ONC's Mostashari: 'We can't afford to wait another 5 years before we have exchange'

By Mary Mosquera
04:48 PM

Dr. Farzad Mostashari, the national health IT coordinator, urged the Health IT Standards Committee to lean forward with standards that are “good enough” to get started on robust health information exchange instead of waiting until they gain maturity and wide adoption.

The lack of transport standards is one of the biggest barriers to providers’ sharing information on a national scale, he said. And it is holding back recognition of the progress made in stage 1 of meaningful use. Currently, exchange occurs mainly through proprietary exchange technology formats and Health Level 7 standards. 

[Q&A: Between the lines of NEJM's EHR report, 'trust trumps tech'.]

Yet stage 2 meaningful use requirements will call for more complex health information exchange, he said at the Sept. 28 standards committee meeting, which advises the Office of the National Coordinator for Health IT (ONC). Providers need a portfolio of standards, tools and services to meet exchange goals.

“My request to you is to push. There is a sense in which not moving on anything is a greater risk than moving forward on something that may be imperfect,” Mostashari said. “We can’t afford to wait another five years before we have exchange in this country.” 

The committee wrestled with how to scale nationally the specifications for the nationwide health information network (NwHIN Exchange) and aspects of how data moves. NwHIN is the set of standards and services that enable typically large organizations and federal agencies to share information securely through the Internet. ONC wants to expand NwHIN Exchange participation.

The NwHIN team explored “if we were to adopt today standards for nationwide use, what seems directionally good enough for that particular purpose and what needs more work,” said Dr. John Halamka, committee co-chair and CIO of Beth Israel Deaconess Medical Center. The group provided its best observations and evaluation of what is available.

Standards, services and policies for NwHIN Exchange must be deployable within an architectural framework capable enough to support secure information exchange at a national scale. “The building blocks have to fit and operate within an architectural framework,” said Dixie Baker, NwHIN team lead and SAIC senior vice president and chief technology officer for health solutions.

NwHIN standards, services and policies need to address transport, security and the content using standards for clinical documents and controlled vocabulary. Structured clinical documents and controlled vocabulary should be equally valuable regardless of what transport is used, whether it’s Direct or Exchange transport or some other transport down the line, she said. 

“That is really, really important for interoperability,” Baker said. Direct Project is the streamlined version of NwHIN for point-to-point sharing. However, neither NwHIN Exchange nor Direct Project is deployed widely.

In other areas, the committee endorsed standards around certain measures and specifications for establishing them to support advanced functions for electronic health records (EHRs). A single guide for describing how to implement a standard will decrease variation and enable successful health information exchange.

“We have come up with standards that exist and which meet criteria for being good enough for prime time today. In the future, there will be others, and it will be a continuous evolution,” Halamka said.

[See also: Mapping the future of NwHIN.]

Among its recommendations, the committee endorsed implementation specifications for syndromic surveillance shared with public health departments, one standard per domain and one implementation guide per standard. For electronic prescribing of medications upon discharge from the hospital, the group supported aligning meaningful use guidance for use of HL7 versions with Medicare Part D requirements.

The committee will transmit its recommendations to ONC, which could incorporate them in the proposed rule for comment for stage 2 meaningful use standards and certification.