Please note: This post by the HIT Standards Committee’s Implementation Workgroup is now closed for comment. Monitor this blog for more posts from the FACA committees and its workgroups as issues develop. Also, please visit the Health IT Buzz Blog to join other Health IT related conversations.
Today, the Health IT Standards Committee within the Department of Health and Human Services will begin an unprecedented effort to get the public’s view on how our work might “pull forward” the benefits of healthcare information technology (IT). Specifically, we’re interested in uncovering new strategies to accelerate the adoption of health IT standards. This effort began with the passage of the American Recovery and Reinvestment Act of 2009, calling for recommendations on standards to promote safe, secure, healthcare information exchange.
“Standards” are really the guardians of quality, consistency, and interoperability. Without thoughtful, clear and uniform standards, we cannot enable the seamless and secure exchange of electronic health information (or the benefits that accrue to providers and patients from such protected exchanges).
So, while the exploration of technical standards may seem mundane to some, it is foundational to electronic health records (EHRs) and electronic health information exchange more broadly. In other words, it’s worth paying some attention to, and voicing your opinions.
Our process continues with a public hearing today in Washington, DC, accessible via phone and webcast at http://healthit.hhs.gov/portal/server.pt. We are convening four panels of experts with on-the-ground experience in interoperability standards – providers, quality stakeholders, health IT vendors, and a group with lessons drawn outside of healthcare. Thanks to HIT Standards Committee member Judy Murphy for her leadership on this effort.
The public hearing draws to a close this afternoon but we will continue the conversation through an Online Forum over the next two weeks. Thanks to Committee Member Cris Ross for his leadership on this effort. Given the breadth of interests, we have arranged a series of Committee Member blog posts to begin the dialogue, starting with HIT Standards Committee Vice-Chair John Halamka’s summary of our work to date, which will post on Friday. We will concurrently enable ongoing discussion threads on the following topics:
1) Proposed Standards (General Discussion)
2) Interoperability
3) Vocabularies
4) Privacy
5) Security
6) Quality
7) Implementation Case Studies (Your Story – the good, bad and in-between)
We have also enabled a “voting” feature on submissions to allow you – the public – an opportunity to emphasize points raised in a given post. Our goal is to harness the shared wisdom of our community to inform the work of the HIT Standards Committee in the weeks and months ahead.
The tight schedule of this process is designed to ensure that your ideas inform the HIT Standards Committee at its November 19th meeting. However, your ongoing feedback on our efforts is also encouraged via written submission or public comment at any of the subsequent monthly meetings of the HIT Standards Committee.
The process of accelerating the adoption of health IT standards will not end this week, this month, or this year. This is an ongoing effort, and your participation will continue to be essential to its success.
– Aneesh Chopra, U.S. Chief Technology Officer
Tags: FACA, Federal Advisory Committee Act, health IT, HIT Standards Committee
Aneesh, Thanks for this opportunity. I’m not quite clear on the timeline or proper place to post comments, however. I had expected to see seven additional Topics in the blog, to which we could post comments, per your statement below, but I don’t see those topics yet. Are those seven topics going to be posted very soon, since the clock is ticking if this was only a two-week comment period? Or should we just post our comments on any of those topics under the current three blog posts (yours, John Halamka’s, and Judy’s)?
“We will concurrently enable ongoing discussion threads on the following topics:
1) Proposed Standards (General Discussion)
2) Interoperability
3) Vocabularies
4) Privacy
5) Security
6) Quality
7) Implementation Case Studies (Your Story – the good, bad and in-between)”
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I totally agree with David. Think people are reluctant to post to “boil the ocean” – that there might be more responses if they could select out just one of the 7 categories that you are seeking input.
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[...] and Human Services and the US CTO, Aneesh Chopra had an open web conference followed up with a blog with open comments. I posted a comment there about the disconnect between how Electronic Medical Records(EMR) systems [...]
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Reading through the discussion it seems like a few important themes are here.
- Doctors and nurses hate EMR systems. Productivity loss due to data entry time may offset any other gains improvements health IT could provide
- Researchers, data aggregators, payers and policy makers need quantifiable facts that only providers can provide. For any hope of efficiency gains through health IT, this is step one.
