HIT Policy Committee and Standards CommitteeDRAFTSummary of the October 15, 2014 Joint Meeting
ATTENDANCE (see below)
KEY TOPICS
Call to Order
Michelle Consolazio, Office of the National Coordinator (ONC), welcomed participants to the joint meeting of the Health Information Technology Policy Committee (HITPC) and Standards Committee (HITSC). She reminded the group that this was a Federal Advisory Committee (FACA) meeting being conducted with two opportunities for public comment (limited to 3 minutes per person), and that a transcript will be posted on the ONC website. After introductions, she instructed members to identify themselves for the transcript before speaking.
Remarks
National Coordinator and HITPC Chairperson Karen DeSalvo noted the significance of the joint meeting of the HIT FACAs. She thanked everyone for organizing the meeting to work toward interoperability.
Deputy National Coordinator and HITSC Chairperson Jacob Reider welcomed and thanked everyone. He acknowledged that although participants may not agree on everything, they all want to improve health. He told them to focus on being successful rather than being on the right path. He suggested that they listen and talk in the right proportion.
Review of Agenda
HITPC Vice Chairperson Paul Tang referred to the importance of the vision and the work plan. HITSC Vice Chairperson John Halamka reported that he is the recipient of many e-mails expressing his colleagues’ disillusionment with technology. A roadmap is needed in order to build a learning health care system to be able to respond to the use cases of the future. He urged them to help identify the focus on the roadmap and to be part of a solution.
Tang mentioned each of the items on the agenda, which was distributed by e-mail prior to the meeting. No additions to the agenda were requested. He said that action on acceptance of the summaries of the previous meetings will be considered at a later time.
Interoperability Framing
Erica Galvez, ONC, read the updated IEEE definition of interoperability. She showed slides and talked about HIT adoption from 2001 through 2013, calling it a dramatic uptake and reminding the members that they had been presented with some of the information previously. In 2013, about one-third of physicians exchanged different types of data. In 2012, 50% received discharge summaries routinely, 25% electronically. 51% of hospitals were able to query patient health information electronically. Although their exchange increased from 2008 to 2013, only 36% exchanged with other hospitals outside their systems. She went on to describe community and state based exchange services. She noted the expansion of the ecosystem from 2012 to 2013. The majority of state public health agencies are accepting immunization, lab and syndromic surveillance data. Transactions have increased. Various governance structures are in operation—DirectTrust, Commonwell, eHealth Exchange, NATE, and Care Quality. But no current approach can bridge these siloes. She cautioned against a sole focus on delivery.
Q and A
Thirteen members commented, frequently prefacing their comments with complements to Galvez. Comments are summarized as follows.
Quality measures of interoperability are needed. For instance, what proportion of these transactions actually matters? What percentage of providers exchange all of the types of data described on slide 4? E-prescribing should have been included. Administrative and financial aspects should be included. Claims forms data are used for many purposes. Health Insurance Exchange should be considered as part of the ecosystem. Use beyond minimum meaningful use requirements should be captured. Cost analysis and the value received from public expenditures should be included.
Categorization and breakdown of transactions by: within global and integrated systems, practice settings, geographical categories, destination, across vendors, and payment systems are needed. On the other hand, David Lansky urged that they think less about differences across settings and focus on the U.S. population as the denominator, returning to the goal of every person in the population having an EHR.
In response to a question about data on semantic interoperability, Galvez acknowledged the need for information on how standards perform and their interoperability in the real world. Surveys are being fielded to try to collect such data. Andy Wiesenthal observed that on-going consolidation across the delivery system affects the need for interoperability. Interoperability with educational and social services is of particular importance in pediatrics. According to Marc Probst, semantic interoperability is needed among committee members and in order to communicate with decision makers, such as board members. The data shown on the slides could be interpreted in different ways. He asked everyone to be clear and to use common definitions and vocabulary.
