Representatives from electronic health record vendors told an ONC panel listening session Aug. 5 that meaningful use Stage 3 is too soon to switch gears from the consolidated clinical document architecture or C-CDA to an approach focused on discrete data elements involving application programming interfaces (APIs) and the proposed HL7 Fast Healthcare Interoperability Resources (FHIR) standard.
Last November, a white paper written by the JASON initiative within the McLean, Va.-based Mitre Corp., and funded by the Agency for Healthcare Research and Quality, concluded that the lack of interoperability among the data resources for electronic health records (EHRs) is a major obstacle to the effective exchange of health information. The paper recommended that CMS use Stage 3 meaningful use to embark upon the creation of a truly interoperable health data infrastructure.
The ONC Jason Task Force is holding hearings to determine whether the recommended approach is feasible, and what its implications would be. On Sept. 3, it will make draft recommendations to the full Health IT Policy Committee.
Task force members asked whether it makes sense to continue working on perfecting the C-CDA standard or switch gears to a new model such as FHIR for Stage 3. Ryan Hamilton, a Cerner Corp. vice president, responded by saying that there are indeed challenges with C-CDA, because many providers report having to sort through lots of data to find what they are looking for. Many believe it is increasing rather than decreasing their burden. Discrete data approaches offer the potential to get that information in a simpler format and standardized ways for EHRs to ingest the data. But he said the two-year window until Stage 3 is too tight a timeline for that to be practical. “To get standards, you have development work, certification, and implementation. I just think it is too aggressive. There is not enough time to do it and do it well.”
Representatives from Allscripts and Epic Systems concurred with Cerner’s Hamilton. When asked which group should lead the effort, Epic President Carl Dvorak noted that the HL7 organization continues to do great cross-vendor work. “We owe them a debt of gratitude.” Perhaps ONC should direct funding and positive energy to HL7, he said.
Charles Parisot, chair of the Electronic Health Record Association's Standards and Interoperability Workgroup, said that in successful approaches, with all key stakeholders agreeing to work together, the forum is not what counts. “I think what we have to learn is a more collaborative approach. We have seen that in HL7. ONC may be at the table, but it doesn’t need to lead.”
On a panel of consumer-facing organizations, John Mattison, M.D., chief medical information officer at Kaiser Permanente, said that that he has confidence C-CDA could be further specified to become more useful. All standards have a natural lifecycle, he noted. “FHIR looks like a good first step, but it is not yet mature. As we all know, there is great demand for something that works today,” he said. Mattison recommended continuing work on C-CDA. Then when FHIR is more mature, develop an explicit roadmap for migration.
In his written testimony, Parisot said that the proposals in the JASON report for specific API requirements as part of ONC certification are neither realistic nor necessary. “The growing industry adoption of standards-based API work such as FHIR, if focused on a few specific high-value use cases, is the more appropriate and sustainable path to accelerated use of APIs across the industry.”
Many speakers said the Jason Report failed to recognize substantial standards progress that has been made over the past few years. In his written testimony, Epic’s Dvorak wrote: “The notion that JASON provides a migration path from legacy EHR systems is odd. The assumption that a migration path is needed is based on a false assumption that EHR vendors, including Epic as well as our many competitors, do not continue to invest heavily in advancing the art and science of healthcare informatics.”