"Social Healthcare" and "Social HIT"

I considered a title of “Socialized Healthcare” as a play on words, just to get some attention. But I’m not talking about socialized medicine and government takeover of healthcare (I won’t touch politics with a 10 foot pole in this blog). Rather, I’m thinking about the implications of social networking and interactive communities. This is a big theme of the Health 2.0 community, of which I’ve attended an innovative and fascinating conference. “Patient engagement” – a key priority in the incentives for Meaningful Use (MU) – isn’t just about patients accessing their electronic health records, but also about interaction among a community of patients, caregivers, care providers, and others. People already “socialize” (talk about) their health quite a lot already, in some cases using IT (e.g., the Internet)!

A little-known fact about the Direct Project is that there was a “bake-off” among four exchange protocols: SMTP (e-mail transport***) chosen by consensus as the primary protocol, SOAP (web services as used by IHE) chosen as an option to bridge to many existing EHRs, REST (web services based on Internet HTTP protocol), and XMPP (the protocol used in Facebook). While XMPP wasn’t chosen, its consideration was intriguing. The state of existing technology adoption in healthcare IT, and the fitness to purpose were factors in reaching the decision, but there was recognition that new technologies could play a significant role in the future. So as healthcare itself becomes more interactive and collaborative, new enabling technologies will become more applicable.

***Caveat – I realize that Direct Project is not just “plain old e-mail” like most people are using, but e-mail is the easiest analogy to explain the Direct push pattern of information exchange.

The key question isn’t about protocols, but how persons and systems interact with each other. Generally speaking:

1. System-system interactions are called interoperability
2. Person-system interactions are called user interface
3. Person-person interactions (facilitated by IT) are sometimes called social networking

The first two have received much attention in discussions about MU. The last has not. Even though there are proposed Stage 2 or 3 Meaningful Use requirements such as uploading patient-sourced data, that’s one-way, not really interactive. Secure patient-provider messaging may be the closest MU requirement in the Person-person category.

While e-mail-style of interaction can appear semi-interactive (i.e., long threads), it’s less interactive than chat/instant messaging or Facebook. It matches those use cases that drove it (e.g., pushing referrals, discharge summaries, results, and immunization updates among known recipients). Facebook, in contrast, has push, pull, and publish/subscribe patterns all rolled together. I haven’t seen many use cases that imply more interactivity (though a few were mentioned in the XMPP link above), so I’d be interested if anyone could point out some.

I haven’t researched or pondered this subject enough to write in depth about it it yet, but foresee huge and possibly transformative potential there. My company’s CEO, John Glaser, said as much at the HIMSS HIT X.0 mini-conference. I look forward to learning more about the opportunities (use cases), technologies, and innovations in “Social Healthcare.”

That Harmonious Spring Break Happened

Well, my big piano recital event for which I had been practicing for a year occurred last weekend. I was happy to play, and now I'll be a little less intense for a while, before I start preparing for the MusicAppassionata piano festival in West Chester, PA August 1-6.

I've uploaded most of my recital performances to YouTube. To find them, search in YouTube for David Tao piano recital and they'll show up. The camcorder sound was compressed, meaning that the soft parts were made louder and the loud parts were softened, so there appears to be very little dynamic variation. Trust me, I actually can play soft, sometimes!

I've related music and its performance to interoperability several times in this blog. One thing that a recital teaches you is that things go awry that you totally didn't expect, but you move on. You can't anticipate everything about some keys making unwanted noises, wheel locks not preventing the piano from rolling away, slight movements in the audience causing a brief distraction and memory lapse, etc. Despite avoidance of sugar and caffeine, and conscious intent to stay under control (knowing adrenaline would amp me up anyway), I still played faster than planned. Similarly, implementing interoperability in the real world seldom goes as you envisioned it or as cleanly as what's written in the standards or even developed in a product, because each participant doesn't have control over the other participants' systems or the environment. But every time you do it, you learn and improve the next time.

Happy Memorial Day Holiday Weekend to everyone!

David

Certification Retrospective Part 4 – Lessons Learned

Note: this blog post concludes my discussion of experiences in CCHIT. The opinions are mine, and do not necessarily reflect the views of CCHIT or Siemens.

