Full Speed with Due Deliberation

We live our lives somewhere between fibrillation and asystole.  The thought occurred to me while listening to the Health Information Technology Standards Committee call earlier this week. 

As we know, the HITSC and the Office of the National Coordinator’s Standards and Interoperability Framework (SIF) teams have been on a frenetic pace to deliver new standards, implementation guides and certification criteria for ONC and CMS to use in regulations for Stage 2 EHR certification and meaningful use incentives.  The August call was a heads-up on what will be formally presented for approval at the September meeting.

New recommendations were advanced for

• limiting code set options in clinical quality reporting to SNOMED CT and LOINC;
• providing patient mapping best practices;
• unifying public health reporting around HL7 2.5.1 messaging even while developing a new 2.5.1 implementation guide for reporting lab results for ambulatory care;
• using a hybrid solution to provider directory services for Direct; and
• selecting the HL7 Clinical Document Architecture and a new clinical information model as the basis for clinical summaries used in all transitions of care. 

These represented a remarkable body of work that has been completed over the last four to seven months.

Yet, throughout the call, the feedback was to slow down, as these recommendations may not be ready for primetime regulations. 

Any move to exclusive use of SNOMED CT would require extensive mapping from many existing data sources that use CPT-4, ICD-9 or HCPCS and an extended transition period, particularly for smaller and less-sophisticated provider organizations. 

Patient mapping recommendations were offered as best practices, suitable for local evaluation, not federal regulations. 

There is no implementation guide for physician practices for reporting immunizations using HL7 2.5.1, so maybe it should be, at best, optional in Stage 2. 

While the recommendations for provider directories met the Direct use case needs with known electronic addresses, they did not meet a more general need for finding electronic services. 

Should there be different directory standards for Direct and the NwHIN Exchange transports?  In any case, the hybrid solution of DNS and LDAP must be worked out. 

The new lab results implementation guide will include constraints to use SNOMED for specimens and UCUM for values.  But the initiative team also recommended that both undergo 12-to 24-month pilots to assure the industry and its CLIA regulators find them workable. The introduction of a new clinical information model and adoption of the traditional CDA may not align or may even block other key initiatives, such as Green CDA, not yet ready for adoption.

Finally, the Committee’s Implementation Workgroup provided a list of reasons why the certification and meaningful use initiatives should slow down in order for EHR vendors to modify their applications and for their provider customers to implement these modifications into their workflow.  Nominally, the recommendation to delay the start of MU Stage 2 requirements until Jan. 1, 2014, while targeting July 2012 for final Stage 2 regulations for certification and incentives, provides an 18-month period for industry to gear up. 

If most of the newly recommended standards, implementation guides and certification criteria must either go through pilots and trials or be subject to an extended transition period, how can they be enshrined in the regulations being developed today while protecting the necessary time to assure successful adoption? 

In next month’s Standards Insight, we will look at dynamic systems, such as the national health IT initiatives, under stress and try to discern the path forward hopefully somewhere between asystole and fibrillation.