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Defining Interoperability: An Interview with Grahame Grieve

flying cadeuciiGrahame Grieve is a long-time leader within HL7 and one of the key drivers behind FHIR. He chats with Leonard Kish about what’s been happening and what’s ahead for interoperability.

LK: First tell me how you got into standards… it’s kind of an odd business to get into.  Why have you chosen this and why are you excited about it?

G: It happened by accident.  I was working for a vendor and we were tasked with getting some exchanges and I wanted them to be right the first time.  That was the philosophy of the vendor.  If we did it right the first time, then we wouldn’t have to keep revisiting and that meant that using the standards correctly.  The more I got involved, the more I discovered that it wasn’t obvious how to do that…and that the standards themselves weren’t good.  I felt personally that we need really good standards in healthcare.  So it became a personal mission and I got more involved through the company I was working for and eventually I left so I could continue doing what I wanted doing with the standards – I enjoy the community aspect of the standards and feel very strongly that it’s worth investing time in and I had the opportunity to build a business out of it, which not many people do. So now I freelance in standards development and standards implementation.

LK: There’s a lot of talk in Congress about the lack of interoperability and everyone probably has their own definition. Do you have a working definition of interoperability or is there a good definition you like for interoperability?

G: The IEEE definition to get data from one place to another and use it correctly is pretty widely used.  I guess when you’re living and breathing interoperability you’re kind of beyond asking about definitions.

LK: Are there ways to measure it then?  Some people talk about different levels; data interoperability, functional interoperability, semantic interoperability.  Are there different levels and are there different ways to measure interoperability?

G: We don’t have really have enough metrics.  It’s actually relatively easy to move data around.  What you’ve got to do is consider the costs of moving it, the fragility of the solution, and whether the solution meets the user’s needs around appropriateness, availability, security, and consent.  Given the complexity of healthcare and business policy, it’s pretty hard to get a handle on those things.  One thing that is key is that interoperability of data is neither here nor there in the end because if providers continue with their current work practices, the availability of data is basically irrelevant, because they treat themselves as an island. They don’t know how depend on each other.  So I think the big open area is clinical interoperability.

LK: Interoperability in other verticals mostly works.  We hear talk about Silicon Valley and open APIs.  There’s perhaps less commotion about standards, maybe because there are less conflicting business interests than in healthcare.  Why is healthcare different?

G: First of all – from an international perspective, I don’t think other countries are by and large better off or different (where incentives are different).  They all have the same issues and even though they don’t have the business competition or the funding insanity that you do in the US, they still have the same fundamental problems.  So I hear a lot of stuff from the US media about that and I think it’s overblown.  The problem is more around micro level transactions and motivations for them and fundamentally the same problem around getting people to provide integrated clinical care when the system works against them doing that.                  

LK:  So can you give me an example of how things are maybe the same with NHS or another country vs. the US in terms of people not wanting to exchange clinical data?

G: In Australia, there’s a properly funded medical health care system where the system is overwhelmed by the volume of work to be provided.  No one get’s any business benefit from not sharing content with other people. Still, because you have to invest time up ahead to exchange data and other people get the benefits later, there’s very low participation rates for any kind of voluntary data sharing schemes that you set up. There’s scandalously low adoption rates.  And that’s not because it’s not a good business idea to get involved but it’s because the incentives are misaligned at the individual level (and the costs are up front).

LK: Right, so it’s maybe it’s also a lack of consumer drive?  It’s there data and you’d expect the incentives to align behind them, but they don’t ask and don’t get, maybe because we (or our providers) only access your record when we really need them.  It’s not like banking or email or other things we use on a daily basis?    

G: Probably that’s part of it, but from a consumer’s point of view, what does it do for them getting access to their data?  Continue reading…

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