EHR Interoperability: What Works?Assessing Panel's Report on XML, Privacy and EHRs
Instead, they call for focusing on further development of existing standards and related implementation efforts, including Health Level Seven and IHE, or Integrating the Healthcare Enterprise, among many others.
The report from the President's Council of Advisors on Science and Technology "almost makes it sound like this XML approach will be the magic bullet" that solves interoperability and exchange issues, says Joyce Sensmeier, vice president for informatics at the Healthcare Information and Management Systems Society. "That does a disservice to those who have been working on this challenge for a long time. If it was that simple, we would have solved this problem a long time ago."
Harry Rhodes, director of practice leadership at the American Health Information Management Association, offers a similar perspective. "In considering the advice of the PCAST report, we must not lose sight of the complexity of health information management," he says. "The future of health information exchange will be a digital network that will employ metadata tags based upon a universal medical exchange language, but it should be built upon the foundation of existing standards, profiles and implementation guides."
HITECH IncentivesThe council recommends in its new report that use of a new universal exchange language, built on extensible markup language, be a requirement for participating in future stages of the HITECH Act electronic health record incentive program. Stage 1 began this month.
"Achieving the full potential of health information technology will require the development and adoption of a robust information-sharing infrastructure to facilitate the exchange of data among institutions," the council said. Such an infrastructure would "allow health data to follow patients wherever they are, with appropriate privacy protection and patient control, while giving patients' various doctors a more complete picture of those patients' medical conditions and needs."
The Office of the National Coordinator for Health IT is accepting comments on the report through Jan. 19. Meanwhile, the Health IT Policy Committee, which advises ONC, has announced formation of a workgroup to discuss the report and consider whether to recommend the adoption of any of its components. That new workgroup will hold a public teleconference Jan. 14.
Unrealistic EHR Goal?Critics of the report label as unrealistic the goal of requiring the use of a universal exchange language for future stages of the HITECH incentive program.
Hospitals and clinics scrambling to qualify for the Medicare and Medicaid incentives "have their hands full with the systems implementations that they currently have going on," Sensmeier says. Meanwhile, statewide health information exchanges now being launched with the help of HITECH funding also would find it impractical to go back to the drawing board to adopt a newly developed standard, she adds. "Many of them have gotten their business plans and technical plans approved by ONC, and they're marching forward."
Requiring the use of a newly developed universal exchange language for Stage 2 or 3 of the incentive program is unrealistic because "it's a fundamental change in course," says Mark Segal, vice president, government and industry affairs at GE Healthcare IT. Segal serves on the executive committee of the HIMSS Electronic Health Record Association, a trade group for EHR vendors.
Segal joins Sensmeier and Rhodes in calling for building on existing Health Level Seven clinical system interoperability standards, which are in use worldwide and leverage XML, as well as the IHE project, which promotes the use of Health Level Seven and other standards for sharing data as well as medical images. He also says broadening implementation of standard clinical vocabularies, including SNOMED-CT and LOINC, would ease interoperability.
Role of MiddlewareThe presidential council stressed that healthcare organizations would not have to replace their EHR systems to accommodate the universal exchange language because EHRs could be made compatible with the new language through middleware.
Segal says it is "overly optimistic" to think that middleware could be used at a reasonable cost to generate metatagged individual data elements.
Although middleware could play an important role, Sensmeier called it "naive" to assume a universal exchange language could be adopted without substantial changes in EHR systems.
XML ApproachSensmeier criticizes the council's suggested approach of using XML to tag specific data elements within EHRs with descriptive information, such as relevant privacy protections. She points out that individual data elements "rarely have meaning outside of their context."
And Segal says that tagging individual data elements, rather than broader groups of data, such as clinical summaries, could lead to "having discrete data elements out there that may have obsolete policy preferences attached to them."
W. Edward Hammond Ph.D., former chairman of Health Level Seven and director of the Duke Center for Health Informatics, says, "The overhead of tying characteristics and privacy controls with each data element every time it is sent doesn't make sense to me. ... There is no such thing as unlimited bandwidth, storage capacity and processing speed."
Further, Hammond criticized the presidential council's call for tagging data elements with patient's consent information specifying, for example, which clinicians can view which data. "It is foolish, incorrect and undesirable to hide information from the persons responsible for the care of an individual," he says. "Further, I think there is a societal responsibility to share one's data for the purpose of extracting knowledge -- comparative effectiveness studies, for example."
In contrast, consumer advocate Deborah Peel, M.D., founder of Patient Privacy Rights, says metatagging data with patient consent information is an inadequate privacy protection step. The approach might "prevent some snoopy doctor or hospital employee or hacker from being able to easily see your sensitive data," Peel says. But she argues that the presidential council's plan would do nothing to prevent patient information from being used for research without an individual's consent.
"The public supports research but only when they know what the research is about and are given the right to choose to participate," Peel argues. The presidential council, she contends, failed to recognize that "people don't want secondary users to have access to their data without their consent."