5. Infostructure and Infrastructure

Interoperability 

Interoperability is one of the requirements to have a functional infostructure. HIMSS (Healthcare Information and Management Systems Society) defines Interoperability as “The ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organisational, regional and national boundaries, to provide timely and seamless portability of information and optimise the health of individuals and populations globally” [3]. Many potential benefits of digital health solutions such as health data integration from different sources (e.g. EHR), real-time feedback and monitoring cannot be achieved efficiently without interoperability.

Interoperability has three dimensions:

1. Basic Interoperability: when two systems can exchange data. However, the proper interpretation of the data is not guaranteed. Therefore, an individual should read, interpret and act upon the received data.
2. Structural interoperability: the systems receiving data can interpret it at the data field levels and the clinical and operational value of the shared data will be preserved, resulting in less human interpretation and intervention.
3. Semantic or advanced interoperability: It is the meaningful exchange of data between two systems where the recipients of data will receive relevant information. For instance, when a patient undergoes surgery, the surgeon will receive information about the patient’s past surgeries from the records of the patient’s family physicians [4].

Building an interoperable system is contingent on a standardised data format, where the information systems, regardless of the language and technologies, can understand the structure and meaning of the data.

Health Data Standards

Standardisation of health data is crucial for designing and building a robust infostructure. Health data standards can be categorised into four groups [5] [6].

1. Information model standards: Information model standards specify the characteristics and structure of different elements of infostructures. These standards make the data exchange between different systems more reliable and predictable. Information models can be closed (i.e., proprietary and defined by IT vendors) or open source. Open-source information models are defined by communities such as CEN (the European Committee for Standardization) and ISO, which may become information standards. There are no widely adopted information standards for healthcare information; however, ISO 13606, HL7 (Health Level Seven International), and CDISC (Clinical Data Interchange Standards Consortium) are more widely adopted. These standards allow information to be re-used and accessible across various services (e.g., hospital to community service or patient to general practitioner).
2. Terminology Standards: Terminology standards standardise the medical terminologies by creating standard codes for each term. Sender and receivers of health data can communicate unequivocally by using these codes. For instance, clinicians may use different terms for one disease (e.g., Brain tumour and Brian cancer) or different terms for diseases in different languages. The terminology standards make the exchange of data possible in these circumstances. SNOMED (Systematised Nomenclature of Medicine) and ICD (International Classification of Diseases) codes are two examples of terminology standards.
3. Content Standards: Content standards determine the structure and content of an exchanged piece of data between two systems. For instance, a standardised prescription template is needed in a pharmacy for dispensing an electronic prescription. The template enables the pharmacy system to accurately recognise and process the necessary information, such as a patient’s name, medication name, billing code, etc. It allows a pharmacist to dispense the right medications to a patient. HL7 (Health Level Seven International)² is one of the organisations that provide standardised templates.
4. Communication standards: specify the formats that should be used to transmit health data between two computer systems. FHIR (Fast Healthcare Interoperability Resources) is an example of a communication standard published by HL7 to facilitate the exchange of health care information between organisations.

The main challenge in designing a robust infostructure is the compatibility of patient-generated data with existing health data. The popularity of health monitoring technologies and mobile applications has resulted in the creation of health data by patients. Many digital health applications and tools are not designed based on data standards and the generated data cannot be integrated with other health data appropriately and securely.