In life in general, and in development of software, standards, and certification criteria, we learn and grow more by trial and error than we do when everything goes smoothly. Frederic Brooks’ classic software engineering book The Mythical Man-Month said “Plan to throw one away; you will anyhow.“ Hence we need prototyping and iterative refinement. The CDA Consolidation Project is fresh on my mind. I voted negative in its HL7 ballot, but that doesn’t mean it won’t succeed, only that it has issues to fix. It would have been a miracle to get that complex task right the first time.

So it is with certification. The CCHIT Interoperability Workgroup (IOWG) experienced growing pains in its early years. 2006 produced only a roadmap, 2007 produced the first (modest) interoperability criteria. 2008 had stronger criteria and roadmap, and 2009 was poised to make big strides toward semantic interoperability. What were my main lessons learned through these years?

What We Got Right (IMHO):

• The “methodical march” sequence of building blocks. Putting the horse before the cart sure helps! As described in Method to our Madness?, we proposed a logical sequence for interoperability:

1. Data Capture
2. Liquidity
3. Standardized Content
4. Data Consumption

Our views crystallized especially in 2008-2009. CCHIT’s criteria included many of the standards that were eventually endorsed by ONC. For example, Lab Results, CCD, e-prescribing, vocabularies (LOINC, RxNorm, SNOMED CT), and leveraging HITSP.

• The Roadmap (“Glide Path”) Concept. I love maps (online, GPS, paper) and want to know ahead of time where I’m going and the milestones along the way. CCHIT published roadmaps for the next two years beyond each certification year. Roadmaps aimed to provide adequate lead time and to encourage developers to plan and head in the right direction. While the HIT Standards Committee did a great job proposing a “Glide Path” to more robust standards in their proposals in late 2009 (see Jamie Ferguson’s August 20th 2009 Clinical Operations Workgroup presentation), that concept was mostly lost when the ONC regulations were published (see comments on John Halamka’s Feb. 10, 2010 blog). For interoperability, developers need to know the target standards, more than a high-level meaningful use matrix, to move forward.
• Staying a Course. Once we defined the roadmap, we might adjust timing and provide more detailed criteria in our next development cycle, but overall there was continuity and stability with a minimum of “surprises.”
• Transparency. CCHIT posted responses to every public comment on its website. Of course not everyone would agree, but we thought everyone deserved to know their comments were considered and our rationale for decisions.
• Teamwork. The IOWG built relationships and trust among multiple stakeholders within CCHIT, as mentioned in Part 1. That enabled us to work through differences and get things done, despite conflicting opinions. In contrast, it’s harder to capture the “team” element in groups where 50-100 people are nominally on a project but attendance is sporadic, yet I understand the need for openness and transparency. Ultimately, a small group forms a cohesive team within the larger group. For example, the Documentation and Testing workgroup within the Direct Project gradually developed a “team” spirit similar to what the IOWG had.

Regrets:

• Lack of Opportunity to Finish What We Started. Last week I used football, now here’s my first baseball analogy. CCHIT, as the “starting pitcher” for EHR certification was relieved by ONC in the 6^th inning – enough to get a quality start, but not enough to win the game. Our methodical march didn’t reach its goal, but I hope that ONC will be a good “closer” to save the win for interoperable EHRs, coordination of care, and the good of the patient.
• Lack of End-to-End Coverage. Interoperability involves senders, receivers/requesters, and perhaps intermediaries. To succeed, it must encompass all participants (e.g., EHRs, HIEs, PHRs, labs, pharmacies, public agencies), because so much exchange goes beyond EHRs. We didn’t achieve this in CCHIT, but not for lack of trying! We envisioned covering some end-to-end interoperability through certification programs for HIEs and PHRs in addition to EHRs. Excellent people were in the HIE and PHR workgroups, and the IOWG had good dialogues with both. The HIE program was launched with poor uptake followed by suspension in light of impending ONC program changes. The PHR program was not launched.
• All-or-Nothing Approach. CCHIT pondered a modular certification approach early on, especially for inpatient EHRs, but didn’t implement it until ONC mandated it in the Certification Final Rule. In hindsight, I wish we had done that sooner. I don’t think we needed an “all or nothing” approach. Truth in labeling would have disclosed each product’s gaps, to help people make informed decisions. Vendors with complete EHR functionality could still differentiate themselves as a “one-stop shop” but others (“little guys”) would not be excluded from certification just because they didn’t provide 100% of all capabilities.
• A year in limbo. From mid-2009 through mid-2010, the industry was paralyzed by uncertainty and lost momentum on interoperability. It was clear that CCHIT criteria wouldn’t be adopted as is by ONC, but no one knew what would replace them. There was no assurance of staying a course or a clear glide path, and people who had done their best to follow the CCHIT roadmap were concerned and confused. Interoperability features (such as standardized coding and discrete data consumption) that the IOWG expected to be in products in 2010 have been delayed, possibly to MU Stages 2 or 3.

