The USA has many such federal government data liberation initiatives – for instance California Governor Arnold Schwarzenegger’s initiative to reduce data centre footprint, NASA’s Nebula cloud computing environment, apps.gov and others.

In the UK, Tim Berners-Lee unveils government data project. London Mayor Boris Johnson unveils a London data store.

Sites like Openly Local and Mash The State are supposed to use that data and create services through mashups i.e. combining data from two or more external services to create a new service.

This is all good, but don’t we need standards for mashups?

There are two issues: firstly, not all data may be ‘combinable’ with other data and the rights and revenue sharing availed by the mashup may be unclear. Secondly, the mashups themselves need a common framework (standard).

It turns out that there is such an industry led mashup standards initiative called the Open Mashup Alliance which is designed to promote an open schema and language for mashups called Enterprise Markup Mashup Language (EMML).

This is a positive step and it is industry led. It recognizes that ‘data liberation’ is only the first step – we need standards for mashups to make use of the ‘liberated data’.

For further in-depth discussion on the role of ICT standardization in Open Government, visit the Open Forum starting at 4 pm GMT Thursday March 18 2010, held in connection to the Sunshine Week.

Behind the innovation and bleeding edge headlines must lie a lot of seemingly mundane collaboration between technologists in India and USA.

By that, I mean: NASA does not wake up one day and decide to call up Bangalore to say that they want to piggyback NASA’s satellite on India’s lunar space craft. There have to be a number of commercial agreements, IP sharing and interoperability. Also, there will be some standards but a lot of issues will be new due to the very nature of the innovation. Often, solutions will be found by the engineers working together. Also, there cannot be very many ‘standards’ since this kind of collaboration is cutting edge. Nor can there be too much government intervention except at a broad/strategic level.

Which brings us to the question of: What is the motivation for collaboration in this case? It is simply pragmatism, innovation and solving specific problems.

Nor is it confined to India and USA. In the past, China, Europe and Russia have also collaborated with the USA on specific space related issues.

Much of this kind of collaboration goes un-noticed and has limited standards governing it, but as we can see, it drives very significant innovation

Ajit Jaokar spoke of the possibility that eHealth will take off in emerging markets and what the implications thereof could be. As an illustration, Jaokar mentioned the M-Pesa mobile payment service which took off in Kenya, serving 6.5 million subscribers by May 2009; such a service is yet to be deployed in Western countries. Jaokar argued that emerging markets have a way of solving real life problems which is likely to mean that eHealth innovation will take place in emerging markets. Further, the lack of infrastructure might actually provide further incentives, as it did in the M-Pesa case. The implications of such a development for global standards are not clear but it is important to not only think of eHealth as a ‘Western’ concept.

Highlighting the fact that the healthcare of yesterday is changing, and a new healthcare experience is emerging, Helen Disney discussed the challenges facing us in ‘the post-bureaucratic age’. New technology can revolutionize the way in which governments and citizens interact and move towards a bottom-up approach; but this requires the development of standards to build trust in new systems. Interoperability is one of the main challenges we are facing as companies are set to compete on delivering eHealth services. More open, network systems will benefit patients but at the same time it will be less easy for governments to intervene, argued Disney. This will ultimately affect which standards are going to be widely used. Further, Disney raised the question whether some of the poorest patients, who lack internet access, face a risk of being left behind in the eHealth-age.

Keith W Boone provided valuable input on US eHealth policy. He expressed concerns over the shotgun approach taken by recent US initiatives and called for more coordination in standardization efforts. Further, Boone was critical to the fact that there is no US ‘national program’, rather conflicts within government and between SSOs are impeding developments. Governments can help by offering a consolidated voice, setting national goals and driving standardization efforts. Unified efforts across the ICT spectra is needed to look after national interests.

Denise Silber expressed her optimism over Health 2.0 services as a driver of eHealth innovation and development. She drew the attention to existing services; blogs, wikis, search engines etc, and pointed to the fact that these are available by computer or mobile phone and contributing to participatory medicine. Lack of standards is not the issue, Silber argues, web to web synchronization is already possible. Security should not be an impediment either, online banks have succeeded and so should healthcare. Rather, the obstacle lies in data not being electronically available or safely portable. Silber called on doctors and laboratories to digitize their information and leave the rest to participatory medicine.

