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standards and interoperability in digital health
explained when people discuss digital health
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the term standards and interoperability often
come up what do they mean and why do they matter
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could such abstract technological
processes actually help save lives
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we will answer this question in three parts first
we will look at a case study to explore why it's
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important to get digital health applications to
communicate with each other second we will see
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how connecting digital health applications through
integration leads to significant cost scalability
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and management challenges third we will show how
to overcome these challenges through standards and
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interoperability let's start with part one the
case study scenario in the fictional country of
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o'nessa lucy the national immunisation officer
at oneessa's ministry of health and isaac the
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district health officer of umbaya are planning
an upcoming child vaccination campaign to get
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child immunization numbers up nationally lucy
has been put in charge of managing the national
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campaign across all the districts she starts
by working in the most populated district first
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isaac's district of umbaya isaac's district
includes some rural areas as well as some smaller
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city centres and in this campaign he will need to
provide immunisation to children in all areas of
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his district through facilities and mobile clinics
lucy visits isaac's district health office to help
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him gather the information he needs to do his
district planning for the child immunisation
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campaign they want to use two different data
points to assist with planning the first is
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they need to know how many children need to be
vaccinated the second is they need to know how
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many vaccines isaac currently has for each of the
service delivery sites if they can't compare this
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information they might not order enough
vaccines for the children in his district
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putting their lives at risk these two data points
exist in two different global goods applications
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open lmis a supply chain application and dhis2
a district health information application
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open lmis can give them a view of the vaccine
supply chain how many vaccines are available
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to be used and where they are stored and
dhis2 can give them a view of the number
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of children in the district catchment area who
are eligible for vaccines but they can't see
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this information together because it is in two
different applications currently to analyze the
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data in this format it takes significant manual
labor and even still sometimes the data sets do
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not align properly resulting in less reliable
and error-prone information ultimately all this
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tedious effort leads to too much time managing
and cleaning large and often inaccurate data
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sets and not enough time making evidence-based
life-saving decisions but why can't these two
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applications automatically exchange information
with each other well when open lmis tells dhis2
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there are five dpt vaccines in umbia clinic this
month dhis2 cannot understand open lmis's shared
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messages because they use different vocabulary and
grammar to describe the same data values so how
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can we help people like isaac and lucy get these
systems to communicate let's explore that next
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in part one we saw the challenges faced by health
system managers trying to make digital health
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applications work for their health programs
and left off with lucy and isaac struggling
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to get their applications to exchange data now
in part two we will examine the way lucy and
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isaac initially try to solve this data exchange
challenge but face problems with this approach
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later when talking to the ministry software
development team isaac and lucy learned that they
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can directly integrate the two applications dhis2
and open lmis to enable communication of data
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they explain that to integrate the two
applications they will need to write custom
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code between the applications to translate how
the data is being described by each application
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using a bi-directional connection this sounds like
a good strategy for solving this simple use case
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however isaac doesn't just manage immunization but
all the health programs in his district many of
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which are supported by their own applications that
could benefit from communicating with each other
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and lucy doesn't just work in this district but
manages the whole country's immunization program
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and she needs many other districts
applications to be able to communicate as well
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so lucy and isaac asked the software
development team about integrating their
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other applications when working with the team
on integrating the larger set of applications
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they encounter new challenges when they
connected just two of their applications
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open lmis and dhis2 they needed just one
bi-directional connection to exchange data
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so the cost was low however this problem compounds
when you add additional applications when they
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add a fourth system they need to maintain six
bi-directional connections and a fifth needs ten
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and if one application changes all the other
applications need to change as well since they
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are now connected this is extremely expensive and
will quickly use up their entire budget why does
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the cost and complexity rise so significantly
with each additional application the software
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development team explains that it is due to a
problem known as the quadratic cost problem named
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after the mathematical concept they illustrate
here the number of bi-directional connections
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increase quadratically not linearly with each
integration of a new application when you have
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a country with as many systems as onassa by the
time you need any more than three applications
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the cost and complexity rise much faster than
the number of digital health applications you
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are trying to connect there must be a better way
integration is not sustainable writing software
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to directly connect to applications or integration
may be able to connect your applications but there
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will still be the quadratic cost problem is there
