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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:

  1. 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.
  2. 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.


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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.
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Rene's Column (English) Rene is the Tutor-in-chief of Ringholm.