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Cited by 393Electronic Health Records SystemsMedical Coding and Health InformationNursing Diagnosis and Documentation

Interoperability of heterogeneous health information systems: a systematic literature review

Open access
Torab-Miandoab, Amir, Samad-Soltani, Taha, Jodati, Ahmadreza, Rezaei-Hachesu, Peyman·2023·BMC Medical Informatics and Decision Making
DOI 10.1186/s12911-023-02115-5PMC PMC9875417
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Abstract

Background: The lack of interoperability between health information systems reduces the quality of care provided to patients and wastes resources. Accordingly, there is an urgent need to develop integration mechanisms among the various health information systems. The aim of this review was to investigate the interoperability requirements for heterogeneous health information systems and to summarize and present them. Methods: In accordance with the PRISMA guideline, a broad electronic search of all literature was conducted on the topic through six databases, including PubMed, Web of science, Scopus, MEDLINE, Cochrane Library and Embase to 25 July 2022. The inclusion criteria were to select English-written articles available in full text with the closest objectives. 36 articles were selected for further analysis. Results: Interoperability has been raised in the field of health information systems from 2003 and now it is one of the topics of interest to researchers. The projects done in this field are mostly in the national scope and to achieve the electronic health record. HL7 FHIR, CDA, HIPAA and SNOMED-CT, SOA, RIM, XML, API, JAVA and SQL are among the most important requirements for implementing interoperability. In order to guarantee the concept of data exchange, semantic interaction is the best choice because the systems can recognize and process semantically similar information homogeneously. Conclusions: The health industry has become more complex and has new needs. Interoperability meets this needs by communicating between the output and input of processor systems and making easier to access the data in the required formats.

AI snapshot

Written from the paper’s full text.

TL;DR

This systematic review synthesizes 36 studies on interoperability requirements for heterogeneous health information systems, finding that work dates to 2003 and is mostly national-level, hospital-based, and aimed at electronic health records. It reports semantic interoperability as the dominant level and identifies HL7 FHIR, CDA, SNOMED-CT, HIPAA, SOA, XML, JAVA, and SQL among the most important implementation requirements.

Key findings

  • From 5,851 retrieved titles, 3,789 remained after duplicate removal; 302 were selected by title, 171 full texts were assessed, and 36 articles were included in the analysis.
  • Interoperability in health information systems has been raised since 2003; most included studies were national-level, aimed at creating interaction between clinical information systems and medical devices to achieve electronic health records, and were set mostly in hospitals. The countries represented most were the United States, Italy, Portugal, Korea, and Spain, respectively.
  • Interoperability between systems was mostly at the semantic level and based on Open EHR and RIM information sources. The most widely used standards were HL7 FHIR and DICOM for transport, CDA for content, SNOMED-CT, LOINC, and ICD 10 for terminology, and HIPAA and ASTM for security; XML, JAVA, and SQL were the most used technologies.
  • Service-oriented and web-based architectures were the most used among modern architectures.

Methods

  • Systematic literature review following PRISMA, searching PubMed, Web of Science, Scopus, MEDLINE, Cochrane Library, Embase, and Google Scholar up to 25 July 2022, with no publishing-year limit.
  • Inclusion criteria were English-language articles available in full text with the closest objectives; letters to the editor, commentary, review, and opinion papers were excluded. Two reviewers independently assessed titles, abstracts, and full texts, and duplicate articles were deleted.
  • Data were extracted with a standardized form covering authors, year, country, aim, interoperable systems, architecture and components, setting, processes, standards, platform and technology, implementation extent, interoperability level, information resource, and key findings. Quality was assessed with the QUADAS checklist (14 questions; score of 7 or greater “yes” indicated high quality).

Limitations

  • The authors state that because interoperability is broad, the review mostly discussed technical, informatics, and management issues; legal and organizational issues were not covered and are suggested for separate future studies.
  • The authors also state that lack of access to some articles due to unavailable full text and non-English language was another limitation.
  • Evident from the text: the review reports a large excluded set (135 of 171 full-text articles) and relies on heterogeneous included studies, but it does not present a meta-analysis or pooled quantitative estimate.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12911-023-02115-5

Cites

41 of 41 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 65 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Medical decision making, reimbursements, telehealth, and disease surveillance were the most commonly utilized applications.

    “Medical decision making, reimbursements, telehealth, and disease surveillance were the most commonly utilized applications, according to the mentioned process.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The body of included studies supports data exchange.

