce the need to invest in the eHealth programme in the longer term, reduce your risk and increase positive economic impact.

Tell us about Integrating the Healthcare Enterprise (IHE) International and the role they can play in helping Africa move towards interoperability?   

Against the five pillars, IHE has a big contribution to offer healthcare in identifying use cases because IHE has been documenting and selecting use cases for many years. In terms of policies or the second pillar, IHE supports the implementation of policies but doesn’t want to play a role in setting policies as such.

The third, fourth and the fifth pillars are at the centre of what IHE does. Building your interoperability specifications for a certain use case by assembling IHE profiles and reusing them in practicality means going from a 1,000 pages down to 20 pages – a massive saving in time and effort.

When it comes to testing and conformity assessments, IHE have testing platforms that have evolved and matured over the years to the point that IHE supports five national programmes and provides the IHE platform to those countries to do their testing. Switzerland is one example whereby the Swiss government identified that they could save maybe 50% in testing by reusing the IHE test platform. Once we completed the assessment with them, they had actually realised an even larger saving.

Having mature testing tools available to you is critical because if the testing tools have errors in them will lead to making the wrong decisions in implementations. Similarly, IHE makes their educational tools available and have tons of methods and people to offer advice and support a number of programmes in developing education. IHE is a not-for-profit organisation and can save all stakeholders a lot of time and money and reduce their risks significantly.

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Charles will be hosting a two-part Interoperability Masterclass at eHealthALIVE2016 to give delegates the practical tools they need to develop and implement strong IOP strategies. Click here to get your tickets.