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NwHIN Power Team: Focus on ‘Least-Regret’ Activities for Stage 3 Query Standards

September 10, 2014
by David Raths
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Need for certification criteria not well aligned with long-range desire to move to HL7 FHIR

In a presentation to the Sept. 10, 2014, meeting of the federal Health IT Standards Committee, one of its subcommittees recommended that if 2017 EHR certification requirements are going to include query capabilities, they should be functional in nature rather than specifying a standard. They said ONC should focus on a “least-regret” approach to avoid compelling vendors and customers to expend time and effort on certification of a temporary approach as standards for query evolve.

The need for certification criteria for the 2017 Edition is not well aligned with the long-range desire to move to HL7 FHIR as the standard for querying for documents and discrete data items, the co-chairs of the NwHIN (Nationwide Health Information Network) Power Team told the Standards Committee members.

Dixie Baker, one of the co-chairs, said the team was recommending that if query is included, it should involve functional requirements as certification criteria, and allow vendors to attest to how their technology provides these functions. The criteria might be that certified EHR systems have the ability to electronically query external EHR systems for patient medical records and respond to searches for patient information from external EHR systems. The team recommends allowing both synchronous and asynchronous queries.

“Assuming there must be query requirements in the 2017 edition, we were asked to recommend standards,” Baker said. Their recommendations are to focus on making FHIR profiles ready for implementation as soon as possible, but in the interim, “the requirements should be functional rather than forcing vendors to implement something they need to tear out and later re-do,” she said. “What we are asking for could be achievable in a number of ways, using existing or emerging standards or membership in a query organization. We don’t want them to invest time and effort on something that might be a temporary solution. ONC should focus on low-regret activities that move toward a RESTful FHIR approach to documents and discrete data elements.”

Those high-priority, “low-regret” activities include fast tracking of improvements to the Consolidated CDA Implementation Guide, including implementation specifications to support “on-demand” retrieval of a simple current patient summary (problems, allergies, current medications, recent labs, etc.).

Committee chairman John Halamka, M.D., noted that when ONC offered optionality for public health reporting transport requirements in Stage 1 and Stage 2 rules, the public health agencies chose many different methods of transport. “The functional description turned out to create a heterogeneity that caused vendors quite a lot of consternation. So I wonder, is there thought that a subset of FHIR that could be rapidly accelerated and we all focus on it and look to a trajectory of having something very specific and FHIR-based in place and good enough to get us started in 2017.”

Baker responded that the recommendation would allow restricted profiles of FHIR that could be used for query but wouldn’t require it. Given that the 2017 requirements are currently being written, she said, it would be a stretch to make FHIR profiles a requirement, and others on the Standard Committee  who spoke at the meeting agreed with her.

NwHIN Team co-chair David McCallie, M.D., Cerner’s vice president for medical informatics, said the team grappled with how to standardize in a rapidly evolving technology space, where the decisions you make today might not see widespread use for four or five years. “It’s painful to think of locking in on something that wouldn’t see use for four years.” He said he believes the trade-off of the advantages of flexibility and nimbleness vs. the downside of optionality is worth making.

At the same meeting, Steve Posnack, director of ONC’s Office of Standards and Technology, noted that ONC would change the naming structure for certifications from the year the certification would be required to be in use to the year the rule was initially published. So if the certifications required for 2017 is published in 2015, it will be called the 2015 certification rule, and a subsequent incremental change would be 2015 Edition, Release 2.

UPDATE: Representatives from Healtheway sent us this response on Sept. 11, 2014:

Healtheway’s response:

“We agree with the recommendation to focus on enabling query-based exchange, by defining the functions and enabling multiple approaches, without prescribing how query-based exchange is conducted. 

We do, however, believe the recommendations need to be tempered in the practical realities inherent in widespread adoption of query-based exchange.

First:  There was a disappointing lack of recognition in the NwHIN Power Team’s recommendations regarding the significant adoption of query-based exchange in production today using existing, mature national and international standards, such as SOAP, IHE XCA, XDS, XCPD, PIX, PDQ.  We recognize that all vendors may not wish to support these standards; however, there should be stronger recognition regarding the widespread adoption of mature, existing standards.

The eHealth Exchange alone, has nearly 80 participants, with an additional 20 nearing production, representing more than 30% of all US hospitals and 10,000 medical groups who treat 100 million patients.  There are millions of query-based transactions exchanged each year, within and between networks using these standards. Industry has already embraced query based exchange; and, it is important to not disrupt this.

We believe there should be more recognition regarding the level of production use of existing query capabilities and assure more balanced support of both existing and emerging approaches in 2017.  We have seen the issues caused by radical course changes and need to learn from those experiences.  

Second, we acknowledge that there is growing interest in using FHIR as it progresses toward pilot implementation. It will take years to fully develop, as well as long-term planning. We caution having national policy primarily focus on an unproven, although potentially promising approach.  Anointing an unproven technology before it’s ready for widespread implementation, and in the absence of having supporting markets would increase costs, introduce burden and would unnecessarily disrupt current production efforts.  We believe that emerging approaches such as RESTful and FHIR should be properly vetted through real-world implementations, with measurable evidence that they will work as “predicted”, and that there is some level of demonstrated maturity and stability. 

In addition, there should be a carefully coordinated and communicated industry-wide implementation planning that allows sufficient time to migrate without disrupting current production efforts, with input from public-private collaborative efforts such as Carequality.

Finally, technology should be a tool for enabling interoperability policy, but should not serve as the policy in and of itself, as the recommendations suggest.”


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