Qual-IT - July 2005 | Archived

In July 2004 the federal Department of Health and Human Services (HHS) released its strategic framework for advancing health information technology (HHS 2004).  This document established several major goals, including linkage of clinicians for health information exchange.  HHS followed that report, in November, with a request for information (RFI) to obtain broad input on mechanisms for achieving interoperability, including key features such as governance, financing, and operations, and to define the federal role in facilitating the deployment of a Nationwide Health Information Network (NHIN).

More than 500 organizations and individuals responded to the RFI, demonstrating widespread interest in and diverse opinions on these issues.  Several broad themes emerged from these responses (HHS 2005):

·         The NHIN should be decentralized in its information architecture, utilize the internet, and operate in accordance with uniform communications standards;

·         The network should be overseen by a public-private governing body that would establish standards and policies for its operation; and

·         Privacy and security standards must be adopted, and varying state legal requirements reconciled, to facilitate health information exchange.

Specific concerns addressed by respondents included uniformity in business processes, definitions for medical terminology, detailed technical implementation models and open source specifications, and standards for data exchange across existing non-standardized systems.  Those standards, it was generally agreed, must address key areas such as terminology and coding, data reporting structure, security (e.g., encryption), and network communications.

Opinion was more divided, however, on the mechanisms and processes for developing these standards.  Several standards-setting organizations are currently grappling with these issues, but their efforts are not formally coordinated, nor are they specifically focused on the high level of interoperability projected for the NHIN.  Some argue that the federal government should take the lead, while others advocate for continued private-sector leadership.  A new standards-setting group may be needed to provide coordination and ensure that all stakeholders' requirements and concerns are addressed.  Once standards are developed, that group or another organization will need to test and certify HIT products.  Finally, it will be important to develop a transition strategy and timeframe, to facilitate data exchange across old and new systems and software, an issue not explicitly addressed in the RFI.

HHS has now solicited proposals – due later this month, with contracts to be awarded later this year – for specific policy and technical solutions dealing with these important issues.  Notably, the solicitation acknowledges the major interdependencies across these activities, so bidders must agree to coordinate their activities, and work with a federal interagency workgroup, on specific tasks such as the development of standard data models and specific functional requirements that would define the types of data needed and how that information will be collected and converted into useful formats.  This requires sufficient agreement among the contractors and the federal government to produce not only specific solutions but also a common organizing framework.

Interoperability needs to address both administrative and clinical data exchanges, and models addressing both of those domains are currently being developed and tested.

The Council for Affordable Quality Health Care (CAQH) is leading a national, multi-stakeholder initiative to develop standardized information exchange rules relating to eligibility and claims status inquiries that flow between physicians and health plans.  CAQH points out that interoperability challenges have been successfully addressed in other industries, such as banking and electric utilities.  Modeling its work after those efforts, CAQH has launched the Committee on Operating Rules for Information Exchange (CORE), which will develop and test processes and standards for exchanging health care administrative data (CAQH 2005).

CORE specifically focuses on eligibility and benefits data that routinely move between health care providers and payers.  Standardizing these operating rules will expedite claims processing and reduce administrative costs. These costs extend throughout the health care system – to physicians' offices, hospitals, insurers, and consumers – so the solutions should provide benefits across the board.  Locally, Empire Blue Cross Blue Shield and Montefiore Medical Center are participating in the group. 

This initiative is significant for several reasons: it is a collaborative effort, reflecting the commitment of industry leaders to seek consensus on information exchange standards;  the model is designed to work in any information systems environment, so it is flexible and scaleable; and it is also based on a strong value proposition – a win-win situation for both payers and providers, in which costs and benefits are clearly identified and allocated.

The Markle Foundation's Connecting for Health (CFH) initiative has fostered the development of a “common framework” for interoperable health information exchange.  This framework was submitted as part of a larger coalition's response to the HHS request for information, and, in reflecting many of the same concepts outlined in that solicitation, signals important points of agreement on the overall approach to large-scale HIT interoperability (Connecting for Health 2005).  Focusing on defining the HIT environment and developing strategies to advance an interoperable HIT agenda, the thirteen major health and IT organizations participating concluded that:

·         The health information environment needs to be driven by open, consensus-based, non-proprietary standards;

·         Connectivity should be established through the internet and other existing networks; and

·         Uniform policies governing privacy and security are essential.

Building on this framework, CFH, in conjunction with the Robert Wood Johnson Foundation, recently awarded grants to three community-based HIT collaborative organizations in Boston, Indianapolis, and Mendocino County, California, that have already developed technology and an organizational framework for data exchange.  Utilizing the common framework, the grantees will develop prototype networks that facilitate secure, authorized, and private exchange of personal health information, while enhancing the functions and expanding the scale of their existing models.  At the same time, the projects will foster the exchange of best practices among some of the more advanced HIT interoperability communities in the U.S.

Interoperability has clearly become a core value of national HIT efforts.  But while there is high-level conceptual agreement, important features still need to be determined:  What standards are most important, and who should establish and maintain those standards?  How will privacy and security be assured in a fully interoperable health information environment?  Can the federal government and the private sector quickly reach conceptual agreement on the key elements of the Nationwide Health Information Network? 

These are important questions, and as the answers begin to take shape, policymakers also need to consider the implications.  Standards alone will not be sufficient to ensure that providers acquire the necessary HIT capability; comprehensive policies must address financing and other barriers.  And even with expanded interoperability, health care providers still must systematically apply HIT to improve patient care and operational efficiency.  New legal theories and practices are needed to address the responsibilities of both professionals and consumers in the new “information-rich” environment.  As the standards and architecture for information exchange are developed, the federal government and all health care stakeholders will also need to collaborate on solutions to these issues.

Connecting for Health.  2005.  The collaborative response to the ONCHIT request for information.  Available online at www.connectingforhealth.org/resources/collaborative_response/toc.php

Council for Affordable Quality Health Care.  2005.  Transforming health care at the CORE.  Available online at www.caqh.org/ahip_coverage.pdf

Department of Health and Human Services.  2004.  The decade of health information technology: Delivering consumer-centric and information-rich health care.  Framework for strategic action.  Available online at www.hhs.gov/healthit/documents/hitframework.pdf

Department of Health and Human Services.  2005.  Summary of Nationwide Health Information Network (NHIN) Request for Information (RFI) responses.  Available online at www.hhs.gov/healthit/rfisummaryreport.pdf

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