Whether right or regret, there are lessons learned that can be applied going forward.

• Follow the methodical march – a logical sequence of capture, liquidity, standardization, and consumption.
• Define a roadmap (glide path) with ample lead time.
• Stay the course.
• Take an end-to-end perspective.
• Be transparent.
• Be flexible, not “all or nothing.”

That’s it! This has been a long blog series, and if you made it to the end, thanks!

Certification Retrospective Part 3 – Controversies Along the Way

Note: this blog post continues my discussion of experiences in CCHIT. The opinions are mine only and do not necessarily reflect the views of CCHIT or Siemens. Please bear this in mind especially considering that the topic is “Controversies”

From my last Certification Retrospective post, I promised to share lessons learned and some “agonizing controversies” we faced in the CCHIT Interoperability workgroup (IOWG). I thought I could do both in one post, but now realize that I’ll need a “Fourth Movement” after this. Each controversy could easily take up a post of its own, but I’ll try to squeeze them into this post, deferring Lessons Learned to Part 4.

1. When should HITSP specs be incorporated into certification? Once HITSP was formed, it (not CCHIT) was designated to select standards. CCHIT, however, could decide when/if those standards would be certified, striking a difficult balance between supporting the federal strategy (HITSP was HHS-funded, CCHIT was partially HHS-funded) and yet being pragmatic. It would have been difficult to require EHRs to develop too much at once when certification was “all or nothing” and not modular. From working in both CCHIT and HITSP, CCHIT tended to give more weight to considerations such as market adoption and lead times, not just whether a suitable standard existed. I along with Jamie Ferguson were appointed to co -chair the 10-member HITSP-CCHIT joint working group, whose goal was to coordinate the work of HITSP and CCHIT and address how/when to include HITSP specs in certification. But some HITSP-selected standards were still in “trial implementation” with little adoption, and the approval of a standard (HL7, HITSP, or any other) didn’t mean it should be mandatory within a specific timeframe. And there were just so many of them to digest, let alone certify! Some people weren’t pleased, thinking that CCHIT should be a more aggressive “enforcement arm” of HITSP. In the end, we included more of HITSP in 2008 and 2009 certification criteria than ONC did in its 2011 certification criteria, most notably the HL7 2.5.1 Laboratory results with LOINC vocabulary starting in 2007, C32 CCD starting in 2008 (adding RxNorm, UNII, SNOMED CT vocabularies in 2009) and HITSP TP13 (IHE XDS.b – see point #2 below). But we also roadmapped (2-3 years out) most other HITSP specs when we published our 2009 criteria. I believe this was a sensible middle of the road approach. IMHO, if we had mandated many more HITSP specs in certification, there would be few or zero certified products today!
2. Should certification require transport standards? Fourth & Ten – we’d better punt! Seriously, we debated this during 2008 and 2009. We recognized this as a glaring gap in interoperability, and wanted to make headway, realizing that lack of secure transport standards would hinder interoperability even if content were standardized. The Direct Project didn’t exist back then. We were aware of diverse ways that HL7 messages were transported, that IHE had defined SOAP-based web services for document transport, and that HITSP had selected many IHE specifications. Many vendors had already tested IHE Cross-Enterprise Document Sharing (XDS.b) at Connectathon. So the IOWG approved XDS.b as 2009 certification criteria (along with PIX/PDQ to support it). But the Board of Commissioners decided to designate these as optional interoperability criteria, not required for certification, because despite the IOWG’s recommendation and strong EHRA support, some commented against it. This was the one case I can recall where my workgroup’s recommendation was overridden by the Board, which I know was a tough decision since the Board usually didn’t do that. This was also a case where we were less aggressive in CCHIT than the EHR Association had proposed. EHRA had sometimes criticized CCHIT for not providing enough lead time, but in this case they were very disappointed that CCHIT had not required this in certification. This one still bothers me as a missed opportunity.
3. Should we require discrete data import, and who owns that decision anyway? We felt that the main point of requiring standardized content formats and vocabularies, not just human readability/liquidity, was for the discrete data to be consumable. Following our “methodical march” mentioned in part 2, we thought in 2008 that the time had come to propose discrete data import (e.g., update your medication, allergy, or problem lists using data from other providers). But now we were into a “boundary condition.” Where did interoperability’s “turf” end and functionality begin? We had a series of “discrete data import” meetings between the IOWG and the Ambulatory and Inpatient Functionality workgroups. We recognized that data must not only be exchanged, it needs to be reconciled (medication reconciliation being an example), and that you can’t just “slam in” all meds, allergies, problems from many external sources to automatically update the active med/allergy/problem list. The functionality workgroups didn’t think the time was right to require such capability in certification for 2009 or 2010. But how were we going to keep making progress toward semantic interoperability? In the end, we proposed criteria to import very specific discrete data elements for medications, allergies, demographics, and immunizations (with problems to come later), as described in my last post. But we didn’t define the functionality, as long as the discrete data were stored somewhere. And in any case, reconciliation criteria would belong to the functionality workgroups, not the IOWG. I think this would have been a reasonable “baby step” but because of the change in certification that started in 2009, those roadmap criteria never had the chance to be certified. I hope that similar careful thought will go into decisions in ONC certification, whenever it gets to that point. End-to-end interoperability involves content creation, secure standardized transport, and content consumption, all of which should be considered holistically.
4. Should we push the industry toward a single standard for clinical problems? This was really part of the broader topic of converging on a singular standard vocabulary for each type of data, but SNOMED CT for problems was the lightning rod topic for several reasons: a) the difficulties of getting physicians to create medical problem lists at all; b) ICD-9 diagnosis codes were already required for reimbursement and some physicians systems were built around ICD-9; c) ICD-10 was already complicating things by looming on the horizon; d) anything that imposed more work on physicians could hinder usability and adoption. So though SNOMED CT seemed a clear winner for an interoperable clinical vocabulary and was HITSP-endorsed, we received considerable pushback from some members of the other workgroups as to how fast SNOMED CT could be required. I was pleased that many in the IOWG stepped up to provide statistics and research facts such as analysis of mapping of ICD-9 to SNOMED CT and clarification that standard codes don’t have to be visible in the clinician’s UI. We knew this was a contentious issue, but staked out our positions in the 2009 roadmap and a Q&A document.

