IHE has just closed (July 5th, 2012) the public
comment period on a new profile designed to support health information exchange
using “mobile” technologies: MHD - Mobile access to Health Documents. IHE (Integrating the Healthcare Enterprise) is an international industry association
dedicated to interoperability. I must admit, I really like IHE. I like the fact
that they don’t write new standards; I like that all of their work product is
centred around implementation guides; I like that a vendor can definitively
establish that its products are interoperable and adhere to a particular set of
IHE Profiles; and (perhaps most of all) I really like the way that IHE governs
the introduction of new candidate profiles.
I must admit, however, that I wasn’t a huge fan of the
draft-for-comment of the new MHD profile. It felt, to me, that it is a bit
mis-named. MHD purports to be a profile to support “mobile” access to health
information. In reality, however, over 85% of the world’s mobile devices could not
use this profile, as it is currently designed.
My eldest son, Harrison, has a turn of phrase that he
sometimes (and occasionally sarcastically) uses. When his sister or brother is
complaining about something such as: “oh no – I left my iPod charger at school
and I’ve only got 4 hrs of music listening left before I’m out of juice”,
Harrison will roll his eyes and mutter: “first-world problems!”. His comment
underlines the simple truth that, really, how big an issue could this possibly
be?
I fear that the focus of the new IHE mobile profile (MHD),
suffers a bit from an analogous issue. The profile purports to be designed to support mobile access to
health information. However, as designed, the profile only supports access using a smartphone or tablet, with an internet connection, that is able to generate and
consume well-formed JSON content exchanged
using a RESTful API. One of the diagrams from the for-public-comment draft profile is shown
below (the annotations, in blue and in red, are mine and were included in the comment
document I posted to the IHE feedback site).
In my feedback comments on the candidate MHD profile, I suggested
that a tablet or smartphone already has
the necessary processing power to do native XDS-based document exchange – so the
MHD profile is simply a new interaction mechanism (REST) for a device that
could already execute the existing data exchange methods. I went on to point
out that, even in the US, only half of mobile phone subscribers have
smartphones… which means that half don’t. And worldwide, smartphone adoption drops to less
than 13%. As was recently reported by Business Insider, 5.6 billion worldwide mobile phone subscribers are Dumbphone users.
Now, I’ve never been a fan of mere nay-sayers and pot-shotters. In my
submission on the draft-for-comment I didn’t diss the hard work that has been
done by the IHE technical committee on the MHD profile. In point of fact, I like
it and think it adds a very useful alternate method to the existing XDS document
exchange specifications. What I don’t think the draft profile did, however, was
define a way to draw in the 5.6 billion mobile Dumbphone users – a group which
includes fully half of US mobile phone subscribers. So, in my submission, I proposed an
alternative.
I illustrated my alternative using a one-to-one pictorial analogy to
the original MHD diagram (shown above). Basically, my suggestion is that a mobile access to health documents profile
should support simple, boring, basic SMS (text messaging) data exchange. In this way, the profile would be usable by all 6.4 billion of the
world’s mobile phone users.
Now, let’s be serious with each other for a moment. We all
know that there are some severe limitations to information exchange over SMS:
- Limited to 140 characters
- No formatting; plain text only
- Numeric input is much simpler than alphanumeric input on basic (non-QWERTY) mobile phone handsets.
Clearly, a 140-character, largely numeric healthcare “document”
exchange is a pretty trivial use case! In fact, that isn’t at all what I was
proposing. What I proposed was a content exchange pattern – a text-based
conversation – that could, subsequently, be constructed into an XDS-conformant
healthcare document. To work, such a pattern would need to rely upon a workflow capability.
To illustrate how I think this alternative might work, I included
in my comments submission the graphic shown above. The premise of my proposed
alternative pattern for MHD is that a workflow-centric document (using the IHE’s
XDW specification, for instance) be employed to enable a guideline-based
conversation. The process steps might go something like
this:
Step 1: A structured CDA document is retrieved which
outlines the healthcare information which is to be obtained from a pregnant mum
during an antenatal care visit. This outline might be based on, for instance, the
WHO’s Every Woman Every Child care guidelines for maternal care.
Step 2: A workflow engine steps through each of the elements in the document and constructs simple “questions” which are sent via SMS to the mobile phone, such as:
What is the mum’s weight (in kg)?
What is the mum’s temperature (in degrees C)?
What is the mum’s systolic blood pressure (in mm Hg)?
For each of these questions, a simple numeric answer may be provided. Rudimentary error-checking can even be done to ensure that answers are within realistic parameters set for each data element (and which may have been expressed as part of the document’s data structure as allowed datatypes and ranges, etc.).Step 3: After the conversation has been concluded, a conformant CDA document is constructed and saved to the pregnant mum's shared health record using the XDS profile. Optionally, if some of the mum's readings are concerning in some way, a new conversation might be launched to escalate her care to a referral centre.
I will readily admit that this scenario is definitely not focused on trying to solve “first-world
problems”. Quite to the contrary, this particular example illustrates how such
a pattern may be used to help community health workers (CHWs) use basic mobile phones
to deliver guideline-based maternal care in rural settings in the developing world. In fact, just such a project is underway, right now, in Rwanda.
To be fair, though, this same pattern of workflow-guided SMS conversations could be used in all kinds of useful ways in the developed world, too. Here in Canada, as in many other countries, we are presently very focused on ways to improve chronic disease management. The "conversational" pattern could be readily employed to provide consumer health support to a diabetic patient at home in downtown Toronto.
“What is your blood sugar (in mmol/L)?”
"What is your weight (in LBS)?"
"How much exercise have you got over the last 3 days (in minutes)?"
The key message is this: To support broad, everywhere-access to shared health information, we should be looking for ways to support data exchange using mobile devices. To do this at scale, we need to find a way to usefully draw in and embrace the most pervasive mobile device on earth, the mobile phone, using the one exchange method every single phone supports: SMS.
To be fair, though, this same pattern of workflow-guided SMS conversations could be used in all kinds of useful ways in the developed world, too. Here in Canada, as in many other countries, we are presently very focused on ways to improve chronic disease management. The "conversational" pattern could be readily employed to provide consumer health support to a diabetic patient at home in downtown Toronto.
“What is your blood sugar (in mmol/L)?”
"What is your weight (in LBS)?"
"How much exercise have you got over the last 3 days (in minutes)?"
The key message is this: To support broad, everywhere-access to shared health information, we should be looking for ways to support data exchange using mobile devices. To do this at scale, we need to find a way to usefully draw in and embrace the most pervasive mobile device on earth, the mobile phone, using the one exchange method every single phone supports: SMS.
I have high hopes for IHE; I am, as indicated at the outset
of this blog, a real fan of the organization. Selfishly, because I’m currently
working in global eHealth, I’m very keenly interested and the ways IHE can potentially
help support meHealth
interoperability in the developing world. I will follow the evolution of this new
candidate MHD profile with interest and, if I’m able to, will work to help it
evolve to become more broadly embracing of existing mobile phone technologies.
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