Sunday, March 11, 2012
Todd Park, Chief Technology Officer for the U.S.
Todd Park recently assumed the role of Chief Technology Officer (CTO) for the United States reporting to the President. Last April, Todd (then CTO of Health and Human Services), Josh Seidman and I participated on a panel moderated by Sean Nolan on Citizen-Centric Health: How Public/Private Partnerships are Changing the Game. Todd's energy and passion on that panel were so great, that it is worthwhile reprising here.
Monday, March 5, 2012
Standards for Distributed Population Health Queries
Originally published in Faster Cures' "bloggersation" regarding: What is the most important thing that could happen in 2012 to ensure better utilization of big data—housed in EMRs or other platforms—for drug development?
“Big data” is typically managed in large pooled data sets, combining data from many settings of care. While there are terrific applications of pooled data, including registries and successful use of large research databases, there are critical issues of policy and strategy. Pooled “Big data” in healthcare has its benefits but also has several drawbacks.
From a policy perspective, pooled data approaches are problematic. Large pools of PHI are targets for attack from bad actors. Also, many PHI-holders have their own consent agreements with their patients. It is difficult to manage these different consent agreements when pooling PHI in one place. Additionally, HIPAA requires covered entities to control the flow of PHI, either directly or through agreements. When data is pooled, the party pooling the data must have a business associate agreement or data use agreement (in the case of research databases) with each covered entity that contributes data to the pool, with the same (or similar terms). This can be impracticable for the third party or undesirable for covered entities, as they often have to agree to non-negotiable terms in the agreement in order to pool their data.
From a strategic standpoint, pooled data is inflexible, stale and inaccurate. Pooled data approaches aren’t generally sustainable: the benefits of pooled approaches are too indirect to support the operational costs and complexity. Furthermore, health care organizations are unwilling to lose control of their information not just for policy reasons, but also due to competitive considerations.
But the absence of a standards-based alternative has given rise to pooled data approaches with all of these substantial drawbacks.
2012 is the defining moment for new standards that will enable big data analytics in a distributed environment. An ONC sponsored open government initiative, Query Health, is defining the standards and specifications for distributed population queries. Researchers will be able to leverage these standards to be “send questions to the data”. Questions can be sent to data sources including EHRs, HIEs, PHRs, payers’ clinical record or any other clinical record. Aggregate responses leave patient level information secure behind the data source’s firewall. Aggregate responses support questions related to disease outbreak, quality, CER, post-market surveillance, performance, utilization, public health, prevention, resource optimization and many others.
The path for these new standards will dramatically cut cycle time for deployment of new questions from years to days – making possible support for a learning health system.
The focus of 2012 should be laying the foundation for success: defining the standards and services for distributed population health queries. This is one extremely impactful way to leverage the potential of big data for research. For more information, visit QueryHealth.org.
“Big data” is typically managed in large pooled data sets, combining data from many settings of care. While there are terrific applications of pooled data, including registries and successful use of large research databases, there are critical issues of policy and strategy. Pooled “Big data” in healthcare has its benefits but also has several drawbacks.
From a policy perspective, pooled data approaches are problematic. Large pools of PHI are targets for attack from bad actors. Also, many PHI-holders have their own consent agreements with their patients. It is difficult to manage these different consent agreements when pooling PHI in one place. Additionally, HIPAA requires covered entities to control the flow of PHI, either directly or through agreements. When data is pooled, the party pooling the data must have a business associate agreement or data use agreement (in the case of research databases) with each covered entity that contributes data to the pool, with the same (or similar terms). This can be impracticable for the third party or undesirable for covered entities, as they often have to agree to non-negotiable terms in the agreement in order to pool their data.
From a strategic standpoint, pooled data is inflexible, stale and inaccurate. Pooled data approaches aren’t generally sustainable: the benefits of pooled approaches are too indirect to support the operational costs and complexity. Furthermore, health care organizations are unwilling to lose control of their information not just for policy reasons, but also due to competitive considerations.
But the absence of a standards-based alternative has given rise to pooled data approaches with all of these substantial drawbacks.
2012 is the defining moment for new standards that will enable big data analytics in a distributed environment. An ONC sponsored open government initiative, Query Health, is defining the standards and specifications for distributed population queries. Researchers will be able to leverage these standards to be “send questions to the data”. Questions can be sent to data sources including EHRs, HIEs, PHRs, payers’ clinical record or any other clinical record. Aggregate responses leave patient level information secure behind the data source’s firewall. Aggregate responses support questions related to disease outbreak, quality, CER, post-market surveillance, performance, utilization, public health, prevention, resource optimization and many others.
The path for these new standards will dramatically cut cycle time for deployment of new questions from years to days – making possible support for a learning health system.
The focus of 2012 should be laying the foundation for success: defining the standards and services for distributed population health queries. This is one extremely impactful way to leverage the potential of big data for research. For more information, visit QueryHealth.org.
Saturday, February 25, 2012
Meaningful Use Stage 2
HHS News Release
Health and Human Services Secretary Kathleen Sebelius announced the next steps for providers who are using electronic health record (EHR) technology and receiving incentive payments from Medicare and Medicaid. These proposed rules, from the Centers for Medicaid & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), will govern stage 2 of the Medicare and Medicaid Electronic Health Record Incentive Programs.
Health and Human Services Secretary Kathleen Sebelius announced the next steps for providers who are using electronic health record (EHR) technology and receiving incentive payments from Medicare and Medicaid. These proposed rules, from the Centers for Medicaid & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC), will govern stage 2 of the Medicare and Medicaid Electronic Health Record Incentive Programs.
“We know that broader adoption of electronic health records can save our health care system money, save time for doctors and hospitals, and save lives,” said Secretary Sebelius. “We have seen great success and momentum as we’ve taken the first steps toward adoption of this critical technology. As we move into the next stage, we are encouraging even more providers to participate and support more coordinated, patient-centered care.”
Under the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Recovery and Reinvestment Act of 2009, eligible health care professionals and hospitals can qualify for Medicare and Medicaid incentive payments when they adopt certified EHR technology and use it in a meaningful way. What is considered “meaningful use” is evolving in three stages:
- Stage 1 (which began in 2011 and remains the starting point for all providers): “meaningful use” consists of transferring data to EHRs and being able to share information, including electronic copies and visit summaries for patients.
- Stage 2 (to be implemented in 2014 under the proposed rule): “meaningful use” includes new standards such as online access for patients to their health information, and electronic health information exchange between providers.
- Stage 3 (expected to be implemented in 2016): “meaningful use” includes demonstrating that the quality of health care has been improved.
