Wednesday, October 27, 2010

The October HIT Standards Committee meeting

This month's meeting focused on the planning for standards which will support meaningful use stage 2 and 3, as well a review of NHIN Direct and its future plans to provide simple transmission of data among stakeholders.

We began the meeting with Jamie Ferguson's Vocabulary Workgroup report.   He highlighted the work that has been done to reduce the intellectual property barriers which have slowed the creation of centralized, web-based resources containing all vocabularies, codesets, and mappings needed by eligible providers and hospitals to achieve meaningful use.  Several financial models have been considered, including federal government funding of vocabulary licensing fees and the establishment of a single administrative group to centrally collect a single fee from providers in return for providing them all the meaningful use vocabulary resources they need.    We discussed two related issues 1) identifying who pays licensing fees and we determined it should be those who generate data not those who receive it or manipulate it as a business associate of the data generator.  2) identifying the need for proprietary code set vendors to create free mappings to federally mandated standards.   For example, RxNorm includes proprietary medication codesets and the vendors of these codesets should offer free mappings from ALL their proprietary codes to RxNorm codes.

Next, Liz Johnson updated the group on the Implementation Workgroup activities.   She highlighted the need for hearings, to be held in December or January, on five topics - the role of RECS in attaining meaningful use, certification experiences, lessons learned from early adopters seeking meaningful use attestation in 2011, experience with performance/quality measures, and the status of health information exchanges.   I discussed two barriers to certification - the fact that the syndromic surveillance implementation guide in the Final Standards Rule is incorrect.   It was updated via an interim final rule  so that has been addressed.   Also that the NIST testing tools for e-prescribing transactions did not include the XML forms of NCPDP standards.   On October 24, NIST issued version 1.1 of those tools, addressing the issue.

Paul Tang and George Hripcsak then presented the guiding principles behind Stage 2 and 3 meaningful use.   Summarizing the key points
*Some aspects of stage 2 will be incremental changes to stage 1 (i.e. raising the thresholds)
*Some will be a stepping stone on the way to stage 3
*Stage 3 will likely including outcomes measures as well as process measures.
*Stage 2 and 3 will likely require analysis of data across a community and not just within an institution, increasing the amount of HIE enablement to be demonstrated.
*Patient engagement in future stages will clarify methods to share data with patients - "access/download" which is real time on demand, "copy" which is a point in time summary of available information including specific use documents/datasets.

Our discussion included the need to clarify the term "document".  Most people concurred that "document" meant a collection of data elements, in electronic form, capable of many reuses.   Ideally, the standards committee will suggest a common container for assembly of structured and unstructured information that does not require creating numerous standards for individual document types.

Arien Malec then updated the group on NHIN Direct.   The consensus of the Direct collaborators is to require secure email (SMTP/TLS/certificates) as the backbone but allow SOAP (XDR) or SMTP at the edges.  This means that senders and receivers can decide how to transmit/receive data (SMTP or SOAP) as long as they have a way to communicate with the SMTP backbone.   Finally, an exception was made for those senders and receivers who agree to use SOAP from point to point by previous agreement.  This approach enables existing vendor products which already support SOAP to continue to do so, while enabling innovative approaches using secure email.   Specifications will be finalized by next month and live implementations will be evaluated by the Standards Committee in March.

Doug Fridsma reviewed the current state of the Standards and Interoperability framework, noting that it now has a set of tools and processes to support health information exchange project development including use case writing, harmonization, implementation guide writing, reference implementation and testing.   Priorities will focus on Meaningful Use data exchanges and the Virtual Lifetime Electronic Record (VLER) project.   Much discussion followed about the best way to incorporate the HIT Policy Committee, the HIT Standards Committee, NHIN, and the Standards and Interoperability Framework into a more coordinated set of activities.   The Concept of Operations document which guides the Standards and Interoperability Framework is being updated to knit all these activities together and we will discuss that at our November meeting.

The November and December meetings will be teleconferences, so I look forward to hearing you all on the phone.


Rich Landen said...

A very informative meeting. Thanks for the great leadership.

One curious thing: the Stage 2 timeline slippage proposed by Paul Tang got underwhelming reaction. By his new timeline, looks like only 3-5 months between Final Rule and 10/1/2012 Stage 2 go-live date, with its 365 day requirement. That's moving beyond light speed: no time for EHR development, QA, testing, roll-out, install, work flow modifications, training,and, oh, yes, NIST test process development and certification.
Major conflict between time-line and patient safety considerations.
My curiousity: the time line appears next to impossible, why such minimal reaction from the committee?

Anonymous said...


Can we expect any provision for incentives for Post Acute Care Hospitals in Meaningful use Stage 2 or 3.

As far as I know, there have been none in Stage 1.

David said...

Thanks John! Nicely summarized. Is the Concept of Operations for S&I framework actually available yet, or do you know when it will be?

Rich -- well said. "Next to impossible" is an understatement -- unless there's assurance that the "clear signal to the market" that Paul mentioned (April 2011) would be a guard rail beyond which the final rule won't go. I haven't heard any such assurance, however, and Stage 1 experience indicated that there were new requirements as well as decreased requirements, when going from the HIT PC MU matrix to the IFR/NPRM to the Final Rules. Hopefully, Stage 2/3 will incorporate improvements to the process.