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:

• 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.

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."

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.

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

Health Wonk Review is up

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

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 QueryHealth.org.

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.

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.

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.

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.

Distribute and BioSense - Query Health Summer Concert Series

Distribute
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
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.

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.

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