HL7 and IHE in Sweden
Publication date: Feb 08, 2015
Why is it that the use of HL7 and IHE standards in Sweden is relatively low?
HL7 Sweden recently organized a number of training courses: (1) an overview of interoperability standards, and
(2) IHE XDS and CDA (a modified version of our standard XDS training course). Interestingly they felt it was necessary to turn
the first training course into a prerequisite for the second one, which to me indicates that they're not expecting
a lot of prior knowledge about international standards such as HL7, IHE and DICOM. With 30 attendees the training course was
sold out, so we'll be back later this year for the provision of additional courses related to CDA, FHIR and XDS.
According to Mikeal Wintell, chair of HL7 Sweden, about 80% of all data exchanges within healthcare
are based on proprietary formats, and 20% standards. Within the imaging departments about 80% of data exchanges are based on DICOM.
So why is it that a country like Sweden, which has been relatively active when it comes to participating in
standards efforts (e.g. they hosted the CEN secretariat for years),
has such low usage of those standards?
Interview with Mikael Wintell and Gustav Alvfeldt
According to Gustav Alvfeldt, former chair of HL7 Sweden and currently one of its board members,
Sweden has had a tendency to embrace new standards as the 'holy grail', and to attempt to
scale its use up to the national level after having tried it in a small pilot. At the national level the standard inevitably
failed, because the 'foundation' (i.e. a use-case and motivation for such data exchanges) is missing. This has happened with
GPICs (a CEN standard in the 90s),
HL7 version 3 messaging (pioneered by Stockholm county), 13606 EHRCom (mandated for a while at a national level
whilst explicitly disallowing the use of competing HL7 standards). The next standard that is at the risk of being
the subject of the Swedish hype-and-crash cycle is CDA, or FHIR.
EDIFACT messages, introduced in the early 1990s, is still being used as the legacy standard for the exchange of messages; HL7 version 2 is also
in use - introduced by international software applications.
From discussions with Mikael, Gustav and other participants the underlying reasons for the low uptake of
interoperability seem to be twofold:
- The small size of the Swedish healthcare IT market. There are only a few Swedish HIS/EHR systems - the initial development of which date back for at least 15 years.
The limited number of organizations involved (software vendors as well as healthcare providers) is none of the reasons as to whey there are a lot of one off solutions -
reusability simply isn't one of the design characteristics. On the other hands, Swedish IT companies that are also active outside of Sweden are well motivated to support
international standards, given that their international customers demand those to be available out of the box.
- The structure of the Swedish healthcare system, which is rather fragmented in nature.
Until recently workflows were department-centric: you'd discharge a patient from one department, to subsequently admit them in another department.
Swedish healthcare is organized along the lines of the 21 counties and hundreds of municipalities.
These have a high degree
of autonomy, they actually compete with each other when it comes to the delivery of care - in order to get a bigger slice of the overall healthcare budget.
There is nationwide legislation related to patient consents - however, all regions and healthcare providers interpret that law in their own way, so even if one
wished to support the exchange of data between healthcare providers there would be all sorts of challenges.
Mikeal likes to compare Sweden (9.6 million inhabitants) with Kaiser Permanente
(with a similar number of clients) - which raises the question as to why Sweden has such a fragmented healthcare system.
One of the exercises during the IHE XDS training course asks the attendees to identify 'the scope your own affinity domain'. In most countries the answer will
be either a region, or one large healthcare provider. One of the attendees of this course in Sweden argued that each and every healthcare provider, down to a GP practice, would be a separate
affinity domain. Which just goes to show the fragmented nature of the healthcare system.
Sweden is currently looking at CDA (as a mature technology) to exchange clinical data between healthcare provider organizations.
The electronic document paradigm is probably the best fit for their requirements, especially given that messaging solutions like Edifact/HL7 v2 and DICOM
will continue to be heavily used within one single provider organization. Experience with earlier new/untested standards (e.g. GPICs, 13606, HL7 v3)
steers them away from FHIR - which is likely to become normative in 2017.
This means CDA is likely to become the focus of implementations for the 2015-2020 time frame.
A key issue for the success of any of these standards will be to establish a solid foundation for data interoperability. Amongst other things that will mean raising the
awareness related to the need for interoperability, as well as knowledge about the existence of tried and tested standards.
