Transcript here - HL7 UK

National Cancer Institute
Achieving Interoperability:
Observations and Recommendations
from
20 Years of Mistakes (and Some Learning)
“What’s right is what’s left
when you’ve done everything
else wrong.” – Robin Williams
Charlie Mead, MD, MSc
Senior Associate
Booz Allen Hamilton
National Cancer Institute
The Starting Point (circa 1985)
• 10 years experience building ambulatory ECG analysis
application
– Single stakeholder role (cardiologists)
– Isolated, well-defined problem
– Primitive tools
– Minimal UI requirements
– Minimal data sharing requirements
• Stable data structures
– Interoperability not a driving force
National Cancer Institute
The Next Step (circa 1995)
• Founded a company to bring ‘point-of-care’ computing to Home
Healthcare
– Multiple stakeholders (nurses, CFOs, payors, regulatory)
– Complex, somewhat ill-defined (shifting) problem
– Variety of tools (DBs, tablet computers, multiple target systems)
– Considerable UI requirements
• Type I vs Type II systems (“All the simple systems have been built” – Grady Booch)
– Extensive data sharing requirements
• Evolving data structures
– Interoperability (clinical/administrative/financial) as a key requirement
National Cancer Institute
Interchange vs Interoperability
• Main Entry: in·ter·op·er·a·bil·i·ty
: ability of a system ... to use the parts or equipment of
another system
Syntax  Structure
Source: Merriam-Webster web site
Semantics  Meaning
• interoperability
: ability of two or more systems or components to
exchange information and to predictably use the information
that has been exchanged.
Source: IEEE Standard Computer Dictionary: A Compilation of
IEEE Standard Computer Glossaries, IEEE, 1990]
Syntactic
interoperability
(interchange)
Semantic
interoperability
National Cancer Institute
“Protocol” and the Semiotic Triangle
Concept 2
Concept 1
“We need to sign off on
the protocol by Friday”
“Protocol XYZ has enrolled
73 patients”
Symbol
Thing 1
Document
Study
“Protocol”
Concept 3
“Per the protocol, you must be
at least 18 to be enrolled”
Source: John Speakman
Thing 2
Thing 3
Plan
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Semantic Interoperability – Different Perspectives
• Exchanging meaning (not just structure)
– Human-to-Human semantic interoperability
– Hybrid/stepwise semantic interoperability
– Computer-to-Computer semantic interoperability
• The critical role of context
– Where does it live?
• Sharing semantics is not just about sharing static
structures; definitions of dynamic behavior are also
equally critical
Abstraction
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The Communication Pyramid
`
Communication
National Cancer Institute
Climbing the Communications Pyramid
• Recognizing the features of complex systems
– Multi-level vertical organizational structure (“the org chart”/silos
of vertical isolation)
– Horizontal processes for producing the system’s Products of
Value
• Healthcare is the epitome of a complex system
• Cross-disciplinary project teams
– Domain Experts / Requirements / Design / Development /
Testing / Documentation and Training / Maintenance
National Cancer Institute
Climbing the Communications Pyramid
• Think architecturally
– Uses and Users
– Static structure
– Dynamic behavior
– Structural Walls / Partitions / Furniture
– Dog houses vs Skyscrapers
National Cancer Institute
Climbing the Communications Pyramid
• Recognize the importance of Organizational Maturity in an
integrated development/user community
– Level 1: Heroism and Passion
– Level 2: A Set of Directions
– Level 3: A Map
– Level 4: Gathering Process Variance
– Level 5: Using Process Variance data to drive Process
Improvement
• Everyone wants to be Level 5
– Progression is stepwise
• Level 1 does not mean incompetence!
National Cancer Institute
Climbing the Communications Pyramid
• Adopt a organization-wide process framework
– The Waterfall Process works when…
• The problem is isolated, well-defined, and stable
• Requirements are stable
– The Unified Process (framework) has evolved over 20+ years
of feet-on-the-ground experience with failed projects, frustrated
users, overworked developers, and angry customers
• Iterative/Incremental (model human problem solving)
• Risk-focused (“do the hard stuff first”)
• Architecture-centric (“functional requirements vs quality
requirements”)
• Driven by visual models (“a picture is worth 1000 words”)
Standardized Models (UML)
Non-standard Graphics
ad hoc Drawings
Abstraction
National Cancer Institute
The Communication Pyramid
Structured Documents
Free-text Documents
`
Discussions
Communication
National Cancer Institute
Climbing the Communications Pyramid
• Utilize standards whenever possible
– Value sets
– Messages
– Documentation
– Process frameworks
• Standards facilitate interoperability
• Standards leverage experience
• Standards decrease maintenance/evolution costs
National Cancer Institute
The Present (for now) (circa 2006)
• This is a HARD PROBLEM!
– Comprehensive Semantic Interoperability – i.e. human,
computer, and/or hybrid/incremental in nature and meaningful
to all stakeholders – in the context of complex systems is – and
will always be – a huge challenge
– Evolving technologies will make it incrementally easier….but it
will always remain a complex, difficult, and challenging
problem...the Semantic Web will not solve all of our problems
– Consider the cost of not achieving semantic interoperability
• Monetary
• Social/Ethical
National Cancer Institute
Top-Down Commitment
(Not Micromanagement – Level 5 organization)
• Willingness to commit management $$s
• Willingness to provide management oversight
– Willingness (and ability) to define standards-for-use
• Process frameworks
• Data exchange standards
• Standards for Milestones/Deliverables
• Management understanding of the short-term difficulties
and the long-term rewards
– Avoid the allure of simple solutions to complex problems
– Avoid the pitfalls of schedule-based project management
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Bottom-Up Passion and Dedication
• Communication
• Collaboration
• Cooperation
• Insatiable appetite for learning
– Understanding must cross-domain boundaries
• Indomitable spirit and vision: “Eyes on the prize.”
– (Semantic) interoperability is still hard work
– Some legacy data may not be computationally interoperable
• Process frameworks and standards are your friend…
– “This is more about sociology than technology”
(George Komatsoulis)
National Cancer Institute
Stepwise Computational Interoperability
Highly “Informational” Systems
*
1001 0100 0100
1011 1110 0101
1001 0100 0100
1011 1110 0101
*
Less “Informational” Systems
*HL7 Clinical Document Architecture: Single standard for
computer processable and computer manageable data
(Wes Rishel, Gartner Group)
1001 0100 0100
1011 1110 0101
National Cancer Institute
Final Comments
• CTWG initiatives
– “Harmonize existing NCI IT systems”
– Build a Clinical Trial database/data warehouse
• Dr. Carmona’s call for “ending the silos”
• “Healthcare is the only business where information
sharing is the norm rather than the exception. Those of
us who build systems are not used to this framework.
However, if we are to provide the healthcare system with
the tools they need, we must embrace this paradigm
completely, committing ourselves to defining, designing,
and building fundamentally different types of system than
those with which we have our predominate historical
experience.”
National Cancer Institute
QUESTIONS
ANSWERS