In a recent blog post, NHSX has hinted that buying technology which is compliant with standards could be a way to obtain interoperability. Ewan Davis explores whether the standards that we have so far have been developed enough to achieve this.

There is a lot of talk about buying standards compliant technology as a way to achieve interoperability like this piece from NHSX. Now I’m all in favour of the enforcement of appropriate standards, but sadly I’m not aware of any standards that are sufficiently developed to achieve this.

The consensus view, with which I concur, is that the leading  standard to support interoperability between heterogeneous systems is HL7 FHIR. 

The problem is that it’s not currently possible to specify FHIR compliance in any meaningful way as the necessary FHIR Profiles against which compliance is measured do not yet exist.

What I would like my NHS clients to be able to put into their contracts is this “The Vendor agrees to implement those FHIR profiles currently published by INTEROPen CIC that fall within the scope of their system. The Vendor further agrees to implement any changes to these Profiles or new Profiles within the scope of their system within six months of such changes or new Profiles being published by INTEROPen.”

For this approach to work, we need to have an initial set of FHIR Profiles and an organisation trusted by Vendors, the Professions and the NHS to only publish Profiles that are fit for purpose and not unreasonably onerous for Vendors to implement. 

Furthermore, for maximum interoperability we also have to ensure that work on FHIR aligns with other standards activity particularly in relation to SNOMED-CT, openEHR and IHE.

This is all entirely possible, but to achieve it we require three things:

1. A better understanding of standards…

Firstly, policy makers need to have a better understanding of the key standards, SNOMED-CT, openEHR, IHE and HL7 FHIR, and how they fit together to support interoperability and beyond.

HL7 FHIR is the right choice for the exchange of data between heterogeneous systems. FHIR can bring some quick wins but won’t, give us the data fluidly we need to fully exploit digital technologies. For this, we need to move towards shared semantics and open platform architectures, incorporating the open standards and frameworks, openEHR and IHE-XDS.

HL7 FHIR is a new standard that’s changing fast. It is currently at version 4 but with most live implementations based on Draft Standard for Trial Use v2 (DSTU2) or Standard for Trial Use v3 (STU3). FHIR version 5 is due to appear at the end of the year and we know there will be breaking changes between version 4 and 5.

FHIR defines a set of base “Resources” representing a framework for chunks of content (like Medication, Observation or List – there are 145 In FHIR 4.1) from which specific “Profiles” can be created. To achieve interoperability, there needs to be a common set of Profiles covering the data items one wishes to share that are agreed and enforced across the  community in which you wish to achieve interoperability. No such set of profiles yet exists for the UK.

It is important that any modelling work done to generate the required FHIR profiles is done in a way that also supports this longer term objective. These are not conflicting approaches. Just as it is possible to tackle climate change both by building new carbon-neutral energy sources *and* more efficient use of fossil fuels, we can move towards shared semantics while improving the interoperability of existing systems.

2. A Trusted Standards Body

Secondly, we need a trusted standards body. Such a body needs to represent the interests of all stakeholders and needs to draw expertise from the Vendors, the Professions and the NHS frontline; and NHS E/D/X need to commission the modelling work required and leave them to get on with it.

We already have such a body in INTEROPen, but it’s not currently working as we need it too primarily due to lack of support from NHS E/D/X, the vested interests of a minority of Vendors and some in the NHS, and the lack of funding to enable the  Professional Records Standards Body (PRSB) to provide appropriate input.

If we want Vendors to commit to implementing UK FHIR Profiles, then they need to have the confidence that the Profiles developed are needed, fit for purpose and not excessively onerous to implement. We will only achieve this if they are equal partners in their development. The Vendor community has both the clinical informatics and practical implementation skills to make this happen, and, in the most part, both wants and needs interoperability to work. Vendor input needs to be supplemented and balanced by input from the front line of the NHS (CCIOs and CIOs) who know what is needed, professional clinical informtications (such as those in the Faculty of Clinical Informatics)  and the PRSB who should ensure quality and safety. 

The role of the Centre NHS E/D/X should be limited to funding the work and ensuring the resulting standards are enforced in procurement. The involvement of the centre in the detailed specification of requirements and even worse  – the detailed work – has been unhelpful in the past and the current approach in trying to create the UK Core is not the way forward. 

3. Enforcement of standards adoption…

Thirdly, we need to enforce the standards and have an appropriate mechanism for establishing compliance. This means ensuring the appropriate terms and conditions are included in contracts and renewals, and providing a lightweight mechanism for Vendors to demonstrate compliance. 

In the past, NHS compliance regimes have been onerous, slow and expensive, and tended to exclude start-ups and new entrants. There is much to learn from the IHE connectathons and the Hackathons being run by INTEROPen. We need an approach to compliance that is effective but simple.

and finally…

Cracking the interoperability challenge is not about the technology or technical standards. We have these! Rather it is about modelling the semantics of clinical discourse. It is a big task, but we know how to do it and have the tools and methodologies to support this work. We need to sweep the politics, empires and vested interests aside and get on with it.