Although billions of transactions occur annually, providers using the same EHR system are not always able to access the records of mutual patients. Cross vendor interoperability needs work. As demonstrated by the index Ebola case in Dallas, exchange systems are not prepared for rapid detection and emergency responses. Patient level data and work flow integration cannot always be predefined; adapted systems must be considered. Use cases beyond minimum compliance with meaningful use should be anticipated. A standard strategy should support development that allows spontaneity. The desires of the customer must be considered. Patient interaction with the ecosystem and patient generated data must be considered. Market drivers should be acknowledged. Which trends meet the no special efforts criteria? The price charged by vendors for interfaces is an issue. No special effort is difficult to measure.
Interoperability Roadmap
Galvez emphasized that her slide presentation represented a very early draft. She emphasized that interoperability is about people. The 10-year road map envisions the following: leverage health IT to increase health care quality, lower health care costs and improve population health, support health, build incrementally from current technology, establish best minimum possible, create opportunities for innovation, and empower individuals. This is not just an HHS or federal government roadmap. It will be completed and released for public comment in January and published March 2015. A number of mechanisms have been and will be used to solicit input. The Interoperability and Health Information Exchange Workgroup will review and provide feedback on the roadmap. Galvez declared that the meeting was an opportunity to solicit feedback on the early draft. She presented draft ecosystem goals in three categories—individual, provider, and population and public. Draft learning system requirements are:
· Ubiquitous, secure network infrastructure
· Consistent, secure transport technique(s)
· Consistent data formats
· Consistent semantics
· Standard, secure services
· Accurate identity matching
· Consistent representation of individual interests in sharing one’s data
· Resource Location
· Verifiable identity and authentication of all participants
· Consistent representation of authorization to access data or services
· Shared governance and measurement of progress
Goals for 2024 are: longitudinal information, ubiquitous precision medicine, reduced time from evidence to practice, and virtuous learning cycle. She went on to describe the five building blocks for interoperability: clinical, cultural, business, and regulatory environments; rules of the road and governance; core technical standards and functions; certification; and privacy and security. For each building block, she summarized the feedback that is being taken into consideration and delineated sample actions for the period 2014-2017 by building block. For instance, for the first block, sample actions are: public and private payors incent or require the exchange and use of essential electronic health information that aligns with national standards in all value-based purchasing arrangements and; ONC and FTC monitor and coordinate activities to advance interoperability by promoting competition and innovation.
Q and A
Tang directed the members to comment on the first steps for the roadmap. Reider requested that comments focus on editorial changes and actionable steps for the committees and workgroups.
Eric Rose referred to slide 7 and 2017. He suggested making summary documents useful to the next doctor. Physicians want summary narratives that communicate meaningful information. According to Galvez, the goal is to have technology to enable rapid communication from producers of research findings to CDS. The mean 17 years from research to practice must be reduced. She agreed to clarify that having more patient data will not necessarily lead to the desired result.
Keith Figlioli requested that the nine guiding principles slide be moved to the front of the deck. Experience in the HITSC indicates that each member responds to issues through the lens of her own experience. Furthermore, innovation fostering is missing. The rapidity of change must be recognized. Galvez responded that flexibility is discussed in the vision paper.
Nancy Orvis referred to slide 9 and the comprehensive near term goals. She wondered about the inclusion of the ED visits. Short term notice is very important. Galvez responded that they were included in the inpatient category due to the importance of having short-term notice of those visits.
Christine Bechtel said that consumers want more than access to longitudinal data. Consumers want access to information that is organized and accurate. Galvez confirmed that the reference to consistent and shared data on the system requirements slide includes patients. Bechtel suggested that it be expanded to engage and empower patients. Regarding the governance section, she asked that the slide be made consistent with Galvez’s statement on making a significant presence.
Cris Ross pointed out a contradiction on slide 19 (feedback). Some feedback indicated that standards are over prescriptive. Regarding slide 20, the required steps from tested and mature standards to becoming a full-fledged ONC standard are not shown. He indicated that the Standards, Certification and Testing Workgroup is interested in working on this topic. McCallie interjected that the JASON Task Force recommendations will address slide 21.
