January 2010
In this issue:
HIE News
Legal Corner
Standards
Tool/Resource of the Month
Calendar of Events
STANDARDS
Clinical Data Exchange
Noam H. Arzt
By Noam H. Arzt, PhD, FHIMSS
Ken Olsen, co-founder of Digital Equipment Corp., once said: “The nicest thing about standards is that there are so many of them to choose from.” We read last month about the work of the Health Information Technology Standards Panel (HITSP) in reviewing available standards and recommending specific standards for recognition by the federal government as selected standards for HIE implementation. This harmonization process is a difficult prospect: the health IT standards landscape is complicated and ever-changing.
Let’s look at just one area of standards development: clinical data exchange. While there are “so many to choose from,” primarily we have three broad categories of standards to consider:
- HL7 Version 2 Messages: Originally developed in the 1990s by Health Level Seven (HL7), a not-for-profit, ANSI-accredited standards developing organization and still under revision, these standards are widely used and define the structure and content of electronic transactions for health data interoperability in a set of specific healthcare domains developed by experts in those fields. Version 2 messages look like delimited text files, whose specifications are detailed and need to be followed meticulously if the receiving system is to receive and understand the transmission correctly. Documents, called implementation guides, help specify more precise message formats, business rules and vocabularies for specific interoperability purposes based on the more generic information expressed in the standard.
- HL7 Version 3 Messages: Currently being developed in parallel to Version 2, these standards serve the same basic purpose but are being developed from the ground up based on a set of comprehensive reference models covering all of healthcare information. More emphasis is being placed on what different message domains have in common and on instituting a more rigorous methodology for developing messages consistently across healthcare domains. HL7 Version 3 messages are expressed as Extensible Markup Language (XML), which “to the eye,” looks like the HTML code used to create Web pages.
- HL7 Clinical Document Architecture (CDA): Being developed in parallel to Version 2 and Version 3 messages, and also employing XML, CDA is a standard for exchanging clinical data that is machine-readable (for system-to-system interoperability) and human-readable (with the right software) in a way that messages were never designed to be. CDA documents more closely match the paradigm and structure of paper-based medical records and represent an evolving standard for sending both comprehensive medical summaries and more limited clinical data.
By far, HL7 Version 2 messages are the most widely deployed, in part because the have been around the longest and because their initial use was for data interoperability within rather than between institutions. However, CDA documents are emerging as the preferred format by both the vendor community and HITSP for most data interoperability due to their more straightforward construction and versatility. HL7 Version 3 is more widely used outside of the United States where clinical data interoperability is more centrally directed and organized. Finally, Integrating the Healthcare Enterprise (IHE) is a membership organization that develops profiles, which are similar to HL7 implementation guides, to further define detailed specifications for the use of HL7 (and other) standards applied to specific real-world needs.
Noam H. Arzt, PhD, FHIMSS, is president and founder of HLN Consulting LLC, San Diego, and does consulting in healthcare systems integration, especially in public health. He serves on the HIMSS HIE Steering Committee and can be reached at arzt@hln.com.
Standards In Use:Check out the discussion of standards (Appendix G) in the Connecticut State HIT Plan, released in June 2009
Tool/Resource of the Month
Participating in a local HIE is an important step for organizations wanting to establish the foundation for improving patient safety and quality of care, as well as decreasing the cost of health-related activities. The newly released white paper A HIMSS Guide to Participating in a Health Information Exchange, now available on the HIMSS Web site, is a tool that assists stakeholders in the decision-making process of joining an HIE. This guide, a work product of the HIMSS Healthcare Information Exchange Guide Work Group, provides the basic background information most people should understand before engaging with an HIE, as well as a list of questions for evaluating particular HIE opportunities. Also included are case studies that can be helpful for understanding the different HIE models and a glossary of terminology. In addition, the guide explores how an HIE can be a tool in healthcare transformation and achieving meaningful use.
HIE NEWS
HIMSS Equips Members for Proposed ‘Meaningful Use’ Regs
On Dec. 30, 2009, the Department of Health & Human Services released the Notice of Proposed Rule Making establishing the Electronic Health Record Incentive Program, better known as ‘meaningful use,’ and the Interim Final Rule establishing the Initial Set of Standards, Implementation Specifications and Certification Criteria for EHR Technology.
