Is a pattern emerging with regard to the push towards Meaningful Use of health information technology? In the effort to leverage HITECH to foster rapid change, are shortcuts being taken? What happened to the sequence of identifying objectives, exploring alternatives to achieving those objectives, selecting standards, testing those standards in pilots/demonstrations in practice, and ensuring that policies are in place and implementation guidance is available? In my post of October 10, I highlighted comments from people who testified at the HITPC Meaningful Use Workgroup meeting on October 5. My favorite quote from that day was by Chantal Worzala:
If Stage 1 was about getting it started, Stage 2 should be about getting it right.
So, it was with significant interest that I read a comment letter about another HHS effort being considered that does not seem ready for prime time.
The National Committee on Vital and Health Statistics (NCVHS) submitted comments last month about the Advanced Notice of Proposed Rule Making (ANPRM) from the Office of the National Coordinator for Health Information Technology (ONC) on “Metadata Standards to Support Nationwide Electronic Health Information Exchange.” For a definition of “metadata” see this Wikipedia entry. The ANPRM states that the term “metadata” is often used to mean:
… ‘‘data about data’’ or, in other words, ‘‘data that provides more information or detail about a piece of data.’’
For readers not familiar with the NCVHS, here is the NCVHS Charter. The following is from the Charter:
The Committee shall assist and advise the Secretary through the Department of Health and Human Services Data Council, on health data, statistics, privacy, national health information policy, and the Department’s strategy to best address those issues.
Published in the Federal Register on 8/9/11, the ANPRM’s immediate scope is stated as:
… the association of metadata with summary care records. More specifically, in the scenario where a patient obtains a summary care record from a health care provider’s electronic health record technology or requests for it to be transmitted to their personal health record.
As put in the NCVHS comments, the ANPRM:
… calls for the adoption of a series of proposed “metadata” standards to “tag” certain information to a patient’s electronic summary of care record before a provider discloses the summary to the patient or, upon the patient’s request, transmits the summary to his or her personal health record.
One of the reasons advanced for the importance of these standards in the ANPRM is the following — which is a very reasonable rationale:
… the HIT Policy Committee noted that if these metadata are available, they could potentially increase the level of trust that receiving providers would place in clinical information that they receive through patient-mediated exchange, such as from a PHR, and could enable patients to more easily sort and re-share their own health information.
The ANPRM also suggests that these standards could be part of Stage 2 of Meaningful Use.
[For a more technical description of the challenge (and his own opinion about the ANPRM), see Keith Boone’s blog post from August. Since Keith refers to the “flawed PCAST report,” readers might find Vince Kuraitis’ post from January 2011 on the Health Care Blog of interest as he summarizes some opinions about the President’s Council of Advisors on Science and Technology (PCAST) report that was released in December 2010.]
However, though seemingly a good idea, the overall NCVHS recommendation to ONC can be summed up in this statement from the comment letter:
Although metadata tagging has the potential to increase the reliability, dependability and trustworthiness of health information exchanges by including metadata descriptors about the data being exchanged, this approach is not in current use and there are no accepted standards for metadata tags. Consequently, we believe that it is premature to start the rulemaking process for metadata standards without having a better understanding of the current level of maturity of those standards, assessment of the degree to which they have been tested or even used in the industry, a careful analysis of possible unintended consequences, and, more importantly, a policy framework that defines their use.
The NCVHS also goes on to point out some of the challenges currently being faced by the health IT industry and providers:
We also agree with the concerns expressed by many commenters on the PCAST report regarding the timing of adoption of these recommendations. Industry and providers currently are focused on a number of time-sensitive initiatives, including Meaningful Use Stage 1, preparation for Meaningful Use Stage 2, the transition to updated administrative transactions and ICD-10 code sets, the implementation of new HIPAA standards and operating rules, and the move towards new forms of health care delivery and financing under the Affordable Care Act. Introducing yet to be tested standards in the midst of these initiatives would pose significant challenges and risks to the health care industry.
The reference to updating administrative transactions and ICD-10 is of particular interest given this week’s announcement by Medi-Cal that:
Due to the considerable complexities of this project, the short timeframe to convert the large group of electronic claim submitters and the competing priorities of the transition from HP Enterprise Services (the outgoing FI) to ACS, Medi-Cal is unlikely to meet the scheduled deadline of January 1, 2012 to accept the latest version of standard electronic health care transactions, including those for medical and prescription drug claims.
NCVHS also identifies significant privacy concerns with the concepts expressed in the ANPRM:
We are concerned that the ANRPM makes a number of technical and operational assumptions about how the system of privacy metadata tagging would work, many of which are yet untested and simply theoretical.
The fact that patients may be able to set their privacy preferences and entities will use metadata tags to attach such preferences to specific documents does not establish a legal requirement on the receivers of such documents to honor, acknowledge, accept or enforce such preferences. Instead, the proposed approach, in the absence of enforceable policies, will create unrealistic and unenforceable expectations among consumers that their choices are to be acknowledged and enforced equally and consistently across health care organizations.
What about other entities? Here’s a key statement from the American Hospital Association comment letter:
The AHA believes that inclusion of these standards in the Stage 2 meaningful use regulations would be premature in the absence of systematic evidence that they offer demonstrated benefits that outweigh the costs of implementation and are feasible for use in all care settings.
… and CHIME (College of Healthcare Information Management Executives):
CHIME believes that these and other initiatives hold promise, but that metadata standards being currently considered for use are underdeveloped. CHIME recommends that ONC investigate metadata standards using an inclusive volunteer network of technical experts established through the Standards & Interoperability (S&I) Framework.
So… whether it’s 5010, ICD-10, Meaningful Use Stages 2 (and 3), or metadata standards, are we seeing the same pattern? These are all well-intentioned efforts to move the United States healthcare system into the 21st century. Ideally, new requirements, functions, and deliverables would be methodically introduced in a sequenced, appropriately coordinated fashion according to a timeline that adjusts based on assessments of progress — and new expectations would only be layered on tested and firmly embedded standards, policies, and practices. Unfortunately, it seems that each wave of new ideas raises concerns similar to those regarding the prematurity of these metadata standards.
What do you think? Déjà vu all over again? How do we break this cycle?
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.