4/25/2006
Standards Harmonization: Music to Our Ears
Leslie Ann Fox, MA, RHIA, Patty Thierry Sheridan, MBA, RHIA, CCS
Thank you to Advance Magazine for permission to use this article

Leslie: Usually my eyes glaze over when I am about to hear a presentation on electronic health record (EHR) standards. However, when I heard John Halamka, MD, chair of the Health Information Technology Standards Panel (HITSP) speak at a recent American Health Information Management Association (AHIMA) industry briefing, I must admit I was in for a most pleasant surprise. While not quite an evening at the symphony, he spoke clearly and wisely about the Standards Harmonization Program, which brings a ray of hope that our industry will soon be adopting universal standards to ensure the integrity and interoperability of health data.

Patty: Over the past few months in this column we have been discussing the role of HIM in creating urgency for standards and providing leadership at the national and local levels. I'm sure our readers would like to know more about how this critically important issue is being addressed at the national level by AHIMA and others.

Leslie: In a recent conversation with Harry Rhodes of the AHIMA staff, I began to get a better understanding of the nature and extent of the standards issue. Let's share that conversation with our readers.

Patty: Harry can you tell us a little about the role that AHIMA is playing in the national standards work and why this is such a critical issue at this point in time?

Harry: Standards are critical to the future of EHRs and the desire for interoperability. What we have now is a whole lot of "black box thinking."

Leslie: What do you mean by that Harry?

Harry: People know what they want the EHR to do, but they either do not know or understand just how to achieve the results. For example, physicians want to be able to access all necessary patient information from a laptop anywhere. They think the regional health information organizations (RHIOs) should make it possible to go out on a network and find current, accurate and reliable patient information whenever they need it. Yet, a good number of physicians are not sure just how this health information will be made accessible. Hence the "black box thinking," I know what I want, I just don't know how to achieve the end result. For a national health information network (NHIN) to succeed, the contents of the EHR systems' black box must be revealed, understood, agreed upon and accepted.

Patty: I must say that is a great vision.

Harry: Yes, it is, but too many providers, vendors, physicians and even policy level people in the industry do not fully understand what still needs to be done with regard to the standards needed to achieve that vision.

Leslie: Do you think it is the scope of the issue that makes it so hard for us to wrap our brains around? Dr. Halamka says that more than a dozen standards-setting organizations—from American National Standards Institute (ANSI) accredited bodies to industry consortia and other forums—have developed a plethora of standards to meet the needs of specific sectors within the health information technology (HIT) market. He says the problem is that disparate messaging systems, data elements and vocabulary now prevent the cross system exchange of health information.

Harry: Yes, redundancy and overlap of effort is a big part of the problem. The last I heard, there are 12 different e-signature models, but no emerging standard. Patient identification is an example of an EHR functional element for which we don't have just one standard. Also, though many standards are already developed, they haven't been organized in a way that people can easily find them. For example, someone may ask a standards development organization to create a standard for tracking amendments and corrections thinking that such a standard does not yet exist. Yet if we knew where to look, lo and behold we find one already exists in ASTM, or HL7, or somewhere else, etc.

The point is that many of the standards that are needed have been developed by one of the many standard development organizations. What we haven't had up until now is an organized central body with organization and funding to help the industry leverage the work that has been done and to reach consensus on the best standards for a given function.

Patty: That's where HITSP and the "Standards Harmonization Program" comes in, right?

Harry: That's exactly right. The Office of the National Coordinator for Health Information Technology (ONCHIT) issued a request for proposal last June, "The Evaluation of Standards Harmonization Process for Health Information Technology," with the intent to bring together organizations with a stake in health data standards to develop a health information technology harmonization process. ANSI was awarded the contract and is responsible for the formation and governance of the HITSP.

Leslie: In describing HITSP, Dr. Halamka said at the AHIMA briefing that the panel brings together experts from organizations across the HIT community—from consumers to doctors, nurses and hospitals; from those who develop HIT products to those who use them; and from government agencies who monitor the U.S. health care system to those organizations who are actually writing the standards. All the stakeholders are empowered to make decisions by consensus. Everything HITSP does is transparent. All meetings are open and available through Web casts and all documents are on the Web.

Patty: HITSP members have committed themselves to setting and implementing standards that will ensure the integrity and interoperability of health data: 1) in some cases redundant or duplicative standards will be eliminated; 2) in other cases new standards may be established to span information gaps; and 3) in all cases, the resulting standards serve the consumer and other health care stakeholders by addressing issues such as data accessibility, privacy and security.

Leslie: Dr. Halamka stressed that the process is not about choosing winners and losers. It is about identifying and creating the clearest, least ambiguous standards possible to achieve data integrity and interoperability. Harmonizing content, structure and transmission methods are all within the HITSP scope to be able to achieve the interoperability that is part of the EHR vision.