CMS’ proposed rule specifies the stage 2 criteria that eligible providers must meet in order to qualify for Medicare and/or Medicaid EHR incentive payments. It also specifies Medicare payment adjustments that, beginning in 2015, providers will face if they fail to demonstrate meaningful use of certified EHR technology and fail to meet other program participation requirements. In a November 2011 “We Can’t Wait” announcement (http://www.hhs.gov/news/press/2011pres/11/20111130a.html), the Department outlined plans to provide an additional year for providers who attested to meaningful use in 2011. Under today’s proposed rule, stage 1 has been extended an additional year, allowing providers to attest to stage 2 in 2014, instead of in 2013. The proposed rule announced by ONC identifies standards and criteria for the certification of EHR technology, so eligible professionals and hospitals can be sure that the systems they adopt are capable of performing the required functions to demonstrate either stage of meaningful use that would be in effect starting in 2014.
“Through the Medicare and Medicaid EHR Incentive Programs, we’ve seen incredible progress as over 43,000 providers have received $3.1 billion to help make the transition to electronic health records,” said CMS Acting Administrator Marilyn Tavenner. “There is great momentum as the number of providers adopting this technology grows every month. Today’s announcement will help ensure broad participation and success of the program, as we move toward full adoption of this money-saving and life-saving technology.”
“The proposed rules for stage 2 for meaningful use and updated certification criteria largely reflect the recommendations from the Health IT Policy and Standards Committees, the federal advisory committees that operate through a transparent process with broad public input from all key stakeholders. Their recommendations emphasized the desire to increase health information exchange, increase patient and family engagement, and better align reporting requirements with other HHS programs,” said Farzad Mostashari, MD, ScM, National Coordinator for Health Information Technology. “The proposed rules announced today will continue down the path stage 1 established by focusing on value-added ways in which EHR systems can help providers deliver care which is more coordinated, safer, patient-centered, and efficient.”
The number of hospitals using EHRs has more than doubled in the last two years from 16 to 35 percent between 2009 and 2011. Eighty-five percent of hospitals now report that by 2015 they intend to take advantage of the incentive payments.
A technical fact sheet on CMS’s proposed rule is available at http://www.cms.gov/apps/media/fact_sheets.asp.
A technical fact sheet on ONC’s standards and certification criteria proposed rule is available athttp://www.healthit.gov/policy-research.
The proposed rules announced today may be viewed at www.ofr.gov/inspection.aspx. Comments are due 60 days after publication in the Federal Register.
Wednesday, February 15, 2012
Query Health: Distributed Population Queries
By Michael Buck and Rich Elmore (and originally published in Health Data Management)
Query Health is an Open Government Initiative that is establishing the standards and services for distributed population health queries. Query Health standards will be used to send questions to clinical data sources which return aggregate measures of population health that can be used for many purposes including disease outbreak monitoring, post-market surveillance, comparative effectiveness research, quality and performance measures.
Query Health is pleased to announce the commitment of leading healthcare organizations to pilot the Query Health standards and specifications. Query Health also plans to present its progress on proposed standards and reference implementation at the HIMSS conference in Las Vegas, February 20-24, 2012. And in an unexpected twist, Query Health standards will deliver potential benefits beyond the scope of distributed population queries.
Announcing the first Query Health Pilot
Today, Query Health is announcing that the Primary Care Information Project (PCIP), within the New York City Department of Health and Mental Hygiene, and the New York State Department of Public Health have announced plans to pilot the Query Health standards and reference implementation. PCIP recently won awards for their work on distributed queries including the 2011 HIMSS Public Health Davies Award of Excellence and Healthcare Informatics first place Innovator Award. They will be using Query Health standards to expand their existing population health monitoring network from an existing 1.6 million ambulatory patients to encompass citywide HIE organizational coverage of both inpatient and outpatient encounters. This enhanced system will support optimal allocation of limited public health resources.
What will be shown at HIMSS?
ONC will host a demonstration of Query Health’s progress on the reference implementation including a live demo of distributed query execution.
· ONC Booth Theater on Wednesday February 22nd at 9:45 AM.
· HIMSS Interoperability Showcase Stage on Thursday February 23rd at 9:30 AM
Are there benefits beyond distributed population queries?
The path for a quality measure today is measured in years from the time of measure definition to delivery in vendor systems and deployment in EHRs. Want another quality measure? Wait several years.
In collaboration with HL7, NQF and CMS, Query Health standards will enable Health IT vendors to dynamically respond to queries, including queries that align with quality measures. So assuming the data is being captured, the cycle time could go from years to days.
The ability to generate measures nationally in a short cycle time has powerful benefits for patients, patient populations while enabling researchers and healthcare organizations to substantially reduce costs and increase speed.
What is Query Health?
Query Health was launched September 2011, with approximately 100 committed member organizations representing diverse healthcare stakeholders contributing to the project.
Today, when health researchers develop questions about a population, in many cases they manually pose these questions to care delivery organizations, which employ technical teams to manually generate queries and produce reports. Even where distributed queries are automated, the costs and time to link each data source are unacceptably high. The Query Health Initiative will make this much more efficient: the question can be delivered in a format that will be interpreted automatically by an HIT system. The HIT system will then generate a report with the “answer” to the query.
Questions can be sent to many different types of data sources including providers’ EHRs, payers’ clinical records, personal health records and health information exchanges. Decisions about which queries to process are under control of the data owner and the aggregated results protect patient level data, which remains safely behind data owners’ firewalls.
For more information:
For more information on Query Health initiative, visit the Query Health website http://www.QueryHealth.org or contact admin@siframework.org.
The authors:
Michael Buck is the clinical work group leader for Query Health and director for the NYC/NYS pilot. Dr. Buck is also Biomedical Informatics R&D Manager at New York City Department of Health and Mental Hygiene and Adjunct Associate Research Scientist at Columbia University’s Department of Biomedical Informatics.
Rich Elmore is the ONC Coordinator for Query Health.
Tuesday, January 10, 2012
Medical Errors Due to Indecipherable Prescriptions
Thanks to e-Patient Dave for the image.
See also the recent report Hospital Incident Reporting Systems Do Not Capture Most Patient Harm which found that "Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm".
Wednesday, December 14, 2011
The December HIT Standards Committee Meeting
by John Halamka, Life as a Healthcare CIO
We began the meeting by relating our standards trajectory to today's agenda.
Our outstanding standards issues for discussion include
1. Content
Continued discussion of GreenCDA on the wire and overview of Stan Huff's CIMI initiative
Standardizing DICOM image objects for image sharing and investigating other possible approaches (e.g., cloud based JPEG2000 exchange). Consider image transfer standards, image viewing standards, and image reporting standards.
Query Health i.e. I2B2 distributed queries that send questions to data instead of requiring consolidation of data
Simplify the specification for quality measures to enhance consistency of implementation.
