Interoperability could be considered the holy grail of healthcare IT. The push for EHR and software application vendors to create systems that can “communicate, exchange data, and use the information that has been exchanged” has the potential to accelerate the coverage and adoption of eHealth technologies.

Making multiple sources of information (as opposed to data) available to healthcare providers at the point of care can have a positive impact on the use of limited resources, the effectiveness of clinical risk management, the ability to provide continuity of care and, ultimately, the improvement of patient outcomes.

However, despite obvious benefits many IT solution vendors are yet to fully adopt the premise of interoperability and open-up their systems accordingly. We can’t blame the vendors entirely – interoperability is a huge technical challenge and, because buyers don’t always mandate it as part of their ICT purchasing specifications, there is still a market for non-interoperable systems.

In South Africa, a fundamental lack of agreed standards has prevented the natural evolution of the various systems in use to include the ability to be interoperable. Until now.

The release of the National Health Normative Standards Framework for Interoperability in eHealth in South Africa (HNSF)  is a profound step in the right direction towards achieving interoperability – but what does this actually mean for the market?

Interoperability reduces duplication of effort

Care providers will attest to the fact that access to the right patient data in a timely fashion is essential to quality healthcare delivery. As a result, as much information as is reasonable (but sometimes more) is collected and stored at each patient encounter.

If multiple systems are able to share information about a patient, it eliminates the need to duplicate the capture of that information into multiple systems to ensure its available when needed. There are very few people out there who will not have felt burdened by having to repeat the same information at every step along a care pathway.

Use of a standards framework to enable the sharing of data not only results in healthcare professionals accessing information to make more-informed decisions and more-personal care, but eliminates huge amounts of administrative work at a stroke.

Interoperability encourages specialist systems

Interoperable solutions allow purchasers the freedom to choose the best systems for their needs. This ‘best-of-breed’ approach to ICT strategy means that less compromise is needed when buying eHealth systems and pushes developers to focus on adding value through depth of functionality rather than breadth of functionality.

In short, individual suppliers don’t need to provide every facet of a solution but can focus on developing the most flexible, ‘useable’ product or application for their area of expertise. The skills, methodology and knowledge required to build a financial functionality are entirely different to developing PACS functionality – and this applies equally to components for PAS, prescribing, maternity and so on.

By committing to integration and adopting a ‘culture of data sharing’, vendors can focus on their areas of expertise and incrementally offer customers more value.

Interoperability offers progress in the South African context

Healthcare providers in South Africa will continue to have mixed environments for the foreseeable future. In order to make best use of existing investment we should avoid the rip-and-replace of existing systems and focus on connectivity and access to new platforms in a gradual and evolutionary manner.

The ability for these systems to work together would dramatically reduce the cost of moving towards a standard infrastructure, which will offer more efficiency and continuity-of-care benefits. As well as maximising the value of existing investments, interoperability allows for innovation to be rapidly adopted by lowering the barriers to integrating a new technology.

Preserving existing value and allowing innovation to let underserved areas ‘leap-frog’ to modern tools allows ICT strategies to be far more agile and channels investment to areas of greatest need.

To interoperability and beyond

Interoperability isn’t all semantics, but it will be. According to the E-health Standards and Interoperability ITU-T Technology Watch report, lack of interoperability with systems used by healthcare providers can only be solved by implementing eHealth standards and specifications.

Standardisation is key to enabling seamless exchange of healthcare information between hospitals, government agencies, insurance companies, pharmaceutical services, primary care physicians or medical specialists. Furthermore, standards reduce the complexity associated with information sharing among multiple systems.

But sharing data is only the first step. That information needs to be useable too and within the context it’s going to be used for. Some of the complexity is developing systems that are interoperable come down to the level of interoperability that needs to be achieved. Simply put, interoperability can be broken down into three levels: Foundational, Structural and Semantic.

Foundational interoperability enables the exchange of data from one system to another, but does not require the ability for the system receiving the information to interpret the data. Structural interoperability is defined by the uniform movement of healthcare data from one system to another, whereby the clinical or operational purpose and the meaning of the data is preserved and unaltered.

Semantic interoperability is the ability for two or more systems to exchange information and use the information that’s been exchanged. Using that information means both structuring the data exchange and coding the data to include vocabulary that the receiving system can interpret. Enabling this level of interoperability makes it possible to exchange often complex patient information from disparate systems to improve the quality, safety and efficiency of healthcare delivery. And this is ultimately what we want and need in the South African health care setting.

Building from the blueprint

The lack of South African eHealth standards until now has resulted in different systems and platforms being implemented within provinces and across the country – most of which aren’t interoperable.  Acknowledging the burgeoning issue of eHealth interoperability, the NDoH and has taken the first steps of action through the eHealth Strategy 2012-2016 and the previously mentioned HNSF.

eHealth Strategy 2012-2016

In 2011 the NDoH released the eHealth Strategy 2012-2016, a document that outlines 10 strategic priorities for eHealth development in the country; number three being standards and interoperability. The strategy highlights the importance of establishing national co-ordination on all initiatives in order to improve the effectiveness of eHealth on all levels – from basic patient interaction to information sharing between facilities. This involves enabling integration between systems, enforcing common standards, norms and establishing common data standards and terminology across information systems.