The above four were prototypical of the controversies we faced in content, vocabulary, and transport. I could go on with more examples. That’s part of the challenge of interoperability work, as evidenced by the fact that ONC and the HIT Standards Committee still have all of the above issues to ponder for Stages 2 and beyond. I should mention that one more big controversy arose in the very first year, when CCHIT was newly formed and struggling to figure out how to set the interoperability bar. Eyes were upon those first members to resolve the CDA vs. CCR debate. Unlike the four issues above, where we took a stand, we weren’t ready to force a decision in 2006, and then HITSP was formed by ONC to deal with such “standards harmonization” issues. So at least our punt had a receiver (and football wasn’t locked out)!

I promise that Part 4 will really conclude this series with my thoughts on Lessons Learned, proudest accomplishments, regrets, and hopes for the future, stemming from my CCHIT experience. Thanks for listening to my sharing from “inside the trenches” of discussions of which the public was not aware.

A Harmonious Musical Spring Break

I expect to conclude my three-part certification retrospective within the week. Since it will end with a discussion of lessons learned as well as some tough controversies, it will need some thoughtful review before I just fire it off. In the meantime, I’m going to take a brief break to return to my non-HIT passion, music, which has many parallels with Health IT as I introduced in my first blog post in December.  One of my physician colleagues recently shared with me an article from the March 15^th edition of the Annals of Internal Medicine, entitled What Musicians Can Teach Doctors. No, I’m not going to use this post to teach doctors, but I recommend the article, as it compares musical training and performance to medical training and practice. Furthermore the aspects of teamwork, rehearsal, and specialization are key to HIT interoperability. Both music and interoperability must be performed by collaborating participants, not just specified in theory, and there’s no substitute for doing it over and over, refining it, and continuously improving.