Deven McGraw referred to slide 24 and privacy and security. She acknowledged that the statements were consistent with the feedback heard. She recommended that Galvez cull through previously made and accepted recommendations for inclusion. She expressed concern that the sample action listed on slide 25 focused on consent. Many transactions for treatment and care coordination do not require consent. Many needed transactions can assume consent. In the near term ONC may want to clarify the legal requirements for full use. She agreed with the encryption recommendation. ONC should work with OCR. Although the focus on consent is important, more clarity on authentication and authorization is needed. She was opposed to accepting the notion of a trade-off. Halamka added that Dixie Baker’s group had worked on encryption on all data at rest. Encryption in a closed environment may be more harmful than the lack of encryption. According to Galvez, more work will be done to incorporate encryption best practices.
Referring to Bechtel’s comment on slide 9, Tang said that the individual should be shifted to the left. Patients need access to their data in order to be activated. Use of data from home devices should occur much sooner than 2020.
Gayle Harrell pointed out the neglect of usability in the guiding principles. Governance must move forward more rapidly. Trust, patient perspective and state variation in laws must be taken into account. The federal government should establish a floor. Regarding the building block of culture and business, the providers’ perspective must be considered as well. Galvez referred her to more detail in the reference documents.
Floyd Eisenberg talked about slide 8. Quality measures, public health and research should not be depicted in separate siloes. The slide should show the interrelationships. In slide 10, the provider roles, capabilities needed, and provenance of data should be captured.
Lisa Gallagher referred to slide 22 and identity management. She indicated that her organization is working on patient data and patient record matching in the near term. It is also looking at digital identity, multifactor, and multilevel of assurance identify as the national ecosystem develops. She requested better explanations for slides 53 and 61. The Transport and Security Standards Workgroup will work on digital identity.
David Coates referred to slide 10, saying that the technical scope goes beyond EHRs. There is a need to be flexible due to rapid changes. The amount of data wanted and used by patients will explode. Privacy preferences and consent for devices should be considered as well as the encryption of data in transit from apps.
Liz Johnson argued that practicality should be included in the guiding principles. There are numerous competing priorities and FY 2014 is gone. Galvez indicated that the 3-year time frame takes into account what is already in place.
Lansky talked about slides 7 and 9 and timing. Information on scale and scope should be included. Some organizations are already doing the things set out in the 10-year plan. Attention must be given to the mechanisms for scaling and how all of this will play out in the market. Turning to slide 14 on business and culture, he wondered what instruments are available as drivers. He suggested strengthening the roadmap by describing the federal role, for example, its purchasing behavior, convening behavior, and tool making behavior. He went on to point out that having more health information moving is not an appropriate goal: the goal is to improve health care. The task is to make sure that a value payment strategy is supporting health improvement, which requires measurement. Moving to slide 32, he said that the definition of longitudinal measures must occur sooner. He recommended acceleration of the longitudinal measures in order to drive the rest of the building blocks.
Rebecca Kush reported that efforts are underway to shorten the 17 years from research to practice. In addition to EHR standards, research and public health standards and the IHE workflow should be used. The standards used by the NIH centers and AHRQ must be considered. CDEs are not necessarily standards. Many existing standards, such as for patient reported outcomes, diaries, and other documents, have yet to be considered. She anticipated that the Semantics Standards Workgroup will work on such topics.
Egerman complained about slide 10. Although it refers to being agnostic about the location of data, the guiding principles refer to building upon existing infrastructure and HIEs. He said that the existing structure may not be the correct one. Galvez talked about trade-offs, balance and practicality. She explained that she had looked at 10 years out and worked back. One must be agnostic regarding the edge system and the source of and recipients of data. They are not known. Egerman was concerned that the content of the slide was a code for preserving the current HIEs, which Galvez denied by saying that HIE is used more broadly than to indicate community and state HIEs. That being the case, Egerman asked her to just say build on existing technology. He declared his objection to keeping the existing intermediaries in place. Moving to another slide that stated new standards will not be adopted until they have been tested and are mature, he pointed out the importance of defining and operationalizing mature. The building blocks do not recognize test beds.