The December meeting included an overview of Query Health and Quality measure standards, leaving the discussion of GreenCDA/CIMI and DICOM to our 2012 meetings.
2. Vocabulary
Extend the quality measurement vocabularies to clinical summaries
Lab ordering compendium
The December meeting included a discussion of the lab ordering compendium, leaving the discussion of clinical summary vocabularies to our 2012 meetings.
3. Transport
Specify how the metadata ANPRM be integrated into the health exchange architecture
Additional NwHIN standards development (hearing re Exchange specification complexity, review/oversight of the S&I framework work on Exchange specifications simplification). Further define secure RESTful transport standards.
Accelerate provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminate lessons learned.
The December meeting included an update on the provider directory and certificate components of transport
Our first presentation was an NCVHS update on ACA Section 10109 by Walter Suarez.
The Committee emphasized the need to coordinate NCHVS work and HITSC work given that division between administrative and clinical data is becoming less distinct over time
Our second presentation was an Implementation Workgroup Update by Liz Johnson about testing procedures that support the certification process.
The committee emphasized the need to pilot these procedures, ensuring they are as simple as possible and reflect a practical evaluation of the functionality intended to support policy goals.
Next, Doug Fridsma and Rich Elmore gave an ONC update. Rich Elmore described the Query Health initiative, as referenced in my previous blog post about sending questions to data (rather than sending data to registries).
The committee endorsed the work and noted that further research will be needed to link patients across multiple databases to avoid double counting individuals in quality measure denominators. The work of Jeff Jonas, as described in my earlier blog post about linking identity.
Doug updated the committee about the S&I Framework initiatives - Transitions of Care, Lab Results, Provider Directories, Data Segmentation (for privacy protection), and electronic submission of medical documentation for Medicare review.
We then discussed a preliminary framework for HITSC 2012 Workplan to ensure the items in the standards trajectory listed above are completed in 2012 as we continue to prepare for meaningful use stage 3.
A great meeting.
We began the meeting by relating our standards trajectory to today's agenda.
Our outstanding standards issues for discussion include
1. Content
Continued discussion of GreenCDA on the wire and overview of Stan Huff's CIMI initiative
Standardizing DICOM image objects for image sharing and investigating other possible approaches (e.g., cloud based JPEG2000 exchange). Consider image transfer standards, image viewing standards, and image reporting standards.
Query Health i.e. I2B2 distributed queries that send questions to data instead of requiring consolidation of data
Simplify the specification for quality measures to enhance consistency of implementation.
The December meeting included an overview of Query Health and Quality measure standards, leaving the discussion of GreenCDA/CIMI and DICOM to our 2012 meetings.
2. Vocabulary
Extend the quality measurement vocabularies to clinical summaries
Lab ordering compendium
The December meeting included a discussion of the lab ordering compendium, leaving the discussion of clinical summary vocabularies to our 2012 meetings.
3. Transport
Specify how the metadata ANPRM be integrated into the health exchange architecture
Additional NwHIN standards development (hearing re Exchange specification complexity, review/oversight of the S&I framework work on Exchange specifications simplification). Further define secure RESTful transport standards.
Accelerate provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminate lessons learned.
The December meeting included an update on the provider directory and certificate components of transport
Our first presentation was an NCVHS update on ACA Section 10109 by Walter Suarez.
The Committee emphasized the need to coordinate NCHVS work and HITSC work given that division between administrative and clinical data is becoming less distinct over time
Our second presentation was an Implementation Workgroup Update by Liz Johnson about testing procedures that support the certification process.
The committee emphasized the need to pilot these procedures, ensuring they are as simple as possible and reflect a practical evaluation of the functionality intended to support policy goals.
Next, Doug Fridsma and Rich Elmore gave an ONC update. Rich Elmore described the Query Health initiative, as referenced in my previous blog post about sending questions to data (rather than sending data to registries).
The committee endorsed the work and noted that further research will be needed to link patients across multiple databases to avoid double counting individuals in quality measure denominators. The work of Jeff Jonas, as described in my earlier blog post about linking identity.
Doug updated the committee about the S&I Framework initiatives - Transitions of Care, Lab Results, Provider Directories, Data Segmentation (for privacy protection), and electronic submission of medical documentation for Medicare review.
We then discussed a preliminary framework for HITSC 2012 Workplan to ensure the items in the standards trajectory listed above are completed in 2012 as we continue to prepare for meaningful use stage 3.
A great meeting.
Monday, December 12, 2011
The Elephant in the Room
Why aren't we talking about pricing failures? The US, has consistently higher prices than any other country. The 2010 report by the International Federation of Health Plans consists of 23 pricing measures and the pattern is the same across each of these measures. And a 2010 investigation of Health Care Cost Trends and Cost Drivers in Massachusetts found that "price variations are correlated to market leverage..."
Before his departure from CMS, Don Berwick was interviewed by the New York Times and took a "parting shot at waste". Berwick listed five elements of waste including overtreatment of patients, failure to coordinate care, administrative complexity, burdensome rules and fraud. Pricing failures didn't make the list. (Many folks have commented and analyzed the five factors including John Halamka's terrific piece on how EHRs can address these 5 factors.)
Then in Berwick's December 7th speech to the IHI National Forum, he adds a sixth element:
Don Berwick defines pricing failures as "the waste that comes as prices migrate far from the actual costs of production plus fair profits." Think about that: "far from the actual costs of production plus fair profits". At a time when total healthcare expenditures consume a huge share of GDP and increasing at rates higher than inflation and wage increases, why haven't pricing failures been on the table? As we struggle to control costs and improve quality, there is intense focus on utilization, regulation and care coordination. Why not also focus on pricing failures?
So why hasn't pricing failures been part of the conversation up to now? Here's how the conversation usually proceeds: Health Affairs November 2011 article, Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs, "found that current Medicare episode payments for certain inpatient procedures varied by 49–130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery."
Sounds like a clarion call for a focus on pricing failures doesn't it? Actually, no... The authors conclusions only speak to cost efficiency and utilization. "Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care."
So is it time to broaden the conversation to include pricing failures? At least one health system has realized that "the jig is up". Perhaps it's time to peel the onion a bit... And take a serious look at pricing failures which deviate "far from the actual costs of production plus fair profits".
_______________________________
Background tables from the IFHP report:
Before his departure from CMS, Don Berwick was interviewed by the New York Times and took a "parting shot at waste". Berwick listed five elements of waste including overtreatment of patients, failure to coordinate care, administrative complexity, burdensome rules and fraud. Pricing failures didn't make the list. (Many folks have commented and analyzed the five factors including John Halamka's terrific piece on how EHRs can address these 5 factors.)