I’ve been applying the principle of “practice” (musical, not medical) for the past year preparing for an upcoming solo piano recital. For too long, I didn’t make time for it, as the demands of family, work, and “life” kept getting in the way, but now on May 20^th and 21^st I’ll perform two concerts. Information is available on the web about the recital program, Youtube video preview “trailer” and location at Immaculata University. So if any blog readers happen to be in the Philadelphia PA area on those dates and would like to come by, you’re most welcome! I realize that solo piano doesn’t illustrate very well the “teamwork” principle that ensemble music would. But I’d like to convey a faithful and yet personal interpretation of the composers’ musical “specifications” to connect with my audience so that they realize the genius and beauty of what Bach, Beethoven, Liszt, et al created. So even though it’s a solo recital, I’m trying to be the “interface” between the composers and my audience. Hopefully, not too much will be lost in translation!

Anyway, after this “break,” next time I’ll return to conclude the CCHIT Certification Retrospective.

Certification Retrospective Part 2 – Method to our Madness?

Note: this blog post will continue discussing my experiences in CCHIT. The opinions are mine, and do not necessarily reflect the views of CCHIT or Siemens.

In Part 1, I talked about CCHIT giving me the privilege to work with great people over the years. But we didn’t volunteer for CCHIT just to meet people, but to do important work to advance the HIT industry. So what did we accomplish, and what were we thinking as we evolved?

One thing I learned is that no group can please all the people all the time. Sometimes, people wondered why we proposed some criteria and not others, or proposed the timeframes that we did. So we tried to explain these “whys” in a white paper Interoperability, Supplying the Building Blocks for a Patient-centered EHR in mid-2009 which still exists on the website of writer John Morrissey. It described the context for what we were doing and the “methodical march” to increasing levels of information interoperability that we proposed. I don’t think this was well understood by the public, who might have thought some of what we did was arbitrary. But here’s what was in our mind (well, I can only speak for myself – mine at least).

Key principles:

• We aren’t starting with a blank sheet of paper. The existing state of adoption (immature as it might be) must be considered, so we started each year with an “environmental scan” on the state of the HIT industry.
• Adequate time must be provided for EHR products to make the transition to a more desirable state. We aimed for 18 months lead time from our first “signal to the market” (new draft criteria) until certification testing of those criteria.

Given these principles, our methodical march followed the path below.

• Data Capture precedes interoperability. You can’t share what you don’t have! When we started CCHIT, not all EHRs even captured all the data that other systems would want, so functionality criteria (ambulatory, inpatient, ED) needed to capture the data elements that could then be shared. Thus in the first certification year, 2006, there were no interoperability criteria required (though several criteria, such as Lab Results and e-prescribing, were roadmapped for later years).
• Information Liquidity (a term we didn’t use, but which implicit in our criteria) is beneficial even prior to semantic interoperability. Thus, the first clinical summaries that CCHIT certified (Continuity of Care Documents, CCDs) in 2008 required human-readable sections for meds, allergies, problems, etc., but not structured data. We were later criticized for this, as if we didn’t care about structured data, but this was always intended as a stepping stone to later stages (as explained in the white paper). Even today (3 years later than the 2008 criteria), many voices espouse liquidity as a more important and realistic for the near-term than semantic interoperability (“don’t let the perfect be the enemy of the good”).  
• Standardized Content (formats and vocabulary). Human-readability is fine for humans, but doesn’t help most EHR systems to “understand” (semantics) and process the information they receive from others. Because of the existing Tower of Babel syndrome most EHRs have been “confounded” in their ability to share information with other EHRs, and to “consume” (not just display) it. So CCHIT supported the goals of ONC and HITSP to progress toward standardization of vocabularies. But it realized that changing an EHR’s vocabulary overnight wasn’t realistic, and that mapping from one vocabulary to another is not simple or foolproof and must be done carefully for patient safety and other reasons. Thus a “glide path” from narrative to standard vocabularies was roadmapped.
• Discrete Data Import (Consumption). When liquidity and standardized content are established, the EHRs that receive or retrieve clinical data can “do something” with the data, more than just file and display it. As early as 2007 criteria, we published certification criteria for ambulatory EHR discrete import of Laboratory Results that referenced the HITSP-endorsed HL7 2.5.1 Lab Results Reporting Implementation Guide, including a common subset of LOINC observation codes. Thus, many of us were disappointed when the ONC Final Rule for certification, published in 2010, lacked a specific HL7 standard and LOINC requirement, not going as far as what CCHIT had been certifying since 2007. There are 127 CCHIT Certified® ambulatory EHRs that already meet this requirement. For CCDs, the challenge of discrete data import is  greater because of the wider variety of data, and multiple applicable vocabularies. Rather than declaring the problem too big to tackle in one shot, we proposed chipping away a few sections at a time, starting in 2010 with discrete import of medications (using RxNorm as specified by HITSP), allergies (using RxNorm and UNII), Immunizations (using CVX) and demographics, then moving on to problems (using SNOMED-CT). These criteria are a matter of public record, and can be found on the CCHIT website: 2008 criteria. See 2008 Criterion IO-AM 11.06 for example, which originally roadmapped discrete data import for 2009, though the date changed to 2010 in the 2009 criteria (published but then withdrawn)***. You can decide based on the facts whether we were too aggressive, or too laggardly, or about right.