HIMSS has responded with a host of online tools, resources and educational opportunities to help members navigate and analyze the nearly 700 pages of regulatory change. Following are the primary tools and resources available to HIMSS Members:
On the Web
Visit the HIMSS “Stimulus” Web page for the latest updates and analysis of all aspects of health reform, including ARRA, meaningful use, certification requirements, and more. A synopsis of the proposed meaningful use regulations, as well as other tools, is available on this site. Also included on this page are summaries, FAQs, social media, RSS feeds, and tools and resources to help HIMSS Members prepare for meaningful use.
Webinars
HIMSS new ARRA Webinar Series on Meaningful Use and Certification Criteria offers the most relevant, up-to-date information on the meaningful use draft regulations and tools for achieving meaningful use. Led by today’s top leaders, the webinars explore what health IT stakeholders need now to take advantage of ARRA funding.
The first webinar in the series, an overview titled Understanding the Meaningful Use Proposed Rule and the Certification Criteria Interim Final Rule: What You Need to Know Now, was held yesterday. During the webinar, sponsored by Cisco, C. Martin Harris, MD, MBA, FHIMSS, CIO & Chairman of the Technology Division at Cleveland Clinic, Executive Director of the e-Cleveland Clinic, Chairman-Elect of the HIMSS Board of Directors, and member of the HIT Standards Committee, highlighted the themes and major components of the draft regulations. Starting tomorrow, this webinar will be available on the HIMSS eLearning Academy.
HIMSS’ ARRA Webinar Series on Meaningful Use and Certification Criteria will run through February. Click here for upcoming times and topics or see the Calendar of Events in this issue of HIELights. All webinar sessions are complimentary for HIMSS Members (member ID required) and $79 for non-members. To register for any of the webinars, click here.
Events
Several HIMSS sponsored events will feature sessions dedicated to proposed meaningful use regulations. HIMSS10 in Atlanta will feature a variety of sessions, topics and exhibits dedicated to meaningful use. Other upcoming events include The ARRA Era in Chicago, the North American Connectathon, distance learning opportunities through the HIMSS eLearning Academy, a track at the June Virtual Conference & Expo, and sessions and programs at various HIMSS Chapters across the nation.
Call for Participation for Public Comment Process
HIMSS is looking for members from the HIE community to participate in the Society’s efforts within the public comment process. To join this effort and be included in upcoming calls, please contact Andrew Piersol, coordinator, Business & Financial Information Systems, at 312-915-9537 or apiersol@himss.org.
New State HIE Toolkit Now Available
The State Health Information Exchange Toolkit, Beta Version 1, is now available. This Toolkit is a compilation of “best practice” resources provided under the auspices of the State HIE Program, sponsored by ONC. Included in the online Toolkit are modules featuring topical information, FAQs, resources, case studies, and links to ONC and federal program documents. Content within the Toolkit addresses general planning and the five HIE domains that must be addressed as part of state Strategic and Operational Plans under ONC’s State HIE Program. Practical “how to” information gives state HIE stakeholders guidance on developing and implementing plans for achieving statewide interoperability.
Georgia County HIE Expected to Go Live in March
Chatham County Safety Net Planning Council (CCSNPC) is working toward a March “go live” for the pilot project of its Chatham County Health Information Exchange (HIE). Founded in 2004 by the Chatham County Commission, CCSNPC is a collaboration of providers, government, advocates, employer representation, funders and consumers working to address the uninsured and underinsured problems in the county. Through this newly-formed HIE, CCSNPC aims to expand the use of health IT and its use in the delivery of healthcare within the community, specifically through the use of electronic medical records and e-prescribing.
