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ONC Annual Meeting: Federal Leaders Are Ready for Interoperability Action

February 3, 2015
by Rajiv Leventhal and David Raths
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Agency pushes for feedback on its interoperability roadmap as challenges lie ahead

Following the first draft release of its interoperability roadmap, federal health IT leaders continued to push the need for greater interoperability and more specific standards at the Office of the National Coordinator for Health IT (ONC)’s Annual Meeting in Washington, D.C. on Feb. 2.

Karen DeSalvo, M.D., National Coordinator for Health IT, opened the day by saying that the government has listened to the health IT community's suggestions on how to make technology work for better health, and they are ready to “execute those actions.” She mentioned President Obama’s recent commitment to interoperability as well, finally urging the audience to give their thoughts on the first draft of the roadmap, with public comments due on April 3. “If we do it right, we build a pathway to get to a place where we have a learning health system,” DeSalvo said.

Regarding the need for greater interoperability in healthcare, Erica Galvez, interoperability and exchange portfolio manager, ONC, noted via Skype (due to inclement weather) that the typical Medicare beneficiary receives care from two primary care providers and five specialists each year, signaling a huge opportunity for care coordination. “Individuals and providers need access to the right information at the right time in a manner they can use it to make decisions that impact their health regardless of geographic or organizational boundaries,” Galvez said.

In the near term, she continued, providers should be able to send, receive, find, and use a common set of clinical information. “Health data needs to flow in the delivery system, but also outside the system, and that is what I see as key to the roadmap,” Galvez said. In terms of measuring success, she said it will be “based on the data sources that we have currently and measures we’re able to track currently. We put this framework in the roadmap, and we want comments on it.”

Computable Privacy

Regarding patient privacy, Lucia Savage, ONC’s chief privacy officer, stressed that the inconsistencies in rules about permission to access, use, or disclose makes it difficult to build software systems that accurately capture, maintain, and persist this data. “But we need software systems to capture and persist both written individual directions and what is permitted without a written individual direction," she said. So how do you manage consent? Savage said her idea is to stop managing it and make it computable. “Let’s make computers be able to do this so we can write privacy rules that software can capture. That’s my vision,” she said.  

According to Savage, capturing a patient’s consent choice on a piece of paper isn’t interoperable. “We can have all the technical standards in the world, but if consent is with pen and paper, the whole system crashes to a halt,” she said. To achieve health, she added, an individual’s electronic health data needs to be digitally connected to their consent choices. “Healthcare providers and their health IT systems need to know what to do when the patient does not document a choice. Telemedicine, community health supports, and other innovative delivery processes will be stunted if we cannot make privacy computable,” she attested.

There are far too many variations in consents, Savage continued. “Sometimes they’re paper, sometimes they’re not, some states require a witness signature, go figure that. States are philosophically aligned, but privacy and consent laws vary and result in a patchwork that complicates data transfer,” she said, bringing up an example of mental health definitions in New York versus Connecticut.  To this end, Savage brought up “basic choice,” a concept present in ONC’s roadmap. Basic choice is the choice an individual makes about the use and disclosure of their health information generally, including electronic exchange of health information that is not subject to heightened use and disclosure restrictions under state or federal law. “Some people don’t want their information shared, and if that’s the case you have to move on,” Savage said.

Chiming in about interoperability standards, Steven Posnack, ONC’s director of standards and technology, said there is a huge need to “get more specific.” He said, “I challenge the whole industry, ONC included, to get down to a certain level of specificity when talking about the type of interoperability that we want. I see too many inconsistencies in interpersonal communication today,” he said. As such, he said feedback from the industry is crucial. “Do not be innocent bystanders,” he urged the audience. “We need your participation.”

Federal Health IT Strategic Plan

Speaking to ONC’s federal health IT strategic plan earlier in the day, Barclay Butler, Ph.D., the director of healthcare technology integration for the Defense Health Agency (DHA), applauded ONC for doing a good job of listening and incorporating suggestions from federal partners in the plan. (The plan is open to public comment until Feb. 6 and will also receive comments from the federal Health IT Policy Committee by the end of March.)

Besides operating 54 hospitals, DHA also works with 380,000 private-sector providers for 10 million beneficiaries who get care through the Tricare insurance program. “That is driving the need for interoperability,” he said. “We need to get information back from those providers into the DoD record to provide continuity of care,” he said.


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"He also pointed out some challenges that still need to be addressed, including provider directories, patient matching..."

Boy is that an understatement.
The ONC deadline calls for provider implementation by 2017. Now here’s yet another date that will get pushed out and I am sure several times while providers will take the brunt of the beatings for the many delays.

I predict all the delays will be tied to one impossible hurdle, buried deep in the plan that could be eliminated with the wave of a Congressional wand. The big, very big hurdle is creating a real unique patient identifier. The issue is covered in a small footnote on page 69 of the plan. It states:

While HIPAA required the creation of national identifiers for patients, providers, hospitals and payers in 1996, subsequent legislation prohibited HHS from funding the promulgation or adoption of a national unique patient identifier. Public Law 105–277. 105th Congress. October 21, 1998. http://www.gpo.gov/fdsys/pkg/PLAW-105publ277/pdf/PLAW-

So there you have it, ONC wants providers to accomplish what Congress refused to deal with and do it through a Rube Goldberg process of virtual and probabilistic methods. And by the way ONC says they will measure via the MU program “provider performance”, e.g., the percent accuracy rate for proper patient identification with the MU penalties if you don’t do it.
Sad story is, if our government was willing to deal with this ID issue head on we could have true interop in six months. After forty years in this industry one thing I have learned is that politics and systems design make terrible bed fellows.

My suggestion is this. If a person wants true health record coast to coast portability they agree to subscribe to a unique ID, if they want to maintain ‘privacy’ they do not. Opt in or Opt out, your choice.
Frank Poggio
The Kelzon Group