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<h2 class="hd hd-2 unit-title">Introduction</h2>
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<p>We now turn to the concept of interoperability in health care. We begin with presenting the landscape of health data standards and discus the benefits and immense challenges of implementation. While we are only beginning to unravel the quagmire of interoperability, fully integrated health information systems will be essential to impact true quality improvement in healthcare.</p>
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<p>The majority of videos in this section are presented by:</p>
<p>Dr. Boonchai Kijsanayotin, MD PhD<br />Thai Health Information Standards Development Center<br />Health Systems Research Institute, Ministry of Public Health, Thailand</p>
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<h3 class="hd hd-2">WHA Resolution</h3>
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<p>To achieve interoperability, all stakeholders need to agree on the use of the same data standards to enable different information systems to exchange data and be able to use that exchanged data. There are many layers of health information standards. It is not as easy as it seems to develop, maintain, and implement standards. Standards and systems interoperability are essential for the development of integrated health information systems that serve the ultimate goal of achieving better health.</p>
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<legend id="47a57e78e9cb48249643bd0ec894174e_2_1-legend" class="response-fieldset-legend field-group-hd">"Standards and interoperability are trivial in a well-functioning eHealth system"</legend>
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<h2 class="hd hd-2 unit-title">eHealth Components</h2>
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<p>The WHO-ITU National eHealth Strategy Toolkit identifies seven important building blocks or components that must be in place to realize the national eHealth vision. The seven components are (1) leadership and governance; (2) strategy and investment; (3) legislation policy and compliance; (4) workforce; (5) infrastructure; (6) service and applications; and (7) standards and interoperability. Interoperability of various health information systems and health data standards are essential for comprehensive and integrated health information, which is primary for effective decision making of all health-related stakeholders, from policy makers and health care providers to the general public.</p>
<p class="TxNITextNoIndent"><strong>Figure: WHO-ITU Model of eHealth Components</strong><img src="/assets/courseware/v1/e949f2ddce76ef2e1c81996a1bc6e213/asset-v1:MITx+HST.936x+1T2019+type@asset+block/figure_12_1.png" alt="" type="saveimage" target="[object Object]" preventdefault="function (){r.isDefaultPrevented=n}" stoppropagation="function (){r.isPropagationStopped=n}" stopimmediatepropagation="function (){r.isImmediatePropagationStopped=n}" isdefaultprevented="function t(){return!1}" ispropagationstopped="function t(){return!1}" isimmediatepropagationstopped="function t(){return!1}" width="660" height="252" /></p>
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<h3 class="hd hd-2">eHealth Components</h3>
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<h4>Health Information Exchanges</h4>
<p>In general, the integrated information needed at point-of-care services includes who received services; who provided them; where; and what type of services were provided. The figure below shows an architectural model of the health information exchange (HIE), presented by the OpenHIE group, which is an enabler of health information integration. HIE refers to the technology, standards, and governance that enable the exchange of data between the information systems of various health care stakeholders. The OpenHIE architecture demonstrates the importance of interoperability and standardization in identifying people, providers, and types of medical services to ensure that the meaning of medical concepts is interpreted in the same way by different applications.</p>
<p><img src="/assets/courseware/v1/fdb6edc9e48b2c5cd06bd3ab89ebbba7/asset-v1:MITx+HST.936x+1T2019+type@asset+block/figure_12_2.png" width="556" height="441" /></p>
<p>The structures number 1-6 are the shared assets of the system. The health interoperability layer (structure number 7) which connects with health data standard components (the shared assets) is the shared services for all applications (number 8). As the results, health information in the application level are able to exchange. </p>
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<h2 class="hd hd-2 unit-title">Interoperability</h2>
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<p>There are multiple levels of interoperability, from the basic level, at which systems can only exchange messages without knowing the meaning of the message—for example, that a person who only knows the English language can receive an e-mail written in Thai—to the highest level of interoperability, in which the disparate systems not only understand the messages but also work together seamlessly with a common business model. </p>
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<ul>
<li>The first level is <b> technical </b> interoperability, which refers to the ability to move data from system A to system B, neutralizing the effects of distance. Technical interoperability is domain-independent. It does not know or care about the meaning of what is exchanged.</li>
<li><b>Structural</b> interoperability means that the systems can exchange messages based on an agreed dataset. It is the standardization of data content.</li>
<li><b>Syntactic</b> interoperability is the level at which various systems adopt the same standards of syntax or format for the exchanged messages.</li>
<li><b>Semantic</b> interoperability ensures that sender and recipient understand the same data in the same way and allows computers to share, understand, interpret, and use data without ambiguity. Semantic interoperability usually involves the use of codes and identifiers that are based on common references and agreed terminology.</li>
<li><b>Process</b> interoperability is achieved when human beings share a common understanding across a network, business systems interoperate, and work processes are coordinated.</li>
</ul>