    “The body of studies support data exchange.”
    Quote in the paperSubstantial claim
  • Findingnone given

    Among modern architectures, service-oriented and web-based architecture were the most used.

    “Among the modern architectures of the world, service-oriented and web-based architecture were the most used.”
    Quote in the paperNot a substantial claim
  • Findingreasoning

    The most often used content standards were CDA.

    “the most often used content standards were CDA;”
    • Also stated in: § Discussion · plain
      “The most often used content standards were CDA.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The most frequently used terminology standards were SNOMED-CT, LOINC, and ICD 10.

    “the most frequently used terminology standards were SNOMED-CT, LOINC, and ICD 10;”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 62
  • May combine two claims. 36

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The majority of research settings were hospitals.

    “The majority of the research settings were hospitals.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most studies were at the national level with the aim of creating interaction between clinical information systems and medical devices to achieve electronic health record.

    “Based on the results, most of the studies were at the national level with the aim of creating interaction between clinical information systems and medical devices in order to achieve electronic health record.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Interoperability has been raised in the field of health information systems from 2003 and is now one of the topics of interest to researchers.

    “Interoperability has been raised in the field of health information systems from 2003 and now it is one of the topics of interest to researchers.”
    • Also stated in: § Results · plain
      “the results of the study show that this topic has been raised in the field of health information systems from 2003; and now it is one of the topics of interest to researchers (Fig. 2).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    The included studies belonged to the United States, Italy, Portugal, Korea and Spain, respectively.

    “They belonged to the United States, Italy, Portugal, Korea and Spain, respectively.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Thirty-six articles were included in the review analysis.

    “36 articles were selected for further analysis.”
    • Also stated in: § Article selection · plain
      “Finally, 36 articles were included in the analysis.”
    • Also stated in: § Results · plain
      “After the assessment, 135 articles were excluded (refer to Fig. 1) and 36 articles were included in the review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The processes of collecting, storing, searching, retrieving, accessing, updating, editing, and deleting were reported in the included studies.

    “In addition, the processes of collecting, storing, searching, retrieving, accessing, updating, editing, and deleting were reported.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Interoperability between systems was mostly at the semantic level and based on the Open EHR and RIM information source.

    “Interoperability between systems was mostly at the semantic level and based on the Open EHR and RIM information source.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Legacy health-care systems were built for a certain activity or facility.

    “The issue with legacy systems is that they were built for a certain activity or facility.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    SNOMED CT is now widely used.

    “SNOMED CT is now widely used, the health industry at large recognizes that adoption of the standard must continue.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    There are a number of ancient health-care systems still in use today that have limited interoperability capabilities.

    “There are a number of ancient health-care systems still in use today that have limited interoperability capabilities.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    The most well-known and widely utilized architecture nowadays is service-oriented architecture.

    “The most well-known and widely utilized architecture nowadays is service-oriented architecture.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Interoperability faces challenges including limited administrative and legal support for information technology and related practice changes, lack of uniformity systems from different vendors, limitations on funding of information technology and resources, and privacy and security concerns.

    “Limited administrative and legal support for information technology and related practice changes; lack of uniformity systems from different vendors; limitations on funding of information technology and resources and privacy and security concerns are other challenges that interoperability faces [38].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [38] Bennara M, Zimmermann A, Lefrançois M, Messalti N. Interoperability of semantically-enabled web services on the wot: Challenges and prospects. In: Proceedings of the 22nd international conference on information integration and web-based applications & services, 2020 Nov 30. p. 149–53. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Most healthcare professionals are resistant to switching from a paper-based to an electronic-based system.

    “This is due to the fact that most healthcare professionals are resistant to switching from a paper-based to an electronic-based system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingreasoning

    The healthcare industry still relies on stacks of handwritten notes (paper records) for patient care.

    “Moreover, in contrast to most businesses, the healthcare industry still relies on stacks of handwritten notes (paper records) for patient care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    Interoperability in the field of health care has not yet been reached.

    “Interoperability in the field of health care has not yet been reached.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    The availability of large-scale open data for drug discovery has greatly improved in recent years due to the expansion of data repositories, particularly those with chemical and pharmacological data sets.

    “The availability of large-scale open data for drug discovery has greatly improved in recent years due to the expansion of data repositories, particularly those with chemical and pharmacological data sets.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Another independent investigator reviewed and verified completeness and accuracy of all data entries.

    “Another independent investigator reviewed and verified for completeness and accuracy of all data entries.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Health information systems currently in use are proprietary, may differ between health institutions, and were developed for local access, resulting in heterogeneity in existing ecosystems.

