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Supercharging the Implementation of Interoperability Solutions Using FHIR
Care Connect
David Hancock – INTEROPen Board Vendor
Co-Chair
Ben McAlister – INTEROPen Board Vendor
Representative and HL7 UK Chair
HETT, 1st October 2019
Quiz
4’
4’4”
4’7½ ”
4’8”
5’
Railway Gauge Widths Used
Before 1830
The Beginning of the Railway Era
In 1821 Stephenson was appointed as Engineer for Darlington to Stockton Railway.
He had previously done horse-drawn railways but proposed an engine driven railway.
He had always used 4”8”. He also used flanged wheels on his locomotive
Railway Opened in 1825 and was 25 miles long
Based on the success of this he was appointed Engineer for Liverpool to Manchester
Railway.
This opened in 1830 and was 31 miles long and was the first inter-city railway with
scheduled services
George Stephenson used a 4 ft 8 1⁄2 in gauge (including a belated extra 1⁄2 in (12.7
mm) of free movement to reduce binding on curves for the Liverpool and Manchester
Railway, Thus the 4 ft 8 1⁄2 gauge became widespread and dominant in Britain.
As Stephenson was commissioned to do more railways the 4 ft 8 1⁄2 gauge became
widespread and dominant in Britain.
However, other railways still used a different gauge – GWR used 7’¼”
The Growth of the Railways
• The 1840s were by far the biggest decade for railway growth. In 1840, when
the decade began, railway lines in Britain were few and scattered but, within
ten years, a virtually complete network had been laid down and the vast
majority of towns and villages had a rail connection
• In 1840 the Railway Inspectorate was established, to enquire into the causes
of accidents and recommend ways of avoiding them
Supplier Led Innovation – Used Nationally
Stephenson’s Skew Arch Bridge - 1830
Mechanical Signalling. Absolute Blocking
Signalling 1860
Fishbelly rail with half-lap joint, developed
by Stephenson 1816
The Beginning of Standards
• In 1844 introduction of minimum standards for carriage construction and
social utility of railways (3rd class ticket)
• In 1845 The Gauge Act was introduced to standardize the gauge at 4’8½”
• It was only by 1892 that GWR converted all of its track to Standard Gauge –
NEARLY 50 years later
Was This Enough for Interoperability?
Loading Gauge
Defines the maximum height and width for railway vehicles and
their loads to ensure that they can pass safely through tunnels,
under bridges and keep clear of track-side structures such as
stations
Great Britain has (in general) the most restrictive loading gauge
(relative to track gauge) in the world
After nationalisation, a standard static gauge W5 was defined in
1951 that would virtually fit everywhere in the network.
A consequence of this is that British Rolling Stock costs more than
equivalent rolling stock in continental Europe
Advantage of keeping to International Standards
• HS2 Rolling Stock costs 50% more so it can also run on
existing lines
1. Priorities set by local areas
1. Fast coverage
2. Late and Incomplete Standards Defn
1. Lack of Interoperability
2. Have to work to lowest common
denominator
3. Market Driven Innovation
1. Innovation became standard
4. Higher Cost
Railways v NHS Health Interoperability
1. Priorities set by NHS England
1. Slow coverage and Implementation
2. Late and Incomplete Standards Defn
1. Care Connect Core not finished
2. Lack of Interoperability
3. ToC, GP Connect still not implemented
3. Little innovation
4. Interoperability still OUR number 1 IT Problem
5. High cost burden of no Interoperability or
Proprietary Interoperability
Railways NHS
Who Are INTEROPen and How Are They Trying to Address this?
• INTEROPen is an OPEN collaboration of individuals, industry, standards organisations and health and care providers
• Has a Board with 2 Co-Chairs (from Vendor Community and The Service) that Meets Monthly▶ Current looking for a 3rd Clinical Co-Chair
• Uses a Collaboration Tool (Ryver) that all members can use• Runs Hackathons/Connectathons
o October 2018o March 2019o June 2019
o INTEROPen One London Hackathon Participant Open API documentation
o October 2019
Commercial interests are put to one side in the group’s activities.
Co-Production
260 Member Orgs
160 Membershttps://www.interopen.org/about-
us/our-members/
Why We Believe Interoperability Has Not Been Successful
Health IT entails both technical and adaptive change and that implementing health IT today is one of the most complex adaptive changes in the history of healthcare, and perhaps of any industry. Adaptive change involves substantial and long-lasting engagement between the leaders implementing the changes and the individuals on the front lines who are tasked with making them work.”
Professor Bob Wachter in 2015 “Making IT Work: Harnessing the Power of Health Information Technology to Improve Care in England”
Demand
PullSupply
PushInteroperability Standards Interoperability Need/AdoptionDo It Yourself
Who
Cares?
Local Health Economies (LHCRs, GDEs,
ICSs, STPs), IT Vendors
International Standards Orgs, NHS Digital,
IT Vendors
Strategy to Supercharge Curation?
• We are missing a completed UK (Care Connect) Core API Implementation
Guide (IG).
• Path to move to FHIR R4 and beyond
• FHIR IGs are a critical element of the FHIR standard and the process of
getting work implemented
• Improving the Clinical → Technical Mapping Process and Governance▶ How we take PRSB clinical models and turn into FHIR Profiles
▶ Bridging the Clinical-Technical Chasm Digital Health Summer School
▶ This is a continuous process and not a one-shot effort
What is a good FHIR IG?
• Represents the consensus of it’s community well
• Good quality internally - consistent, correct, efficient
• Clearly describes what you have to do to ‘get it right’
• Provides good documentation to support implementers ▶ A problem of many perspectives
• Consistent with other implementation guides
• Clearly describes how to interact with the community
• The UK as a community must work together on our community process
if we are going to be successful
• We must keep abreast of what other FHIR implementer communities
are doing elsewhere in the world.
Common Issue
• Common feedback: everyone is concerned about profusion of profiles and
implementation guides
• What are the sources of this? ▶ Wishel’s rule: Change the consensus group, change the consensus
▶ Different communities have different (overlapping) requirements
▶ Different communities have different heritages around architecture, design choices,
balance between lean+freedom | heavy+controlled
▶ Different life cycles and time frames
▶ Different commercial motivations
FHIR Community Process
• https://wiki.hl7.org/index.php?title=FHIR_Community_Process
• A common process where different communities collaborate to work together
so that:▶ Projects are announced to each other
▶ Overlaps & collaborations are documented in public
▶ Projects have clearly document transparency / process / license
▶ A community of interest
• Goal: Minimise Conflict AND Learn from Others
INTEROPen’s Role
• Facilitating the production of FHIR Profiles and Implementation Guides for
the UK▶ Mapping of PRSB (or other) Clinical Logical Model to Technical mapping to FHIR
resource profiles,
▶ Creating a community and forum bringing together Vendors, IHE UK, OpenEHR,
PRSB, NHS Digital, NHSX,, the Service etc.
▶ HL7 UK can help with specifics of supporting UK Communities in adopting
proposed FHIR Community Process and in using some of the HL7 infrastructure to
help facilitate.▶ HL7 FHIR Implementation Guide Publisher
▶ Use HL7 for Technical Assurance
”How” We Do This
• The NHS cannot control everything in the standards development process▶ It is is complex adaptive problem
▶ Base Standard
▶ Draw on HL7 UK Community Knowledge and all other stakeholders through
INTEROPen
• Skill up Local Health Economies to do their own Profiling▶ Enable being able to move from Local → National
KEEP
CALMAND
USE
HL7® FHIR®
