September 4, 2017
Has IHE gone off-track? Forcare CTO Mark Sinke shares his opinion:
A few weeks ago I was reviewing two new specifications put forward by one of the IHE technical committees. While I was reviewing, it dawned on me that we may have gone off-track and something needs to happen.
To explain what I mean, we first have to go back in history.
Act 1: Radiology Workflow
IHE (Integrating the Healthcare Enterprise) is an organization of users and vendors of healthcare IT equipment and IT systems. It was born almost 20 years ago (in 1998) out of the need to unlock the possibilities of the digitization of image acquisition modalities that were becoming more common.
In order to do so, it became apparent that these devices needed a way to communicate their - now digital - image output to systems that could use this output to streamline and improve the radiology reading workflow.
It was immediately clear that it would be necessary to have different vendor's systems work together to achieve that goal. Hospitals that sourced all their equipment and IT systems from a single vendor were rare, if existent at all.
Imaging devices needed a way to communicate their digital image output to systems that could use this output to streamline and improve the radiology reading workflow.
Standardization had taken off on the level of how images were stored and communicated through the DICOM standard, which has been in existence since 1993 (and its predecessors a number of years before that). However, just the standardization of the format and required data to be communicated did not unleash the improvements sought after.
The key thing that needed to change was that the standards needed to be put in the context of a clinical workflow. And for that, just standardization by technical folks from the vendor community was not enough.
The standards needed to be put in the context of a clinical workflow.
A few tech-savvy radiologists and the vendors joined forces in the newly formed IHE organization and worked on a process to tackle this problem. I have written before about the process, so I won't go into detail here. The net result of running the process was that the Scheduled Workflow (SWF) profile was created, which details how imaging equipment, image management, workstations, and reporting equipment work together to create a workflow without gaps. This profile was a huge success, and all major imaging vendors today support it.
Act 2: Standards Development
Fast-forward 10 years.
In 2003, IHE had grown significantly, and way beyond radiology. In that year, the IT Infrastructure (ITI) committee was created to work on profiles that would serve multiple clinical domains. In 2004, the XDS (Cross-Enterprise Document Sharing) profile was launched. It addressed a general way to share clinical information beyond a single department or organization. Note that this profile did not address workflow. In a sense, it sits on the level of the DICOM standard: defining format and protocol to make the exchange possible, but without a particular clinical workflow context.
Even the XDS-I (XDS for Imaging) profile, created a year later by the Radiology committee, only dealt with the infrastructure aspects of the exchange. Many more formats of content to be exchanged over XDS were defined later by the PCC (Patient Care Coordination) committee.
How to get back to workflow, which made the original radiology profile (and with it, the IHE organization) so successful?
I am missing something.
Well, a step was taken with the advent of the XDW (Cross-Enterprise Document-based Workflow) profile. That profile however, again needed to address an apparent lack of standardization. So it focuses on the way to structure and store workflow state, but not on a particular workflow. A few specific workflow profiles (in the eReferral, and tumor board-specific workflow profiles) were later created, but did not turn out to be widely adopted.
You will have noticed by now where I am going. I am missing something. We are still looking for the 'killer application' that would unlock the potential of all the siloed IT systems that are in our healthcare facilities today.
In my opinion, IHE has not discovered these applications, because we have lost sight of the users, and their workflow needs. We are focusing on technology, instead of making things work.
In 2011, the Health Level 7 standardization organization embarked on a new initiative to revive their aging 'HL7 version 2' standard. FHIR (Fast Health Interoperability Resources) was a new attempt to define a standard structure and messaging protocol for clinical information elements. FHIR has attracted a lot of attention, because of the way it uses modern web technology as both its underlying standard, as well as its own definition process. This also means that HL7 has taken on a much more modern community-driven, and less committee-driven approach to standards development.
FHIR might replace XDS as the fundamental information exchange protocol.
I am a fan of FHIR. Because of its modern underpinnings, it has the potential to level the playing field for exchanging clinical information. If it lives up to its promise, FHIR might, in the next 10 years, replace XDS as the fundamental information exchange protocol. That is why we are so heavily involved in standardization and implementation of the specification, with a graceful transition path from XDS.
Act 3: Final Call to Action
However, replacing one message format and exchange protocol with another is not a goal in itself. The real goal should be to relieve the pain the clinical user feels when their workflow is broken.
That problem is not up to the techies to define. The user community in IHE has proven they are good at identifying and scoping the problem. The vendors in IHE have proven they can take technology to solve the identified problem. IHE as an organization has the experience to balance governance and pragmatism in the resulting solution design.
Back to workflow and the user-level view.
And that is exactly where IHE should be heading: back to workflow and the user-level view. Then fill out the technology from there. We need to focus on stringing systems together instead of musing about individual message exchanges. We - the industry - should take back our role in IHE to apply the standards (be it XDS, XDW or FHIR) in the context of those real clinical workflow problems.
Mark Sinke, Forcare Founder and CTO