Then in Berwick's December 7th speech to the IHI National Forum, he adds a sixth element:
- "Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
- Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.
- Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.
- Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.
- Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits.
- Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few. We have estimated how big this waste is – from both the perspective of the Federal payers – Medicare and Medicaid – and for all payers."
Don Berwick defines pricing failures as "the waste that comes as prices migrate far from the actual costs of production plus fair profits." Think about that: "far from the actual costs of production plus fair profits". At a time when total healthcare expenditures consume a huge share of GDP and increasing at rates higher than inflation and wage increases, why haven't pricing failures been on the table? As we struggle to control costs and improve quality, there is intense focus on utilization, regulation and care coordination. Why not also focus on pricing failures?
So why hasn't pricing failures been part of the conversation up to now? Here's how the conversation usually proceeds: Health Affairs November 2011 article, Large Variations In Medicare Payments For Surgery Highlight Savings Potential From Bundled Payment Programs, "found that current Medicare episode payments for certain inpatient procedures varied by 49–130 percent across hospitals sorted into five payment groups. Intentional differences in payments attributable to such factors as geography or illness severity explained much of this variation. But after adjustment for these differences, per episode payments to the highest-cost hospitals were higher than those to the lowest-cost facilities by up to $2,549 for colectomy and $7,759 for back surgery."
Sounds like a clarion call for a focus on pricing failures doesn't it? Actually, no... The authors conclusions only speak to cost efficiency and utilization. "Our study suggests that bundled payments could yield sizable savings for payers, although the effect on individual institutions will vary because hospitals that were relatively expensive for one procedure were often relatively inexpensive for others. More broadly, our data suggest that many hospitals have considerable room to improve their cost efficiency for inpatient surgery and should look for patterns of excess utilization, particularly among surgical specialties, other inpatient specialist consultations, and various types of postdischarge care."
So is it time to broaden the conversation to include pricing failures? At least one health system has realized that "the jig is up". Perhaps it's time to peel the onion a bit... And take a serious look at pricing failures which deviate "far from the actual costs of production plus fair profits".
_______________________________
Background tables from the IFHP report:
Monday, November 21, 2011
The November HIT Standards Committee
by John Halamka, Life as a Healthcare CIO, November 16, 2011
Today, the HIT Standards Committee shifted gears from the Summer Camp work on Meaningful Use Stage 2 and began new interoperability efforts.
We began the meeting with a presentation by Liz Johnson and Judy Murphy about the Implementation Workgroup's recommendations to improve the certification and testing process. These 15 items incorporate the Stage 1 experience gathered from numerous hospitals and eligible professionals. If ONC and NIST can implement this plan, many stakeholders will benefit. The Committee approved these recommendations without revision.
Next, we focused on content, vocabulary and transport standards.
In my October HIT Standards Committee blog post, I noted that HITSC should work on the following projects:
Content
*Continued refinement of the Consolidated CDA implementation guides and tools to enhance semantic interoperability including consistent use of business names in "Green" over-the-wire standards.
*Simplifying the specification for quality measures to enhance consistency of implementation.
*Standardizing DICOM image objects for image sharing and investigating other possible approaches. We'll review image transfer standards, image viewing standards, and image reporting standards.
*Query Health - distributed queries that send questions to data instead of requiring consolidation of the data
Vocabulary
*Extending the quality measurement vocabularies to clinical summaries
*Finalizing a standardized lab ordering compendium
Transport
*Specifying how the metadata ANPRM be integrated into health exchange architectures
*Supporting additional NwHIN standards development (hearings about Exchange specification complexity, review/oversight of the S&I Framework projects on simplification of Exchange specifications). Further defining secure RESTful transport standards.
*Accelerating provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminating lessons learned.
The November Committee agenda included a discussion of Consolidated CDA, Quality Measures, and NwHIN Implementation Guides.
Doug Fridsma began with a discussion of the Consolidated CDAwork and the tools which support it.
The Committee had a remarkable dialog with more passion and unanimity than at any recent discussion. We concluded:
*Simple XML that is easily implemented will accelerate adoption
*That simple XML should be backed by a robust information model. However, implementers should not need expert knowledge of that model. The information model can serve as a reference for SDOs to guide their work
*Detailed Clinical Models, as exemplified by Stan Huff's Clinical Information Modeling Initiative (CIMI) hold great promise. Stan has assembled an international consensus group including those who work on
-Archetype Object Model/ADL 1.5 openEHR
-CEN/ISO 13606 AOM ADL 1.4
-UML 2.x + OCL + healthcare extensions
-OWL 2.0 + healthcare profiles and extensions
-MIF 2 + tools HL7 RIM – static model designer
Their work may be much more intuitive than today's HL7 RIM as the basis for future clinical exchange standards.
*Rather than debate whether Consolidated CDA OR GreenCDA(simplified XML tagging) should be the over the wire format, the Committee noted that "OR" really implies "AND" for vendors and increases implementation burden. The Committee endorsed moving forward with GreenCDA as the single over the wire format.
*We should move forward now with this work, realizing that it will take 9-12 months and likely will not be included in Meaningful Use Stage 2, but it is the right thing to do.
Thus, the future Transfer of Care Summary will be assembled from a simple set of clinically relevant GreenCDA templates, based on CIMI models, as needed to support various use cases. There will be no optionality - just a single way to express medical concepts in specific templates.
To support this approach, we'll need great modeling tools. David Carlson and John Timm presented the applications developed to support the VA's Model Driven Health Tools initiative. This software turns clinical models into XML and conformance testing tools. The committee was very impressed.
Next, Avinash Shanbhag presented the ONC work on Quality Measures that seeks to ensure quality numerators and denominators are expressed in terms of existing EHR data elements captured as part of standard patient care workflows.
Avinash also presented an update on transport efforts, which include easy to use, well documented implementation guides for SMTP/SMIME and SOAP. The work is highly modular and does not require that the full suite of NwHIN Exchange specifications be implemented for SOAP exchanges.
As part of the ongoing efforts to improve NwHIN Exchange, the HIT Standards Committee is seeking input from NwHIN implementers per this blog post.
Finally, Wil Yu updated the committee on the SHARP and other innovation programs.
There will be a great body of challenging work to do in 2012. What's needed after that? The next 5 years will include many new regulations as healthcare reform is rolled out. It's clear that the Standards Committee will have many topics to discuss.
Today, the HIT Standards Committee shifted gears from the Summer Camp work on Meaningful Use Stage 2 and began new interoperability efforts.
We began the meeting with a presentation by Liz Johnson and Judy Murphy about the Implementation Workgroup's recommendations to improve the certification and testing process. These 15 items incorporate the Stage 1 experience gathered from numerous hospitals and eligible professionals. If ONC and NIST can implement this plan, many stakeholders will benefit. The Committee approved these recommendations without revision.
