Several federal regulations enacted over the past few years specify technical standards required in electronic health record vendor products. Some standards, such as C-CDA, focus on the exchange of clinical summaries and notes, while others, such as SNOMED CT, focus on encoding clinical information with specialized clinical vocabularies. The goal of these technical standards is to improve provider and patient access to health information, and improve patient safety, care provisions and clinical outcomes. While it is more common to know what standards are required, there is little knowledge and transparency about how to implement and measure these standards.
Interoperability Needs Consistency
Standards contain both a degree of ambiguity and optionality that allows for variations in their implementation and use. The customization of standards implementation can negatively affect the ability of seamless exchange of information by participating systems. In other words, standards can enable seamless exchange of health information, but only when consistently interpreted, implemented and used. Lastly, standards require continuous monitoring and improvement to maintain their relevance (and goals!) in a field as dynamic as information technology.
Measurement Is Key for Improvement
In April 2017, the Office of the National Coordinator for Health Information Technology (ONC) published a Proposed Interoperability Standards Measurement Framework that aims to define the measures to track how interoperability standards are contained in health IT products and services, and the subsequent use and/or customization of these standards by end users. By measuring these standards, ONC hopes to understand the state of interoperability and determine paths forward to further adoption. Working in concert with the HIMSS Interoperability & Health Information Exchange (I&HIE) Committee, the HIMSS Standards Advisory Task Force, which is comprised of specialized multi-stakeholder industry experts, reviewed and commented on the proposed framework. Highlights from this response are included below.
Feedback from HIMSS
- The group agrees that a voluntary, industry-based measurement reporting system is the best method to implement the framework, and recommends exploring improved efficiency of reporting through government incentives and guidance. The group also felt that voluntary reporting might bring several challenges, such as industry inertia, lack of participation from smaller organizations, and reporting bias. To overcome these barriers, closer collaboration is required with industry consortia (including HIMSS) as well as national, statewide or regional health information exchanges (HIEs).
- Whenever possible, use existing reporting systems, such as various registries, to leverage technical infrastructure in which the industry has already invested. For example, public health agencies, such as CDC, may have statistics on provider use of standards to report data for programs, such as National Health Surveys or National Program of Cancer Registries (NPCR). Additionally, standards development organizations, such as IHE, already have IHE Product Registry that collects data on how and where IHE-related standards are implemented. Lastly, other professional, non-profit and for-profit health IT organizations should be engaged in executing a reporting framework. These include, but are not limited to, standards development organizations (SDOs), national trust frameworks, (i.e. eHealth Exchange, DirectTrust, CommonWell Health Alliance), EHR vendors, and physician-based organizations, such as the American Medical Informatics Association (AMIA), American Medical Directors of Information Systems (AMDIS), the Physicians’ EHR Coalition (PEHRC), and the HIMSS Physicians Committee.
- The group believes that it is also important to not only capture information about the implementation of standards, but also, more importantly, to understand the level of consistency in use of these standards. Beyond use, it would also be valuable to understand the outcomes related to the use of these standards in how they improve aspects of care (i.e. preventing duplicate tests, incorporation/reconciliation of data).
- The group cautions that the current measurement areas are too vague and require further definition - such as whether standards ‘have been built into products and/or deployed.’ Instead, recommendations include defining specific interoperability needs, similar to the Interoperability Standards Advisory (ISA), and selecting corresponding measures that satisfy clinical scenarios (also known as use cases) across the care continuum. One such scenario may be transitions of care that measure the use of the C-CDA content standard.
In summary, the measurement framework is a long-awaited proposal that can close the loop between standards development, adoption, use and, most importantly, improvement. It is definitely a step in the right direction!
About the author: Mark Roche, MD, MS, is physician informaticist who previously worked on several U.S. national and international EHR initiatives, and has served at the HIMSS Physician committee and I&HIE committees. He is currently chair of the HIMSS Standards Advisory Task Force.