    “However, the systems currently in use are proprietary, may differ from one health institution to the next, and were developed for local access, resulting in heterogeneity in the existing ecosystems [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Dixon BE, Rahurkar S, Apathy NC. Interoperability and health information exchange for public health. In: Public health informatics and information systems. Cham: Springer; 2020. p. 307–24. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Studies were identified to 25 July 2022 by searching PubMed, Web of science, Scopus, MEDLINE, Cochrane Library, Embase, and Google Scholar.

    “Studies were identified to 25 July 2022. They were selected by searching the online databases PubMed, Web of science, Scopus, MEDLINE, Cochrane Library and Embase, and Search Google Scholar.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two researchers analyzed all identified studies for risk of bias.

    “Two researchers analyzed all of the identified studies for risk of bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    A patient's health information may be distributed among multiple healthcare facilities and is not interchangeable or accessible to another health institution.

    “The health information of a patient may be distributed among an unspecified number of healthcare facilities. A hospital's medical information are not interchangeable and accessible to another health institution.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Ndlovu K, Mars M, Scott RE. Interoperability frameworks linking mHealth applications to electronic record systems. BMC Health Serv Res. 2021;21(1):1. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The full text of chosen articles was independently reviewed and a standardized data extraction form was used.

    “The full text of the chosen articles was then independently reviewed by the reviewer. The standardized data extraction form was used to extract the data from the selected articles.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Lack of interoperability between health information systems reduces the quality of care provided to patients and wastes resources.

    “The lack of interoperability between health information systems reduces the quality of care provided to patients and wastes resources.”
    • Also stated in: § Background · hedged
      “The lack of interoperability leads to redundant, disorganized, disjointed and inaccessible medical information, that may affect the quality of care provided to patients and waste of financial resources [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Powell K, Alexander G. Mitigating Barriers to Interoperability in Health Care: OJNI. On - Line Journal of Nursing Informatics 2019;23(2)-6.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two reviewers separately assessed titles and abstracts for eligibility.

    “Two reviewers separately assessed the titles of the articles.”
    • Also stated in: § Results · plain
      “Two reviewers screened the titles and abstracts for relevance, and 3487 articles were deemed irrelevant to the review topic and were excluded.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    All differences between researchers were overcome by agreement.

    “All differences were overcome by agreement.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    This review followed the PRISMA guidelines for reporting a systematic review.

    “This review followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for authors reporting a systematic review.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Moher D. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol. 2021;134:103–12. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    Searches included online books, published papers, conference abstracts, seminar and reference publications to avoid publication bias and include as many articles as possible.

    “Searches included online books, published papers, conference abstracts and seminar and reference publications to avoid bias in publishing and to ensure that as many articles as possible were included.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    The quality of initially chosen studies was assessed using the QUADAS checklist.

    “The quality of the initially chosen studies was assessed and analyzed to support the inclusion / exclusion process. The used critical appraisal tool was a quality assessment of diagnostic accuracy studies (QUADAS) checklist.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol. 2003;3(1):1–3. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Reference lists and bibliographies of articles and reviews were hand-searched for potentially relevant articles.

    “Additionally, the selected articles reference lists were searched for other relevant studies. In addition, the bibliographies of articles and reviews published were searched by hand for potentially relevant articles.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Interoperability meets the health industry's new needs by communicating between the output and input of processor systems and making easier to access data in required formats.

    “Interoperability meets this needs by communicating between the output and input of processor systems and making easier to access the data in the required formats.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The health industry has become more complex and has new needs.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    Delays in data transport are caused by a variety of factors, but interoperability can assist in reducing these issues.

    “Delays in data transport are caused by a variety of factors; however, interoperability can assist reduce these issues.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    There will be no duplication of testing between settings, and the patient will only have to tell their history once.

    “Hence, there will be no duplication of testinga between settings, and the patient will only have to tell their history once.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Interoperability in healthcare reduces paperwork for employees and eliminates the need for human data entry.

    “Interoperability in healthcare reduces paperwork for employees and eliminates the need for human data entry.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Interoperability allows saving a lot of time.

    “Interoperability allows to save a lot of time.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Healthcare interoperability allows health institutions to build the technology infrastructure needed to maximize the value of their EHR data and provide more comprehensive care.