So what’s the point of this retrospective? I’ll sum up lessons learned in the next post. I’ll also speak more about how CCHIT’s interoperability criteria compared to ONC’s criteria.

I’ll also discuss some of the agonizing controversies that we faced, particularly in 2008 and 2009 over issues like standardized transport, discrete data import, data reconciliation turf (is it interoperability or functionality or both?) and the feasibility of requiring SNOMED-CT. We wrestled with each of these, and did our best. We might not have succeeded perfectly in all of them, and our criteria development work was superseded by ONC before we could resolve them all, but we learned much in the methodical march!

David

*** (Long Footnote)

The 2009 Ambulatory Certification criteria, along with the CCHIT 2009 certification program, were not launched, since they were in limbo awaiting decisions on ONC-ATCB certification. But eventually most of these criteria (without the roadmap) were relabeled and launched as the 2011 CCHIT Certified® ambulatory criteria. If the 2009 program had proceeded, Criterion IO-AM 11.06 would have required the following in 2010, adding much specificity beyond what had been proposed in the same criterion in 2008:

The system shall provide the ability to display CCD documents, using a subset of the HITSP C32 specification for the Medication and Immunization History module, file them as intact documents in the EHR, and import the discrete data from one or more of the entries in a structured form into the patient record. The system shall provide the ability to import as discrete data the following data elements from the C32 Medications Module: Free text SIG, free text product name, free text brand name, coded product name, coded brand name, product concentration, status of medication, quantity ordered, order date/time, order expiration date/time, prescription number, quantity dispensed, and fill number. (Note: fill number means the number of fills dispensed, not the number of fills prescribed). The “required if known” (R2) data elements will not always be known, and therefore will not be present in every instance of a C32 document, but if present, the system shall be able to import them

More was explained in the Comments column:

Medication and Immunization History-Coded Subset includes the following content modules of the HITSP C32: Person Information, Healthcare Provider, Medications-Prescriptions and Non-Prescription, Information Source, Comments

The intent for 10 Certification is not to require specific capability to use the imported data but only to show the system is capable of processing discrete data elements from a CCD. In future certification years, more functionality criteria to “use” the data may be added. Fulfillment of the 10 Certification criteria may be demonstrated in a variety of ways, including but not limited to any one of the following:

- Reconciliation functionality that allows CCD data to be compared with existing data, and selectively imported into a list

- A display of data captured from external sources, including the imported discrete data. The physical storage location (database table, file, etc.) is at the vendor’s discretion and does not need to be the same location as the active allergies.

- Creation of an CCD that includes the elements previously imported as discrete data

Vendors may innovate and differentiate their products by how well such data are used, but 10 Certification will not limit vendors to any particular approach

Certification Retrospective -- Part 1

Note: this blog post will discuss my experiences in CCHIT. The opinions are mine, and do not necessarily reflect the views of CCHIT or Siemens.

It’s been a long time since I blogged, even though there have been many HIT topics to blog about, such as Stage 2 meaningful use, the ONC Standards and Interoperability Framework, the ONC Strategic Plan, the NPRM on Medicare Shared Savings (Accountable Care Organizations), and more. I’m getting back on the wagon. One topic I’ve wanted to blog about for a while, even though it’s not a current “hot topic” in the news, is my experience in the Certification Commission for Health Information Technology (CCHIT) prior to the establishment of the ONC certification program. This bubbled to the surface when I read a HISTalk “Time Capsule” posting. So I’ll write another mini-series (probably two or three parts). This first post will simply introduce the “cast of characters” and how they interacted. The next posts will talk about what the Interoperability Workgroup of CCHIT did, and how its work through 2009 related to the ONC-ATCB certification program as we know it today. There are useful lessons learned.