PermaLink to this page: http://www.ringholm.com/column/HL7_IHE_in_Sweden.htm
Index of columns:
- Advantages of online training courses (Oct 12, 2020)
- Combining the best of IHE XDS with HL7 FHIR (Jun 27, 2019)
- FHIR DevDays and the year in review (Dec 27, 2018)
- Creation and Curation of FHIR Profiles - process and governance (Dec 14, 2017)
- De Algemene Verordening Gegevensbescherming (AVG) in de zorg (Dutch, Sep 19, 2017)
- Impact of the GDPR on the use of interoperability standards (Jun 27, 2017)
- News from the FHIR DevDays in Amsterdam (Dec 15, 2016)
- Next XDS Release (Oct 27, 2016)
- Five years of FHIR (Aug 11, 2016)
- Interoperability projects in Ireland - FHIReland (Mar 14, 2016)
- 2016 FHIR Jedi Calendar (Jan 06, 2016)
- Top 10 HL7 videos watched in 2015 (Dec 24, 2015)
- Update from the trenches on CDA R2.1/R3 and HL7v2. (Oct 15, 2015)
- FHIR DevDays - UK GP System APIs (Sep 16, 2015)
- IHE XDS - testing and implementation tools (Aug 25, 2015)
- Most often implemented IHE Profiles (Jun 08, 2015)
- Why we sponsor the HL7 WGM (May 10, 2015)
- FHIR in Paris (Apr 21, 2015)
- Mapping HL7v2 messages to FHIR. (Apr 13, 2015)
- Analysis of CDA R2 testing tools - most requirements are neither tested nor respected. (Feb 13, 2015)
- HL7 and IHE in Sweden (Feb 08, 2015)
- 2015 FHIR Chiefs Calendar (Jan 07, 2015)
- The Merry FHIR Choir caroling the 12 Days of Christmas (Dec 09, 2014)
- Chicago FHIR Update (Oct 13, 2014)
- Internationalization of HL7 (Sep 25, 2014)
- New XDS Advanced training course on offer by IHE Services and IHE Academy (Jul 14, 2014)
- Recent and Future developments of the DICOM standard (Mar 06, 2014)
- Top 10 HL7 videos watched in 2013 (Jan 02, 2014)
- Report from the HL7 WGM in Cambridge (Oct 16, 2013)
- Documenting the history of HL7 (Sep 03, 2013)
- Histology Lab Device Automation using HL7 version 2 (Jul 23, 2013)
- HL7 FHIR Elevator Pitch (Jul 15, 2013)
- Interoperability Standards - the no-sales pitch (Jul 09, 2013)
- HL7 UK - new landscape, new opportunities (Jun 26, 2013)
- Validation and error correction at the IHE Connectathon (Apr 25, 2013)
- CDA Implementation Guides - (not) invented here (Apr 17, 2013)
- Usage of IHE Profiles (Feb 25, 2013)
- 10 year anniversary - Dutch Ringholm HL7 v2 training courses. (Feb 19, 2013)
- About IHE Academy and new IHE training courses (Jan 12, 2013)
- CDA implementation experiences in the UK (Dec 04, 2012)
- Musings on free HL7 IP (Oct 01, 2012)
- HL7 Connectathons (Sep 09, 2012)
- Renovate HL7 version 3 (Aug 03, 2012)
- Frequency of use of HL7 message types (Jul 24, 2012)
- Lighting the FHIR, HL7s new major interoperability standard (Jun 15, 2012)
- Reflections on the HL7 membership model - the affiliate life cycle (Dec 28, 2011)
- Thinking like an OWL reasoner (Sep 17, 2011)
- RFH (Resources for Health): HL7 version 3 taken to the next step (Aug 18, 2011)
- What's so great about the HL7 organization? (Aug 04, 2011)
- Kerndossier: een Nederlandse versie van CCD (Dutch, May 03, 2011)
- A HL7 RIMBAA update (Apr 21, 2011)
- Timezone Hotel (Mar 29, 2011)
- HL7 and openEHR are cooperating (finally) (Jan 21, 2011)
- Increasing demand for IHE training courses (Dec 18, 2010)
- Context issues with the IHE QED profile (Dec 15, 2010)
- The changing role of HL7 country organizations (Jul 16, 2010)
- Implementing HL7 version 3 - the book (May 06, 2010)
- Adding openness to a closed world (Feb 09, 2010)
- How to lower the hurdle for HL7 v3 implementers (Jan 21, 2010)
- HL7 v3 deployment statistics (Dec 17, 2009)
- There's Trouble in Paradigm (Sep 25, 2009)
- Internationalization of HL7 (Sep 24, 2009)
- HL7 UK signs deal with Ringholm to deliver HL7 v2/v3 training courses in London (Sep 17, 2009)
- The use of HL7 in South Africa (Aug 20, 2009)
- The Next Web Conference in Amsterdam (Apr 17, 2009)
- The HL7 UK AGM and RIMBAA (Apr 16, 2009)
- The HL7 Wiki reaches 2000 pages (Mar 02, 2009)
- The HL7 roadmap for CDA R3 and the CCD (Jan 17, 2009)
- HL7 Affiliates Meeting in Orlando (Jan 11, 2009)
- Swiss and Dutch HL7 News (Dec 31, 2008)
- Devices and Prizes (Nov 22, 2008)
- HL7 in Norway: a situation report (Sep 02, 2008)
- Russian whitepaper (Jul 09, 2008)
- The HL7 Interoperability Conference - IHIC 2008 (May 30, 2008)
- HL7 creates a RIM Based Application Architecture (RIMBAA) group (May 18, 2008)
- Notes from the HL7 WGM in Phoenix (May 08, 2008)
- HL7 v3 RIM based applications: an unintended side effect (Jan 19, 2008)
- Collaborative Tools (Jun 21, 2007)
- HL7 ist Pflicht in der deutschen Telematikinfrastruktur (German, Mar 16, 2007)
- HL7 based Tree inventory system (Jan 30, 2007)
- The link between HL7 and Open Source Software (Jan 06, 2007)
- Workflow Bribery (Sep 15, 2006)
- Timezones in HL7 (Jan 23, 2004)
- Controlled vocabularies: "@*%!!!" ? (Sep 01, 2003)
- Trusting the other Party (Nov 01, 2002)
About Ringholm bv
Ringholm bv is a group of European experts in the field of messaging standards and systems integration in healthcare IT.
We provide the industry's most advanced training courses and consulting on healthcare information exchange standards.
See http://www.ringholm.com or call +31 33 7 630 636 for additional information.
Rene is the Tutor-in-chief of Ringholm.