Restoring a Health Information Infrastructure: Launching an HIE Post Hurricane Katrina
James S. McIlwain
By James S. McIlwain, MD
Devastation in the Mississippi Gulf Coast Region from Hurricane Katrina in August 2005 highlighted the critical importance of restoring the state’s healthcare information infrastructure, particularly in providing care for Mississippi’s poor and underserved minority populations. Governor Haley Barbour created the Mississippi Health Information Technology Infrastructure Task Force per executive order in March 2007 to develop strategies for health information technology adoption and health information exchange infrastructure development for Mississippi. The resulting task force established an action plan and called for a "proof of concept" project for the six-county area where Hurricane Katrina had the greatest affect. This led to the creation of the Mississippi Coastal Health Information Exchange (MSCHIE).
The exchange will complete a phased three-year implementation plan with state grant funding administered by the non-profit Medicare QIO, IQH. Beginning in November 2008, every milestone has been met to-date with a “go-live” target of this month. MSCHIE will initially deploy a centralized model for sharing of clinical information across participants but expects to expand to include Medicity’s Record Locating Service (RLS) to support stakeholders across the state that could participate under a confederated or hybrid architecture model.
Don’t miss Dr. McIlwain’s presentation at the HIMSS10 HIE Symposium—Meaningful HIE, where he will offer his views on the challenges faced and successes achieved in building a local/regional HIE in Mississippi post Hurricane Katrina.
James S. McIlwain, MD, has served as president of Information & Quality Healthcare (IQH) since 1997. His experience with the Medicare quality improvement organization includes serving as medical director, clinical coordinator, review physician and member of the board of directors. He was appointed by the office of the Governor to be a member of the Southern Governor’s Association (SGA) Gulf Coast Health Information Technology Task Force, and was named co-chair of the Governor’s state task force for HIT/HIE adoption. He has served as chief of the medical staff at Hinds General Hospital and the medical director at Methodist Medical Center Hospital. Dr. McIlwain is certified by the American Board of Quality Assurance and Utilization Review Physicians and the American Board of Family Practice.
HIMSS Call for Committee Volunteers Now Open
HIMSS is seeking volunteers interested in applying for a Committee appointment for fiscal year 2011. Committee participation is open to all members who have at least one year of consecutive membership (12 continuous months) and are not currently serving in a HIMSS leadership position. Committee appointments are assigned by the HIMSS Chair-Elect with input from existing committee leadership. Committee terms are for two years (June 2010 through July 2012). Accepted applicants will be notified of their appointments via e-mail on or before April 30.
For more information and to complete the online application form, visit HIMSS’ Committee page online. Members with questions regarding serving on a committee or the application process should contact Member Services Coordinator Megan McGuirk.
Calendar of Events
Upcoming HIE Events
HIMSS Chapter HIE Roundtable Call
Thursday, Jan. 21, 12 pm Eastern
Topic: Meaningful Use and HIEs—Nouns and Verbs
Guest Speakers: Tom Leary, Senior Director, Federal Affairs, HIMSS; and Jonathan French, Manager, Federal Affairs, HIMSS
Topic: Discussion of the Certification Interim Final Rule
Guest Speaker: Lisa Gallagher, Senior Director, Privacy & Security, HIMSS
Register here for this free event!
HIMSS10 HIE Symposium—“Meaningful HIE”
Feb. 28, 2010
Held in conjunction with the 2010 Annual HIMSS Conference and Exhibition in Atlanta, the full-day HIMSS10 HIE Symposium—Meaningful HIE explores issues and challenges facing today's HIEs and shares success stories. Topics include:
- The national landscape of HIEs
- Grants and programs available through the American Recovery and Reinvestment Act
- Plans for achieving meaningful use across states
- Success stories from HIEs in rural and underserved communities
The symposium wraps up with a networking reception.
Registration
Save $100 when you register for the full conference and a pre-conference symposium. This special discount applies to full paid conference registration (Sunday-Thursday) only and is not available for students. The discount will be applied automatically during the registration process. Visit the HIMSS10 Web Site for more information.