This seems ripe for innovation. Listening to the frantic views of providers worried about productivity it seems that few EMR vendors have found ways to fit into their practices. A view of health IT as forms, data and reports may be a poor model. Perhaps the idea of domain specific languages (computer readable mini languages) could help. I seem to remember seeing charting by my nurse wife which had more structure and nomenclature than plain old English. Could some of this be parsed for data extraction? Are there other types of notations that would be more useful?
Even if these approaches aren’t possible, we are still talking about solving one key problem, transcribing notes into quantifiable facts. Some parts can happen at the point of entry but it should not add cost to the system by lowering productivity of the caregiver. This transcription doesn’t have to be done by the doctor or caregiver. It probably doesn’t have to happen immediately and not even at the doctor’s office. Some parts could be automated, others not and it may vary widely by specialty.
Understanding that would seem to say that health IT standards should not be deeply invested in vocabularies and structured data. Instead it should be more about extensible document exchange with vocabularies limited to some pretty basic health concepts. This is consistent with much of the testimony in the conference, but not with how people describe the EMR systems’ role in the current system.
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My perspective comes as a practicing PCP (Internist) who has used an EMR since 2002, as Medical Director of Clinical Information Systems for a large primary care group, as a past Medical Director for an EMR company, and active consultant in the EMR space.
I’m all for using EMRs meaningfully, and second, I’m all for rewarding physicians! However, I believe (as many do) that our current crop of EMRs are far from perfect and I have to question whether we could spend that $36 billion a better way than by rewarding mediocre vendors whose products are poorly adopted and poorly used (see the Natonal Research Council’s recent report: http://books.nap.edu/openbook.php?record_id=12572&page=R1). Rather, for a fraction of that money, perhaps we should consider creating a national EMR framework upon which vendors could build their applications (yes- sort of like the iPhone). This then solves interoperability immediately, and lets the vendor compete on applications and user interfaces rather than on all wasting time/money trying to replicate databases which limit their ability and creativity in building what we really need. More thoughts on this topic: http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090430/REG/304309994/1029&nocache=1#
However, if we do keep the current definitions of Meaningful Use, then my three main talking points would be:
1. E-Prescribing: make this definition broad enough to reward providers who use their EMR to create and print out scripts, don’t limit to just electronic transmission to the pharmacies, as that is not yet a perfect science.
2. Interoperability: reward based on ability to share data in a group or with a hospital, but don’t require regional or national sharing at this point, that is way beyond the means of most providers and vendors.
3. Data reporting: reward based on producing the reports, whether from the EMR, an EDW (Enterprise Data Warehouse) or similar. Most EMRs are bad at report writing, and other tools are needed.
More details on all three at: http://www.histalkpractice.com/2009/08/25/drlyles-meaningful-discussion-about-meaningful-use-82609/
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Social comments and analytics for this post…
This post was mentioned on Twitter by rebekahco: Listening to great testimony on Health IT standards. The conversation continues (w/public input) @ new ONCforum http://bit.ly/4vPEVs #hitpol…
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Health care and Smart Grid IT standards are being assembled at a very rapid pace. The rapidity and raw materials (pre-existing proprietary methods, some open standards) are leading to potential serious downstream hazards. It is time to take a careful look at the implications of the present designs for ease of implementation, potential for evolution, accommodation for competition, and likelihood of interoperability.
Elaboration:
It is understandable that there is a great desire to move quickly on standards for Smart Grid and Health Care IT. Both of these are intimately related to the present economic crisis and to the long term economic health of the country. Recovery funds allocated for Smart Grid and for Health Care IT need to be spent quickly to be effective and it is widely understood that standards are needed to assure that the resulting expenditure produces a coherent result.
Sadly these two outcomes (fast expenditure, coherent result) are in potential conflict with one another. Getting the standards right can have major positive benefit. Getting them wrong will have major downside consequences.
While I have been only peripherally involved in both of these initiatives, I have come away with the distinct impression that both of these efforts suffer from key weaknesses. In the Health IT sphere, the problem appears to be a creeping monolithic character in which the protocol(s) lump together many functions, including security, in such a way that implementation, testing and change will be extremely difficult. More generally, both systems suffer from aggregation of function that should be factored. “Factored Design” is a term intended to suggest that the design should exhibit modularity to allow some things to change without forcing wholesale reimplementation and testing of protocols. This notion manifests in the Internet as “layering.” I am not arguing that strict layering is required but rather that some care in factoring functional design can have major long-term benefits. If, for example, strong authentication is needed, it might make sense to factor this function out so that it can apply to multiple applications and can be evolved over time without requiring every application that needs it to change.
