Federal policymakers directing the government's multibillion-dollar health information technology incentive program were in a quandary again last week—as they have been for a couple of months—over how to deal with recommendations from a council of presidential advisers.
The President's Council of Advisors on Science and Technology, or PCAST, has called for IT program leaders at HHS to shift into a higher gear and at least partly drive in a different technological direction.
Planning for those changes were key HHS advisory groups, the Health IT Policy Committee and its sister Health IT Standards Committee, plus a work group of both, which met in a daylong, joint hearing last week in Washington. Twenty witnesses testified.
The following day, members of the PCAST workgroup met for four hours to try and digest the testimony they had just heard and to begin drafting policy recommendations that will be presented to the workgroup's two parent committees. From there, the recommendations will flow to the Office of the National Coordinator for Health Information Technology, where they could inform or even drive policy changes affecting the government's national incentive programs for electronic health-record system adoption.
Both meetings were devoted to addressing PCAST's 108-page report, Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans, released in December.
The report encouraged the ONC to “move more boldly” to ensure the nation has EHR systems “that are able to exchange health data in a universal manner based on metadata-tagged data elements.” Metadata are data that describe or categorize other data.
“I think you're telling us to go boldly where nobody has ever gone before,” said PCAST workgroup member Carl Gunter, an engineer from the University of Illinois. Gunter's remarks came near the end of the longer Feb. 15 meeting and were directed at Microsoft executive Craig Mundie, a PCAST member.
PCAST recommended HHS push harder toward achieving advanced interoperability of EHRs by asking that HHS include mandating use of its proposed web-based architecture in the government's Stage 2 meaningful-use criteria, which become effective in 2013. To accelerate interoperability, PCAST recommended the government oversee the creation of a universal computer language for information sharing based on extensible mark-up language, or XML—a language common to the Web. The proposed new XML-based language would enable medical records and even “granular” elements of a record, such as a single diagnostic code, to be affixed with metadata tags.
Providers who testified at the hearing complained of PCAST additions to their already full IT plates, including a switch this year to the Version 5010 data transmission standard and conversion by Oct. 1, 2013, to ICD-10 diagnostic and procedural codes.
Dr. Theresa Cullen, chief information officer for the Indian Health Service, sees the PCAST recommendations as a mixed bag.
“Interoperability is critical, but I don't think we're there yet, so I think a focus on that in 2013 and 2015 is good,” she said. Cullen said she shares the concerns expressed by fellow panelists, that the real issue is, “what's doable?”
“There are a zillion things coming at us,” Cullen said. “The 5010 and ICD-10 are going to require a substantial change in the systems, including recoding, that I think are going to be overwhelming.”
Cullen said the IHS recently did an analysis of its home-grown EHR, which is related to the VistA system used by the Department of Veterans Affairs, and found “only about 15% of our data fields are filled 90% of the time,” she said. That argues against affixing metadata tags to every data field in an EHR and indicates some work needs to be done on prioritizing what data needs to be tagged for sharing.
“I definitely feel there is a median ground here,” she said.
Dr. Kevin Larsen, chief medical information officer at 471-bed Hennepin County Medical Center in Minneapolis, said the conversion to an XML-based exchange system might be doable from a provider standpoint, if, initially, there were a limited number of use cases.
Larsen said in a telephone interview that requiring metadata tagging for immunization records would be an ideal first-use case.
With immunizations, privacy rules are less of an issue and “there has already been a lot of work and a lot of relationships established,” Larsen said.
Metadata tagging would facilitate easier location and retrieval of data for medical research using what the PCAST calls data-element access services, or DEAS.
The DEAS providers would not hold medical records per se, but would store the locations of a patient's records held by providers and others, and basic information about what type of information is contained in each.
The DEAS providers would act like electronic bird dogs, pointing to the location and nature of patient records for authorized users; querying the service using techniques similar to those of Web-based search engines such as Google or Yahoo.
Under the PCAST scheme, the metadata tags to be attached to patient records also could carry patient privacy directives that would remain attached to the data when it moves, giving patients and providers a high-tech tool to help assure patient privacy is protected wherever data is sent.
Mundie, in explaining the PCAST report to the workgroup, said the advisers didn't contemplate wholesale and immediate replacement of providers' existing IT systems to accommodate metadata tagging, but that copies of the data placed in some form of storage would be tagged. The tagging could be performed by special software created for that purpose.
“The assumption was that the data would be extracted some way, and that's where you would create the alter ego of the data,” Mundie said. That idea, he said, was based on a further assumption that providers already were creating data warehouses or archives.
Mundie noted the federal Securities and Exchange Commission has mandated that corporations adopt a common, Web-friendly format for submission of their financial reports.
Rather than conduct a pilot of PCAST-recommended technology at a few locations, Mundie recommended the government and the industry “stage its introduction” industrywide. He suggested the government fund development of the new, common healthcare exchange language and set up the DEAS as “a public good.”
Then, providers could ease into using the language and DEAS network by adopting one or more use cases to demonstrate interoperability via the new technology.