American Health Information Community
Electronic Health Records Workgroup
Summary of the 22nd Web Conference of This Workgroup
Tuesday, April 29, 2008
PURPOSE OF MEETING
The purpose of the 22nd Web conference of the Electronic Health Records Workgroup (EHR WG), chaired by Dr. Jonathan Perlin and Ms. Lillee Gelinas, was to begin planning EHR WG activities related to the transition of the American Health Information Community (AHIC) from a federal advisory body (AHIC 1.0) to an independent public-private partnership in the private sector (AHIC 2.0). The documents used in the presentations to the EHR WG at this conference are available online at http://www.hhs.gov/healthit/ahic/healthrecords /ehr_archive.html
INTRODUCTORY REMARKS
Dr. Perlin gave an overview of the EHR WG’s agenda for the day, noting that several last-minute changes had been made to the agenda. Ms. Gelinas explained that because of time constraints, a discussion of social marketing (an action item from the previous EHR WG meeting) would not occur at this meeting.
KEY TOPICS
1. Brief Report on the April 22, 2008, AHIC MeetingMs. Gelinas and Dr. Bell
Ms. Gelinas and Dr. Bell reported that a key item on the agenda of the April 22, 2008, AHIC meeting was preparing for the transition to AHIC’s successor AHIC 2.0. Dr. Mark McClellan updated AHIC members on the status of the four AHIC 2.0 planning groupsGovernance, Membership, Business Sustainability, and Transitionthat have been convened. The first three planning groups are on a fast track to make their recommendations by May 31, 2008. The Transition Group will make it recommendations in the fall of 2008. Dr. Bell indicated that ONC staff would send EHR WG members information about opportunities for public feedback related to the transition to AHIC 2.0.
Staff Action Item #1: Send EHR WG members information about opportunities for public comment on the transition to AHIC’s successor AHIC 2.0.
Dr. John Loonsk from ONC gave a presentation at the April 22nd AHIC meeting on proposed 2009 use case options. His presentation was followed by a robust discussion about the use case process and the need to extend and fill in gaps in existing use cases, which generated additional discussion about the interoperability of health information technology (HIT), which led to the decision to invite the chairs of the Certification Commission for Healthcare Information Technology (CCHIT) and the Healthcare Information Technology Standards Panel (HITSP) to the April 29th EHR WG meeting to give their perspectives on where the country stands with respect to interoperable HIT and the best options for moving forward in 2009.
2. Presentation: Update on the Ad Hoc Clinical Decision Support Planning Group’s Recommendations to AHIC on April 22, 2008Dr. Blackford Middleton
Dr. Middleton reported on the Ad Hoc Clinical Decision Support (CDS) Planning Group’s recommendations for fostering CDS capabilities within EHRs. All of the CDS recommendations presented at the April 22nd AHIC meeting were unanimously accepted by AHIC. The CDS Planning Group will remain empanelled, and AHIC Workgroups will continue CDS discussions at upcoming meetings as needed.
3. Perspectives on What Needs to Be Done to Drive the Adoption and Use of Interoperable EHRs by CCHIT Chair Mark Leavitt and HITSP Chair John Halamka
Dr. Leavitt and Dr. Halamka offered their perspectives on what where the country stands in terms of EHRs and interoperability standards at both the human level and the machine level (computable semantic interoperability); what plans are already in the pipeline at HITSP and CCHIT; and what work remains to be done to drive the adoption and use of EHR products.
a. CCHIT Chair Mark Leavitt’s Perspectives
Dr. Leavitt explained that the certification of EHRs helps assure potential purchasers and users that EHR systems will meet criteria for functionality, security, and interoperability. Certification can help lower the risk for providers, thereby increasing the volume of sales of EHRs and potentially reducing costs. This would also increase incentives for payers and purchasers to offer motivation for the adoption and use of EHRs.
More than 150 EHR products have been certified by CCHIT since CCHIT’s inception two years ago, representing more than 75% of the EHR marketplace. In fact, fifty percent or more of inpatient systems are going to be certified within this first year of certification. CCHIT’s certification process has been widely accepted by professional organizations and HIT vendors. There has been major progress in EHR interoperability, and a CCHIT-certified EHR purchased in 2008 will be a system that can send and receive a clinical summary to another doctor or to a hospital.
CCHIT’s roadmap for the future includes (1) expanding HIT certification to new healthcare domains (emergency department EHR, cardiovascular medicine, child health, behavioral health, long-term care); (2) increasing depth in established domains (ambulatory EHR, inpatient EHR); (3) driving standards-based interoperability progressively into all certified HIT systems; (4) enhancing the technical robustness and automation of certification inspection and testing; and (5) enhancing outreach and communication to health care providers and HIT vendors to raise confidence in HIT investment and increase the rate of successful adoptions (e.g., via the launch of a new Web site to help educate physicians called EHRDecisions.com).
Dr. Leavitt concluded his presentation with two slides illustrating the importance of optimizing the degree of data structuring in EHRs so as to maximize the usefulness and usability of EHRs. He stressed that it’s important to have structure only where it really pays off. Dr. Leavitt believes that the work that HITSP and CCHIT have done has already hit the “sweet spot” in terms of structuring information about problems, medications, allergies, lab values, vital signs, and procedures.