Recognizing that seamless access to information is important in eHealth, and that standards are vital in achieving this, Jay Kesan expressed concern over the likeliness of governments’ early involvement in the standardization process, choosing winners (and losers) prematurely. The reason for this, he said, is because the governmental role in healthcare is not as challenged as that in other sectors. Kesan argued that it is the ICT private sector that are the domain specialists and that they must be allowed to work towards standardization, jointly developing standards within private SSOs. Thus, competition should be fostered among private firms developing downstream, innovative, proprietary technologies relying upon ICT standards. Learning from past behavior, Kesan also argued that US authorities are more likely to focus on spectrum management and setting power ratings to avoid interference, while letting different industry solutions and standards compete with each other, European authorities will be prone to mandate interoperability.

Also, prior to the forum Talkstandards conducted an exclusive interview with David Ingram, Founding Chairman of openEHR. Ingram spoke of the difficulties of gathering all challenges of eHealth under one common umbrella, and expressed concern over governments sometimes being excessively enthusiastic. It is vital that governments appreciate the scope of ICT standardization and development, as to handle the challenges properly. The approach to eHealth should be practical and empirical, Ingram said, and welcomed the fact that practical progress toward interoperability is actively sought. Although difficult barriers to eHealth implementation exist in Europe which might be hard to overcome, Ingram is optimistic with the direction developments are taking. Ultimately, Ingram said, implementation is the best way to achieve progress since it offers a sense of learning-by-doing.

The discussion around these topics is bound to continue. Please visit the Open Forum Event Page for further reading.

That said, I am concerned about the process of standards development in this sector. There is a real danger that the government might step in unquestioned and prematurely pick winning technologies (and in the process, losers) since the government’s role in e-health is not challenged as much as in other sectors. There are important reasons for government regulators to be actively engaged in issues such as the management of private patient information including the setting of minimum criteria for privacy of healthcare records in order to cultivate patient trust. Nevertheless, the ICT private sectors who are the domain specialists in this arena, must be allowed to work together to jointly develop standards within private standards-setting organizations.

In this respect, competition among private firms that develop downstream, innovative, proprietary technologies relying upon basic ICT standards should be fostered.

A small comparative note between the U.S. and Europe is also relevant. Just as the Federal Communications Commission (FCC) in the U.S. is much more focused on spectrum management and setting power ratings to avoid interference and, unlike Europe, less concerned about mandating interoperability, instead preferring to leave different industry solutions and standards to compete with each other—the same philosophical and regulatory differences in approach will manifest itself in e-health too.

That brings up the issues of international compatibility (e.g. document sharing) and patient mobility in a “medical tourism” world. But that is for another day.

Biography Jay Kesan
Jay P. Kesan is Professor & Mildred Van Voorhis Jones Faculty Scholar and Director of the Program in Intellectual Property & Technology Law at the University of Illinois. He clerked for Judge Patrick Higginbotham in the Fifth Circuit Court of Appeals, and he worked as a patent attorney in the former firm of Pennie & Edmonds LLP. He continues to be active in the area of patent litigation and he has served as a Special Master in patent lawsuits. An author of several books and articles in the area of intellectual property, his academic interests and writings are in the area of patent law, cyberlaw, entrepreneurship, and law and technology. He is a registered patent attorney and received his J.D. summa cum laude from Georgetown University. He also has a Ph.D. in Electrical and Computer Engineering from the University of Texas at Austin and worked for several years as a research scientist at the IBM T.J. Watson Research Center in New York. For a more complete bio, please see www.jaykesan.com.

So, is there any hope in a world of “ubiquitous heterogeneity”? Surprisingly enough, hope is all around us. This hope is Web 2.0, and it is dominating Internet growth.

