Opinion: Secure messaging interoperability is more than a slogan

The work of the secure messaging vendors on the FHIR-based proof of concept trials is to be congratulated and is a key step in improving existing interoperability for delivery of point to point electronic communication.

As every GP knows, millions of secure messages such as discharge summaries and test results are being successfully exchanged daily, using the services of a small number of secure messaging vendors and direct sending of orders and results between some pathology providers to their referrers.

The issue with current messaging systems is not that secure communication is unobtainable, difficult to implement, costly and insecure. The FHIR initiative enables messaging vendors to network their services in the same way as phone companies or banks so that messages sent via one can be delivered by another. Not all customers are signed up to the same service.

So far so good. However, there are are a few major hurdles to be jumped. A collaborative effort to achieve networking by messaging vendors some eight years ago was run in a process facilitated by IHE Australia, HL7 Australia and the MSIA.

The technical issue of how to connect vendors was rapidly achieved (before FHIR existed) however goodwill to collaborate fell over when commercial issues in the free market of competitive messaging vendors surfaced. Identifying and addressing these business issues will be essential for success this time.

Firstly, who is going to pay who for the delivery of messages originally sent by another messaging service, and will this grow or shrink the size of the market and business?

The second barrier to successful cross-transfer of messages is that the messages sent by almost all health services do not comply with Australian messaging or vocabulary standards.

Likewise the major clinical system vendors are not capable of processing a standard HL7 message, if one were to be delivered to them. Senders and receivers have each interpreted the international HL7 messaging standard independently of the agreed Australian standard and associated implementation guidelines.

There were at one time over 15 variants of the HL7 pathology result message being sent daily. Currently this barrier is overcome by messaging services keeping a close track of the formats sent and accepted by their customers' IT systems and "fixing" the message format "on the wire" as it passes through their messaging hubs.

This is less than ideal as we don't expect the post office to open, read and fix grammatical errors on letters as they past through the system. Computers being basically "stupid" (unless endowed with complex machine learning) means that where such errors are not fixed the receiving system can not read the message. GPs could not receive reports electronically.

This service of fixing messages and ensuring end to end quality of service is one of the key functions of messaging vendors that can easily be overlooked by simplistic processes to achieve interoperability.

One of the unanticipated outcomes of the Secure Message Delivery (SMD) standard developed by NEHTA (now ADHA) is that enhanced encryption of messages means that messaging services can not open the message in order to customise it to be acceptable to clinical software like Best Practice, Medical Director, Zedmed and the others.

If SMD were mandated and implemented tomorrow, messaging as we know it would just stop happening.

This issue of conformance with standards has been known for over 20 years, but while a workable solution to fixing messages has been available, there has been no real incentive for labs or GP vendors to address the message standards compliance problem. From their perspective, why spend money and effort fixing something that is "working" and flexible for end users, and which is part of the messaging service they pay for?

No authority has been prepared to mandate or regulate that standard messages are used. No funder has been prepared to throw sufficient financial rewards at health services or vendors to get them to implement the standards.

Time will tell if ADHA paying health IT vendors $30,000 to implement SMD is enough. Private pathology providers have proven to be resolutely resistant to implementation of standard pathology messaging and vocabularies.

Effective messaging depends on the content of the message (the "payload") just as much as getting the transport "messaging" format correct. In addition to paying GP system vendors to implement the SMD standard, it is necessary to implement and test the Australian standard HL7 message 4700.2 for lab, radiology and referral messaging.

International efforts in implementation of standards and systems have found that collaboration and testing events called connectathons help with troubleshooting and testing of implementations. IHE Connectathons are a key part of creating system-wide interoperability and trying to tackle interoperability without provable implementation of standards is sure to fail.

If this makes sense to the readers of Pulse+IT, then it should becoming increasing clear that achieving interoperability is not as simple as "changing to SMD", "adopting secure messaging", "opt in or opt out" – it is a complex socio-technical undertaking.

Fixing all of this is not just a task for ADHA; it needs all of us.

Peter MacIsaac is a GP and health informatician who has been involved with development and implementation of standards for interoperability for over 20 years. He is secretary of the Australian committee of Integrating the Healthcare Enterprise - IHE (Australia).