    “Approximately, healthcare interoperability allows health institutions to build the technology infrastructure needed to maximize the value of their EHR data and provide more comprehensive care [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Hussein R, Crutzen R, Gutenberg J, Kulnik ST, Sareban M, Niebauer J. Patient-generated health data (PGHD) interoperability: an integrative perspective. In: MIE, 2021 May 27. p. 228–32. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Medical errors that result in an adverse medication event are caused by lack of information available to patients, according to a study conducted in an inpatient setting.

    “Medical errors that result in an adverse medication event are caused by lack of information available to patients, according to a study conducted in an inpatient setting.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Voskanyan Y, Shikina I, Kidalov F, Davidov D. Medical care safety-problems and perspectives. In: International conference on integrated science, 2019 May 10. Cham: Springer. p. 291–304. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationnone given

    Use of interoperability in healthcare allows caregivers to better understand phrases and concepts as data is transferred from one system to another while maintaining the content's meaning.

    “The use of interoperability in the healthcare arena will allow caregivers to better understand phrases and concepts as data is transferred from one system to another while maintaining the content's meaning.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Sharing healthcare data among health systems, payers, and providers improves both the quality of care and the efficiency with which it is given.

    “Sharing healthcare data among health systems, payers, and providers improves not only the quality of care but also the efficiency with which it is given.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Each year, over one million individuals are injured because of faulty health-care processes and system breakdowns.

    “In addition, each year, over one million individuals are injured because of faulty health-care processes and system breakdowns [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Voskanyan Y, Shikina I, Kidalov F, Davidov D. Medical care safety-problems and perspectives. In: International conference on integrated science, 2019 May 10. Cham: Springer. p. 291–304. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    Interoperability will contribute to the development of healthcare by ensuring that communication systems receive the correct meanings of medical language.

    “Subsequently, interoperability will contribute to the development of healthcare by ensuring that communication systems receive the correct meanings of medical language.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Because the medical interoperability gateway extracts and shows patient data in an existing system, providers can spend more time treating patients.

    “In addition, because the medical interoperability gateway extracts and shows patient data in an existing system, providers can spend more time treating patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    If a patient is unable to communicate effectively, health or care providers can fill in the gaps without contacting general practitioner offices or other agencies.

    “If a patient is unable to communicate effectively, health or care providers can fill in the gaps without the need to contact general practitioner offices or other agencies.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Interoperability solutions that promote accuracy and accessibility lower risks and improve care quality.

    “So, interoperability solutions that promote accuracy and accessibility lower these risks while also improving care quality.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Interoperability solutions in healthcare are key to overcoming some of the industry's most difficult challenges and promise to drastically cut healthcare costs.

    “Interoperability solutions in healthcare are the key to overcoming some of the industry's most difficult challenges, and they promise to drastically cut healthcare costs [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Ndlovu K, Scott RE, Mars M. Interoperability opportunities and challenges in linking mHealth applications and eRecord systems: Botswana as an exemplar. BMC Med Inform Decis Mak. 2021;21(1):1–2. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Coordinating care and sharing information between health and social care organizations can help determine if a patient is ready to be discharged, lowering readmissions.

    “Coordinating care and sharing information between health and social care organizations can help determine if a patient is ready to be discharged, lowering readmissions [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Braunstein ML. Health care in the age of interoperability: the potential and challenges. IEEE Pulse. 2018;9(5):34–6. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Data and insights can be shared with members to enhance medication adherence and chronic disease management, resulting in a higher return on investment for health plans.

    “Additionally, the data and insights can be shared with members to enhance medication adherence and chronic disease management, resulting in a higher return on investment for health plans [16].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] Kouroubali A, Katehakis DG. The new European interoperability framework as a facilitator of digital transformation for citizen empowerment. J Biomed Inform. 2019;94:103166. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Healthcare interoperability solutions provide physicians with the information they need to better coordinate care while also lowering patient healthcare costs.

    “In essence, healthcare interoperability solutions provide physicians with the information they need to better coordinate care while also lowering patient healthcare costs—a win–win situation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16] Kouroubali A, Katehakis DG. The new European interoperability framework as a facilitator of digital transformation for citizen empowerment. J Biomed Inform. 2019;94:103166. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    By supporting seamless health data sharing, interoperability solutions take over labor-intensive activities, limit manual tasks, reduce redundant work, and eliminate the burden placed on providers by payers.