Web 2.0 for Health or Health 2.0 means the deployment of Web 2.0 tools in health care: collaborative professional and patient communities, wikis, blogs; search tools to find quality medical content, health care professionals, services, clinical trials; online health and medical record keeping, online consultation, tele-imagery. All are available on computer or mobile phones and contributing to participatory medicine.

Has a lack of standards perturbed their advancement? From web to web, not really. Increasingly 2.0 tools synchronize to one another. Upload to Facebook, Twitter; blog and other more health-specific platforms, give the instruction, and all your accounts will display the same information.

What about security and privacy? Where online banks have succeeded, cannot healthcare as well? But there is still one obstacle: a consumer who would like to create a first online health record will most likely have to enter data from paper or digital documents until professionals are able to export data securely.

Doctors and laboratories, unite! Digitize and secure your data and participatory medicine will do the rest!

Biography Denise Silbert
Denise Silber, an American in France, heads Basil Strategies, ehealth emarketing consultants and co-producers of Health 2.0 Europe 2010. Denise has been the French-American Ambassador of eHealth since the web was launched in the mid 90s and is proud to be driving greater interest in Health 2.0 in Europe through the conference. Denise is a frequent public speaker, author, and blogger (http://www.denisesilber.com/ehealth)  on eHealth and Health 2.0 subjects, as well as the founder of the French Association for the Quality of Health Care on the Internet. She holds an MBA from Harvard and an undergraduate degree from Smith and is president of PharMBA.

Current US regulation and funding will dramatically increase the use of ICT standards in healthcare. More than 100 new initiatives were just announced at a cost of around $750 million US dollars. Without coordination there will be a lot of new invention, much of which could ignore standards. This is a shotgun approach that needs more focus to be successful.

My own experiences with the US Federal initiatives around eHealth are mixed. My chief complaint is that we do not have a “national program” the way other countries do. We have a loosely agglutinated collection of initiatives that do not communicate. The lack of a Federal eHealth strategy on standardization has been getting in the way, even inside the government itself. Competition between standards organizations is also a problem.

The diversity of organizations and initiatives where one must participate is daunting. There needs to be a way to communicate across these initiatives and the standards organizations. The Health Information Technology Standards Panel (HITSP) formed by ANSI four years ago helped to drive communication for the US. However, HITSP’s contract with the Federal government recently expired, and a request for proposal to replace that organization has been delayed, but is expected in the next couple months. A more unified effort should be sought which includes representation of national interests to standards bodies.

Where governments can truly help is insuring that there is a consolidated voice across the ICT spectrum, and setting national goals that can be driven into standardization efforts.

Biography Keith W Boone
Keith W. Boone is a Standards Architect for GE Healthcare. In this role he represents GE Healthcare to standards organizations such as HL7 International, Integrating the Healthcare Enterprise, ANSI/HITSP, ISO TC 215, ASTM and Continua. Keith cochairs committees in HL7, IHE and HITSP, and is also an instructor for the Continituity of Care Document tutorials given by HL7. Keith entered the field of healthcare in 2001 and has more than 25 years experience in software development. He brought his extensive background in Internet and document markup standards to healthcare, and quickly became a leader in the use of standards such as the HL7 Clinical Document Architecture. He lives just south of Boston, Massachusetts and writes regularly about standards at motorcycleguy.blogspot.com.

So what does this mean for e-health and for standards? E-health will become more prevalent – especially if it can be proven to save time and lower costs. Standards will also be required particularly to build patient trust and confidence in new technologies and help speed up the process of change. But there are challenges. In the age of ‘post bureaucracy’ some IT solutions may revolutionise our systems – companies will compete more to provide e-health services and interoperability may be the most important factor in linking a set of diverse, bespoke e-health solutions. More open, networked systems may benefit the patient but it will be less easy for Governments to intervene or impose a single solution, which will affect which standards end up being widely used. And what of the many patients without any access to the internet – some of the poorest in society who have most need of health treatment? Will it be possible to engage them in the e-health age or will they simply be left behind?

Biography Helen Disney
Helen Disney is the chief executive and founder of the Stockholm Network.

