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There's Trouble in Paradigm

Publication date: Sep 25, 2009

Some controversies are brewing within HL7 and IHE about the ‘proper’ use of interoperability paradigms. The new HL7 EAF may help to resolve these issues.

When people talk about interoperability paradigms they quite often list messaging, services and documents as examples. These interoperability paradigms each have their own unique characteristics. Determining which of the interoperability paradigms is a best fit for a particular use case for the exchange of healthcare data is a tricky issue (e.g. see the Document vs. Message discussion).

One of the current controversies was stirred up by IHE (a standardization body that among other things creates HL7 implementation guides) – a whitepaper has been proposed within IHE which states that (in the context of inter-organizational communications) Laboratory orders shall be sent as a HL7 CDA document. This choice of paradigm is inspired by the IHE XDS standard which specifies a document based EHR/EMR. Therefore, in that context, ‘everything is a document’ – if all I have is a hammer, everything looks like a nail. The responsible group with HL7 is of the opinion that the workflow surrounding Lab orders cannot be supported using the document paradigm, and is eminently suited to be served by the messaging or services paradigm. There is ongoing discussion within HL7 how (and if) the use of CDA based lab orders can be made to work. Up to now the answer is a resounding "can't work/won't work".

Another open issue is that its functional service specification standards (see the Application Functional specifications section of the HL7 product List are isolated from any of the HL7 version 3 work. Those that have written the functional service specifications complain that nobody on the messaging side of the HL7 organization (messaging was the initial paradigm supported by HL7) seems to have read their specifications. The messaging side is frustrated by the fact that those who wrote the functional services specifications ignored the work done by the messaging side. The services side chooses to focus at the functional services level, and refuses to write an implementable specification based on HL7 v3 models. The messaging side is perfectly happy with their current set of messages – based on over 20 years of experience with messaging. When both groups have a joint meeting the outcome is mostly frustrating for both sides. They’re willing to communicate, but they really come from totally different backgrounds.

HL7 is in the process of defining an EAF (Enterprise Architecture Framework). It tries to bridge the gap between all interoperability paradigms. The EAF is being edited right now to ensure that it can be understood by mere mortals, and not just by enterprise architects. Keith Boone (one of the HL7 co-chairs) attempted to demystify parts of the EAF - which makes it somewhat easier to grasp the idea behind it.

The EAF will probably help in solving some of the issues surrounding the various interoperability paradigms. It will require that all standards developers within HL7 have a grasp of the essentials of the EAF - that'll take some time given that standards developers have a wide range of backgrounds. Having a "EAF for HL7 domain experts with a clinical background" would probably help all of us (including those with a computer sience background) to understand its core aspects.


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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.