I dare to suggest that an architectural review of the present designs for both Healthcare IT and Smart Grid be undertaken by a panel of proven protocol architects with the intent of uncovering opportunities for factoring of the design. Simplicity is our friend here, as has been evidenced in the Internet. The stable interfaces between layered protocols have permitted stability while accommodating remarkable changes of implementation within each layer. This is not to say that strict layering is necessarily the answer for Healthcare IT and Smart Grid, but something like it, perhaps a kind of “aggregation” and “segregation” of function, may be extremely beneficial.
I urge you to give serious consideration to this question on the grounds that a great deal of American infrastructure is going to be implemented based on the evolving protocols for these two application areas. An ounce of analysis now will prevent a ton of paralysis later.
Hot debate. What do you think?
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After researching EMR’s for over 5 years and listening closely to colleagues who had implemented them, we chose a hybrid EMR (SRS) for our very busy orthopaedic group. While we have participated in the other federal incentive programs successfully, the stimulus money for “meaningful use” of a “certified EMR” is simply not worth the costs to implement. Even though I had several quotes for full EMRs and could have purchased one for the same cost as the hybrid, the loss of productivity would have cost as much or more than the potential return. Not only would the physician have to completely change their practice pattern, they would also have to begin tracking and reporting on things that currently do not have any relevance to orthopaedic care.
Much of the relevant information needed can be found in the Practice Management systems, with the physician documentation (office note) being the exception. We can share office notes easily from within the EMR.
I’ve known several groups who have implemented full EMR’s only to yank them out because of the difficulty in using them, the loss of productivity and the way it forces them to change how they see and interact with patients. We had no loss of productivity at all – didn’t reduce the schedule by even one patient, and the physicians now have easier access to the information than they ever did before.
Barbara Sack, MHSA, CMPE
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Where can we view a copy of the attachments mentioned in the letter:
Attachments (3):
“HIT Standards Committee Meaningful Use Measure Data Element Grid” “Summary of Clinical Operations Workgroup Recommendations” “Privacy and Security Standards Applicable to ARRA Requirements”
Incidentally, I would invite all of the physicians who have commented about their personal EHR experiences to share it with a larger community, I’m sure your colleagues would like to learn more:
http://www.myhithome.com/
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1) For years I have consulted in the VAH system. As for the higly touted EMS, HA!. I can’t tell you the number of times I have asked about a finding on the last visit only to watch the resident flail around trying to find a simple bit of information. In some instances, a “shadow chart” is kept so that infomration is readily available.
2) Our 9 doctor ophthalmology practice moved to a hybrid sytems (SRS) 4 years ago. We expected a significant loss of productivity and resistance from older doctors. Six weeks into the process a paper record was handed to a senior doc who looked at it, handed it back and said, ‘Scan this for me, it is easier to use that way”
3) The goal is to “communicate”, not just be connected. When I get a typical 5 page computer EHR, I have to spend 10 minutes trying to find the one bit of signicant data that wasn’t defaulted it.
4) Medicine’s agreement to the current payment system is partially to blame. Paying by the “number of boxes checked” only assures that lots of boxes are checked, clogging the system. “No change since last” isn’t so bad.
5) Is this webpage managed by someone who has responsibility for new EHRs? Is it my imagination, or is it misinstalled so that you can only Aggree-Disagree once on the page, not once per post.
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EMR are tools and only work in the presence of a meaningful intervention strategy to reduce risk and improve outcomes of the high morbidity, high mortality hi cost diseases. It has been estimated that we spend $6000 per cap per year on healthcare. A streamlined plan to assess those at risk (population wide) and intervene early, using the appropriate tools we now have available, would change the face of medicine, by reducing the risks identified, improving the outcomes, and reducing the cost. It is a doctor-patient contract, and can be sponsored and funded by the government, but not employed or advanced without recognition of this fact. All outside of this contract have been parasitic on it for years. Thus, hospitals, pharmacies, insurances, and pharmas should all be presented with such a plan, but it must go through the physician/patient contractual obligation.”
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