On Feb. 25, the Chicago-based American Health Information Management Association (AHIMA), the 61,000-member national association for health information management (HIM) professionals, joined an increasingly crowded field of healthcare associations providing input to the Office of the National Coordinator for Health Information Technology (ONC) regarding the proposed meaningful use requirements under Stage 2 under the federal ARRA-HITECH (American Reinvestment and Recovery Act/Health Information Technology for Economic and Clinical Health) Act.

The letter, authored by Dan Rode, vice president, policy and government relations, for AHIMA, made a number of substantive suggestions to ONC officials, among them, requesting strongly that ONC and the HIT Policy Committee adopt “recognized terminologies and classifications” to “limit confusion and misunderstanding of facts”; adopt vocabulary standards; “use a combination of nomenclature standards, such as SNOMED-CT, LOINC, and ICD-10-CM/PCS, along with additional national and internationally recognized standards in complementary roles in health records systems”; employ “standard terms for data elements… so database fields can employ a ‘collect once use many times’ approach to ensure the ability to share and compare data with others”; and consider that “global interoperability for information exchange is facilitated by use of internationally recognized terminologies and classifications.”

Allison Viola, AHIMA’s director of federal relations, who works out of AHIMA’s Washington, D.C. office, recently articulated the concerns and perspectives that she and AHIMA’s members share, in an interview with HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.

Healthcare Informatics: Where are your organization’s deepest and broadest concerns within the set of recommendations you made to ONC last month?

Allison Viola: I think one of our big concerns is addressing the workflow challenges. It’s about bringing that awareness to CMS [the federal Centers for Medicare and Medicaid Services] and ONC, because there’s so much emphasis on the idea that you implement health information technology, and it will give you proven quality improvement; but the vulnerability in this is that if it’s not aligned with the hospital’s or provider’s workflow, it will create frustrations and lack of use on the part of eligible providers or hospitals. So there needs to be a little bit more emphasis on integrating this into clinician workflow. We don’t dispute that we need to move toward greater electronic adoption, we support that; but it’s more than just slamming systems in there and walking away.


Allison Viola

Another issue is the use of standards. In one area, where they’re allowing the scanning of documents—that’s not really where we want to go. If you’re going electronic, you want to allow the entry of data into data fields, and if you scan a document, you can’t achieve that. So addressing gaps in standards is critical in helping the industry forward; and allowing scanning is not going to help.

HCI: Would it be accurate to say you approve of the overall thrust, but that you see a lot of missing or problematic details?

Viola: Yes. We want them to be prescriptive, such as, what’s in the longitudinal record, and what is the appropriate evidence for particular objectives? Don’t be too prescriptive where there’s no flexibility, but they need to provide some framework to enable you to know where your boundaries are, in terms of functions and reporting.

HCI: What are a couple of examples of your concerns that we could talk about, and that might be of particular interest to CIOs and other healthcare IT leaders?

Viola: There’s one that we would really like the CIO community to pay attention to. It’s a core measure: “Provide patients with an electronic copy of their health information.” The core issue we’re seeing here is explained on page 9 of our document. One issue here is that they [at ONC] have similar measures that involve access to the patient information, getting a copy of the health record, etc. We feel they need to tighten that up or align the two different mentions for consistency. The other issue is that allowing patients to get a copy of their information once again precipitates a workflow issue, as well as potentially setting up a potential security issue within an organization. Will the organization provide that information via e-mail, or download it on a CD or on a USB stick, or will patients be required to bring in their media? And if the organization has something similar to the DoD [Department of Defense], where you can’t bring in anything externally to touch your system, there’s a question. So I think that needs to be thought through very carefully from an IT-security perspective.

HCI: I think most hospital organizations will move towards patient portals in order to support this set of tasks. Do you support that?

Viola: Yes, we do support that, though we’re not sure most vendors have the full range of capabilities in that area. But again, is it going to be in a standard format in which they’ll get their information? Will you end up with 50 pages of irrelevant information printed out? So there are a lot of elements in that measure to really flesh out a little more.

HCI: Could you provide one more example of concerns for your organization?

Viola: It involves one of our general comments, but it’s an important thing we brought up, on page 2 of the document; it involves the timing of the shift to ICD-10, in the context of all the other regulatory requirements being mandated. There’s got to be a pause for everyone to understand how all these initiatives integrate and align and interact with each other, including with regard to accountable care organizations and the medical home model. There will be new care delivery systems emerging right at the time that we’re in the middle of the meaningful use process and of the ICD-10 transition, and all those measures will have to be retooled. And then there’s the PCAST report [the President’s Council of Advisors on Science and Technology’s “Realizing the Full Potential of HIT To Improve Health Care for All Americans,” published in December 2010]. That involved a group of individuals who got together and produced this report, essentially, out of the White House, and encouraging ONC to be more aggressive and progressive, asking CMS to update and modernize their IT infrastructure. So the HIT Policy and Standards Committee out of ONC set up a workgroup to address the recommendations from the PCAST report, and they’ll be making recommendations to the National Coordinator, whoever it might be at that time, on how ONC can take some of these recommendations and incorporate them into the activities. The PCAST report recommends that these recommendations be implemented by 2013. They want to do meta-tagging down to the data element level, for example. So you have all these things coming together, and it’s a lot.

HCI: What are they recommending, with regard to meta-tagging down to the data element level?

Viola: Basically, it would involve creating another set of information attached to a particular piece of data that would provide the “meta-data.” So, for example, for you, Mark Hagland, one might attach the following pieces of meta-data to your name: that you are Editor-in-Chief of Healthcare Informatics, your date of birth, etc. And one of the things they’re suggesting is, down to that data element level of Hagland, I don’t want anybody to see that name, protecting your identity privacy to some extent, say if you had an HIV test, or a psychiatric admission, or cancer, for example. All the information is out there then in a cloud in an aggregated way. So you could search for Mark Hagland’s information, and it could be out there in the cloud. What they’re recommending is a different approach to what has been published as a regulation for Stage 1 and leaning towards Stage 2; it’s a different approach; and in addition, there is a time factor involved, since the PCAST report recommends making this transition in 2013, which is right around the corner for IT world.

HCI: Do you think that ONC and CMS will be fairly responsive to the concerns addressed in your association’s letter of last month?

Viola: They know we’re very active in the activities that they’re developing for the stages. I think they’ll be paying attention to certain areas in particular, particularly with regard to access to patients’ health information and to privacy and security. I think they’ll expect it; I would hope so. And our experience has been that I haven’t seen anybody get down to the detailed level we have, but that’s because our membership deals with the healthcare data on a day-to-day basis, to operationalize it, so we have to understand how to deal with it.

And, broadly speaking, let’s not recreate the wheel on some of these things. For example, the Joint Commission has a lot of good things already established in terms of patient engagement [requirements and measures]. Let’s make use of some of the resources already existing in the field. Let’s refer to what’s already been developed when possible, and try to align efforts, because you have so many quality reporting initiatives going on now, so let’s just try to align efforts, because we’re all trying to do more with less these days.