Interoperability Stack” – developed to help communicate categorical reasons why health interoperability is not occurring.
In comments submitted last week to the National Science Foundation’s (NSF) Networking and Information Technology Research and Development Program (NITRD), the American Medical Informatics Association (AMIA) supported their future vision for interoperability among medical devices, electronic health records, and other systems within the healthcare ecosystem.
In doing so, AMIA observed that the future of interoperability will undoubtedly include data from remote monitoring devices and other kinds of patient-generated health data (PGHD), as well as data from community sources outside the bounds of traditional care institutions.
Last month, NITRD issued a Request for Information (RFI) to determine whether a vision of sustained interoperability in the hospital and into the community is feasible and, if so, what it will take to realize it. The RFI also included a short vignette describing an idealized state of healthcare environment where “people with serious injuries or illness are hospitalized [and] medical device additions and changes are automatically recorded with no deficit in patient safety, loss in data fidelity, or data security as the patient transitions across the continuum of care.” NITRD anticipates hosting a conference this summer to gather further feedback on this topic.
AMIA Supports “Future Vision”
AMIA supported the “Future Vision” articulated in the RFI, but it noted the omission of patient-generated health data (PGHD) and data generated from outside of traditional care spaces. It also urged NITRD to view “interoperability” not as a solution to be obtained or a final destination, but as an ongoing process only achieved through coordinated efforts across stakeholders.
Why Healthcare Interoperability Is Not A Definable End-State
The AMIA has long maintained its position that “interoperability” is not a definable end-state, but rather, should be defined operationally. According to the AMIA, “Interoperability exists when there is both the ability to exchange information and use that information once exchanged; however, there may be multiple reasons why information systems cannot interoperate.”
AMIA’s Socio-Technical Interoperability Stack
In the comments, the AMIA also presented its “Socio-Technical Interoperability Stack” to describe the multiple and multi-faceted reasons why information systems may not interoperate. The “traditional technology stack” illustrated represents the basic building blocks for interoperability that must be defined and understood (i.e., standardized) for interoperability to occur.
API Layer
The API layer is the packaging of the four preceding layers for specific purposes. An important characteristic of the technical stack is each layer’s modularity and substitutability. The modern internet runs on four APIs, comprised of standards across the four layers of the traditional technology stack. The ability to substitute different security or transport standards without redesigning the entire system underpins the success of all complex systems, and this is possible only because the standards are modular and substitutable.
Implementation/Policy and Business Drivers
In healthcare, there are five additional layers, which comprise the social aspects of the Socio-Technical Stack. The AMIA states that implementation decisions regarding how to apply and when to apply the data must be defined. Finally, policy and business drivers – including business incentives, contractual obligations, and policy/legal responsibilities all impact whether systems are interoperable.
It is important to note that the AMIA strongly recommends against framing this work as a means to develop a solution, or to think simply in terms of technical architecture.
“This vignette envisions a complex socio-technical ecosystem of technology, processes, and human actors – not an interoperability solution. To have any chance of being achieved, a framework is needed to delineate actions and responsibilities of dynamic and evolving actors, technologies, and policies. There will never be a single platform capable of the functionality described in this future vision. Even a set of improbably capable technology platforms will not be sustainable as actors, processes, and standards evolve,” said AMIA President and CEO Douglas B. Fridsma, MD, PhD, FACP, FACMI.