She has over a decade’s experience of influencing public policy debates. Formerly an editoral writer for The Times and an editorial writer and commentator for the Daily Express, as CEO of the Stockholm Network she continues to write regularly on a range of public policy topics for newspapers, magazines and websites.

Helen’s cuttings include the Wall Street Journal Europe, Financial Times, Newsweek, The Times, the Daily Express and Sunday Express, Public Finance magazine, Public Service Magazine, as well as a range of other magazines, websites and trade press articles.

She has made regular appearances on TV and in radio debates including ‘Heart of the Matter’, ‘Kilroy’, BBC News, BBC Radio Scotland, Radio 4’s Talking Politics, the BBC World Service and 18 Doughty Street.com.

From 1996-2000, she worked at the Social Market Foundation, an independent pro-market think-tank in Westminster, where she was deputy director and editor of its quarterly journal.

She has contributed to and edited numerous think-tank publications including Impatient for Change, Poles Apart? and An Apology for Capitalism? published by the Stockholm Network.

She sits on the advisory board of the Centre for Medicine in the Public Interest (CMPI), a US think tank and has advised many new think tanks on how to develop their influence on the media and public policy.

Helen is a member of the Chartered Institute of Journalists, Women in Journalism and the Women Writers Network and speaks fluent French and Italian.

She is married with a son, and lives and works in London.

This is not as far-fetched as it first sounds.

The mobile payment system M-Pesa took off in Kenya in a big way capturing 6.5 million subscribers by May 2009 with 2 million daily transactions in Kenya alone. So far, no industrialised nations (outside of Japan and Korea) have managed to create a viable mobile payments system.

The problem is not technical as it is operational. Gartner says that emerging markets are increasingly driving global innovation but they add that the nature of innovation is different:

“In our increasingly customer-centric world we are moving away from the traditional view of innovation, as internally managed and R&D focused,” said Sandy Shen, research director at Gartner. “Innovation doesn’t come from a laboratory. It comes from solving real life problems and responding to everyday needs regardless of how sophisticated the market might be, with the ultimate goal of enriching people’s lives.”

This emphasis for solving real life problems is likely to mean that e-health innovation may take place earlier in emerging markets and in addition to solving real life problems, there is an added incentive that there is little or no existing infrastructure. Ironically, that helped M-Pesa as well to take off in Kenya.

Questions are: If this happens, then How important are standards? Both in relative and absolute terms?

While there is no doubt that standards are important in absolute terms for any e-health implementation. In emerging markets, training may be almost as important to avail of the benefits as an essay Keys and obstacles to e-health in low income countries says:

“Key to implementing e-health tools in developing countries is developing local human capacity; but there is a chicken and egg problem. Low-income countries typically lack programs to train individuals to develop and implement health information technology tools. Without the implementation of these tools there is no place to train people to work with them.”

So, while we are all focused on e-health standards in industrialized countries, emerging markets may be the drivers for innovation and this could have implications for standards.

Part III: Openness, implementation and governance

(This is the last of three parts of the interview. Read Part I on The future of eHealth here, and Part II on eHealth in an international perspective here.)

Talkstandards [TS]: openEHR is well known for its advocacy of open standards and specifications, what is the rationale behind this view?

David Ingram [DI]: Insecurities are more easily avoided and safety is promoted by allowing users to “open the hood” of a specification.

This conjecture is based on my own experience, coming from physics and moving into medical services and being close to the implementation of health IT, as I have often witnessed a discrepancy in how users think a system will work and how it actually functions. When people can view the specifications beforehand they are more prepared on what they get. This helps implementation. Keeping an open process also helps making specifications better.

The issue of IPR is complex but I believe that open source is important in academic areas, it helps sharing and handling of information and contributes to a stronger development process. I also believe that there is an issue with patenting something that everyone uses; it would be like Pythagoras patenting his theorem. Open source specifications provide a body of knowledge that can serve as public education.

TS: The three usual activities of openEHR are said to be “…implementation, implementation, implementation”. How far has Europe come in implementing eHealth technologies? And what are the main barriers for further deployment?

