Why eHealth interoperability?


There is no universally agreed definition of “interoperability”, let alone of “eHealth interoperability”.[1] Antilope proposes the following definition:

“Interoperability is the ability of a system or a product to work with other systems or products without special effort on the part of the customer. Interoperability is made possible by the implementation of standards.”[2]

“customer” is understood to mean here the “user” of a system or a product, whether it be an end-user (individual citizen or patient), a professional (physician, nurse, social worker…) or an enterprise (a healthcare practice, hospital, healthcare network or regional administration). All want their products or systems to work with others without making special efforts such as hiring technicians or companies to perform the integration or interoperation with other systems.


What does interoperability look like? There may be two examples that may hold lessons for eHealth:

  • Mobile communication: In the early days in the 1980s, several visions of mobile communications and different standards were competing and it is hard but not impossible to imagine a world where interoperability would not have happened. GSMA, founded in 1987, helped create today’s world of ubiquitous and affordable mobile devices by promoting interoperable standards and billing processes. Adoption rates show that those markets achieved highest penetration and usage rates where operators embraced GSM standards. Today, consumers take mobile telephony across countries for granted: a success story for interoperability, with many unsung heroes that worked hard to make it happen.[3]
  • Universal Serial Bus (USB): Virtually everybody knows or uses USB, be it in the form of memory sticks, computer peripherals, phone chargers or other usages. USB has made our lives better and offers a compelling case for interoperability. Started by an industry consortium of major players that included DEC, IBM, Intel, Microsoft, and Compaq in the 1990s, USB specified connectors, electrical properties, and protocols for data transmissions. Before USB, PC computers connected with peripherals (printer, mouse, modem, joystick, etc.) through dedicated plugs and protocols. USB created common interfaces that not only made PCs and laptops cleaner and simplified life for users, but also helped usher in an ecosystem of computers, peripherals and (now) mobile and other devices that interconnect regardless of brands and vendors.[4]

Another commonly understood example could be the banking sector and the interoperability of payment systems: banking is in fact often upheld as a model for the health sector. However, financial interoperability is not based on open standards, but rather on a set of (competing) commercial proprietary networks like Maestro, Visa, Cirrus and others: hardly a model for healthcare.


The examples of mobile communications and USB help illustrate the benefits of interoperability for everybody. They include:

  • Choice: Users can replace devices or parts without having to replace entire systems. Vendors cannot lock in their customers through mere proprietary systems.
  • Competition: Interoperability creates a level playing field that comes with all textbook benefits of a free market, including lower prices.
  • Market development: In fragmented markets, users hesitate to invest for fear of “backing the wrong horse”. Interoperability creates and lifts markets by building consumer confidence.
  • Innovation: An ecosystem based on open standards lowers the barriers to enter the marketplace for innovators and other new entrants to the market.

There are some specific benefits of interoperability for the healthcare sector. They include:

  • “Easy access to patients records” including the facilitation of integration and sharing of information and establishing a continuum of care;
  • “Easy comprehension of medical terms” through standardisation of the healthcare language benefiting both professionals and patients;
  • “Reduction of medical errors” through better and more timely information at the healthcare professionals’ disposition and point of care;’
  • “Reduced healthcare cost” through more effective sharing and communication of information among various stakeholders;
  • “Integration of health-related records” leading to better and integrated care; and
  • “Enhanced support for the management of chronic diseases” including better prevention.[5]

Last not least, there are also immediate benefits of choosing interoperable products for the buyer:

  • Interoperable systems are “future proof” in that they allow for the replacement of components and devices, reducing the total cost of ownership over the lifetime of the system.
  • They save time and money (the “special effort” on the part of the customer) spent otherwise on integration and maintenance.

The savings are demonstrated by a real example: After a powerful earthquake and tsunami hit Japan in March 2011, the Japanese health system set up a remote monitoring system for the care of displaced survivors. Using Continua devices saved them more than 80 percent in integration cost, and setting the system up just took two weeks instead of twelve.[6]

What does a world without interoperability look like? Look around. Widespread fragmentation holds the market back: buyers are loath to invest for fear of making the wrong choice, and those who do invest risk creating more island solutions and information silos that may solve specific issues but neither advance nor scale.

How does interoperability come about?

The existence of standards alone does not create interoperability: they need to be adopted by the market. It is classic chicken-and-egg problem: the benefits of a system that adheres to standards only emerge if there are other systems compatible with the same standard. It seems the natural state of the market is fragmentation. To adopt a standard, markets often require a push.

  • In the case of USB, the push came from Apple, a major player in the PC market. In 1999 Apple introduced the iMac which had no legacy ports, only USB ports. Suddenly, device and peripherals makers had a powerful incentive to produce compatible devices, which encouraged other PC makers to include USB ports as well. Within a few years, USB had conquered the back sides of personal computers.[7]
  • In the case of GSM, the push came from governments, or rather, representatives of mostly state-owned monopoly telecom service providers who, pushed by their respective governments, signed an MoU in 1987 pledging cooperation to create and deploy a mobile phone system across Europe.[8]

Who will provide the push in eHealth? In Europe’s public healthcare systems, there is no dominant player like Apple was in the PC market. The push will have to come from public buyers and regional/national governments that require their healthcare buyers to mandate commonly agreed standards in their procurements.

Which standards?

“The nice thing about standards is that you have so many to choose from.”
(Andrew S. Tanenbaum)

There may indeed be such a proliferation of standards that it may defeat the purpose. Rather than giving a blanket endorsement of any specific standard organization, the European eHealth Interoperability Framework study[9] and the Antilope project propose an approach based on specific, defined use cases. Selecting and tuning/refining these use cases and their associated realisation scenarios for a particular project offers access to proven and widely used standards and profiles, and also to the associated testing and certification methodologies and tools.[10]



[1] The European eHealth Interoperability Framework study, which serves as a point of departure and point of reference for Antilope, does not define interoperability either.

[2] The definition is adapted from the IEEE, an international standards development organisation (SDO): http://www.ieee.org/education_careers/education/standards/standards_glossary.html

[3] See http://www.gsmhistory.com/the-beginnings/

[4] See http://web.archive.org/web/20100110094907/http://www.ibm.com/developerworks/power/library/pa-spec7.html

[5] Olaronke Iroju et al, “Interoperability in Healthcare: Benefits, Challenges and Resolutions”, International Journal of Innovation and Applied Studies, Vol. 3 No. 1 May 2013, pp. 262-270.

[6] Data on Japanese integration from Continua December 2014 presentation to governments and markets.

[7] Ibid.

[8] See http://www.webcitation.org/5yRRJnMZw

[9] See http://ec.europa.eu/digital-agenda/en/news/ehealth-interoperability-framework-study

[10] For more information see the Antilope deliverables.