Harry: They are developing the process based on "use case models." For example, a patient wants to create a personal health record (PHR) or wants to add to her electronic clipboard; a series of events and actions must occur to accomplish the desired result. The panel's technical committees would take the use case models that are developed and map standards to it. They would look at each event and action that exists in the process work flow and determine what needs to be done to capture information. The technical committee's members map the model use cases to existing standards, so they can see where there are standard redundancies or gaps.

Patty: With regard to the issue of gaps, I wonder why some standards are further along than others?

Harry: Some standards initiatives have just had more resources and time allocated to them than others. I didn't mean to imply that all standards that are needed already exist. Lots of standards still need to be developed, but for some standards there probably wasn't a group who identified the need, or if the need was identified, the resources weren't there to develop the standards. That is exactly why this coordinated national program is so critically important.

Leslie: Monitoring the activities around standards is another important role for HIM professionals who are involved, or who want to be actively involved in the EHR transformation initiatives in their organizations.

Harry: That's right Leslie. Think how valuable it would be to health care organizations to have an HIM professional on their team who has the big standards picture. Someone needs to be keeping track of all standards, knowing how to apply them, knowing which standard is used to move information around, which ones define data elements, etc.

Patty: We haven't really talked about ICD-10 yet. After all that is also a standard, a classification standard that has been adopted internationally, although the United States hasn't yet adopted it.

Leslie: Good point Patty. The ICD-10 issue underscores another interesting point that Dr. Halamka made at the briefing. When asked if the standards that his panel selects will be put out as regulations, he was very clear that putting the standards into government regulations was not the intent of the Standards Harmonization Process. It is too hard to change standards in a timely way when they are put into regulations or legislation. In a rapidly evolving area like HIT, we need an orderly process that enables the industry to continuously evolve standards by consensus.

Patty: I see his point. The use of the ICD-9-CM classification system as the standard for calculating reimbursement is in the government regulations and it requires either the Department of Health and Human Services (HHS) or an act of Congress to change that standard to ICD-10. That's why we are still using a 30-year-old classification system, which is outdated and obsolete.

Leslie: The day after the industry briefing, I had the opportunity to participate in AHIMA's Capital Hill Day, where approximately 140 members of the association had face-to-face appointments with senators, representatives or legislative aides. We asked them to support legislation that would adopt ICD-10. In the House of Representatives, we asked for support of HR4157, The Health Information Technology Promotion Act, which includes language for implementation of ICD-10.

If passed within the next month or two, ICD-10 could be required by 2009. In the Senate, they have already passed S1418, Wired for Health Care Quality Act, which does not include ICD-10. If HR4157 passes, then the bills will go to conference and we asked our senators to work with the House to add language that would require adoption of ICD-10 in the United States. We stressed in these appointments that outdated codes produce inaccurate and limited data.

Patty: Did you talk to people about the opposition to implementing ICD-10?

Leslie: Yes, some of the aides that we spoke with were concerned about positions that have been presented to them by other groups who assert that the change to ICD-10 will require a very costly overhaul of information systems, and that it is ill-timed, with the industry now preparing for the national provider identifier and other important IT changes. We acknowledged that there are competing priorities, but that the longer we wait to adopt ICD-10, the more costly it will become to implement. Just imagine all the physicians' offices that will implement EHR systems over the next 5 to 10 years, with a coding and billing component based on ICD-9-CM. They will barely be up and running when they will have to spend more money to change those systems.

Patty: Well, despite some opposition, there is clearly more and more support for upgrading to ICD-10 now. The American Hospital Association, the American Informatics Association, the Federation of American Hospitals and the National Association of Health Data Organizations are among the other organizations working with AHIMA to help the legislators understand how critical it is to adopt ICD-10 as soon as possible. What else can our readers do to support this legislation?

Leslie: We need to keep creating urgency about this issue. It would certainly help if every one who reads this column would immediately contact their representative and senators asking them to support legislation for ICD-10. AHIMA members can do this very easily by using the "Advocacy Assistant" on the AHIMA Web site, www.ahima.org. You can also find excellent resources for informing staff and colleagues at your institution about ICD-10 at www.ahima.org/icd10.

Patty: I want to thank Harry Rhodes for his help in enlightening us about the standards issues. And I want to thank all of the HIM professionals who gave their time to go to Capital Hill to lobby for our position on ICD-10. These are issues critical to our nation's health care system. We all need to understand them and to be able to speak confidently about them in our own spheres of influence.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president of Care Communications Inc., a national HIM consulting and staffing company headquartered in Chicago. They invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or pthierry@care-communications.com .