    “By supporting seamless health data sharing, interoperability solutions are smoothly taking over labor-intensive activities backlogged in systems inboxes, limiting the amount of tasks that require manual touches, reducing redundant work, and eliminating the burden placed on providers by payers [20].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Suess TM, Beard JW, Ripchinski M, Eberts M, Patrick K, Tharappel LJ. Smart pump-electronic health record (EHR) interoperability with auto-documentation is associated with increased submission of infusion-therapy billing claims at a community hospital. PharmacoEconomics-Open. 2019;3(4):619–29. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Clinical decisions can be made faster and safely after viewing the medical record, reducing transfer of care, distress, and protracted hospital stays for patients.

    “Clinical decisions can be made faster and safely after viewing the medical record, reducing transfer of care, distress, and protracted stays in the hospital for patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    Patient outcomes are improved, service delivery is streamlined, and financial performance is improved when interoperability solutions are extended across a health system.

    “Patient outcomes are improved, service delivery is streamlined, and financial performance is improved when interoperability solutions are extended across a health system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Medical errors are the sixth biggest cause of death in hospitals.

    “Medical errors are the sixth biggest cause of death in hospitals, hence they are a major problem in the healthcare industry.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Voskanyan Y, Shikina I, Kidalov F, Davidov D. Medical care safety-problems and perspectives. In: International conference on integrated science, 2019 May 10. Cham: Springer. p. 291–304. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationreasoning

    In order to guarantee data exchange, semantic interaction is the best choice because systems can recognize and process semantically similar information homogeneously.

    “In order to guarantee the concept of data exchange, semantic interaction is the best choice because the systems can recognize and process semantically similar information homogeneously.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    CDA allows the entire patient medical history to be displayed in one document, reusable in several applications, and eliminates content diversity.

    “It allows the entire patient medical history to be displayed in one document, reusable in several applications, eliminates content diversity [29].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Ji H, Kim S, Yi S, Hwang H, Kim JW, Yoo S. Converting clinical document architecture documents to the common data model for incorporating health information exchange data in observational health studies: CDA to CDM. J Biomed Inform. 2020;107:103459. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Using different standards leads to confusion.

    “From there, using different standards leads to confusion.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    SOA provides high availability.

    “High availability. On request, anyone can use the SOA facilities.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [32] Hustad E, Olsen DH. Creating a sustainable digital infrastructure: the role of service-oriented architecture. Procedia Comput Sci. 2021;181:597–604. source

      Not checked in the free run.

    • cites [33] Chiang MC, Huang CY, Wu CY, Tsai CY. Analysis of a fault-tolerant framework for reliability prediction of service-oriented architecture systems. IEEE Trans Reliab. 2020;70(1):13–48. source

      Not checked in the free run.

    • cites [34] Lim AP, Thenuardi DS, Soewito B, Antonyova A. Survey on quality assurance testing on service oriented architecture. In: 2020 international conference on information management and technology (ICIMTech), 2020 Aug 13. IEEE. p. 443–7. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    SOA increases reliability.

    “Increased reliability. Because small services are easier to debug than massive code, SOA produces more dependable applications.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [32] Hustad E, Olsen DH. Creating a sustainable digital infrastructure: the role of service-oriented architecture. Procedia Comput Sci. 2021;181:597–604. source

      Not checked in the free run.

    • cites [33] Chiang MC, Huang CY, Wu CY, Tsai CY. Analysis of a fault-tolerant framework for reliability prediction of service-oriented architecture systems. IEEE Trans Reliab. 2020;70(1):13–48. source

      Not checked in the free run.

    • cites [34] Lim AP, Thenuardi DS, Soewito B, Antonyova A. Survey on quality assurance testing on service oriented architecture. In: 2020 international conference on information management and technology (ICIMTech), 2020 Aug 13. IEEE. p. 443–7. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    CDA is an XML-based standard for clinical document content that is flexible and can be read by both humans and machines.

    “The reason CDA is so popular is that it is an XML-based standard for clinical document content that is flexible and can be read by both humans and machines.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Ji H, Kim S, Yi S, Hwang H, Kim JW, Yoo S. Converting clinical document architecture documents to the common data model for incorporating health information exchange data in observational health studies: CDA to CDM. J Biomed Inform. 2020;107:103459. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    SOA services are simple to keep up with (maintainable).

    “Simple to keep up with. Because each service is self-contained, it is simple to modify and update them without affecting other services. The running costs of an organization will also be reduced as a result of this.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [32] Hustad E, Olsen DH. Creating a sustainable digital infrastructure: the role of service-oriented architecture. Procedia Comput Sci. 2021;181:597–604. source

      Not checked in the free run.

