What Lies Ahead for ONC: Meaningful Use and Beyond

In this presentation Farzad Mostashari focuses on the strategy, principles and future direction of the Office of the National Coordinator for Health Information Technology. He outlines the notable health IT trends over the best year and gives and overview of the current efforts of the Office of the National Coordinator for Health Information Technology (ONC). He then goes on to show a future for healthcare in this country that is technology enabled and patient centered. This is an outstanding talk that is well worth your time...

What Lies Ahead for ONC: Meaningful Use and Beyond

Farzad Mostashari, MD, ScM serves as National Coordinator for Health Information Technology within the Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services. Farzad joined ONC in July 2009.

Previously, he served at the New York City Department of Health and Mental Hygiene as Assistant Commissioner for the Primary Care Information Project, where he facilitated the adoption of prevention-oriented health information technology by over 1,500 providers in underserved communities. Dr. Mostashari also led the Centers for Disease Control and Prevention (CDC) funded NYC Center of Excellence in Public Health Informatics and an Agency for Healthcare Research and Quality funded project focused on quality measurement at the point of care. Prior to this he established the Bureau of Epidemiology Services at the NYC Department of Health, charged with providing epidemiologic and statistical expertise and data for decision making to the health department.

He did his graduate training at the Harvard School of Public Health and Yale Medical School, internal medicine residency at Massachusetts General Hospital, and completed the CDC’s Epidemic Intelligence Service. He was one of the lead investigators in the outbreaks of West Nile Virus and anthrax in New York City, and among the first developers of real-time electronic disease surveillance systems nationwide.

He gave an overview of this talk, Ignite style, at the first Health Foo in Cambridge, Massachusetts. This is a great synopsis and a brilliant Ignite talk...

New Top Level Domains and Healthcare Implications

The Internet is about to get a whole lot bigger...

The Internet Corporation for Assigned Names and Numbers (ICANN) after years of discussion has finally decided to allow new custom generic top-level domains. Applications for the first round will open on January 12, 2012 and will close on April 12, 2012. New gTLD’s should be operational by November 2013.

Top Level Domians (TLDs) with two letters (such as .de, .mx, and .jp) have been established for over 250 countries and external territories and are referred to as "country-code" TLDs or "ccTLDs". They are delegated to designated managers, who operate the ccTLDs according to local policies that are adapted to best meet the economic, cultural, linguistic, and legal circumstances of the country or territory involved. Most TLDs with three or more characters are referred to as "generic" TLDs, or "gTLDs". In the 1980s, seven gTLDs (.com, .edu, .gov, .int, .mil, .net, and .org) were created. Domain names may be registered in three of these (.com, .net, and .org) without restriction; the other four have limited purposes. Now there will be waves of new gTLDs available for almost every conceivable purpose.

This could open things up quite a bit as anyone will be able to register virtually any word or phrase in almost any language or script as a gTLD. This could also provide some additional level of security for some industries. As David Talbot said in the MIT Technology Review:

A specialized top-level domain such as .bank might be secured with domain name security called DNS-SEC which verifies that a domain name seen by a user corresponds to the numerical computer address assigned to a bank's servers. This would require an additional vetting process for any company that applied for a .bank domain name. But then users could feel particularly confident that the site they are viewing is legitimate.

While there are concerns that new Top Level Domains could introduce confusion and possible security risks, I still think that there are some potential benefits and the risks could be mitigated. For one thing the $185,000.00 non-refundable cost would be a barrier. I am also confident that ICANN will have strong policies in place and agree that they are making the right move. This will ultimately be a good thing for the Internet.

I and some others have proposed for some time that healthcare would benefit from a gTLD of it's own. At the time Wes Rishel made some good arguments against the idea on his blog, but I have still thought that the idea has merit. As John Halamka points out on his blog the HIT Standards Committee has reconsidered a Top Level Domain for healthcare but it was decided that this may be considered in the future, but there is no need to implement one now. I would say that if there are going to be plans to implement this in the future the time to begin planning is now.