DI: I believe that implementation is important because it offers a learning-by-doing approach to answering questions. There is much implementation in the process and healthcare is getting constantly better. Implementation of eHealth technology provides valuable knowledge and ensures that new solutions are built on a solid foundation and thus serves as a promoter of innovation.

The healthcare sector is traditionally conservative, putting much effort in maintaining ethical responsibilities, which to some extent could inhibit innovation. Although changes are coming fast, systems are evolving and we are constantly learning there is still a long way to go in developing eHealth solutions. We need to find a balance between innovation and professional assurance and I am optimistic about the direction developments are taking.

I do wish, however, that governments would prioritize moving further toward learning about the scope of the challenges we are facing and experiment with different solutions. More transparency need to be brought to the teamwork between organizations, governments, clinical practitioners etc, and openness in that collaboration is critical; this is also what we learned from the early NHS projects that brought into healthcare people with valuable knowledge.

TS: You have expressed a need to restructure the organization of openEHR and work to better meet the growing interest from different regions and sectors. Can you comment on this?

DI: I have stated that openEHR needs a new form of governance, mainly as recognition of the fact that the organization has grown to include many different stakeholders. The goal is to make barriers to adoption of our specifications as small as possible and provide a better public understanding of the practical details of the organization. openEHR has from the start been very flexible in the innovation of specifications, but providing a commercial interface as an open source environment for adoption has taken a bit longer.

We recognize that the currently small executive group brings agility and flexibility but it can also stand in contrast to the image of a truly democratic organization. Bringing openEHR to where we are today has taken time and resources we simply cannot continue to spend. We are actively seeking partnerships with other organizations of which the most predominant are those with IHTSDO and EuroRec. This sort of partnerships will offer us a chance to follow other examples of basic principles and practical approach, but also to bring governance forward and handle the growing size of openEHR.

Part II: eHealth in an international perspective

(This is the second of three parts of the interview. Read Part I on The future of eHealth here, and Part III on Openness, implementation and governance here.)

Talkstandards [TS]: There is a significant difference between health care systems in the USA and Europe. How are these differences reflected in eHealth standardization in your opinion?

David Ingram [DI]: Without being too specific, I think it is important to recognize the cultural differences that separate the USA and Europe. Healthcare in Europe is sometimes characterized as “socialized medicine” in the American debate while the US healthcare system is sometimes giving negative vibes in Europe particularly when it comes to the lack of universal coverage.

However in terms of health informatics, innovative companies in health information technology emerged earlier in North America than in Europe and similarly, academic progress in the area was making progress earlier in the US. This is because the North American industry came to recognize the need to build bridges between different systems and applications at an early stage, thus working towards interoperable standards.

In Europe, an educational gap between clinical practice and science on the one hand and information technology on the other contributed to bringing the clinical challenge of information technology into focus later. Progress was sought through clinical practice rather than IT.

Some welfare states in Europe has a problem of scale; managing healthcare for a population of 5-10 million is easier than for a population of 50-60 million. Governments can and should make priorities for industry and the health care sector. New cooperation between industry and government is needed to handle the challenges at hand. This can also be vital in avoiding lock-in in outdated technologies, which is a dangerous trap in the fast moving IT sector. This is an important rationale for openEHR to be open; to maximize the possibility to detect and adapt to new and superior technology.

TS: Health care markets have historically been local and national. Is it possible that eHealth and ICT standards contribute to the longstanding European vision of a single market for healthcare services?

DI: The European single market is an important economic driver but considerable impediments exist, e.g. cultural, financial and political barriers, which mean that full integration will take time. I do believe that the goals are good, but it is key to have a bottom-up approach. Change needs to come from the grass root level. One particularly challenging task in this perspective is to reach harmonization of data.

In order to create a single healthcare service market, trust and understanding are vital elements. It is important not to generalize as patient preferences differ between areas of healthcare. For certain services familiarity is essential for assurance while in other areas patients are more open to evidence-based and innovative treatment.