Next, we focused on content, vocabulary and transport standards.
In my October HIT Standards Committee blog post, I noted that HITSC should work on the following projects:
Content
*Continued refinement of the Consolidated CDA implementation guides and tools to enhance semantic interoperability including consistent use of business names in "Green" over-the-wire standards.
*Simplifying the specification for quality measures to enhance consistency of implementation.
*Standardizing DICOM image objects for image sharing and investigating other possible approaches. We'll review image transfer standards, image viewing standards, and image reporting standards.
*Query Health - distributed queries that send questions to data instead of requiring consolidation of the data
Vocabulary
*Extending the quality measurement vocabularies to clinical summaries
*Finalizing a standardized lab ordering compendium
Transport
*Specifying how the metadata ANPRM be integrated into health exchange architectures
*Supporting additional NwHIN standards development (hearings about Exchange specification complexity, review/oversight of the S&I Framework projects on simplification of Exchange specifications). Further defining secure RESTful transport standards.
*Accelerating provider directory pilots (Microdata, RESTful query/response that separates the transaction layer from the schema) and rapidly disseminating lessons learned.
The November Committee agenda included a discussion of Consolidated CDA, Quality Measures, and NwHIN Implementation Guides.
Doug Fridsma began with a discussion of the Consolidated CDAwork and the tools which support it.
The Committee had a remarkable dialog with more passion and unanimity than at any recent discussion. We concluded:
*Simple XML that is easily implemented will accelerate adoption
*That simple XML should be backed by a robust information model. However, implementers should not need expert knowledge of that model. The information model can serve as a reference for SDOs to guide their work
*Detailed Clinical Models, as exemplified by Stan Huff's Clinical Information Modeling Initiative (CIMI) hold great promise. Stan has assembled an international consensus group including those who work on
-Archetype Object Model/ADL 1.5 openEHR
-CEN/ISO 13606 AOM ADL 1.4
-UML 2.x + OCL + healthcare extensions
-OWL 2.0 + healthcare profiles and extensions
-MIF 2 + tools HL7 RIM – static model designer
Their work may be much more intuitive than today's HL7 RIM as the basis for future clinical exchange standards.
*Rather than debate whether Consolidated CDA OR GreenCDA(simplified XML tagging) should be the over the wire format, the Committee noted that "OR" really implies "AND" for vendors and increases implementation burden. The Committee endorsed moving forward with GreenCDA as the single over the wire format.
*We should move forward now with this work, realizing that it will take 9-12 months and likely will not be included in Meaningful Use Stage 2, but it is the right thing to do.
Thus, the future Transfer of Care Summary will be assembled from a simple set of clinically relevant GreenCDA templates, based on CIMI models, as needed to support various use cases. There will be no optionality - just a single way to express medical concepts in specific templates.
To support this approach, we'll need great modeling tools. David Carlson and John Timm presented the applications developed to support the VA's Model Driven Health Tools initiative. This software turns clinical models into XML and conformance testing tools. The committee was very impressed.
Next, Avinash Shanbhag presented the ONC work on Quality Measures that seeks to ensure quality numerators and denominators are expressed in terms of existing EHR data elements captured as part of standard patient care workflows.
Avinash also presented an update on transport efforts, which include easy to use, well documented implementation guides for SMTP/SMIME and SOAP. The work is highly modular and does not require that the full suite of NwHIN Exchange specifications be implemented for SOAP exchanges.
As part of the ongoing efforts to improve NwHIN Exchange, the HIT Standards Committee is seeking input from NwHIN implementers per this blog post.
Finally, Wil Yu updated the committee on the SHARP and other innovation programs.
There will be a great body of challenging work to do in 2012. What's needed after that? The next 5 years will include many new regulations as healthcare reform is rolled out. It's clear that the Standards Committee will have many topics to discuss.
Monday, November 14, 2011
The Elephant in the Room: The Prequel
At the October HIT Policy Committee, Charles Kennedy described his work with health systems establishing accountable care models. His clients "have actual health plan products that are private labeled products with the delivery systems' name on it that they’re selling."
Kenedy talked with the COO of one health system that was particularly high cost. Kennedy asked the COO: "Why on earth would you want to form an ACO? You’re a monopoly. You’re making tons of money. You can keep doing this for some period of time."
The COO replied “Look I understand that the jig is up.”
The COO went on to say "I know how to take $60 out per member per month. $60 - - out of my cost structure. I know exactly how to do it. I never had a motivation to do it before - - until health care reform happened." Kennedy explained that the COO has now "taken those costs out of his delivery system and because he has a product in the marketplace he gets to reap those efficiencies. The second thing he said was that 'I never really had a use for health IT until I began to take costs out of my infrastructure'."
Kenedy talked with the COO of one health system that was particularly high cost. Kennedy asked the COO: "Why on earth would you want to form an ACO? You’re a monopoly. You’re making tons of money. You can keep doing this for some period of time."
The COO replied “Look I understand that the jig is up.”
The COO went on to say "I know how to take $60 out per member per month. $60 - - out of my cost structure. I know exactly how to do it. I never had a motivation to do it before - - until health care reform happened." Kennedy explained that the COO has now "taken those costs out of his delivery system and because he has a product in the marketplace he gets to reap those efficiencies. The second thing he said was that 'I never really had a use for health IT until I began to take costs out of my infrastructure'."
Wednesday, October 12, 2011
Query Health at the September HIT Policy Committee Meeting
Today the HIT Policy Committee is considering the Privacy and Security Tiger Team recommendations on the Query Health policy sandbox.
By way of background, here are the minutes from last month's introductory discussion from the September HIT Policy Committee:
Richard Elmore of ONC presented on Query Health, recently launched initiative to develop standards and services for distributed population queries. Guidance from and linkage to the HITPC will be crucial to the success of this effort. Elmore presented the vision of Query Health as follows: ―Enable a learning health system to understand population measures of health, performance, disease, and quality, while respecting patient privacy, to improve patient and population health and reduce costs.
The nation is reaching a critical mass of deployed EHRs with greater standardization of information in support of HIE and quality measure reporting. There is an opportunity to improve community understanding of population health, performance, and quality through:
Elmore commented that the challenges include the high transaction and ―plumbing‖ costs associated with variation in clinical concept coding (even within organizations), the lack of query standards, and the lack of understanding best business practices. There is also a centralizing tendency that moves data further away from the source, increases personal health information exposure, and limits responsiveness to patient consent preference. Another challenge is that the work done to date, with a few exceptions, has been limited to larger health systems (with large IT and/or research budgets).