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Statewide Health Information Exchange: Becoming Operational

The 2011 State Healthcare IT Connect Summit held June 21-23, 2011 examined the role of state health IT modernization and transformation at the intersection of HITECH and State Health Reform. At the summit, policymakers and leading HIT strategists provided critical insights into state health IT's function at the intersection of HITECH and health reform. Administrators of leading edge Accountable Care Organization pilots and the associated technology infrastructures presented their experiences, and health IT experts looked at the developing role of statewide health information exchange and Regional Extension Centers as the supporting infrastructure for quality improvements and reform.

The session below from June 23, 2011 was on operationalizing Statewide HIE and gives some excellent insights into strategies that states are using to enable robust health information exchange capabilities in their states. One of the presenters is Carol Robinson from Oregon. Carol is currently serving as the State Coordinator of Health Information Technology for Oregon and is also the Director of the Health Information Technology Oversight Council (HITOC). Prior to her current appointment, she served Governor Kulongoski as the Interim Executive Director of the Oregon Health Fund Board during the 2009 legislative session. In that position, she led the political effort that resulted in the passage of HB2009, Oregon’s renowned health reform bill. From 2006-2009, Robinson held the post of Executive Director of Oregon Health Forum, where she also served as publisher of Oregon Health News. Robinson’s background spans both business and grassroots activism. She worked from 2003-2006 as Director of Public Relations and Development for Oregon Business Association, assisting many of Oregon’s leading employers develop consensus policy positions on issues including health care, renewable energy, state finance and education. She was an active force in the 1999, 2001 and 2003 legislative sessions, working with public school advocates and education organizations and she currently serves on the Advisory Board for the Center for Women in Politics and Policy at Portland State University.

Statewide Health Information Exchange: Becoming Operational

Metadata Power Team Recommendations

The Metadata Power Team has developed exchange use cases that link meaningful use and the report from PCAST (President’s Council of Advisors on Science and Technology), where they intersect at the importance of engaging the patient. The PCAST report called for a universal exchange language, which is an extensible markup-like (XML) language, and other standards to enable healthcare providers to share health information more reliably and effectively in order to modernize and coordinate patient care. PCAST's report also proposed that health data be separated into the smallest individual pieces that make sense to exchange. These data elements would be accompanied by a mandatory metadata tag or minimal standards that describe the data and the patient’s preferences for the data’s uses and security and privacy protections. The Power Team was charged to identify metadata elements and standards for three areas: Patient Identity, Provenance, and Privacy.

Dr. John Halamka gave a great overview of the metadata discussion on his blog:

Stan Huff led the metadata discussion and reviewed the work that has been done to date on patient ID and provenance standards. For patient ID, we considered many options but selected a very simple XML construct based on a streamlined CDA R2 header. This XML has nothing healthcare specific such as OIDs in it. For provenance, we considered many options but selected a very simple XML construct based on a streamlined CDA R2 header and X.509 certificates for digital signature. The signature could be an institution, a department, or an individual, as needed by the use case. For Privacy we considered many options and recommended a CDA R2 Header with a simple vocabulary to indicate that sensitive data is present. The list of sensitive data types could include mental illness, substance abuse, sexually transmitted disease data, HIV data, domestic violence data etc. or it could be a simple indicator that sensitive data is present. Specifying such a vocabulary is future work.

A robust discussion followed about privacy flags. Here are important clarifications:

1. During transmission, the envelope of metadata plus the payload of content is fully encrypted and so the metadata is not readable until it arrives inside the organization or to the person authorized to read it.
2. Much of the time, no privacy flags are needed because the patient will be the source of the data and will elect what to disclose to whom. Privacy flags would likely be needed when data is assembled from multiple sources and is received by a provider who needs to obtain special consent before viewing it or apply special protections before storing it.
3. A privacy flag would enable data to be automatically routed to specially protected areas of the EHR.
4. The CDA R2 header standards are used millions of times per day throughout the world but this subset of them and constrained specifications of how/when they are used should be tested before regulations require them for specific transactions.
5. The recommendation to use CDA R2 headers for metadata is the beginning of a formal ONC process to seek comment, feedback and stakeholder engagement regarding their use.

Based on all these clarifications, the HIT Standards Committee approved the use CDA R2 header for metadata as a formal recommendation to ONC as it begins the NPRM process.

Below is the slide deck and audio from the Metadata Power Team presentation at the June 22, 2011 HIT Standards Committee meeting: