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On February 23, 2010, the Vocabulary Task Force established by the Clinical Operations Workgroup of the Health IT Standards Committee will hold a public hearing on “Vocabulary Subsets and Value Sets” as facilitators of meaningful use of electronic health records (EHRs). The Task Force’s working definitions of vocabulary subsets and value sets are available here.
As background, the Standards and Certification Interim Final Rule (IFR) was released on December 31st, 2009, along with a Notice of Proposed Rulemaking on Meaningful Use. You can find both of these documents, and other useful information about the rules, here: http://healthit.hhs.gov/standardsandcertification.
The Task Force invites public comment by March 5, 2010 on a series of questions about vocabulary subsets and value sets.
With reference to the Task Force’s working definitions, please respond to at least four of the following questions about convenience subsets and/or value sets that are needed to facilitate meaningful use of EHRs. Be sure to specify which questions you are answering and to which categories of subsets and value sets your comments apply.
- Who should determine subsets and/or value sets that are needed?
- Who should produce subsets and/or value sets?
- Who should review and approve subsets and/or value sets?
- How should subsets and/or value sets be described, i.e., what is the minimum set of metadata needed?
- In what format(s) and via what mechanisms should subsets and/or value sets be distributed?
- How and how frequently should subsets and/or value sets be updated, and how should updates be coordinated?
- What support services would promote and facilitate their use?
- What best practices/lessons learned have you learned, or what problems have you learned to avoid, regarding vocabulary subset and value set creation, maintenance, dissemination, and support services?
- Do you have other advice or comments on convenience subsets and/or value sets and their relationship to meaningful use?
- What must the federal government do or not do with regard to the above, and/or what role should the federal government play?
Please submit your responses below. Your comments and questions will help form the agenda for the on-going work and recommendations of the Vocabulary Task Force.
We also want to be clear that comments on this blog are not a substitute for official feedback on the regulations. We urge interested parties to also submit comments on the regulations, and the appropriate place to do that is on the http://www.Regulations.gov website before March 15, 2010.
Thank you for your contribution.
– Jamie Ferguson and Betsy Humphreys, co-chairs, Vocabulary Task Force
Tags: FACA, HIT Standards Committee, IFR
http://healthit.hhs.gov/blog/faca/index.php/2010/02/18/health-it-standards-committees-vocabulary-task-force-seeks-input-on-subsets-and-value-sets/
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Hot debate. What do you think?
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Are such minutes now publically avaialble and if so where? Thanks
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The following comments are offered from the Indian Health Service Office of Information Technology:
1. Who should determine subsets and/or value sets that are needed?
A United States central authority (or in HL7 terms a Realm) needs to be established. The National Library of Medicine would be a logical location for such an effort. The entity should be as independent as possible and insulated from both political and vendor influences.. Working with such bodies as HL7, X12, HITSP (or its successor), the NHIN and the National Institutes of Health, content should be developed by a central authority. A process for requests, change management and versioning requirements needs to be developed.
2. Who should review and approve subsets and/or value sets?
Domain experts for clinical value sets must be the final arbiter of content. Again, a methodology with criteria for clinical evaluation must be developed. A venue such as the HL7 Clinical Information Interoperability Council should be considered (http://btc.hl7.org/index.php?title=Main_Page) for such an activity.
3. How should subsets and/or value sets be described, i.e., what is the minimum set of metadata needed?
Value set metadata should be based upon ISO11179. Research may indicate that extensions may be necessary. Consider the recommendations from Technical Note 903 from HITSP.
4. In what format(s) and via what mechanisms should subsets and/or value sets be distributed?
The method and format of distribution need to be defined. The RRF format is useful but may be too flexible for distribution. Downloads must be centralized and able to be accessed 24/7 through a web service. Consider collaborating on the development of and then using the Common Terminology Services 2 (CTS2) specification being developed by HL7 and the OMG.
5. How and how frequently should subsets and/or value sets be updated, and how should updates be coordinated?
Updates will be impacted by the sponsoring organizations’ schedules and the domain in which the value set is based. At a minimum, the updates should be published twice a year. For those value sets that cover pharmacy or other domains that are subject to frequent change, the updates will be more frequent. Provisions should be made to allow for daily updates should they be needed. Larger terminologies such as SNOMED-CT and LOINC should be twice yearly.
6. What support services would promote and facilitate their use?
A fairly extensive infrastructure would be needed to make the value sets accurate and accessible. Consider examining and then adopting best practices from such organizations as Canada Infoway, the UK National Health Service or the Australian National eHealth Transition Authority, NEHTA).
At a minimum:
a. Create a library of common data elements with their vocabulary bindings.
b. Create value set request process.
c. Detailed implementation guidance and support from the basics of what is a vocabulary, to the use of terminologies within electronic health records, to detailed implementation and conformance guidance.