    • cites [33] Chiang MC, Huang CY, Wu CY, Tsai CY. Analysis of a fault-tolerant framework for reliability prediction of service-oriented architecture systems. IEEE Trans Reliab. 2020;70(1):13–48. source

      Not checked in the free run.

    • cites [34] Lim AP, Thenuardi DS, Soewito B, Antonyova A. Survey on quality assurance testing on service oriented architecture. In: 2020 international conference on information management and technology (ICIMTech), 2020 Aug 13. IEEE. p. 443–7. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    SOA can be implemented using any service-based technology, such as REST, WSDL and SOAP, and SOA-based systems can function independently of development technologies and platforms.

    “SOA can be implemented using any service-based technology, such as REST, WSDL and SOAP. SOA-based systems can function independently of development technologies and platforms (such as Java, XML and.NET, etc.) [35].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] Hamzah MH, Baharom F, Mohd H. An exploratory study for investigating the issues and current practices of service-oriented architecture adoption. J Inf Commun Technol. 2019;18(3):273–304.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    SOA is scalable.

    “Scalable. SOA enables services to run on several servers, resulting in increased scalability. Furthermore, companies can limit the amount of interaction between customers and services by employing a uniform communication protocol. Scaling apps without adding extra pressure is possible by lowering the intensity of engagement [32–34].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [32] Hustad E, Olsen DH. Creating a sustainable digital infrastructure: the role of service-oriented architecture. Procedia Comput Sci. 2021;181:597–604. source

      Not checked in the free run.

    • cites [33] Chiang MC, Huang CY, Wu CY, Tsai CY. Analysis of a fault-tolerant framework for reliability prediction of service-oriented architecture systems. IEEE Trans Reliab. 2020;70(1):13–48. source

      Not checked in the free run.

    • cites [34] Lim AP, Thenuardi DS, Soewito B, Antonyova A. Survey on quality assurance testing on service oriented architecture. In: 2020 international conference on information management and technology (ICIMTech), 2020 Aug 13. IEEE. p. 443–7. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    SOA services are reusable.

    “Reusable. Services can be repurposed to create a variety of applications. Because SOA services are stored in a service repository and linked on demand, each service becomes a generalized resource available to everyone. Reusing services allows businesses to save time and money when it comes to development.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [32] Hustad E, Olsen DH. Creating a sustainable digital infrastructure: the role of service-oriented architecture. Procedia Comput Sci. 2021;181:597–604. source

      Not checked in the free run.

    • cites [33] Chiang MC, Huang CY, Wu CY, Tsai CY. Analysis of a fault-tolerant framework for reliability prediction of service-oriented architecture systems. IEEE Trans Reliab. 2020;70(1):13–48. source

      Not checked in the free run.

    • cites [34] Lim AP, Thenuardi DS, Soewito B, Antonyova A. Survey on quality assurance testing on service oriented architecture. In: 2020 international conference on information management and technology (ICIMTech), 2020 Aug 13. IEEE. p. 443–7. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Clinical health records using SNOMED CT support populations by facilitating early detection of emergent health issues, community health monitoring, and quick reaction to changing clinical practices, providing precise access to pertinent data while eliminating costly duplications and errors.

    “Clinical health records using SNOMED CT support populations by facilitating early detection of emergent health issues, community health monitoring, and quick reaction to changing clinical practices, providing precise access to pertinent data while eliminating costly duplications and errors [30].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Nikiema JN, Bodenreider O. Comparing the representation of medicinal products in RxNorm and SNOMED CT-consequences on interoperability. In: ICBO, 2019. p. 1–6.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Access to a large quantity of diverse information from institutions must be readily available to understand the underlying causes of disease and develop diagnostics and therapeutics with better efficacy and safety.

    “In order to understand the underlying causes of disease and develop diagnostics and therapeutics with better efficacy and safety, access to a large quantity of diverse information from institutions must be readily available.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] Gaudet-Blavignac C, Raisaro JL, Touré V, Österle S, Crameri K, Lovis C. A national, semantic-driven, three-pillar strategy to enable health data secondary usage interoperability for research within the Swiss personalized health network: methodological study. JMIR Med Inform. 2021;9(6):e27591. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    The lack of interoperability between healthcare systems reinforces the information silos that exist in today's paper-based medical files, resulting in private ownership over health data.

    “The lack of interoperability between healthcare systems reinforces the information silos that exist in today's paper-based medical files, resulting in private ownership over health data.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Manufacturing architectures have evolved into integrated networks of automation devices, services, and businesses due to recent developments in manufacturing technologies including cyber-physical systems, the industrial internet, artificial intelligence, and machine learning.

