Healthcare Framework or Standards: The Facts Are the Facts
November 18, 2024
Introduction: The Long Road to Interoperability
For decades, frameworks like DICOM (Digital Imaging and Communications in Medicine) and HL7 (Health Level Seven) have served as pillars of healthcare data exchange. They have enabled the sharing of clinical information and medical imaging across systems and institutions, contributing to better workflows and patient care. However, despite their foundational role, these frameworks have not delivered the seamless interoperability healthcare desperately needs.
While updates to these frameworks, including web-friendly versions like FHIR, have been introduced, they’ve done little to address the underlying issues preventing universal standardization. Healthcare remains plagued by data silos, limited cross-system compatibility, and inefficiencies that inhibit innovation, research, and optimal patient care.
In 2019, during a healthcare interoperability panel, I shared a stark reality: if we’re waiting for a universal standard to emerge and solve interoperability, we may be waiting forever. Without a unified industry effort, the odds of achieving such a standard in our lifetime seemed slim. Now, five years later, the landscape hasn’t changed significantly. Interoperability remains a persistent and costly challenge, limiting progress across the healthcare ecosystem.
Yet, today, I’m more hopeful. Advances in artificial intelligence, cloud computing, and modern technology have created opportunities for meaningful transformation. The solutions we need are achievable, but only if we shift our mindset and approach.
This article aims to highlight a fundamental truth: DICOM and HL7 are not true standards. They are frameworks—flexible tools that lack the strict enforcement required for universal compatibility. By comparing these frameworks to true standards like TCP/IP and examining other industries’ success with strict standards, this article will provide a roadmap for moving healthcare beyond its current interoperability challenges.
DICOM: A Framework Masquerading as a Standard
Since its introduction in 1993, DICOM 3.0 has been the de facto framework for managing medical imaging data. While DICOM is often referred to as a “standard,” its flexible design and optional implementation choices reveal it to be more of a guideline than a true standard.
The Flexibility Problem
DICOM’s flexibility allows vendors to develop proprietary adaptations tailored to their specific needs. While this customization enables solutions that fit particular workflows or technologies, it undermines interoperability. Vendors can:
Add private attributes or custom fields to DICOM headers.
Use proprietary data elements and transfer protocols.
Develop unique workflows that deviate from standard practices.
As a result, “DICOM-compliant” systems often fail to communicate seamlessly. Middleware or extensive customization is frequently required to bridge the gaps between implementations.
Proprietary Versions of DICOM
Large technology companies and healthcare organizations have developed their own DICOM-based solutions, each with unique adaptations that fragment the ecosystem. Examples include:
PI-DICOM (Philips): Customized for Philips imaging systems.
Microsoft Azure DICOM: Cloud-optimized for Microsoft’s ecosystem.
Siemens Syngo DICOM: Tailored to Siemens’ radiology workflows.
Epic’s DICOM Integration: Integrated with Epic’s EHR for imaging data.
Each of these versions claims DICOM compliance but includes proprietary modifications that limit compatibility with other systems. These adaptations illustrate why DICOM operates more like a framework for imaging workflows than a universal standard.
DICOM vs. TCP/IP: A Lesson in Rigidity
True standards, like TCP/IP, operate with strict rules that ensure consistency across every implementation. TCP/IP powers the global internet by adhering to a rigorously defined protocol stack. There is no room for deviation, every device, from smartphones to servers, must follow the same rules to communicate effectively. If a device fails to meet these specifications, it simply won’t work.
In contrast, DICOM’s flexible structure allows for deviations, optional fields, and private tags that fragment the standard and hinder seamless interoperability. Two DICOM-compliant systems may require significant integration work, or even middleware, to exchange data effectively. This is a far cry from the universal compatibility enabled by TCP/IP.
IHE Profiles: Trying to Standardize a Standard
Recognizing DICOM’s limitations, the Integrating the Healthcare Enterprise (IHE) initiative developed profiles to provide consistency. These profiles specify how existing standards like DICOM and HL7 should be implemented in specific clinical contexts, such as:
Radiology Scheduled Workflow: Standardizes radiology imaging and scheduling processes.
Patient Identifier Cross-Referencing (PIX): Addresses patient identity management across systems.
Laboratory Testing Workflow: Guides lab order and result sharing.
While IHE profiles attempt to enforce structure, their adoption is inconsistent. Vendors often implement profiles partially or modify them to meet proprietary needs, resulting in variability and compatibility gaps. This layering of guidelines highlights the lack of true enforcement within DICOM and similar frameworks.
Lessons from True Standards in Technology
Other industries have achieved seamless interoperability through strict, universally enforced standards. These standards eliminate fragmentation and enable innovation by ensuring that systems work together seamlessly. Examples include:
Wi-Fi (IEEE 802.11): Every certified device connects effortlessly to any compatible router.
USB-C: Eliminates proprietary cables, enabling universal power and data delivery.
Bluetooth: Ensures short-range wireless communication between any compliant devices.
HTML and SMTP: Standardize web content and email transmission across platforms.
These examples demonstrate how strict standards create predictable, reliable outcomes. Healthcare’s reliance on flexible frameworks like DICOM and HL7, in contrast, perpetuates inefficiencies and hampers innovation.
Healthcare’s USB-C Moment
Apple’s recent transition to USB-C illustrates the power of embracing universal standards. After years of using proprietary connectors like Lightning, Apple adopted USB-C, aligning with the broader tech industry. This shift simplified connectivity, reduced waste, and improved the user experience.
Healthcare needs a similar transformation. Moving from flexible frameworks to true standards would enable:
Simplified Integration: Reducing the need for middleware.
Universal Compatibility: Ensuring seamless data exchange across systems.
Cost Savings: Allowing resources to focus on innovation rather than patching gaps.
Conclusion: From Frameworks to True Standards
The time has come for healthcare to evolve. Frameworks like DICOM and HL7 have brought us far, but they lack the rigidity required for universal interoperability. By embracing true standards, with strict, enforceable specifications, healthcare can unlock a future where data flows freely, systems work together effortlessly, and patients receive better care.
Just as TCP/IP connects the world through a unified protocol, healthcare must adopt universal standards to overcome the fragmentation that has held it back for decades. The facts are the facts: it’s time to stop treating frameworks as standards and start building a truly interoperable future.
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Jim Conyers