Health Tech Newsletter 2nd Edition- A Path to Healthcare Interoperability

By Ayo-Olagunju Muna

A Path to HealthcareInteroperability

The Johnsons are your typical middle-class Nigerian household. Femi and Linda have been married for 5 years and have had relatively successful careers culminating in their being property owners. Prior to owning this property, they formerly resided in a rented apartment within the suburb of the Ajah axis in Lagos, Nigeria which is about 24km from their offices at Victoria Island. As with most cosmopolitan cities around the world, the cost of living is usually high and usually compensates with high-earning job opportunities. As such, it is not an alien practice to see people work in major cities, where the economic prospect is richer, and reside on the outskirts of the city, as a strategic cost-cutting approach.

Their new home is strategically situated on the outskirts of town, approximately 140km from their offices, more than 5 times their regular commute to work. The absence of a metro means the commute would have to be made via road. The heightened insecurity and the ongoing road repairs along that axis make the commute even more precarious and challenging. They decided to reduce the frequency of this journey by getting an inexpensive self-contained not too far from their offices, while they journey home only on weekends and public holidays. Their plan had kicked in, and this was their new normal. On one of such weekend trips, tragedy struck, as they were involved in a ghastly auto crash on their way home.

They were rushed, both unconscious to the closest hospital within proximity of the accident. Femi’s unique hospital number was gotten from his phone’s emergency details. His details were used to cross-reference Linda’s details, being his next of kin. The attending physician was able to access his consolidated medical history, which revealed him to be diabetic and his wife was 4 weeks pregnant. They were equally able to access their blood groups and other associated histories. The readily available nature of their medical histories impacted and informed decision-making regarding the quality of care they received and of course, the hospital was able to comfortably proceed with the treatment since they were equally able to determine they both had valid health insurance and their insurers had been contacted as required. When they were stable, they were both taken to a diagnostic centre, for a CT scan, the result of which was automatically sent to the requesting hospital, upon availability.

While the hospital part of The Johnsons’ ordeal might have sounded a tad bit fictional, considering our immediate healthcare environment. However, the scenario described is purely factual and is the reality in the UK, US and some other developed countries and this is possible simply due to interoperability.

Interoperability within the context of healthcare is the ability of multiple, disparate systems to share, interpret and use healthcare data cohesively within and across organization bounds, towards improved healthcare delivery and population health outcomes. The scenario described above is one of the most simple and basic use cases of interoperability in healthcare, yet we can easily see how the exchange of data and the ability to meaningfully use this data between various players within the healthcare value chain translated to improved and optimum quality of care. The caretakers could determine the appropriate treatment plan, having full visibility of the Johnsons’ medical history promptly. The caretaker could render the best possible care, without any limitations, knowing fully well both patients are insured and they are certain to get paid for their services. Cost savings could be achieved by

not having to engage in redundant tests and superfluous processes. It will help with improved disease surveillance and monitoring, ultimately leading to population health benefits. These are just a few of the benefits of healthcare interoperability.

We are in a digital age, which is marked by the proliferation of the internet. The ubiquity of the internet has made the information exchange of data of various forms and kinds possible and the continuous advancements in technologies have made it even faster. The ability to take advantage of these technologies to improve human life and endeavour, especially in healthcare service delivery, is critical to achieving sustainable growth and development, especially in developing countries like Nigeria (Akintunde et al., 2019). The availability and on-demand accessibility of health information, when required, is essential in determining the quality of healthcare service delivery. This brings about the practical need for health information exchange, meaning various health systems would need to interface with each other, exchanging on-demand data that is understood by the receiving systems. Several considerations have to be examined because communication is not limited to two systems, but between multiple complex systems. Keeping it simple, let’s assume we are looking to facilitate health information exchange between two different systems; A and B, integration can address this. You would need to write custom codes to facilitate the bi-directional exchange of data between both systems. A fairly simple solution to a straightforward problem. However, when you add other systems to the consideration, integration is no longer a viable solution. At 2 systems, they needed just 1 bidirectional connection, the effort required was lesser and the cost was low, the problem compounds with

Figure 1: Integrating 2 systems

Additional system. With 4 systems, 6 bidirectional connections will be required and 10 bi-directional connections would be required for 5 systems. Since all the systems are now connected, If there is a change in one of the systems, it would mean a change in all the systems. This approach is very complex and extremely expensive making it not sustainable in the long run as it births another problem known as the quadratic cost problem – The number of bidirectional connections increases quadratically, not linearly, with each integration of a new application, which would easily balloon the cost. The quadratic cost problem can be addressed by standards, which would help towards interoperability. In software, standards are a set of rules, that enable information sharing in a uniform and consistent manner across any system. They are approved and published by an authoritative organization (TechChange, 2021).

