What should healthcare and healthcare IT leaders be focused on right now, as they try to move the needle forward around interoperability on a global scale, in a particularly precious-feeling moment in the world? That question was top of mind for healthcare IT leaders from a variety of countries, as they discussed key issues in a panel entitled “Expanding the Global Health IT Ecosystem: Interoperability Priorities,” on Tuesday morning, March 16, at HIMSS22.
The panel discussion took place in the Interoperability Showcase Theater, in Hall E of the exhibit hall of the Orange County Convention Center in Orlando, where HIMSS22, sponsored by the Chicago-based HIMSS (Healthcare Information & Systems Society), and being held this week, March 14-18.
The panel was moderated by Didi Davis, vice president of informatics, conformance, and interoperability at the Sequoia Project. Davis was joined by Petra Wilson, EU program director at HIMSS; Herko Coomans, international digital health coordinator at the Netherlands Ministry of Health, Welfare, and Sport; Jan Larsson, senior advisor at Cambio Healthcare Systems; and Amit Traveti, senior director, informatics and health IT standards, at HIMSS.
And, at the very beginning of the session, the panelists agreed that the terrible situation in Ukraine since the start of the Russian invasion of that country, is showing the world how important it will be to develop interoperability so that patient records can be accessed in order to care for the millions of refugees pouring into different countries as they flee Ukraine. In addition to all the other challenges, the panelists agreed, the refugee crisis will demand an agile response that supports care for displaced people.
Then, Davis began the formal discussion by referencing that HIMSS has framed four levels of interoperability: functional (point-to-point); structural (defined structures for data transport); semantic (coded with vocabularies, value sets, digestible by machines); organizational. We’ll focus on organizational, including the policy governance framework.
Wilson said at the outset of the discussion that “One of the big policy challenges in the EU and across Europe is interoperability of services, devices, networks,” and outlined some of the challenges facing the European Union as a community, and, more broadly, the international community as a whole.
“What does true global interoperability look like?” Davis asked the panelists. “What are some of the challenges involved in working to achieve global interoperability?”
“I’m going to start at the end,” Wilson said. “What I think is really important is that, if we want to get governments, funders, clinicians, everyone to buy into interoperability, we have to know what it looks like.”
“For me, the outcome, especially at the global level, is that as a patient or healthcare professional, I can trust that the data I need is where it needs to be,” Coomans said. “And the biggest challenge is to be reminded about interoperability isn’t just a technical issue: it’s about culture, change, ethics. It is about trust that the data you need and is relevant, is where it needs to be.”
Larsson said that, “At the end of the day, it’s about patient safety and trust, and technology has to be embedded in a way that we can trust the systems.”
“I’d like to echo trust and patient safety as well,” Traveti stated. “Sometimes, we say that interoperability is a moving goalpost. Because our expectations today are very different; we’re no longer talking about point-to-point exchange, but about the uses of data.”
Lessons learned from a successful COVID-related initiative
“What have been some of the biggest successes in the interoperability area so far, in Europe?” Davis asked the panelists.
“The European COVID certificates—digital certificate for proof of vaccination, positive test, recovery,” Coomans said. “Those have been codified into digital certificates, and made available through apps that every country has developed and deployed. What’s significant,” he said, “is that they were developed in six weeks’ time, based on international standards, but with a very specific use case. And the program was implemented across 27 member states and three additional European Economic Area states; and in 35 non-member countries—but not the United States. What can we learn from this?” he asked. “First, it’s possible. We had the same people, technology, legal structures, as before. There was a little bit more money because of the sense of emergency; and we made it work in six weeks’ time. And there was a one-billion euro investment.”
Still, Coomans said, “What it made it work is that we had a very specific use case, so we had to discuss both the technical issues and the ethical framework around certificates. We tend as an industry to focus too much around the technology, and not the problem we’re trying to fix,” he said. “And one of the lessons is that we should devote a lot of time and effort to determine what problem we’re trying to fix. And the breakthrough was legislation, not technology. The European treaty says you have the freedom to travel throughout the EU, and that article was suspended because of the crisis, but we needed to enable cross-border travel in the EU again. The fact that we had legislation that binds everyone to use these certificates—that really helped. We had a European authority that was able to mandate interoperability at the international level. That set the bar for 35 other countries to join this. And we need at the global level for some sort of authority of that kind going forward.”