Discussion of Financial Incentives for Sharing Information. In response to a question from Dr. Perlin, Dr. Leavitt emphasized that what is most needed now to drive the adoption and use of EHRs are financial (and other) incentives for health care providers to share information from EHRs. He stated that incentives for EHR adoption have begun to emerge in both the public and private sectors, but without incentives for sharing information, people may adopt EHRs solely to make their offices more efficient. Unless health care providers use HIT to exchange information with entities outside their own offices, the potential benefits of HIT will not be realized.
b. HITSP Chair John Halamka’s Perspectives
Dr. Halamka described the state of HITSP interoperability standards for what he considers the basic EHR data set: problem list, medications, allergies, notes and reports, laboratory values, radiology (reports and images), EKGs (reports and wave forms), and vital signs. He reported that HITSP has addressed standards for the interoperability of many of the basic EHR data items using the HL7 Continuity of Care Document (CCD) and a few other standards.
The CCD summarizes the most commonly needed pertinent information about an individual’s current and past health status in a form that can be shared by all computer applications. It includes a problem list, medications, allergies, free-text notes, lab values for transmission from an EHR to a personal health record, vital signs, and other items. Dr. Halamka proposed using the CCD as the basic data set for exchanging information among health care providers’ EHRs, as well as for exchanging information for secondary uses such quality measurement, biosurveillance, and public health reporting. He noted that this use of the CCD might help drive the adoption and use of EHR products. Some interoperability standards for the data in the basic EHR data set that are not covered in the CCD, but HITSP is working on these now. Although the CCD can transmit a lab value from an EHR to a personal health record, it is not intended to transmit data from a commercial lab to an EHR. HITSP has done messaging standards that allow a lab message to go from commercial lab to an EHR (HL7 2.5.1 standard), but there are still some issues that remain to be worked out.
Interoperability standards for radiology reports and images are now being addressed by HITSP as part of AHIC’s transfers of care and coordination use case. Electrocardiograms (EKGs) have not been included in AHIC use cases to date, but developing standards for the EKG report and numerics will be fairly easy for HITSP. The challenge will be figuring out how to represent the EKG waveform in a standard way. Dr. Halamka said he expects that in about 3 years, the “low hanging fruit” will be standardized and incorporated into CCHIT’s certification criteria, and EHRs will have a much greater degree of interoperability than we have today.
Discussion of HIT Interoperability Standards. Dr. Halamka and Dr. Leavitt emphasized that the goal should be to have the minimum set of necessary HIT standards needed to be able to have interoperable health information. Rather than the quantity of HIT standards, what should be measured is the richness of clinical information flowing between providers, the reduction in patient risk and medical errors, and the improvement in quality and convenience.
Dr. Bob Dolin emphasized that that the foundation of interoperability should not be standards for data elements, but standards for narrative documents such as patient history and physical consultations. The strategy HL7 has been taking with the Clinical Document Architecture and with the CCD is first to make sure there is a narrative base, then to start chipping away at high-priority data elements. Dr. Dolin suggested that it would be reasonable to try to further standardize the Clinical Document Architecturewhich defines a standard for the computer representation of clinical notes such as clinician progress notes, discharge summaries, consultationsand maybe take it through HITSP.
4. Discussion of AHIC’s 2009 Use Case Extensions and GapsDr. Bell
Dr. Bell showed a slide listing the AHIC vote on candidate 2009 use case extensions/gaps and noted that AHIC voted that if 5 out of 10 voters agreed that a proposed use case extension or gap was a high priority, then it would be considered. She asked EHR WG members to consider whether the use case priorities they recommended in December 2007 were adequately represented in the 2009 AHIC use cases that are going forward. Time was running short, however, so Dr. Bell indicated that ONC staff would figure out where the EHR WG’s use case priorities fit into the 2009 AHIC use cases.
Staff Action Item #2: Figure out how best to accommodate the EHR WG’s recommended priorities for AHIC use cases identified in December 2007 within the 2009 AHIC use cases that are going forward.
5. EHR WG Gap Analysis and Planning for the Transition to AHIC 2.0Dr. Bell, Dr. Perlin, and Ms. Gelinas
Ms. Gelinas, who is co-chairing AHIC 2.0’s Transition Group, noted that this planning group is very dependent on current AHIC workgroups’ saying what they want to have done in AHIC 2.0. Dr. Bell stated that four EHR activities related to transition planning were listed on page 8 of a “predecisional” document entitled “Electronic Health Records Workgroup Summary,” prepared by ONC staff:
1. Track all recommendations to date. Dr. Bell asked EHR WG members to review the document prepared by ONC staff entitled “Summary of AHIC EHR WG Recommendations as of April 2008” and identify any recommendations that need to be extended or worked on.
2. Analyze past EHR WG testimony. Dr. Bell asked EHR WG members to review the document prepared by ONC staff entitled “AHIC EHR WG Testimony Summary2006, 2007, and 2008” and comment on whether any additional testimony might be needed.