7. What best practices/lessons learned have you learned, or what problems have you learned to avoid, regarding vocabulary subset and value set creation, maintenance, dissemination, and support services?
Recommend that an environmental survey be done to establish best practices. This survey would include the review and documentation of both private and public sectors (e.g. The Veterans Administration and a major vendor such as Cerner or Epic) with the US and other countries; include feedback from terminology vendors such as Apelon, and Health Language.
Review the work that was done through the Value Set Summit held in 2007.
Review the white paper that Harold Solbrig produced on the use of RRF as part of the HL7 NLM contract.
8. Do you have other advice or comments on convenience subsets and/or value sets and their relationship to meaningful use?
While the HITSP data dictionary and other documentation, as well as United States Health Information Knowledge Base (USHIK) HITSP web portal, are good first steps, the provisioning of value sets for meaningful use must be more robust and automated.
We also urge the development and/or inclusion of vocabulary sets that address behavioral health as well as non-traditional determinants of health including such things as homelessness, poverty, other barriers to access, adverse childhood events, and so forth.
9. What must the federal government do or not do with regard to the above, and/or what role should the federal government play?
The federal government must provide a central authority by which the value sets are created and housed. This entity is key to the management of the terminology and the interoperability specifications needed to support the continued evolution of interoperable electronic health record systems.
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I fully support the responses Keith provided. He highlights that a single vocabulary setting body would not be appropriate and that long-term maintenance must be part of the initial planning. I would further mention that proprietary vocabularies/value sets will be problematic and efforts should consider how to allow their widespread use while protecting the investment of the vocabulary/value set authors.
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These responses can also be found at: http://motorcycleguy.blogspot.com/2010/02/subsets-and-value-sets.html
1.Who should determine subsets and/or value sets that are needed?
It depends. Subsets or value sets are needed for implementation guides and for much broader use cases such as Laboratory ordering and Results. Consensus standards organizations should be responsible for determining which subsets or value sets are needed for their implementation guides. Broader use cases may be driven by various initiatives at regional or national levels. An organization responsible for harmonization of standards similar to ANSI/HITSP should also have a role in identifying value sets.
2.Who should produce subsets and/or value sets?
Consensus based Standards bodies should produce and MAINTAIN them. Production seems easy, but a value set or subset that has no maintenance process has no life.
3.Who should review and approve subsets and/or value sets?
It depends upon what they are used for. Primarily the concensus groups of the producer organizations, but in some cases, such as value sets used for quality measures, review and approval could also include organizations like NCQA.
4.How should subsets and/or value sets be described, i.e., what is the minimum set of metadata needed?
See HITSP TN903: Data Architecture Technical Note
5.In what format(s) and via what mechanisms should subsets and/or value sets be distributed?
Value sets should be available in a standard format, such as the Rich Release format used by NLM for RxNORM and UMLS.
6.How and how frequently should subsets and/or value sets be updated, and how should updates be coordinated?
It depends on their use. Updates for fairly static value sets should be reviewed at least every five years (ANSI rules uses this figure for reaffirmation of Standards). Value sets for clinical use should be reviewed and updated at least annually. Some value sets and subsets may need to be updated quarterly, montly or even weekly (e.g., medications). Updates may be delivered as a subset containing only the changes in more frequently updated value sets.
7.What support services would promote and facilitate their use?
Value sets should be available from a Web Service, such as that described in the HITSP T66 Retrieve Value Set Transaction.
8.What best practices/lessons learned have you learned, or what problems have you learned to avoid, regarding vocabulary subset and value set creation, maintenance, dissemination, and support services?
Building a value set requires a commitment to ongoing maintenance of it. Dissemination should support both manual download automated retrieval and update. Support services require that there be a feedback mechanism (such as an e-mail list service) to comment on it. Public input is absolutely necessary in the creation and maintenance of a value set. Quick response may be needed for clinical value sets to address issues like H1N1 or new medications or treatment options.
9.Do you have other advice or comments on convenience subsets and/or value sets and their relationship to meaningful use?
Isn’t this enough…
10.What must the federal government do or not do with regard to the above, and/or what role should the federal government play?
The Federal Government should have a role in the coordination of value set deployment activities. Presently the CDC, NLM and AHRQ (USHIK) all have some role in the development or deployment of value sets, which includes overlapping distribution, delivery and maintenance responsibilities. Duplication of these efforts is not useful. It would be better if there was a single coordinated effort, which could include participation from all of these bodies.
NLM has appropriate infrastructures for manual download, licensing and deployment. CDC has appropriate infrastructures for some development of public health oriented value sets. USHIK has appropriate infrastructures for delivery of knowledge about value sets (e.g., metadata). To my knowledge, none of these provide for automated computer update of value sets using simple web services such as those described in the HITSP T66 Retrieve Value Set Transaction, but I believe CDC is closest to having that capability.
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