Figure 2: Integrating 4 systems

Over the years, health data has always been challenging to access and share securely. The nature of health data creates a paradox: It’s difficult to share because it’s sensitive, requiring a high level of privacy and security, yet the inability to access it when it’s needed has the potential to negatively impact care (IBM, 2021). Having determined the need for a connected healthcare ecosystem that facilities information sharing, and interoperability as the only means of achieving this on a large scale. It’s often said, the journey of a thousand miles starts with a step, and a vision often precedes this journey itself. Nigeria has to have a strategic vision for healthcare interoperability that examines where we are, how we want to achieve it, key success milestones and the eventual outcomes Let’s outline a possible path to achieving healthcare interoperability in-country.

1. Governance & Regulation

2. Adoption of EMR

3. Standardization

4. Incentivization

5. Create an interoperability roadmap

Findings reveal that Nigeria’s health tech legal and regulatory framework is nascent. There is no sole regulation set aside to guide the operations of healthcare tech vendors in the country. On the contrary, what exists is several pieces of legislation that are aimed at regulating the operations of orthodox medicine providers. Some of these include; the National Health Act (NHA) 2004, Patients Bill of Rights (PBoR), Freedom of Information Act (FoI Act) and Cybercrimes (Prohibition & Prevention) Act 2015.

With the proliferation of the internet and interoperability in other sectors, people are becoming increasingly aware of the need for security, confidentiality and privacy. Up until the Nigerian Data Protection Regulation (NDPR) 2019, extant regulations fell short of adequately achieving this since they were drawn up in an era where digital health and health tech were not prevalent. With the influx of several health tech vendors in an already regulatory porous space, extra attention would need to be paid to ensure patients’ rights are sufficiently protected by extending the coverage to their digital health records.

For information exchange to thrive, patients would have to be guaranteed a high level of security, transparency, accountability and protection, to comfortably embrace e-Health. Patients are becoming more aware of the value of their data. Hence, regulation needs to be lucid in terms of ownership, consent and release, data sharing, use of data, and security and privacy concerns. NDPR, being a subset of the UK GDPR sufficiently addresses these concerns from a sector-agnostic perspective. The slight drawback is that this regulation is not specific to the health sector and it focuses more on Personally Identifiable Information (PII). Drawing learnings from the Health Insurance Portability and Accountability Act (HIPAA) 1996 and Health Information Technology for Economic and Clinical Health (HITECH) Act 2019, we need a regulation that serves the dual purpose of protecting a patient’s health information specifically and additionally regulating the operations of the health tech industry. The inclusion of this regulation, coupled with the existing ones would ensure a robust and enabling regulatory framework, which is indeed a prerequisite to achieving healthcare interoperability as it would help in building the much-needed stakeholders’ trust and confidence in the process.

Adoption of EMR

Paper-based records are still the mainstay in this part of the world when it comes to documenting patients’ medical encounters. With electronic medical records still in their infancy and having no regulatory backing, the majority of clinics, hospitals and healthcare facilities are still heavily reliant on manual processes and paper-based records. Paper-based records are a major hindrance to healthcare information exchange as they are accessible only by one person at a time in a particular location. The world has advanced beyond this general limitation through the adoption of digitization and penetration of the internet.

Electronic files allow information to be accessed and shared simultaneously and securely by authorized users across multiple locations, which is central to information sharing. The use of EMRs has to be mandated by legislation to encourage increased adoption beyond the obvious benefits the providers stand to gain from them.

With the passage of the modified National Health Insurance Authority (NHIA) Act and the operationalization of various State Health Insurance Schemes, it presents the enablement and incentive to mandate the use of EMR by providers for empanelment into the schemes.

Since infrastructure challenges are part of the limitation behind the adoption of EMRs, the regulators need to be more pragmatic in setting a cut-off phase for its adoption.

Standardization

To facilitate intersystem information exchange, there has to be a common denominator across all the systems. In this case, more aptly put, a common vocabulary. This is what standardization seeks to address.

System A stores and sends data in an agreed format that can be processed and understood by Systems B and C. There are 2 types of standards that are responsible for this; semantic and syntactic standards. Semantic standards help applications establish a common vocabulary. However, despite the common vocabulary, there might still be the underlying problem of a lack of comprehension (i.e. they cannot understand each other). This is where syntactic standards come in. Syntactic standards help applications establish a common grammar, thus understanding each other.