ARRA Webinar Series on Meaningful Use and Certification Criteria
Translating from Theory to Practice: Certification Criteria and Standards for Obtaining Meaningful Use
Jan. 13
12 – 1 pm CT
Takin’ HIT to the Streets: The ARRA Era
Jan. 15, 2010
Chicago
ARRA Webinar Series on Meaningful Use and Certification Criteria
Quality Metrics Requirements for Obtaining Meaningful Use: Developing a Plan for Implementation
Jan. 20
12 – 1 pm CT
ARRA Webinar Series on Meaningful Use and Certification Criteria
The Economics of ARRA: Understanding the Payments for both Medicare and Medicaid
Jan. 27
12 – 1 pm CT
This Webinar is sponsored by Cisco.
ARRA Webinar Series on Meaningful Use and Certification Criteria
Privacy and Security: Understanding the Latest Developments
Feb. 3
12 – 1 pm CT
ARRA Webinar Series on Meaningful Use and Certification Criteria
Workforce Development: An Industry Update
Feb. 10
12 – 1 pm CT
2010 Annual HIMSS Conference & Exhibition
March 1-4, 2010
Atlanta, Ga.
2010 World of Health IT Conference & Exhibition
March 15-18, 2010
Barcelona, Spain
HIMSS AsiaPac10 Exposition
May 26-28, 2010
Beijing, China
Legal Corner
Information from HIEs – What Standard Will Apply to Data Use by Clinicians?
By Allen Briskin and Gerry Hinkley, Pillsbury Winthrop Shaw Pittman LLP
Gerry Hinkley
Allen Briskin
As the National Health Information Network (NHIN) develops, a question that local and regional HIE programs have grappled with is now receiving attention at the national level: what will be the standard of care applied to use of data provided by the NHIN? In other words, how will clinicians decide what data is useful? This is a question that will have to be addressed and answered if the data from the NHIN is going to useful to NHIN Participants making clinical decisions.
The Data Use and Reciprocal Support Agreement (DURSA), developed by the NHIN Cooperative DURSA Team, is a work in progress. In the words of the Team, the DURSA “is a multi-party agreement, a single agreement that establishes the rules of engagement and obligations to which all NHIN Participants agree and that all NHIN Participants sign as a condition of joining the community.”
On the subject of information accuracy, the DURSA calls upon content sources to represent that, at the time of the transmission, the message content is an accurate representation of what is available through the content sources’ system. The content source makes no representation regarding clinical accuracy, content or completeness of data, or the continued availability of data. Data is provided “AS IS” and “AS AVAILABLE.”
NHIN Participants acknowledge in the DURSA that data supplied is not a complete record or history, but represents only available, exchangeable data. Under the DURSA, Participants who are healthcare providers are responsible for obtaining all necessary information, medical decision-making and patient care utilization and quality management.
In effect, the DURSA imposes upon Participants who are clinicians the responsibility for putting NHIN content in context and giving it appropriate weight—for separating the “wheat from the chaff.” Some would say this is not any different from the responsibility that a clinician has in dealing with oral and documented data even without electronically supplied content. But the electronic availability of data raises some issues that probably do change the clinician’s responsibilities:
- Will the standard of care require a clinician to access electronic data if it is available?
- If a clinician queries a data bank, what standard will the clinician apply to evaluating the usefulness of the resulting data?
- Will the source of the data be sufficiently evident to provide a basis for the clinician to make an informed decision about the integrity, authenticity and accuracy of the data, for example data, from a personal health record where clinical records are not intact, but are potentially aggregated and self-managed by the patient?
To resolve these issues, attention must be paid to refining what is an evolving standard of care for the use of electronically sourced data to guide clinicians. The standard of care is commonly defined as the diagnostic and treatment process that a clinician should follow for a certain type of patient, illness or clinical circumstance. Commonly, the standard is established through proof not necessarily of what a majority of clinicians would have done, but sometimes proof of what a respectable minority of clinicians would have done. In the case of information received from a data bank, determining what is the appropriate standard of care is complicated by technical considerations beyond the ken of many clinicians and clinical considerations outside the skills set of most technical personal.
However, technical and clinical cooperation is clearly necessary to work toward establishing at least what a respectable minority of clinicians would think is appropriate in the circumstances. As the NHIN moves from pilot to national resource, in order to assure that clinicians are willing NHIN Participants, this is going to require some work.