    “Manufacturing architectures have evolved into integrated networks of automation devices, services, and businesses thanks to recent developments in manufacturing technologies including cyber-physical systems, the industrial internet, artificial intelligence, and machine learning.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] McGuire MR. A critique of interoperability, big data, artificial intelligence and medical care in general currently. Health Sci J. 2018;12(5):1–2. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The architecture and platforms used by machines and software programs present a considerable obstacle to interoperability in smart manufacturing.

    “The architecture and platforms that are utilized by machines and software programs present a considerable obstacle to this.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] McGuire MR. A critique of interoperability, big data, artificial intelligence and medical care in general currently. Health Sci J. 2018;12(5):1–2. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Personalized medicine approaches can address these difficulties.

    “Personalized medicine approaches can address these difficulties.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] Gaudet-Blavignac C, Raisaro JL, Touré V, Österle S, Crameri K, Lovis C. A national, semantic-driven, three-pillar strategy to enable health data secondary usage interoperability for research within the Swiss personalized health network: methodological study. JMIR Med Inform. 2021;9(6):e27591. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationreasoning

    The issues mentioned could encourage much-needed change in the information systems development field and promote further steps toward general interoperability in the national and international healthcare environments.

    “Added to that, the issues mentioned could encourage much-needed change in the information systems development field and promote further steps toward general interoperability in the national and international healthcare environments.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    The findings of this study could serve as strategic starting points for further integration of interoperability principles into the healthcare sector and more efficient ICT integration, particularly in countries where e-health planning and development is still in its early stages.

    “Therefore, it can be said, the findings of this study could serve as strategic starting points for further integration of interoperability principles into the healthcare sector and more efficient ICT integration, particularly in countries where e-health planning and development is still in its early stages.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Connectivity from interoperable EHRs can drive improvements in translational research and clinical decision support, leading to improved patient outcomes and completing the bench to bedside and back paradigm.

    “This connectivity can drive improvements in translational research and clinical decision support, leading to improved patient outcomes and completing the bench to bedside and back paradigm [39].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [39] Gaudet-Blavignac C, Raisaro JL, Touré V, Österle S, Crameri K, Lovis C. A national, semantic-driven, three-pillar strategy to enable health data secondary usage interoperability for research within the Swiss personalized health network: methodological study. JMIR Med Inform. 2021;9(6):e27591. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Promoting interoperability between information systems that deal with sensitive information takes a significant amount of time and requires a large multidisciplinary expert team.

    “Nevertheless, promoting interoperability between information systems that deal with sensitive information takes a significant amount of time and requires a large multidisciplinary expert team.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Connecting outputs to inputs in computational drug discovery can be challenging and necessitate manual preprocessing of output and input files.

    “Such an undertaking can be challenging and necessitate manual pre-processing of the output and input files.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Schaduangrat N, Lampa S, Simeon S, Gleeson MP, Spjuth O, Nantasenamat C. Towards reproducible computational drug discovery. J Cheminform. 2020;12(1):1–30. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Improved collaboration and data sharing are fundamental to managing the rise in complicated chronic diseases.

    “Regardless of how personalized medicine is defined, it is evident that improved collaboration and data sharing are fundamental to managing the rise in complicated chronic diseases.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [39] Gaudet-Blavignac C, Raisaro JL, Touré V, Österle S, Crameri K, Lovis C. A national, semantic-driven, three-pillar strategy to enable health data secondary usage interoperability for research within the Swiss personalized health network: methodological study. JMIR Med Inform. 2021;9(6):e27591. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationreasoning

    Lack of interoperability has led to risen healthcare costs, deteriorated patient care quality, and compromised ability to integrate patient data across healthcare systems.

    “Consequently, healthcare costs have risen, patient care quality has deteriorated, and the ability to integrate patient data across healthcare systems has been compromised.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    Legal and organizational issues are among the most important bottlenecks in interoperability.

    “However, legal and organizational issues are among the most important bottlenecks in interoperability, which were not covered in this study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Computational drug discovery projects probably require preprocessing and connecting outputs of one software or tool as input to another.

    “Pre-processing and connecting the outputs of one software or tool as input to another software or tool would probably be required for this.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Schaduangrat N, Lampa S, Simeon S, Gleeson MP, Spjuth O, Nantasenamat C. Towards reproducible computational drug discovery. J Cheminform. 2020;12(1):1–30. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Lack of access to some articles due to lack of access to their full text and their non-English language was a limitation of the study.