Section 4.8 of the document is dedicated exclusively to eHealth standards, and the overall strategy acknowledges that while a wide range of eHealth standards have been developed internationally by organisations such as ISO and CEN, very few have been localised and formally adopted in South Africa.

The strategy goes on to identify key areas that require standards: pharmaceutical coding, diagnostic coding schema, procedural coding schema, Diagnostic Related Groups (DRGs) and standards for clinical content.

The strategy did however acknowledge an active Private Healthcare Information Standards Committee (PHISC) within the private health sector that aims to maximise cooperation in eHealth standards across the country. The strategy indicates that PHISC provides a forum for debate and consensus on health information standards issues for the private sector with the overall aim of identifying appropriate common standards applicable to both the public and private sectors.

PHISC has been involved in collaborating in processes relating to clinical coding standards, such as performing the groundwork for the implementation of ICD-10 in South Africa, healthcare information governance, messaging standards, pharmaceutical coding and DRG. Further details can be found here.

The strategy also suggests creating a national standards board and a national guideline – which was created and released in March 2014 in the form of the HNSF.


The HNSF is a ‘go-to’ manual for software application and EHR vendors operating in the country. The framework document includes a patient story to highlight the continuity that interoperability enables and offers technical guidance for implementation.

The researchers behind the HNSF focused on concepts and theories put forward by well-established organisations, such as the applicability of Integrating the Healthcare Enterprise’s (IHE) profiles to the South African eHealth setting and the significance of the WHO-ITU eHealth Strategy Toolkit.

The ultimate objective of the HNSF is to ensure patient information systems comply with the nationally approved interoperability standards. For this to happen, the HNSF states that the systems must be subjected to independent conformity assessments to ascertain its level of compliance with the normative standards, which would result in the issuing of certificates.

The document also strongly recommends that the NDoH allocates a budget to establish and maintain the national shared eHealth infrastructure, whose purpose would be to facilitate health information exchange, security and audit services, demographic registries and shared clinical repositories.

The HNSF also states how the NDoH should establish a National eHealth Standards Board to govern and maintain the implementation of the framework. This would result in the continual updating and publication of the framework by the NDoH.

Since the release of the HNSF, eHealthNews has focused on specific aspects of the framework and published articles pertaining to the WHO-ITU eHealth Strategy Toolkit being identified as best practice, whether smart healthcards are suitable for South Africa, the 42 identified Health Information Systems (HIS) in the country and the eHealth standards evaluation process.

eHealthNews will continue to follow the implementation progress of the points mentioned above to find out more about the yet-to-be-determined allocated budget (source and sum), players involved in compliance assessment and the imposed timeframe for suppliers to adhere to in adapting and modifying their products.

Industry insight

We were interested in finding out what some of the leading eHealth players in the country thought of the HNSF. The main questions we put forward included whether they support national eHealth standards, how the standards would affect their organisational practices and their views of the bigger, national picture of governance and actual implementation.


Meditech SA’s Dr Jacob Poo offered his opinion on the HNSF by saying “it’s the furthest we’ve ever been in setting eHealth standards; we now need to institutionalise these ideas and make sure the Government implements structures as outlined in the framework.”

When asked about the framework being implemented and if he expected eHealth supplier consolidation, he responded with “it’s difficult to say at this early stage. I’m not sure if providers will go out and change their plans to comply with the standards.”


Shortly after the HNSF was released Dr Sean Broomhead from tinTree discussed his views in a blog posted on eHNA.

Dr Broomhead believes the HNSF is a “superb document” that has a clear scope and offers advice on how to select the best standards available.

“The big interoperability (IOp) challenges are how to select enough, affordable IOp to meet current and short-term requirements and simultaneously lay down and expand the IOp foundations for the future. The HSNF offers a constructive way into them and reinforces the need for continuous, selective IOp implementation over a viable timescale.”

Dr Broomhead also mentioned how it’s encouraging that the HSNF identifies the need to deal with security, privacy and data management, which is an ongoing cause of concern in the international eHealth industry.

Dr Broomhead is involved with the development of eHealth initiatives across the continent, and believes the HNSF provides an essential source of learning for other African countries.

Discovery Health

Discovery Health CEO, Dr Jonathan Broomberg, also offered his opinion on the HNSF during a recent interview with eHealthNews.

“Discovery Health supports what the HNSF represents; my colleagues even contributed to the document’s development. I believe it’s critical to have eHealth standards so systems can talk to each other; this is an enduring principle. “


In a recent discussion with eHealthNews, TOMPSA co-founders Dr Yasheen Khan and Dr Mohammed Dalwai shared their views on the development of eHealth standards in the country.

“We believe both the eHealth Strategy 2012-2016 and the Western Cape 2030 Strategy demonstrate a progressive outlook on a national and provincial level. It’s great both mHealth and eHealth are finally getting the attention they deserve,” said Dr Khan.

Dr Mohammed added that “it’s essential to have key structures in place to improve patient care; the standards should be developed further to cater for the growing use of mobile touchscreen technology.”

eHealthNews will continue to follow and report on the development of eHealth standards in the country.

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