3. Develop materials for AHIC 2.0 as needed. Dr. Bell asked EHR WG members to review and comment on the document prepared by ONC staff entitled “Draft AHIC 2.0 Transition EHR Workgroup SummariesApril 21, 2008.”
4. Provide input to AHIC 2.0 based on the body of work of the EHR WG.
Some EHR WG members reported that they had not received the “predecisional document” that Dr. Bell was referring to. For that reason, and because time was running short, it was agreed that ONC staff would take comments on the EHR WG summary and planning documents offline, then update them as needed, so the EHR WG could discuss and come to agreement on these documents at its next meeting on May 21, 2008.
Staff Action Item #3: Solicit comments on the EHR WG predecisional summary and other planning documents prepared by ONC staff offline, then update the documents as needed, so that EHR WG members can consider them and come to agreement on these documents at the EHR WG’s meeting on May 21, 2008.
Dr. Perlin, who is co-chairing AHIC 2.0’s Membership Group, reported that the Membership Group has looked at four buckets of work: (1) standards; (2) creating momentum for advancing implementation; (3) National Health Information Network realization; and (4) improving health outcomes. Dr. Perlin said these buckets are very useful when one combines them with principles or meta-messages such as the following: (1) financial incentives for sharing information are important for accelerating the use of EHRs (Dr. Leavitt’s point); (2) the ideal is to have the minimum set of necessary HIT standards needed to be able to have interoperable health information (Dr. Halamka’s point); and (3) it is important to establish priorities that offer rapid return and greater payoff. Ms. Gelinas suggested that the EHR WG use the framework suggested by Dr. Perlin to discuss meta-messages at the EHR WG’s next meeting.
CONCLUDING REMARKS
There were no public comments, and Ms. Sparrow noted that the date of the next AHIC meeting has been changed to June 3rd, a week earlier than originally scheduled. The next EHR WG meeting will be Wednesday, May 21, 2008. Dr. Bell indicated that ONC staff would solicit ideas for agenda items for the EHR WG’s next Web conference offline.
Staff Action Item #4: Solicit EHR WG members’ ideas via e-mail for suggestions for agenda items for the EHR WG’s May 21, 2008, meeting.
SUMMARY OF ACTION ITEMS
Staff Action Item #1: Send EHR WG members information about opportunities for public comment on the transition to AHIC’s successor AHIC 2.0.
Staff Action Item #2: Figure out how best to accommodate the EHR WG’s recommended priorities for AHIC use cases identified in December 2007 within the 2009 AHIC use cases that are going forward.
Staff Action Item #3: Solicit comments on the EHR WG predecisional summary and other planning documents prepared by ONC staff offline, then update the documents as needed, so that EHR WG members can consider them and come to agreement on these documents at the EHR WG’s meeting on May 21, 2008.
Staff Action Item #4: Solicit EHR WG members’ ideas via e-mail for suggestions for agenda items for the EHR WG’s May 21, 2008, meeting.
MEETING MATERIALS
Agenda
DRAFT Meeting Summary (February 12, 2008, Meeting)
Middleton - Ad Hoc Clinical Decision Support Update”
Leavitt/Ray - Update on CCHIT for the AHIC EHR Work Group
Loonsk - Candidate 2009 Use Case Extensions/Gaps (presented by Dr. Bell)
Letter to HHS Secretary Michael Leavitt with the Ad Hoc Clinical Decision Support Planning Group’s recommendations (April 22, 2008)
Cronin - American Health Information CommunityApril 22, 2008
Summary of AHIC EHR WG Recommendations as of April 2008
AHIC EHR WG Testimony Summary2006, 2007, and 2008
Draft AHIC 2.0 Transition EHR Workgroup SummariesApril 21, 2008
Electronic Health Records Workgroup
Members and Designees Participating in the Web Conference
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Co-chairs |
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Lillee Gelinas |
VHA, Inc. |
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Jonathan Perlin |
Hospital Corporation of America |
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Office of the National Coordinator for Health Information Technology Staff |
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Karen Bell |
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Alicia Bradford |
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John Loonsk |
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Members and Designees |
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Bonnie Anton |
University of Pittsburgh Medical Center |
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Nahn Do |
Department of Defense |
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Peter Elkin |
Mayo Clinic |
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Catherine Hoang (for Linda Fischetti) |
Veterans Health Administration |
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Jason Kreuter (for Richard Hayes) |
American College of Cardiology |
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Howard Isenstein (for Charles Kahn) |
Federation of American Hospitals |
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Robert Juhasz |
American Osteopathic Association |
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Blackford Middleton |
Partners Healthcare System |
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Mike Kappel (for Pam Pure) |
McKesson |
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Robert Smith |
Veterans Health Administration |
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Presenters |
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John Halamka and Robert Dolin |
Healthcare Information Technology Standards Panel (HITSP) |
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Mark Leavitt |
Certification Commission for Healthcare Information Technology (CCHIT) |
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Blackford Middleton |
Partners HealthCare System |
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