The goal is to improve the community understanding of patient population health to be able to ask a question, whether it is to a small physician’s office or a larger hospital, and obtain an aggregate result back. Questions could focus on disease outbreaks, prevention activities, research, quality measures, etc. With regard to scope and approach, Elmore explained that Query Health is being structured in a way that is similar to the Direct Project. It is a public-private partnership project focusing on the standards and services related to distributed population queries. The concept is to have an open, democratic, community-driven consensus-based process. There is a critical linkage with the HITPC and Privacy and Security Tiger Team to provide the guidance needed to drive this project.
Elmore reviewed a series of user stories to demonstrate how to adjust queries with simple, secure use cases to establish the standards and protocols for patient data that is going to be queried against, the query and case definition, and then getting the results back to the requestor of the information.
The organization has a voting group of committed members, the Query Health Implementation Group. There are three workgroups (Clinical Workgroup, Technical Workgroup, and Business Workgroup). In terms of timeline, Query Health is at the requirements and specification stage (the next steps are approaching consensus, and undergoing pilots). Query Health was designed with goals alignment with the S&U Framework, as an open government initiative that is engaging a wide variety of stakeholders. Query Health is also aligned with meaningful use and various standards, as well as with one of ONC’s major strategies, the digital infrastructure for a learning health system.
Elmore described the Summer Concert Series, a presentation by the practitioners that have working on distributor queries that highlights the importance of this project. Through this event, a number of challenges were identified, including best practices for data use/sharing, sustainability, auditability, etc.
It is hoped that the HITPC and Privacy and Security Tiger Team will provide Query Health with policy guidance and will monitor Query Health’s progress. It is anticipated that the first activity with which Query Health will be looking for such guidance is in the policy sandbox and to ensure that the project is safe, cautious, and conservative for the purposes of starting that initial pilot work. The initial set of policy sandbox ideas has been modeled after previous S&I Framework initiatives in consultation with ONC policy and privacy and S&I Framework leaders and their staff. The concept is that query requests and responses will be implemented in the pilot to use the least identifiable form of health data necessary in the aggregate within the following guidelines: (1) a disclosing entity should have its queries and results under their control (manual or automated); (2) the data being exchanged will be mock or test data, aggregated de-identified data sets or aggregated limited data sets, each with data use agreements; and (3) for other than regulated/permitted use purposes, cells with less than five observations in a cell shall be blurred by methods that reduce the accuracy of the information provided.
Discussion
By way of background, here are the minutes from last month's introductory discussion from the September HIT Policy Committee:
Richard Elmore of ONC presented on Query Health, recently launched initiative to develop standards and services for distributed population queries. Guidance from and linkage to the HITPC will be crucial to the success of this effort. Elmore presented the vision of Query Health as follows: ―Enable a learning health system to understand population measures of health, performance, disease, and quality, while respecting patient privacy, to improve patient and population health and reduce costs.
The nation is reaching a critical mass of deployed EHRs with greater standardization of information in support of HIE and quality measure reporting. There is an opportunity to improve community understanding of population health, performance, and quality through:
- Enabling proactive patient care in the community
- Delivering insights for local and regional quality improvement
- Facilitating consistently applied performance measures and payment strategies for the community (hospital, practice, health exchange, state, payer, etc.) based on aggregated, de-identified data
- Identifying treatments that are most effective for the community.
Elmore commented that the challenges include the high transaction and ―plumbing‖ costs associated with variation in clinical concept coding (even within organizations), the lack of query standards, and the lack of understanding best business practices. There is also a centralizing tendency that moves data further away from the source, increases personal health information exposure, and limits responsiveness to patient consent preference. Another challenge is that the work done to date, with a few exceptions, has been limited to larger health systems (with large IT and/or research budgets).
The goal is to improve the community understanding of patient population health to be able to ask a question, whether it is to a small physician’s office or a larger hospital, and obtain an aggregate result back. Questions could focus on disease outbreaks, prevention activities, research, quality measures, etc. With regard to scope and approach, Elmore explained that Query Health is being structured in a way that is similar to the Direct Project. It is a public-private partnership project focusing on the standards and services related to distributed population queries. The concept is to have an open, democratic, community-driven consensus-based process. There is a critical linkage with the HITPC and Privacy and Security Tiger Team to provide the guidance needed to drive this project.
Elmore reviewed a series of user stories to demonstrate how to adjust queries with simple, secure use cases to establish the standards and protocols for patient data that is going to be queried against, the query and case definition, and then getting the results back to the requestor of the information.
The organization has a voting group of committed members, the Query Health Implementation Group. There are three workgroups (Clinical Workgroup, Technical Workgroup, and Business Workgroup). In terms of timeline, Query Health is at the requirements and specification stage (the next steps are approaching consensus, and undergoing pilots). Query Health was designed with goals alignment with the S&U Framework, as an open government initiative that is engaging a wide variety of stakeholders. Query Health is also aligned with meaningful use and various standards, as well as with one of ONC’s major strategies, the digital infrastructure for a learning health system.
Elmore described the Summer Concert Series, a presentation by the practitioners that have working on distributor queries that highlights the importance of this project. Through this event, a number of challenges were identified, including best practices for data use/sharing, sustainability, auditability, etc.
It is hoped that the HITPC and Privacy and Security Tiger Team will provide Query Health with policy guidance and will monitor Query Health’s progress. It is anticipated that the first activity with which Query Health will be looking for such guidance is in the policy sandbox and to ensure that the project is safe, cautious, and conservative for the purposes of starting that initial pilot work. The initial set of policy sandbox ideas has been modeled after previous S&I Framework initiatives in consultation with ONC policy and privacy and S&I Framework leaders and their staff. The concept is that query requests and responses will be implemented in the pilot to use the least identifiable form of health data necessary in the aggregate within the following guidelines: (1) a disclosing entity should have its queries and results under their control (manual or automated); (2) the data being exchanged will be mock or test data, aggregated de-identified data sets or aggregated limited data sets, each with data use agreements; and (3) for other than regulated/permitted use purposes, cells with less than five observations in a cell shall be blurred by methods that reduce the accuracy of the information provided.
Discussion
- Larry Wolf asked how Query Health relates to other activities focused on quality measure initiatives. Elmore indicated that this issue has been raised during the Summer Concert Series as well as in Query Health’s Technical Workgroup. In the next few months, it is expected that decisions will be made as to which standards will be applied. Query Health will be leveraging other ongoing initiatives moving forward. Wolf suggested minimizing the diversity of requirements generated for systems to handle queries and result sets.
- In response to a question about information exchange, Elmore commented that the assumption is that the information behind an organization’s firewall is identifiable. Only in an instance of a public health permitted use would identifiable data be outside the firewall.
