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.

Monday, September 19, 2011

September HIT Policy Committee on Query Health

The HIT Policy Committee recently reviewed Query Health, the ONC sponsored initiative to define standards and protocols for distributed population queries.

HIT Policy Committee audio:

Query Health - Rich Elmore - HIT Policy Committee 2011-09-14

Thursday, September 15, 2011

Health Wonk Review is up

 David Williams at the Health Business Blog hosts Health Wonk Review, the very best of the Health Policy blogosphere.

Wednesday, September 7, 2011

Introducing Query Health

The Office of the National Coordinator for Health IT (ONC) recently hosted the Summer Concert Series on Distributed Population Queries. Practitioners presented their work related to distributed population queries. They illustrated their approach and rationale for using aggregated information from distributed queries to improve healthcare quality, medical research, public health monitoring and prevention, among others. These are vitally important applications to the health of patients and populations.

Query Health will establish standards for distributed population queries of electronic health records and other sources of health information. The ultimate success of the effort relies on the participation of a wide range of stakeholders including patient advocates, clinicians, health IT experts, health systems, payers and other interested parties. Query Health is an Open Government Initiative that is consensus-based, transparent, and open. Those interested in working with ONC, national health leaders and innovators can get involved by signing up at

The Query Health launch included presentations by Farzad Mostashari (National Coordinator for Health IT), Todd Park (Chief Technology Officer HHS), Doug Fridsma (ONC Director of Standards & Interoperability) and me (ONC Coordinator for Query Health).

Query Health Launch from S&I Framework on Vimeo.

Tuesday, September 6, 2011

i2b2 / SHRINE - Query Health Summer Concert Series

Informatics for Integrating Biology and the Bedside (i2b2) is one of the projects sponsored by the NIH National Centers for Biomedical Computing. The purpose of this project is to provide clinical investigators with the software tools necessary to integrate medical record and clinical research data in the genomics age, a software suite to construct and integrate the modern clinical research chart. Patient medical record data, including diagnoses, medications, laboratory values, and outcome variables, along with the accompanying patient demographics and encounter information can be combined with clinical research data into a single cohesive unit and be queried in a manner that is unprecedented in clinical research. This is achieved by maintaining specific aspects of ontology management, data ownership, and patient privacy while overlaying a generic data architecture. The generic data model and the service oriented architecture of i2b2 lends itself to a natural implementation of a distributed query system, for example the Shared Health Research Information Network (SHRINE) at Harvard. Shawn Murphy and Zak Kohane present.

Query Health - i2b2/SHRINE Presentation from S&I Framework on Vimeo.

Monday, September 5, 2011

Observational Medical Outcomes Partnership - Query Health Summer Concert Series

OMOP is a public-private partnership chaired by the FDA and administered by the Foundation for the National Institutes of Health. OMOP conducts methodological research to inform the appropriate use of observational healthcare data including administrative data and electronic health records. OMOP has established a central research laboratory and a distributed data network of over 150 million lives, and has developed a series of standardized analytics to characterize data sources to support the understanding of the effects of medical products. In this discussion the OMOP team presents the OMOP common clinical information model and applications of systematic tools across the data network. The presentation demonstrates how these tools have been applied for many use cases identified as priorities within the ONC Query Health initiative. Patrick Ryan, Marc Overhage and Tom Scarnecchia present.

Sunday, September 4, 2011

Regenstrief Distributed Query - Query Health Summer Concer Series

Created by the Regenstrief Institute in the mid-1990's, the Indiana Network for Patient Care (INPC) is one of the nation’s most comprehensive and longest tenured health information exchanges, containing more than 3.1 billion coded standardized clinical observations, a global patient index containing more than 20 million person entities that represent more than 12 million unique persons, and a physician cohort exceeding 19,000 providers. The system allows physicians working in a variety of clinical settings, with the patient's permission, to view as a single virtual record all previous care at dozens of Indiana hospitals. A centrally managed federated clinical data repository, the INPC supports many other use cases including public health reporting, clinical research, and quality reporting. In this presentation, the INPC framework and supported applications are described. Shaun Grannis presents.

Saturday, September 3, 2011

Distribute and BioSense - Query Health Summer Concert Series

The Distribute project was initiated by the International Society for Disease Surveillance (ISDS) in 2006 to pilot influenza-like illness (ILI) monitoring using data aggregated from syndromic surveillance systems operated by state and local health departments. In 2009, following the first wave of H1N1 influenza pandemic, it was rapidly expanded to enhance ILI surveillance, covering approximately one-third of US emergency department visits. Staff from the CDC (BioSense program and Influenza Division) and the Public Health Informatics Institute (PHII) supported ISDS during the Distribute scale-up, including assisting with outreach and direct technical support to health departments, and in providing timely analysis. Approximately half of the sites currently contributing ILI data to Distribute come through BioSense or linking health departments syndromic surveillance systems to CDC.  David Buckeridge presents.

BioSense is a program of the Centers for Disease Control and Prevention (CDC) that tracks health problems as they evolve and provides public health officials with the data, information and tools they need to better prepare for and coordinate responses to safeguard and improve the health of the American people. By November 2011, the redesigned BioSense (or BioSense 2.0) will develop a community-controlled environment (architecturally distributed in a cloud-based model) that state and local health departments can access to support potential expansions of their syndromic surveillance systems under the Meaningful Use program. By integrating local and state-level data into a cohesive “picture,” the BioSense Program will improve its utility for state and local users.  Taha Kass-Hout presents.

Query Health - Distribute & BioSense Presentations from S&I Framework on Vimeo.

Friday, September 2, 2011

DARTNet - Query Health Summer Concert Series

DARTNet is a collaborative of seven electronic health record based research networks that have agreed to standardize data codification and underlying analytical data models. The groups work together to advance research methodology from the macro level, such as study design, to the micro level, such as analytical decisions. All participants share an underlying practice-based research framework on which they are adding the ability to conduct large comparative effectiveness and pragmatic clinical trials. The groups ares constantly looking to expand data sources available to improve clinical care and research capabilities. Wilson Pace presents.

Query Health - DARTNet Presentation from S&I Framework on Vimeo.

Thursday, September 1, 2011

Hub Population Health System - Query Health Summer Concert Series

The New York City Department of Health's Hub Population Health System ("The Hub") enables the distribution of electronic health record queries, targeted clinical decision support, and secure messages to more than 350 small practices and large community health centers using eClinicalWorks in New York City, covering 1.1 million patients. Query results are received as aggregate counts for population health purposes. Over 600 unique queries have been run over 80,000 times covering the areas of population health evaluation, EHR system utilization, Hub system performance, syndromic surveillance, etc. Jesse Singer and Michael Buck present