Demonstration projects, like the Health Level 7-Integrating the Healthcare Enterprise Interoperability demonstration ( ), which will be displayed at the annual meeting of the Healthcare Information and Management Systems Society in Orlando, Fla, February 22-26, 2004, are a great opportunity to take a look at system integration as it should be and can be, not necessarily as it is. There is always a balance in the design of a demonstration between being “real world” and taking the opportunity to push the boundaries. In the words of our chief clinical consultant, who I will not embarrass by quoting by name, “We know what we can do today, and it sucks.”

In the demonstration, we build on components of real systems, available technology, from a wide variety of system vendors, an anticipated 25 participating organizations. With these “real world” pieces, plus the standards and profiles developed by Health Level 7 (HL7) and the Integrating the Healthcare Enterprise (IHE), we can take a leadership position showing how far we can go when open standards create a level playing field and a receptive atmosphere for integration and innovation. Most of the tough problems today stem from politics, culture, and economics. In the demonstration context, we can set these aside and let the technology shine, hopefully creating more demand for open standards compliance throughout the industry.

This year, by pooling the resources of HL7 and IHE, and their constituencies, we are planning innovative and perhaps even provocative views of how we can manage adverse events such as drug-drug interactions, public health emergencies such as a botulism outbreak, and routine operations such as referrals, tumor reporting, claims, and clinical trials, can be managed in a distributed information system, without overloading clinicians with awkward or redundant data entry. Today, as we know, the demands of patient safety, public health reporting, and clinical trials seem to take physicians away from their core work, but with open standards working across platforms and vendor applications, we can get the efficiency and return on investment from these tools that have always been promised. This efficiency is not just for extraordinary circumstances or a highly integrated care setting: we will demonstrate how open standards can provide ubiquitous access to distributed information using simple tools available in a small physician office.

Just how “blue sky” are these scenarios? Blue sky enough that we know we do not have the systems and standards to fulfill them. Last year, in conjunction with the Institute of Medicine (IOM) Patient Safety Data Standards Committee, we set a precedent for reporting on our own work. The IOM wrote a demanding clinical scenario, then we tried to support it with the technology and standards available. Where we were not able to support the case as written, we reported on the gaps in technology and in available standards. We will do the same this year, reporting on where the demo reproduces today’s reality, where it uses draft standards, and where implementation either was not possible or required custom integration.

New this year will be a draft for a National Health Information Infrastructure using techniques and messages being deployed in Finland and The Netherlands and an open source metadata registry. We will upload simple HL7 V3 metadata messages to the registry, developed as part of a larger pilot project by the National Institute of Standards and Technology. Queries to the registry will fetch pointers to the full documents and images where they are maintained in their local PACS or document repositories. This will use two new IHE Profiles on Retrieve Information for Display (RID): Patient Identifier Cross Referencing (PIX).

We are working on several document/image linking vignettes using these profiles together with the draft DICOM WADO (Web Access to DICOM Objects) and the HL7 Clinical Document Architecture (CDA). WADO will give us a standard, consistent method to specify the format and resolution of a DICOM object and to retrieve that object over the Web. CDA will be the centerpiece in patient referrals, providing the key information required for continuity of care when a patient transfers between providers. This project builds on a growing consensus over the content and handling of referrals, championed by the Massachusetts Medical Society here in the United States and by national standards bodies in New Zealand, Australia, Japan, and the European Union. CDA will also be tested as a vehicle for comprehensive public health reporting to a tumor registry and a pilot application built by the California Department of Public Health, and we expect to implement CDA Claims Attachments, as proposed for the Health Insurance Portability and Accountability Act compliance. The proposal for CDA claims attachments will make it possible to submit simple electronic documents produced by a transcription system, electronic health record, or web form for claims adjudication under HIPAA. For background information on these projects, see the demonstration documentation on .

As I write this in early October, the plans seem enormous, but also tremendously exciting. The best part of putting this demonstration together is working with the great pool of talent provided by our participating vendors and partner organizations. If you plan to come to HIMSS 2004, please stop by and see what they have created.

Liora Alschuler is a consultant in the application of extensible markup language to health care information systems and is cochair of the Health Level Seven Structured Documents Technical Committee and the HL7 Marketing Committee