“Petra, how can interoperability leaders demonstrate the return on investment to get buy-in from international leaders?” Davis asked Wilson.
“That’s a great question,” Wilson replied. “I’m a public health lawyer, and I do think that legislation is a very important element in getting there. In the EU, we’ll soon have legislation that will mandate interoperability of electronic medical records across the 27 states of the EU: European Health Data Space, to be published on April 5. But that’s only part of the story. We need to highlight what interoperability can do. Interoperability can help to drive efficiency: all the time that a nurse or other person is taking, in obtaining information from patients repeatedly—and also the over-testing because of repeated testing, that’s a waste of resources. Taking it up one level further, the one thing that COVID and the Ukraine situation have demonstrated to us is that our healthcare systems are not sustainable and not resilient. We demonstrated a level of resilience with regard to COVID, but only in terms of one issue. In Europe, we’re facing an aging population and long-term staffing shortages. And while technical and semantic interoperability will be important to long-term resilience, they’re only elements.”
“How can global interoperability empower patients?” Davis asked.
“Interoperability, from the patient perspective, can be pretty depressing sometimes,” Traveti said. “We do have to celebrate the wins when we have them. One of them, building on what Herko said before, is the apps we built to celebrate vaccination. There are all sorts of privacy, equity, and mobility issues. But, per the interoperability issues, we spent so much time asking whether FHIR will work; but you need a smartphone to use any apps. But we’ve made progress on vaccine credentialing. And we can extend that progress in other areas.”
“And we have the foundational building blocks,” Davis noted. “Jan, with the current crisis in Ukraine, what are some ways the EU can manage patient health data?” she asked.
“What I foresee is three major changes” on a global scale, Larsson said: “climate change, which is huge, the pandemic, where we pushed digitalization forward more than 10 years in one year; and conflicts. We have three million refugees coming out of Ukraine in three weeks; and there is a forecast for 25 million refugees. We have to package, and we have to do this fast, and well. It’s time for global alignment.”
“The thing that we need is some kind of global health authority,” Coomans said. “The US, Canada, the EU, Canada, Australia, India, Saudi Arabia, Japan: these are the authorities working together” in a number of areas, around interoperability. “It’s not that we need to create a new authority, but we need a place where we can align policies together. And from there—that’s one of the interoperability layers we need to address. And we can have very clear interoperability initiatives, with the European Commission, with all sorts of agencies, to make it more concrete, and to localize it within countries. For instance, the WHO—they’re a member of the Global Digital Partnership as well. I would plead for this to be a truly global effort. It has to be a collaborative effort of us working together.”
“It takes a village, and a community of us all working together,” Davis agreed.
Tracking international progress
“What are the groups or initiatives and guidance coming out that people can follow, around global interoperability as a whole?” Davis asked.
“I’m serving on the committee for interoperability and global change, and we did a good job on the white paper around digital certificates,” Larsson said. “What I would like to see is a thrust around an international patient summary. I’m thinking of these 25 million people coming into Poland. It needs to be a global effort.”
“In fact,” Traveti said, “Yesterday, at the Interoperability Symposium, one of the final questions was what we can do to move things forward? And there was a call to advance the IPI.”
“Especially with vaccine credentialing, we have to be careful not to think that we need more technology,” Coomans advised. “Many people have the yellow passport that is paper-based. The idea behind that is that we don’t need automatic processing of this data at all these different points, at the border or when applying for a visa or something. But now, with COVID, making that the norm for the need, is missing the point; this is a technical solution for a problem that doesn’t exist. We have to be careful to define the exact technical needs. What the American health smart card is doing is redefining the need and using technology.”
And, Wilson noted, “There is a kind of viral infection in the healthcare industry: the ‘not-invented-here syndrome.’ Healthcare has a bit of a thing about that,” she said: “my hospital is a bit different, my region, my country, my patients, are a bit different; and the not-invented-here problem is a bit of an obstacle to interoperability. Even in the EU, there’s very little control over procurement saying that if you’re using public funds, the legislation must demonstrate various levels of interoperability. So let’s really require interoperability as part of procurement, to combat the not-invented-here virus.”