Monday, June 12, 2006

More Problems in UK Health IT Implementation Efforts

What follows (dating from earlier in the year) has a new relevance given current financial problems with the UK's multi-billion pound Connecting for Health initiative

31 Jan 06 10:54 Failure of due diligence
The LSP contracts were granted in the expectation that P1R2 deployments would begin in December 2004. The contracts were awarded a year or less before this date. EMR's have a development lifecycle of many years. These contracts should not have been awarded on promises, but on working software. P1R2 required systems to transmit clinical data within HL7 Version 3 messages, encoded in SNOMED Terminology and the UK Drugs and Medicines Dictionary. It was manifest that >no< supplier had a working system using any of these. Three years later on it seems none had even performed an adequate impact analysis of switching to these standards. (Even the Johnny-come-lately PACS systems have patchy if any support of the relevant 'spine' standards). In the first two years of NPfIT, even relatively simple 'ADT' (admission, transfer and discharge) transactions using HL7 V3 have proven challenging to implement. Legacy systems will never use these, placing another burden on LSPs to set up and operate heterogeneous messaging infrastructures of inordinate complexity. Contrary to popular belief, SNOMED was never going to drop effortlessly into the ICD-9 'slot' in existing systems. Meanwhile moving to the Drugs and Medicines Dictionary requires fundamental retooling of electronic drug formularies and systems using them. It is also fair to say that HL7 V3, SNOMED and DM+D remain, even now, immature as standards and a 'moving target' for LSP's and suppliers. All the above was known back in 2002-3, understood and documented by hundreds of people in the NHS, system suppliers and informatics community. (post edited by EHI)

31 Jan 06 12:50 What "standards"?
Why are SNOMED CT and the dm+d "immature" and in what sense are they "standards? Looking at the ISB web site, it appears that they have only got to the first hurdle in the standards approval process. It must be almost 7 years now since the SNOMED and Read merger began, a long time even by comparison with the much-maligned Read Codes version 3 project of the mid 1990s in which so many of us clinicians participated. As far as I can see, the issue is with the specification of HL7 v3, SNOMED CT etc as standards for CfH systems in the first place, when they appear not to have reached a stage of testing when their suitability could be confirmed. Let's not forget that the NAO report into the Read Codes showed how difficult developing new clinical codes could be. If the "moving target" of evolving standards is a significant factor in CfH delays, the perhaps it's time to revisit the so-called standards that are being specificed.

02 Feb 06 23:02 HL7 V3 standard
One of the problems with HL7 V3 'standard' is that is was 'farmed' out to the HL7 organisation by the NHS. This is a body of experts who are amateurs ,in the sense that they have 'day jobs' as well. Members of the HL7 organisation attend the meetings but very few, if any, members derive their main income from developing HL7 standards. The 'standards' are voted on by the members and such a process, is long winded and often seems to result in the lowest common denominator as a 'standard' i.e there is no weighting of votes for the expertise of the participant. As HL7 V3 messages are the basis for communications in the new NHS I would have thought it a good idea to get the messaging standardised and working before the s/w systems which depend on the messaging were developed. Then the systems would have been built on a firm foundation. Disasters I fear may be imminent.

08 Feb 06 16:18 SCRAP HL7
RE:"As HL7 V3 messages are the basis for communications in the new NHS I would have thought it a good idea to get the messaging standardised and working before the s/w systems which depend on the messaging were developed. ......." Better never than late. As anyone who is competent in IT messaging knows, If you want to send a message, just send the message. There is no justification for "translation" into a "messaging format" such as HL7, XML, EDIFACT et al. The scrapping of HL7 at this stage would have the advantage of reducing costs and timescales.

08 Feb 06 19:46 HL7 shoots itself in the foot
One of the main troubles with HL7 is that from a practical point of view, it goes out on a limb and is idiosyncratic. The basic metamodel is in UML - lots of people understand UML- it rapidly becoming an IT standard worldwide. So far so good. To produce messages however HL7 V3 goes it's own way. It devises it's own modelling methodology and representation - using MS Visio. It does not even use UML and all the HL7 'symbols' are color coded. Bad luck if you don't have a color printer or are color blind !!! Plus the, would be user/practitioner, must learn a completely new 'symbolology' which is only used by HL7 V3. There is thus a heavy learning curve, and who wants to learn an esoteric modelling language which is only used in the context of HL7 ? Having built your model you then process the Visio 'model' programmatically to produce the XML schema. It is not clear what the precise rules are for this transformation, but much of it seems to produce unnecessarily complex XML. The reliance on Visio and their own modelling symbols renders HL7 V3 unusable in the standard modelling tools for UML, which are well tried and trusted. If anyone had set out to complicate the description and generation of XML messages one couldn't do better than the HL7 V3 committee. They really have shot themselves and others in the foot. The trouble is, that if we continue in this fashion, the taxpayer will not be the only one to suffer.