The January Meeting of the HIT Standards Committee

The January meeting of the HIT Standards Committee was a discussion of the refinements to content, vocabulary, and transport/security standards needed to reduce barriers and accelerate adoption of interoperability.

Dr. David Blumenthal began the meeting with an overview of the national HIT accomplishments to date.  A year ago, we did not have a Regional Extension Center Program, a Health Information Exchange Program, a Workforce Development Program, a Beacon Community Program, or a SHARP Research Program.    He highlighted that Stage 2 of Meaningful Use will include a greater focus on interoperability.  There is a great sense of urgency among policymakers, the White House, and many stakeholders to align incentives for interoperability and provide the tools to accelerate data exchange.

Dr. Farzad Mostashari offered an overview of the 2011 priorities for the HIT Standards Committee.   ONC programs aim to increase electronic transaction volumes for lab result reporting, e-prescribing, transitions of care, consumer engagement, and public health.   At a high level, standards, governance, architecture, and a trust framework are needed.  At a more specific level, provider directories, certificate management, and identity assurance processes are needed.    As we think about the future of health information exchange, we cannot be limited to just point to point push transactions (which is our 2011 focus).   To support the enhanced outcomes, reduced cost, and improved quality we want, we'll also need a nationwide system that supports queries/pull transactions.  Tomorrow, ONC will announce good news on EHR adoption rates, but there is much more work to do.  EHRs need to be more usable and we must be wary of creating a digital divide - the technology haves and have nots.   We need more consumer engagement by  enhancing provider/patient data exchange including integrated educational materials.  We need more decision support.   We need to be more directive about the way transport, certificates, and directories are implemented by HIEs.   The HIT Standards Committee members agreed that ONC's priorities for interoperability seemed appropriate and we need a workplan for the Committee to address these items quickly.

Farzad also provided a brief overview of the work of the PCAST workgroup which kicked off last week.   Questions to be explored include:

1. What standards, implementation specifications, certification criteria, and certification processes for electronic health record (EHR) technology and other HIT would be required to implement the following specific recommendations from the PCAST report:
That ONC establish minimal standards for the metadata associated with tagged data elements;
That ONC facilitate the rapid mapping of existing semantic taxonomies into tagged data elements;
That certification of EHR technology and other HIT should focus on interoperability with reference implementations developed by ONC.

2. What processes and approaches would facilitate the rapid development and use of these standards, implementation specifications, certification criteria and certification processes?

3. Given currently implemented information technology (IT) architectures and enterprises, what challenges will the industry face with respect to transitioning to the approach discussed in the PCAST report?
Given currently implemented provider workflows, what are some challenges to populating the metadata that may be necessary to implement the approach discussed in the PCAST report?
Alternatively, what are proposed solutions, or best practices from other industries, that could be leveraged to expedite these transitions?

4. What technological developments and policy actions would be required to assure the privacy and security of health data in a national infrastructure for HIT that embodies the PCAST vision and recommendations?

5. How might a system of Data Element Access Services (DEAS), as described in the report, be established, and what role should the Federal government assume in the oversight and/or governance of such a system?

6. How might ONC best integrate the changes envisioned by the PCAST report into its work in preparation for Stage 2 of Meaningful Use?

7. What are the implications of the PCAST report on HIT programs and activities, specifically, health information exchange and Federal agency activities, and how could ONC address those implications?

8. Are there lessons learned regarding metadata tagging in other industries that ONC should be aware of?

9. Are there lessons learned from initiatives to establish information sharing languages (‘‘universal languages’’) in other sectors?

Arien Malec and Doug Fridsma presented an update on the Direct Project and the Standards and Interoperability Framework.   The Direct Project is completing 3 documents
a.  A core specification for senders and receivers using S/MIME and SMTP
b.  A supplemental specification for senders and receivers using an XDR/XDM Gateway to connect to the Direct backbone (which is S/MIME and SMTP)
c.  An overview of what it means for senders and receivers to be "Direct compliant" for receipt of structured and unstructured data

The initial projects of the Standards and Interoperability Framework include
a.  Clinical Document Architecture Consolidation - a cleanup and harmonization of work done by HITSP, IHE, HL7 and others which will hopefully result in a single, easy to use, template-based implementation guide
b.  HL7 2.x Lab simplification - harmonization of content and vocabulary standards to significantly simplify the implementation of a single use case - Lab to EHR result reporting
c.  Transition of Care - creation of easy to use implementation guidance and tools to support the need of care transitions

A committee member noted that aligning incentives to share data will motivate the marketplace and stakeholders to create better tools and implementation guidance.   Better standards alone are necessary but not sufficient to accelerate adoption.

Micky Tripathi and Walter Suarez presented the Provider Directory guidance from the Information Exchange Workgroup.  Their work includes an important short term focus on organization to organization exchange and the entity level provider directories (ELPD) needed to support that workflow.    Future work includes individual provider directories (ILPD).   The workplan is to build the "yellow pages" first and the "white pages" second.   The "yellow pages" is easier and will be sufficient to accelerate data exchange, just as email today includes organization to organization transport but there is no national email "whitepages".

Judy Murphy and Liz Johnson reviewed the themes of the January 10-11 Implementation Workgroup hearing.   High level themes included:

Regional Extension Centers - There is significant variation in cost, business models (at least 4), and services provided by RECs, resulting in mixed customer satisfaction.

Certification - Certification bodies are working very well.  There is some confusion as to how best to acquire complete EHRs with modular EHRs add on products.   If a customer wants to replace a portion of a complete EHR with a certified EHR module, do they still need to buy all the components of the complete EHR?

Health Information Exchange - there is great demand for interoperability specifications that are clear and concise.  The sustainability/value proposition of most HIEs is still unclear.   Some private HIEs are working better than public efforts.

Timing issues - Certification specifications were finalized in the Summer which gave vendors very little time to complete their products and install them in time for the January start of the  Meaningful Use reporting period.  

Quality Measures are difficult - The specifications are challenging to interpret and the computations are difficult to produce.

Overall, there is great energy and all stakeholders are highly motivated to achieve Meaningful Use.   A multi-year roadmap would make planning for the future easier.

Jamie Ferguson provided a brief update on the Clinical Operations Workgroup.  The group will begin work on device standards (especially vocabularies) and a offer advice on the S&I Framework priorities.

Dixie Baker provided a brief update on the Privacy & Security Workgroup.  The group will begin work on digital certificate standards per the Policy Committee's request.

Based on all we discussed, it's clear that 2011 promises to be a busy year - likely one that will mark a tipping point in interoperability for the country.