<p>In the remainder of this subsection, we will primarily focus on <i>structural</i>, <i>syntactic</i>, and <i>semantic</i> interoperability.</p>
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<h2 class="hd hd-2 unit-title">Standards</h2>
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<p>Interoperability needs standards. A standard is a definition, a set of rules or guidelines, a format, or a document that establishes uniform engineering or technical specifications, criteria, methods, processes, or practices. In addition, it has to be approved by a recognized standards-development organization or have been accepted by the industry. The eHealth Initiative defines a standard as a well-defined approach that supports a business process, has been agreed upon by a group of experts, and has been publicly vetted.</p>
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<h3 class="hd hd-2">What is standardization?</h3>
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<p>Standards are basically universally agreed-upon ways to handle data to ensure interoperability. Standards can also be described as a group of guidelines concerning the essential requirements that a certain process, product, or service must meet in order to attain quality objectives. Standards allow data to be shared across systems and across stakeholders, regardless of the application. In fact, standards are the foundations of interoperability; it is not possible to build interoperable systems without them. Standardization is a process of agreeing upon the standards that represent the common language allowing the exchange of data between disparate data systems. The goals of standardization include achieving comparability, compatibility, and interoperability between independent systems; ensure data compatibility; and reducing duplication of effort and redundancies.</p>
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<h3 class="hd hd-2">System Interfaces</h3>
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<p>The issues of health data standards and interoperability are not trivial. Many health IT projects, regardless of size, have failed in many countries because health IT services and applications were not interoperable. Information exchange is difficult to achieve in health care systems due to an absence of standards. Studies indicate that lack of standards create a barrier for people to effectively collaborate because their information systems are not interoperable, making it difficult for them to share or interpret data across systems.</p>
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<h3 class="hd hd-2">Benefits and Limitations</h3>
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<h2 class="hd hd-2 unit-title">The challenge of interoperability and standards</h2>
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<p>Having interoperability and achieving standardization is easier to say than to implement.Health information standards are complex. For example, the worldwide use of electric sockets is supposed to be one standard but in the real world, it is not. Imagine how convenient and effective it would be if only one standard were adopted across the world.</p>
<p>Many standards are needed to make different systems interoperate. Although there are many international standards developed and ready for implementation, countries need capacity to know which standards to choose and how to use and customize the standards to suit the country context. Health information standards implementation takes time and investment, and interoperability benefits will not prevail until the majority adopts these standards. Unfortunately, this capacity and investment are usually lacking in the lower- and middle-income countries (LMIC). Commitment from all stakeholders, the development and establishment of a good governing body, and having a clear roadmap for which standards to implement to achieve interoperability in health care systems are also of importance. There is no silver bullet or best answer for how LMIC should make systems interoperable or implement health information standards.</p>
<p>However, having knowledge of a country’s current eHealth situation, learning from other country experiences, and working together among LMIC through networking will help. In Asia, a group of health IT/eHealth professionals from South and Southeast Asia countries have formed a health IT/eHealth peer-to-peer and learning network called the Asia eHealth Information Network. Composed of members from ministries of health, academia, nongovernmental organizations, and international development partners such as WHO, ADB, UNICEF, GIZ, and others, it promotes better use of ICT to achieve improved health through peer-to-peer assistance, knowledge sharing, and learning via a regional approach. The network works on eHealth governance, enterprise architecture, and standards and interoperability within and across countries.</p>
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<p>Andrew S. Kanter, MD MPH FACMI</p>
<p>Department of Biomedical Informatics, Columbia University</p>
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<h3 class="hd hd-2">Terminology Case Study: Millennium Villages Project</h3>
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<h2 class="hd hd-2 unit-title">Recommended Links</h2>
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<p>Most of the sites listed below have substantial information on stated standards. They are regularly updated and provide educational content.<o:p></o:p></p>
<ul>
<li><a href="https://loinc.org/" target="_blank">https://loinc.org/</a></li>
<li><a href="http://www.searo.who.int/entity/health_situation_trends/topics/health_data_standrads/en/" target="_blank">http://www.searo.who.int/entity/health_situation_trends/topics/health_data_standrads/en/</a></li>
<li><a href="http://www.ihtsdo.org/snomed-ct" target="_blank">http://www.ihtsdo.org/snomed-ct</a></li>
<li><a href="http://www.himss.org/" target="_blank">http://www.himss.org/</a></li>
<li><a href="http://www.himss.org/library/interoperability-standards" target="_blank">http://www.himss.org/library/interoperability-standards</a></li>
<li><a href="http://www.imia-medinfo.org/new2/" target="_blank">http://www.imia-medinfo.org/new2/</a></li>
<li><a href="https://www.amia.org/" target="_blank">https://www.amia.org/</a></li>
</ul>
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