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Lessons From the Putative Failure of HL7 V3

by Wes Rishel  |  August 16, 2011  |  4 Comments

Graham Grieve, a major participant in HL7 standards writes HL7 needs a fresh look because V3 has failed.

I agree with much of what he says, in particular his distinction between clinical interop and semantic interop. I take it to mean that the level of rigor required for getting to working clinical interop is less than full semantic interop and more likely to be handled with feasible modifications to existing products.

[BTW, a big +1 to Graham for his blog name: Health Intersections. It really captures the nature of interoperability as interfaces at the intersection of different systems, businesses and medical and IT cultures. This is the POV that leads to the distinction between clinical interop and semantic interop.]

I also agree with some commenters that V3 Is Not a “Total Failure.” The RIM is a basic contribution to  healthcare modeling that for the first time captured the role of “role” in relating administrative and clinical data. It’s use of “mood” to capture the alignment of and differences among clinical data throughout the workflow of healthcare was equally brilliant. It is a shame that the developers chose to describe that discovery in terms that played well in academic circles and added barriers to sharing the knowledge with the 95% of IT folks that do the real work. This same pursuit of the perfect abstraction extended into the data types, adding to general difficulty in getting acceptance of V3 artifacts.

V3 Messaging is close enough to having had zero impact as to not merit further discussion. Some RIM-based artifacts, however,  such as the CCD and other documents in the CDA family have achieved centers of use and are at least at the level of “it’s better to use these than to start over.” (That may not sound like much but it is exactly the level of success that HL7 V2 enjoys.)

It’s interesting to explore why CDA has fared better than V3 messaging. Here are some factors to consider:

Fighting a Different War. V3 messaging was the classic case of the generals fighting the last war. CDA explored new territory and looked at interfaces in a manner that was well-understood by clinicians (signed documents). It thereby received support from a class of pragmatists who would not invest a lot of time in improving  interfaces that were working “well enough.”

Detachment from the Communication Paradigm. CDA documents are all about content. They are not tied to how (or even whether) they get transported.

Less Top-Downedness. Because a great deal of CDA development was focused on specific use cases it was sometimes possible to hide the complexities of the RIM in stuff the clinicians and other business experts were willing to accept as “the XML gibberish.”

Implementation Guides. The nature of CDA permitted focus on fairly narrow use cases. This led to the development of implementation guides that allowed implementers to figure out what to plug in among the XML gibberish in order to communicate. Not ideal but able to make  headway for those that are fighting a new war.

Less Bad SNOMED Juju. In the U.S., CAP was seen as interested in financially exploiting its the intellectual property in SNOMED and deeply suspected within parts of the AMIA community. In some other countries SNOMED was seen as a US-only product. HL7 was driven by folks on the side that was suspicious of, if not outright hostile to, SNOMED. As a result most of us in HL7 ignored the intricate nature of the relationship between codes and information structures on the theory that codes were a separate problem. Although SNOMED CT still has many issues, the formation and behavior of IHTSDO has led to the widespread view that it is better to work with IHTDSDO to improve SNOMED than to start again.

[I am honestly not clear on why the CDA group had less hostility to SNOMED. Perhaps it was because it formed later in the history of HL7 and brought in new blood; perhaps it was because it was more focused on specific use cases it had a more utilitarian view. It is also possible I am imagining that there was a difference. The important point is that a “fresh look” in HL7 has to purge HL7 of residual resentment of SNOMED and include cooperation with IHTSDO as a base part of its methodology.]

Applying the Lessons
I am not arguing that CDA was a raging success; I see growing adoption of implementation guides that include CDA documents but the pace of adoption since CDA R2 became a standard does not justify a view that CDA represents a perfect solution to the overall problems in the HL7 V3 series of standards. Nonetheless it is important that the fresh look be fighting the right war, detached from the communication paradigm, less top-down, have tool-based support for the rapid development of implementation guides and squarely aligned with IHTSDO.

What’s in a Word?
Several of the commenters on Graham’s post implied that declaring V3 a failure has negative political consequences. This can be true. Backing for national level programs in their countries may not transfer to the fresh look if they have to acknowledge that what they were backing failed. These are the realities we face working in a world where spending decisions are made by agencies with wide scope and little depth. However, the countervailing concern is that some more comfortable political formulation might leads diehards within HL7 to believe that all that is needed is to tweak version 3. Should that view prevail, the relevance of HL7 will substantially decline.

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Category: healthcare-providers  interoperability  

Tags: ehr  health-20  health-information-exchange  health-it  healthcare-interoperability  healthcare-providers  hl7-fresh-look  simple-interop  

Wes Rishel
VP Distinguished Analyst
12 years at Gartner
45 years IT industry

Wes Rishel is a vice president and distinguished analyst in Gartner's healthcare provider research practice. He covers electronic medical records, interoperability, health information exchanges and the underlying technologies of healthcare IT, including application integration and standards. Read Full Bio

Thoughts on Lessons From the Putative Failure of HL7 V3

  1. Joan Duke says:

    Thanks Wes. These comments are right on! I am pondering HIPAA 5010 and CORE right now. Do you have any thoughts on these standards for administrative transactions?

  2. Grahame Grieve says:

    Hi Wes

    Thanks for picking up on my comments – and for appreciating the name (had to pick some name for the company).

    you say:

    > I take it to mean that the level of rigor required for getting to
    > working clinical interop is less than full semantic interop and more
    > likely to be handled with feasible modifications to existing products

    Well, yes, and no. In many cases, clinical interop is *more* demanding than semantic Interop, as you basically cover subsequently. On the other hand, clinical interop between people is lower level – doesn’t need such granular information.

    Either way, good coding is necessary. Regarding your comments about Snomed-CT, I’ve never been aware of substantial resistence to it in the way you document. Of course, the licensing was a problem – and still is, with IHTSDO, but less of a problem. Any anyone who cares about meaning has to be at least unhappy with snomed as it stands. But it was really the licensing that did – and does – prevent HL7 from depending on snomed.

    You last comment about tweaking: the organization faces a difficult decision. One underlying causative problem with v3 is that HL7 tried to do too much. So any solution that tries to do too much is automatically – and deservedly – suspect. But any solution that doesn’t do enough is a waste of time. I very much fear that there is no sweet spot there.

  3. Lloyd McKenzie says:

    I think any solution we undertake should be *capable* of scaling to the full extent of healthcare. However, that doesn’t mean we need to undertake all of that from day 1. One of the challenges we had with v3 is that some of the “core” areas of healthcare had limited stakeholder interest because their needs were well-met with existing solutions (primarily v2). Examples include basic observations and encounters. Interest in those areas primarily came from national programs that wanted to have all of their data captured using a consistent platform. On the other hand, some of the fringes that weren’t well supported by existing solutions (clinical trials, clinical genomics, etc.) found considerable interest in v3.

    If we’re serious about a new solution being a true replacement for v2, then we’ll have to really work to ensure the basics are covered. But failure to support things like clinical trials, claims and other aspects (if not immediately then eventually) would be a significant mistake.

    Realistically, any solution in the healthcare space can easily be applied to any domain. The trick is ensuring that the solution scales well enough that navigation, content management and alignment don’t become issues.

  4. Pingala says:

    Though there is a considerable implementation friction on V3, I think it is a good interoperable standard, especially for hormonized, normalized, aggregated, etc. clinical data exchange (CDX).

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