The standardization that needs to be achieved far exceeds the semantics and syntax standards required for health information interchange. Several aspects of the orthodox health industry itself need to come to terms with standardizing aspects of its operations. For instance, hospitals currently have an endless list of service tariffs they maintain for each insurer. This makes the process of medical billing very complex. The US addressed this with Current Procedural Terminology (CPT) coding. Standardized billing would help promote transparency and curb insurance fraud. It would spur innovation amongst insurers as they no longer compete majorly on pricing, translating to better value for the patients.

A standards definition committee comprising of policymakers and technocrats representing all stakeholders in the healthcare ecosystem would need to be established. The health data standards to be defined cuts across; vocabulary/terminology, content, transport, privacy and security, and identifiers. Extensive work has already gone into developing some of these standards, which are already operational in the West, some of which we can adopt, whilst we leverage the rest as a base for defining our unique standard. Some of these standards include; ICD-10, CPT, HL7 CDA, and HL7 FHIR.

The major output of this standardization exercise is to get all stakeholders within the health care ecosystem, especially the health tech vendors to adhere to their various implementation. The output of this roundtable dialogue would achieve the dual aim of standardizing and sanitizing the health tech space, setting the true foundation for healthcare interoperability.

Incentivization

The key to achieving interoperability lies not merely in the adoption of EMRs, but their effective utilization. Despite mandating its use, the healthcare industry has been operational and managed to thrive without the need for EMR, so it would be a huge culture shock for the physicians, especially the more experienced, older-generation ones, who struggle to come to terms with its usefulness.

To accelerate adoption, the government would need to find a way to creatively incentivize stakeholder interest and participation. Despite the technological advancements in the US and the early proliferation of technology in their society, they still had to incentivize participation, to record the 95% EMR penetration rate they currently boast (Sonal & Jawanna, 2019). From their experience, regulation ensured that every doctor, clinic, and hospital had an EMR, but it couldn’t dictate if and how well it was used, which would counteract their interoperability goals. They recognized this early enough and developed a program termed Meaningful Use (MU).

The Meaningful Use program had as its primary objective the capture, exchange and reporting of specific clinical data and quality measures by the physicians such that it counts towards the data sharing goals of their healthcare interoperability roadmap. Another thing the MU program was able to achieve was sanitization of the various EMR products. Any vendor/product that failed to meet the defined standards was not certified for participation in the MU program. Physicians could use only Certified Electronic Health Records Technology (CERT). Essentially, they had to meaningfully use the CEHRT.

These clinical data and quality measures were broken down into stages, for ease of conformance, giving rise to 3-MU stages. Financial incentives were given to providers that conformed to each of the stages, while penalties were awarded for non-conformance. Bringing this home, we can adopt a similar approach to the MU program. The incentives can come in the form of increased insurance enrolees and penalties can likewise come in the form of reduced enrolees. Realistic timelines for achieving the MU goals need to be set, factoring in our general computer literacy level and infrastructural challenges.

Create an interoperability roadmap

This is the final and crucial stage toward our journey to healthcare interoperability as it builds upon the gains from the earlier phases. At this stage, we would need to draw up a detailed interoperability roadmap, which would define our strategic interoperability vision and goals. This process would involve multisector stakeholder participation and collaboration between, the Federal government, State governments, development partners, the private sector and patients. This roadmap is meant to lay out a longer-term set of drivers and policy and technical components that will achieve the outcomes necessary to achieve the vision. The process of drawing up the roadmap would start with a review of the outcomes and impacts of the activities from the earlier phases to wholistically shape its development and improvement. It would have three main sections; the “Drivers”, which are the mechanisms that can galvanize the development of a supportive payment and regulatory environment that relies on and deepens interoperability. The next is the “Policy and Technical

Components,” which are essentially what stakeholders will need to implement in similar or compatible ways to enable interoperability, such as shared standards and expectations around privacy and security and a section that finally speaks to “Outcomes,” which serve as the metrics by which stakeholders will measure the implementation progress. Each of these sections will include specific milestones, calls to action, and commitments that will support the development of a nationwide, interoperable health IT infrastructure. The roadmap is intended to be a living, breathing document. As such, it is expected to accommodate changes based on the completion of the milestones and the realities of the operating environment. Below is the roadmap adopted by the US toward their healthcare interoperability journey

The path outlined to achieving this is not the sole path, nor does it need to be followed in this exact order, but one thing is certain, all the steps here need to be undertaken at some point during the journey. Whatever path is chosen, it is a long and arduous one that requires concerted effort, heavy stakeholder dialogue and collaboration and strong political will, to bring it to reality.

The Journey to achieving a truly interconnected healthcare system is a huge one and a feat when achieved would certainly strengthen our health system, putting it almost on equal footing with the West and stimulating our economy in several aspects, among other several benefits.