The ONC 10 Year Vision

John D. HalamkaOn June 5th 2014, ONC released  “Connecting Health and Care for the Nation: a 10-Year Vision to Achieve an Interoperable Health IT Infrastructure." The plan is divided in 3 year goals, 6 year goals, and 10 year goals. Five specific tactics support the strategies.

Below is a summary of the report and a few comments from my Massachusetts experience that support the reasonableness of the ONC goals. Based on the trajectory of current technology and policy, I’m confident we can achieve these milestones. One caveat - since Meaningful Use Stage 3 takes effect in 2017, three years from now, we will need to adjust the scope and focus of Stage 3 to align with the ONC three year goals. I’ve written in previous posts that we should simplify future stages of Meaningful Use to less than 10 policy goals, highlighting interoperability, without being overly prescriptive. The ONC Vision gives us the opportunity to do that.

Three-Year Agenda: Send, Receive, Find, and Use Health Information to Improve Health Care Quality

1.  Ensure that individuals and care providers can send, receive, find, and use a basic set of essential health information. This requires the ability to appropriately search for and retrieve health information, in addition to point-to-point information sharing.

Massachusetts has already built statewide Direct gateways for transport of payloads from one location to another. The Commonwealth is also live with a master citizen index, relationship locator service, consent repository, and the necessary web services/standards to support query/retrieve workflows. We stand ready to share 100% of our implementation guides with the HIT Standards Committee and ONC. I know that the send, receive, find, and use goal is achievable in three years, because Massachusetts is in production with the functionality today.

2.  Address critical issues such as data provenance, data quality/reliability, and patient matching.

As with the first goal, the state government of Massachusetts has already implemented statewide patient data matching and a team to support demographic data cleanup.   BIDMC has worked with the Massachusetts eHealth collaborative to build a community-wide Quality Data Center that successful merges CCDAs from the state HIE, taking into account data provenance,  patient matching and data quality issues. We’ve experienced the operational realities of maintaining a public utility for patient identity management and data normalization, so we know it is possible to achieve at scale.

3.  Enhance trust by addressing key privacy, security, and business policy and practice challenges to advance secure, authorized health information exchange across existing networks.

Massachusetts has established a set of HISP to HISP connections using a combination of whitelists and blacklists. Our approach has become simpler over time, shaped by the experience of day to day operations. I am confident that a trust fabric of federated networks is possible without overcomplicating the technology and policy.

Six-Year Agenda: Use Information to Improve Health Care Quality and Lower Cost

1.  Enable individuals to be active participants in managing their care as an important contributor of information to the health record (e.g., patient experience, self-rated health, and self-generated data).

Since 1999, Beth Israel Deaconess has been gathering patient generated data in its PHR and EHR. Massachusetts  has already connected sources of patient generated data to the health information exchange, delivering data from cloud-hosted consumer applications to the BIDMC EHR. I’ve reviewed the Apple Healthkit technology and am confident it can serve as healthcare device middleware in the home. I look forward to working with Apple on the terminology standards for HealthKit that will enable semantic interoperability between patients and providers.

2.  Multi-payer claims databases, clinical data registries, and other data aggregators will incrementally become more integrated as part of an interoperable technology ecosystem.

As mentioned above, BIDMC has aggregated clinical and financial transactions for its ACO in a community wide quality data center connected to the health information exchange. We’ve sent over 2 million transactions from EHRs through the HIE to the data center and are confident that the all payer claims database, registries, and quality reporting goals in ONC’s Vision are achievable.

3.  As value-based payment gains traction across Medicare, Medicaid, and commercial payers and purchasers, there will be new methods of measuring clinical quality that represent the most important aspects of care delivery and health outcomes.

Massachusetts stakeholders agree that current quality measurement methods are insufficient. BIDMC’s approach has been to send clinical observations, in the millions, to a third party cloud hosted solution which has the agility to compute all measures for ACO reporting, PQRS reporting, and pay for performance reporting. We do not need hardcoded quality measures in our EHRs and the cloud hosted approach provides low cost and high value. ONC’s vision is the right one.

10-Year Agenda: The Learning Health System

1.  More standardized data collection, sharing, and aggregation for patient-centered outcomes research.

All the hospitals associated with Harvard have implemented I2B2 for federated query of clinical data in support of outcomes research. The ONC QueryHealth project in the Standards and Interoperability framework leverages the I2B2 experience. Hundreds of studies and thousands of queries have already been enabled by I2B2, so this is achievable.

2.  Clinical decision support that is widely available to all stakeholders

BIDMC has implemented cloud hosted, centrally curated, decision support in several contexts including radiology ordering (with lab ordering currently in progress). As suggested by ONC HealtheDecisions project in the Standards and Interoperability framework, we send questions to the cloud and receive knowledge as a response.    This works today and is definitely achievable in commercial EHR within 10 years.

3.  Clinical trials, public health surveillance, and evidence available at the point of care

Massachusetts has connected all of its public health data gathering and reporting functionality to the state HIE. The Meaningful Use transactions (immunizations, syndromic surveillance, reportable lab) are already in live production. We are beginning work on query/retrieve of public health data (prescription drug monitoring program, immunization history), so I know this will be ready in 10 years.

The tactics listed by ONC include

1.  Core technical standards and functions - although Meaningful Use includes most of the content, vocabulary and transport standards needed to support the ONC vision, there are a few gaps to fill. Massachusetts has already filled some of the gaps, so I’m confident the standards can be ready.

2.   Certification to support adoption and optimization of health IT products and services - the concept of certification is good. Now that ONC has reorganized and those writing the regulation will be responsible for certification and testing, I’m confident that the certification challenges of the past can be overcome.

3.  Privacy and security protections for health information - with increased Office of Civil Rights enforcement of the HIPAA Omnibus Rule, healthcare organizations throughout the country are building privacy educational programs and enhancing information security staffing, so the industry will be ready for new requirements.

4.  Support business, clinical, cultural, and regulatory environment - To me, the one great challenge of Meaningful Use Stage 2 has been the readiness of the cultural environment for such requirements as community wide transition of care summary exchange. ONC’s focus on the ecosystem as well as policy/technology is welcome.

5.  Rules of engagement and governance of health information exchange - Each state has implemented its own rules of the road. Massachusetts has solved its consent policy issues, but those solutions are different than other New England states. I do not expect ONC to establish a single set of policies for the country, but a framework for policy development and governance would be very helpful.

ONC has done a good job with this vision statement, outlining a series of stepwise goals, reducing the scope of its projects so that existing staff/budgets can be applied at greater depth to fewer initiatives. I look forward to being a part of the process.