a way for multiple applications to communicate
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with each other that addresses the quadratic cost
problem yes we will explore this in the next part
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now in part three we will see how lucy and
isaac learn about investing in an approach
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that addresses these challenges and allows
multiple applications to exchange data
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the software development team explains that
the solution is standards and interoperability
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first they show lucy and isaac what standards
are and then they explain to them how it will
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help with interoperability what are standards
in software standards are a set of rules that
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allow information to be shared in a uniform and
consistent manner across any application they
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are approved and published by an authoritative
official organization as the systems are currently
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configured for lucy and isaac's immunization
campaign open lmis and dhis2 cannot currently
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communicate with each other remember dhis2
has been trying to ask open lmis a simple
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question how many dpt vaccines are at empire
clinic this month but they cannot understand
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each other without a common set of standards the
software development team instructs lucy and isaac
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on the importance of two specific types of
standards to enable interoperability semantic
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and syntactic standards that help applications
establish a common vocabulary are known as
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semantic standards for the two applications lucy
and isaac are using in their immunization campaign
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they need to agree on two vocabulary lists
in order for the applications to communicate
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one for the vaccines and one for facilities
for example the semantic standard to refer
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to the dpt vaccine is vax dot dpt and for the
empire health facility is facility 145 once
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they agree on a semantic standard they both use
the same terms to describe the same commodity
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when dhis2 asks open lmis how many facts.dpt
vaccines are at facility 145 this month
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open lmis responds to dhis2 with a question what
do you want to know about vax.dpt and facility145
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with semantic standards even though both
applications are now using the same words open
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lmis still doesn't understand what is being asked
open lmis can understand the vocabulary of bax
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dot dpt and facility 145 but not how they relate
knowing what the terms mean isn't enough so the
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software development team explained to lucy and
isaac that these applications also need to have
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common grammar to communicate meaning standards
that do this are known as syntactic standards
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they help you determine how the words fit together
the software development team shows lucy and isaac
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what happens when they have both semantic and
syntactic standards with both sets of standards
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in place the dhis2 and open lmis applications
can share data automatically and seamlessly so
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when dhis2 asks open lmis how many vax dot dpt
vaccines there are at facility 145 open lmis
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can provide dhis2 with that data responding that
there are 5 fax dot dpt vaccines at facility 145
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now that isaac and lucy understand
standards they must determine
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all the different semantic and syntactic
standards they would like to adopt in onese
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the software development team explains that
investing in standards will make it easier and
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more cost efficient to enable interoperability
between all their digital health applications
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interoperability is the ability of multiple
applications to communicate with one another
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by accessing exchanging and making use of data
in a coordinated manner to achieve health goals
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to ensure true interoperability at a
large scale between all their systems
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lucy and isaac learn that they need to invest
in a component known as a health information
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exchange a health information exchange or hie is
part of a country's enterprise architecture that
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connects multiple applications and allows them
to move data between one another using standards
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bundled together to provide implementation
guidance for the software developers
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this approach overcomes the quadratic cost problem
open hie is an example of such an architecture
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one of the things that hies do is store lists of
terms and concepts mapping how these lists relate
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to each other across different applications
standards make this mapping process easier
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the hie receives the data from each of
our applications and keeps track of how
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they relate and will translate between
the different applications in real time
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this enables the three or more applications
to communicate through our hie as a central
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translator now any new application that gets added
only needs to be able to communicate with the hie
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and if an application changes only the hie needs
to be updated while all the other applications can
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still communicate this is one way to keep costs
down and avoid the quadratic cost problem we saw
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in part two now that isaac and lucy understand
how standards let applications communicate
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both vocabulary and grammar and that an hie
lets many applications easily exchange data
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in a cost effective way they want to invest in
building one and are ready to learn more about
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how the components of an hie architecture
can interact with their applications
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once they know this they can work with the
mohs digital health lead to ensure that the
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investment roadmap for their national hie will
meet their needs the next year when isaac and
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lucy need to do their planning they can pull the
data they need from the different systems together
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this lets them see how many children need to be
vaccinated how many vaccines they have available
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and how many they need to order with their
applications linked isaac and lucy can ensure that
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all the children in their district and country
are vaccinated and can grow up healthy moreover
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by using an hie to help interoperate their
applications data is showing them population
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level trends they couldn't see before and now they
can make time-sensitive evidence-based decisions
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that impact the lives in every district at every
age group and at each point of the health journey