- Farzad Mostashari noted that Query Health’s strategy has significant architectural and certification implications in the near future. Getting in front of those and considering them early on will be critical. Clarity about the potential timeframe is needed, as it affects work in areas such as quality measurement. The business case for this effort also requires careful consideration.
- Gayle Harrell noted that there is a tremendous upside to Query Health, but there is also a significant potential for abuse that may frighten the public. She asked about the role of the HITPC in terms of providing input as this project moves forward. Deven McGraw noted that Query Health will be discussed at the next Privacy and Security Tiger Team meeting. Elmore added that the HITPC and Privacy and Security Tiger Team will be relied on to provide significant input for guiding the future of Query Health. He noted that with the exception of public health, where it is already allowed by law today to send some identifiable information, Query Health will be dealing with aggregated information and will not be exposing individual’s information. The project itself will be trying to drive towards enabling a non-centrally planned use of technology that is under the control of those responsible for the data.
- Arthur Davidson discussed the burden faced by organizations trying to participate in these important population-based efforts to analyze and move towards the learning healthcare system. He asked if there has been a discussion at the ONC level regarding the leadership role that either the ONC or the HITPC might play in harmonizing these various data models. Elmore noted that Query Health’s Technical Workgroup is examining these data models with the vision of some harmonization of standards.
- It is expected that, from the point of view of keeping it simple for an initial pilot implementation, the pilot will probably create a focus around the clinical record, whether that be an EHR or more of an HIE.
Tuesday, October 4, 2011
E-Consent Trial Project Contract Awarded
From the ONC Announcement:
"ONC's Office of the Chief Privacy Officer recently awarded a contract to find an efficient, effective, and innovative way to help patients better understand their choices regarding whether and when their health care provider can share their health information electronically, including sharing it with a health information exchange organization. The project team will design, develop, and pilot innovative ways to electronically implement existing patient choice policies, while improving business processes for health care providers.
To learn more about the E-Consent Trial project, please see the Statement of Work. ONC's formal launch of the E-Consent Trial Project will be in October."
"ONC's Office of the Chief Privacy Officer recently awarded a contract to find an efficient, effective, and innovative way to help patients better understand their choices regarding whether and when their health care provider can share their health information electronically, including sharing it with a health information exchange organization. The project team will design, develop, and pilot innovative ways to electronically implement existing patient choice policies, while improving business processes for health care providers.
To learn more about the E-Consent Trial project, please see the Statement of Work. ONC's formal launch of the E-Consent Trial Project will be in October."
Thursday, September 29, 2011
The September HIT Standards Committee Meeting
by John Halamka, Life as Healthcare CIO
Today was a big day - the end of Standards Summer Camp. We presented the HIT Standards Committee work of the past 6 months and then attended a celebratory reception at the White House.
Judy Sparrow, the ONC "national coordinator" who orchestrated all our HITSC meetings, announced her retirement last month. Jon Perlin and I presented her with a silver bowl, engraved with the words "The Standard Bearer". Thanks for all you've done, Judy.
As we discussed our Summer Camp work during the meeting, we were guided by a few basic principles:
While it might not be perfect, does it represent the best we have at this point in history?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed going forward through the SDO community?
Doug Fridsma presented an overview of our Summer Camp activities to date:
The Metadata Analysis Power Team lea by Stan Huff completed the standards for patient identification, provenance (which organization generated the data), and security flags. Simple XML constructs from CDA R2 and standard X.509 certificates were chosen for these requirements.
The Patient Matching Power Team led by Marc Overhage completed its analysis of best practices for patient matching, noting the types of demographics that should be captured in systems to optimize the sensitivity and specificity of patient matching applications.
The Surveillance Implementation Guide Power Team led by Chris Chute chose one implementation guide for each of the public health transactions - surveillance, reportable lab, and immunizations. We had a spirited discussion about the optional fields in the implementation guides and made it clear that we want the core elements to be the certification criteria. We do not want each state public health department to mandate different "optional" fields. Our transmittal letter will note that EHRs that send the core set should meet the certification criteria. Public health departments should accept this core set. Optional fields are just that - optional items for future reporting needs.
Farzad Mostashari, National Coordinator, framed the important discussion of transport standards by noting that we must move forward, boldly specifying what is good enough. If we specify nothing, the silos of data we have today in hospitals, clinician offices, pharmacies, and labs will persist. There's a sense of urgency to act.
The NwHIN Power Team led by Dixie Baker presented its thoughtful analysis of the 10 standards guides included in NwHIN Exchange and the 2 standards guides included in NwHIN Direct. This analysis was not a comparison of the two, but was an objective look at the suitability of each standards guide for its intended purpose to support aspects of transport functionality at a national scale. The team did not discuss their suitability for use at the local, state, or regional scale. The team did not declare "push or "pull" as a superior architecture. Their thoughtful analysis led to a very robust discussion. I'd summarize it as:
*Direct is low risk for the purpose intended, pushing data from point A to point B using SMTP/SMIME with an optional XDR (SOAP) connector. Additional work needs to be done on certificate discovery, but that will use DNS and LDAP, two well adopted technologies.
*Exchange needs additional work to ensure it scales at a national level for pull and push transactions. The S&I Framework teams are working on modular specifications that should enable a subset of Exchange components to be used, simplifying implementation and support. The Standards Committee will seek additional testimony from Exchange implementers to learn more about their experience.
*It's worthwhile to think about additional transport standards that do not yet have well specified implementation guides, such as a combination of REST, oAuth and TLS - something that Facebook, Amazon, or Google would use to create a highly scalable transport architecture.
The ePrescribing of Discharge Meds Power Team led by Jamie Ferguson presented the use of HL7 2.2-2.51 transactions to support hospital information system workflows in a manner that is compatible with Medicare Part D. We clarified that newer versions of HL7 2.x which are backward compatible should also be allowed.
The Clinical Quality Workgroup and Vocabulary Task Force led by Jamie Ferguson presented their transition plans for vocabularies, identifying the cross maps between vocabularies that need to be created and supported as we evolve from our current use of vocabularies to a future state in which there is one structured vocabulary per domain of medicine (problems, medications, labs, allergies etc).
Doug Fridsma then presented an overview of the Standards and Interoperability Framework activities and next steps:
Transitions of Care - Doug described a brilliant approach that incorporates simple XML, such as has been used in the CCR, with the expandability of the CCD. He calls this next evolution of clinical summaries "Consolidated CDA templates". It's likely that the clinical summary certification criteria will evolve to a single XML format that is easy to use, fast to implement, expandable, based on a reference model, and human readable. Well done!
Reportable Labs - In the past, standards harmonizers struggled to balance simple, easy to implement lab specifications such as ELINCS with the comprehensive and full featured lab specifications from HITSP. The S&I group created a foundation based on ELINCS that is expandable to include all the features of the HITSP specifications using a single HL7 2.51 implementation guide. Amazing work.