    “Also, lack of access to some articles due to the lack of access to their full text and their non-English language was another limitations of the study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A typical research project in computational drug discovery uses a variety of software, programs, and tools to read input files, pre-process data, perform one or more computations, and do post-analysis.

    “A typical research project in computational drug discovery uses a variety of software, programs, and tools to read input files, pre-process data, perform one or more computations, and do post-analysis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Schaduangrat N, Lampa S, Simeon S, Gleeson MP, Spjuth O, Nantasenamat C. Towards reproducible computational drug discovery. J Cheminform. 2020;12(1):1–30. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    The growth of manufacturing technologies has led to a rising requirement for interoperability at all levels of the manufacturing ecosystem.

    “The rising requirement for interoperability at all levels of the manufacturing ecosystem is one of the difficulties that have come about as a result of this growth.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] McGuire MR. A critique of interoperability, big data, artificial intelligence and medical care in general currently. Health Sci J. 2018;12(5):1–2. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationcitation

    Successful interoperability implementation in smart manufacturing will lead to efficient communication and error-prone data interchange between devices, users, systems, and platforms.

    “Thus, a successful interoperability implementation in smart manufacturing will lead to efficient communication and error-prone data interchange between devices, users, systems, and platforms.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] McGuire MR. A critique of interoperability, big data, artificial intelligence and medical care in general currently. Health Sci J. 2018;12(5):1–2. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    Industry-specific interoperability and their corresponding logical semantics can help comprehend the topic better.

    “Industry-specific interoperability and their corresponding logical semantics can help us comprehend the topic better [41].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [41] McGuire MR. A critique of interoperability, big data, artificial intelligence and medical care in general currently. Health Sci J. 2018;12(5):1–2. source

      Not checked in the free run.

81 of 81

  • The paper relies on this without support.

    No systematic study of the issue of interoperability of health information systems exists.

    “To the best of our knowledge, there has been no systematic study of the issue of interoperability of health information systems.”

  • The paper relies on this without support.

    The health industry has become more complex and has new needs.

    “The health industry has become more complex and has new needs.”

  • The paper relies on this without support.

    The issue of interoperability of health information systems is currently in a state of disarray.

    “Despite the importance of the interoperability of health information systems, the various approaches taken to create it, and the growing academic interest in it, this issue is currently in a state of disarray.”

  • The paper relies on this without support.

    Interoperability has a significant positive impact on healthcare.

    “Without question, interoperability has a significant positive impact on healthcare.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Centralized data-sharing systems have limitations including data privacy and security concerns, interoperability issues, and single points of failure.

    “However, centralized data-sharing systems have limitations, such as data privacy and security concerns [5]interoperability issues [6], and single points of failure [7].”

    From Federated learning meets blockchain in decentralized data-sharing: Healthcare use case (2024) · cites this paper as [6]

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. Powell K, Alexander G. Mitigating Barriers to Interoperability in Health Care: OJNI. On - Line Journal of Nursing Informatics 2019;23(2)-6.
  2. Hamzah MH, Baharom F, Mohd H. An exploratory study for investigating the issues and current practices of service-oriented architecture adoption. J Inf Commun Technol. 2019;18(3):273–304.

Cited by

Sorted by citations

Related

Authors
Torab-Miandoab, A., Samad-Soltani, T., Jodati, A., & Rezaei-Hachesu, P.
Affiliations
Tabriz University of Medical Sciences (IR)
ORCID
Venue
BMC Medical Informatics and Decision Making
Publisher
Springer Science and Business Media LLC
Published
2023-01-24
Volume
23
Issue
1
Pages
18-18
ISSN
1472-6947 (ISSN-L)
DOI
10.1186/s12911-023-02115-5
PMC
PMC9875417
OpenAlex
W4317904523
Cited by
393
References
41
Citations by year
2026: 129 · 2025: 135 · 2024: 109 · 2023: 19 · 2022: 1
FWCI
15.27
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Medical Informatics and Decision Making (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • Tabriz University of Medical Sciences
  • University of Tabriz
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
Keywords
interoperability, health information systems, heterogeneous systems, electronic health records, HL7 FHIR, Clinical Document Architecture, HIPAA, SNOMED CT, semantic interoperability, data exchange, integration mechanisms
MeSH terms
Humans, Systematized Nomenclature of Medicine, Electronic Health Records, Health Information Systems

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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