Where to start ?

On April 27, 2004, by executive order President Bush established the Position of the National Health Information Technology Coordinator (NCHIT) reporting to the Secretary of Health and Human Services. NCHIT's mission is to serve as the Secretary's principle advisor on the development, application, and use of health information technology.

This includes the following key goals:

1. Oversee the coordination of the Department of Health and Human Services' (HHS) health information technology programs.
2. Ensure that HHS health information technology policy and programs are coordinated with those of other relevant executive branch agencies.
3. Oversee the development, maintenance and implementation of a strategic plan to guide the nationwide implementation of interoperable health information technology in both the public and private health care sectors. Known as the National Health Information Network or NHIN, this technology would have the goal of providing useful and appropriate information to guide medical decisions at the time and place of care, improving care delivery and reducing cost.

Sound easy? Consider this. In the overwhelming response to a Request for Information for what would be needed to build the NHIN, standards stood out as the number one roadblock to success. Why? Because even if your provider organization is fortunate enough to have an electronic medical record application, chances are they cannot communicate with other systems external to their implementation. The reason is historic. EMR vendor competition tended to lead software development into focusing on digitizing the patient record and not on interoperability. Conversely, provider organizations while acknowledging the benefits of an electronic record within their organization, has viewed the external communication of such information with apprehension. Privacy issues, considerable cost, data integrity, and loss of control have been often cited. At a time when provider organizations are forced to watch every dollar spent on technology, interoperability with external systems have simply not been a priority.

While the goals EMRs and interoperability with health information networks are not necessarily in conflict, for interoperability to be successful systems must be able to communicate with each other. It is therefore no surprise that much of the work pursued on the NHIN has focused on health information standards.

Fortunately, the news isn’t all bad. For years individual health systems have had the problem of communicating clinical, financial and administrative information electronically between internal disparate vendor applications. Classic examples include best of breed clinical systems passing information to patient financial applications or financial applications communicating with Human Resource applications. As simple peer-to-peer solutions grew to complex EAI applications, agreement on data information standards became necessary. This in turn led to the establishment of numerous standardization bodies to recommend subject domain standards. Key among these are:

• Health Level Seven (HL7) – ANSI accredited organization providing standards and methodologies for the communication of health information in several specific healthcare domains.
• Health Industry Business Communications Council (HIBCC) – ANSI accredited organization providing standards for the exchange of information among trading partners.
• International Organization for Standardization (ISO) – With representation from more than 140 countries ISO provides standards development for the global communication of information.
• Digital Imaging and Communications in Medicine (DICOM) – Provides standards for medical imaging.
• Logical Observation Identifiers Names and Codes (LOINC) – Provides universal identifiers for laboratory and other clinical observations.
• Systematized Nomenclature of Medicine (SNOMED) – Provides standardization for clinical terminology.
• Accreditation Standards Committee X12 (ASC X12) – Provides standards for the communication of electronic data.
• World Health Organization (WHO) – Provides international standards for the classification of diseases

To facilitate impartiality and ensure success, advocacy organizations from both the private and public sector have taken the lead in standards development. Leading the way are the Healthcare Information and Management Systems Society (HIMSS), the American Medical Association (AMA), American College of Radiologists (ACR), the governments Agency for Healthcare Research and Quality (AHRQ), and the American Nurses Association (ANA).

While the establishment of healthcare standards, their supporting bodies and advocacy groups are an important and necessary prerequisite, much more work is necessary for the NHIN to take shape. Issues related to the content or semantics of healthcare data will need to be resolved. This is especially true for clinical information and its management.

Finally, an overall agreement must be achieved on which standards will be used, how will they be implemented, and under what controls. Many believe that this will require the leadership of the federal government similar to the efforts behind the implementation of HIPAA. To this point the ONCHIT has tendered a number of requests for proposals related to healthcare interpretability.  One is specifically focused on the unification of healthcare standards.