Provider Directories - The S&I Framework team had the courage to admit that directory standards are still evolving and need more testing/piloting before selection. DNS/LDAP approaches are likely to work well for certificate discovery. Other aspects of directories such as provider routing addresses and electronic service capabilities may be stored in web pages (microdata), LDAP (HPD), or X12 274 directory structures.
Doug also described new works in progress - Query Health for distributed data mining, Data Segmentation to manage disclosures of protected health information, and Electronic Submission of Medical Documentation for transmission to Medicare review contractors.
Finally and very importantly, the Implementation Workgroup led by Liz Johnson and Judy Murphy presented the Implementation Workgroup certification criteria analysis. We had a thoughtful discussion of each open issue and suggested a path forward for each certification item.
Truly an inspiring meeting - the most work we've ever done in a single day.
The delivery of Meaningful Use Stage 2 Standards and Certification criteria was recognized at a White House celebration by Aneesh Chopra, Chief Technology Officer and numerous members of the Obama administration senior staff. Thanks so much to Aneesh and others for celebrating our work.
As I told the Standards Committee today, I am honored to serve with this team, the hardest working Federal Advisory Committee in government. A milestone day for the country.
Today was a big day - the end of Standards Summer Camp. We presented the HIT Standards Committee work of the past 6 months and then attended a celebratory reception at the White House.
Judy Sparrow, the ONC "national coordinator" who orchestrated all our HITSC meetings, announced her retirement last month. Jon Perlin and I presented her with a silver bowl, engraved with the words "The Standard Bearer". Thanks for all you've done, Judy.
As we discussed our Summer Camp work during the meeting, we were guided by a few basic principles:
While it might not be perfect, does it represent the best we have at this point in history?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed going forward through the SDO community?
Doug Fridsma presented an overview of our Summer Camp activities to date:
The Metadata Analysis Power Team lea by Stan Huff completed the standards for patient identification, provenance (which organization generated the data), and security flags. Simple XML constructs from CDA R2 and standard X.509 certificates were chosen for these requirements.
The Patient Matching Power Team led by Marc Overhage completed its analysis of best practices for patient matching, noting the types of demographics that should be captured in systems to optimize the sensitivity and specificity of patient matching applications.
The Surveillance Implementation Guide Power Team led by Chris Chute chose one implementation guide for each of the public health transactions - surveillance, reportable lab, and immunizations. We had a spirited discussion about the optional fields in the implementation guides and made it clear that we want the core elements to be the certification criteria. We do not want each state public health department to mandate different "optional" fields. Our transmittal letter will note that EHRs that send the core set should meet the certification criteria. Public health departments should accept this core set. Optional fields are just that - optional items for future reporting needs.
Farzad Mostashari, National Coordinator, framed the important discussion of transport standards by noting that we must move forward, boldly specifying what is good enough. If we specify nothing, the silos of data we have today in hospitals, clinician offices, pharmacies, and labs will persist. There's a sense of urgency to act.
The NwHIN Power Team led by Dixie Baker presented its thoughtful analysis of the 10 standards guides included in NwHIN Exchange and the 2 standards guides included in NwHIN Direct. This analysis was not a comparison of the two, but was an objective look at the suitability of each standards guide for its intended purpose to support aspects of transport functionality at a national scale. The team did not discuss their suitability for use at the local, state, or regional scale. The team did not declare "push or "pull" as a superior architecture. Their thoughtful analysis led to a very robust discussion. I'd summarize it as:
*Direct is low risk for the purpose intended, pushing data from point A to point B using SMTP/SMIME with an optional XDR (SOAP) connector. Additional work needs to be done on certificate discovery, but that will use DNS and LDAP, two well adopted technologies.
*Exchange needs additional work to ensure it scales at a national level for pull and push transactions. The S&I Framework teams are working on modular specifications that should enable a subset of Exchange components to be used, simplifying implementation and support. The Standards Committee will seek additional testimony from Exchange implementers to learn more about their experience.
*It's worthwhile to think about additional transport standards that do not yet have well specified implementation guides, such as a combination of REST, oAuth and TLS - something that Facebook, Amazon, or Google would use to create a highly scalable transport architecture.
The ePrescribing of Discharge Meds Power Team led by Jamie Ferguson presented the use of HL7 2.2-2.51 transactions to support hospital information system workflows in a manner that is compatible with Medicare Part D. We clarified that newer versions of HL7 2.x which are backward compatible should also be allowed.
The Clinical Quality Workgroup and Vocabulary Task Force led by Jamie Ferguson presented their transition plans for vocabularies, identifying the cross maps between vocabularies that need to be created and supported as we evolve from our current use of vocabularies to a future state in which there is one structured vocabulary per domain of medicine (problems, medications, labs, allergies etc).
Doug Fridsma then presented an overview of the Standards and Interoperability Framework activities and next steps:
Transitions of Care - Doug described a brilliant approach that incorporates simple XML, such as has been used in the CCR, with the expandability of the CCD. He calls this next evolution of clinical summaries "Consolidated CDA templates". It's likely that the clinical summary certification criteria will evolve to a single XML format that is easy to use, fast to implement, expandable, based on a reference model, and human readable. Well done!
Reportable Labs - In the past, standards harmonizers struggled to balance simple, easy to implement lab specifications such as ELINCS with the comprehensive and full featured lab specifications from HITSP. The S&I group created a foundation based on ELINCS that is expandable to include all the features of the HITSP specifications using a single HL7 2.51 implementation guide. Amazing work.
Provider Directories - The S&I Framework team had the courage to admit that directory standards are still evolving and need more testing/piloting before selection. DNS/LDAP approaches are likely to work well for certificate discovery. Other aspects of directories such as provider routing addresses and electronic service capabilities may be stored in web pages (microdata), LDAP (HPD), or X12 274 directory structures.
Doug also described new works in progress - Query Health for distributed data mining, Data Segmentation to manage disclosures of protected health information, and Electronic Submission of Medical Documentation for transmission to Medicare review contractors.
Finally and very importantly, the Implementation Workgroup led by Liz Johnson and Judy Murphy presented the Implementation Workgroup certification criteria analysis. We had a thoughtful discussion of each open issue and suggested a path forward for each certification item.
Truly an inspiring meeting - the most work we've ever done in a single day.
The delivery of Meaningful Use Stage 2 Standards and Certification criteria was recognized at a White House celebration by Aneesh Chopra, Chief Technology Officer and numerous members of the Obama administration senior staff. Thanks so much to Aneesh and others for celebrating our work.
As I told the Standards Committee today, I am honored to serve with this team, the hardest working Federal Advisory Committee in government. A milestone day for the country.
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