As a matter of disclosure, I’ve been a CCHIT volunteer for more than five years, and am still officially a co-chair of CCHIT’s Interoperability Workgroup, but this group has been inactive for about a year though it still nominally exists. The reason for its inactivity is that it was chartered as a group to propose certification criteria EHRs, a role that was displaced by ONC and the HIT Standards Committee. CCHIT still offers its branded certification program called “CCHIT Certified®” that is completely distinct from the ONC certification for which CCHIT is an authorized testing and certification body (ATCB). The branded program includes criteria that I and many others worked on until 2009. In interoperability, CCHIT is currently performing testing based on the NIST test scripts and some optional tools, but it is not developing any new interoperability criteria at this time.

Industry collaboration – whether in standards organizations or groups like CCHIT – has been a rewarding and mind-expanding aspect of my career. It’s about the people who work together to benefit many more people (e.g., patients and providers), trying to leave their agendas and “organization hats” at the door. So this first post focuses on some facts about the volunteers of CCHIT interoperability.

I found it fascinating to compile a list of the people I’ve served with on Interoperability workgroups at CCHIT. See this link for a table of volunteer names. It’s a pretty diverse and impressive list, IMHO. The list of CCHIT workgroup members has always been publically posted, though I don’t know if it’s preserved historically, so I had to dig through my archives. My apologies if there are some typos in my list. The organizations listed were as of the time the people were on the workgroup, not necessarily where they are now. And occasionally there were people who had to resign for lack of time and a few were replaced but that may not be reflected in my table.

Each year, the Interop Workgroup had between 13 and 24 members (the 24 divided into two groups). Over 60 members served on the workgroup at some time. Of these, 9 were from EHR vendors (only counting vendors of products subject to certification, not vendors of different product types like e-prescribing, lab systems, or HIE tools). The EHR vendor reps were generally active participants, but they didn’t dominate the workgroup. Of course, there are many other interoperability experts who could have been on CCHIT but weren’t, since there was limited space. In that sense, CCHIT was not open like a Standards Development Organization, but it tried to establish a small committed group of volunteers, selected by an application process according to guidelines for stakeholder balance. Sometimes, we knew what we didn’t know, and invited guests to educate us at our meetings, on topics like e-prescribing, vocabularies, and clinical documents.

Sometimes the group was split into an Inpatient Interop WG and and Ambulatory Interop WG (in which case I was on the Inpatient side). In the last year, it divided into an Advanced Interoperability WG and a “regular” Interoperability WG (I co-chaired the latter). Usually a small subset of volunteers would work on specific subsets of criteria (e.g., Lab, eRx, clinical documents) and the entire WG would review and refine.

I have very positive feelings towards these people. They’re some of the finest I’ve worked with, and I am grateful to them. There was a strong sense of collegiality and teamwork, and the sense that we were doing something important. While there were downsides to the group being selected rather than open, that also helped motivate most members since they couldn’t passively leave the work to “someone else” as tends to happen in larger groups. Collaboration was real across different stakeholders and even among vendor competitors. Sure we wouldn’t always agree. Some members thought criteria should be much more aggressive. Others couldn’t understand why features they regarded as only “nice-to-haves” should be mandatory for certification. Sometimes (as co-chair) I’d feel frustrated if I thought someone wasn’t pulling their weight (e.g., not showing up for meetings). It’s inevitable that in volunteer organizations not everyone contributes equally, but everyone had the opportunity.

In acknowledgments, there’s always a risk of omitting someone important, but I especially want to thank Amit Trivedi and Anita Samarth who alternated as CCHIT staff leads for interoperability. Their support was tireless and outstanding: I still remember 4am e-mails from both of them as they worked towards tight deadlines! And I really appreciated the commitment, passion, and the desire to do the right thing, from my fellow-co-chairs such as Dr. Alan Zuckerman, Dr. Pat Hale, and George Robinson.

The Board of Commissioners was mostly “out of sight” for the workgroup. They respected and endorsed the expertise of the volunteers, but would attend our meetings if we needed them (Dr. Leavitt did this several times), offering guidance but not dictating what we should do. I only remember being “overridden” by the Board on one substantive issue.

In the subsequent post(s), I’ll talk more about the interoperability work products that we developed, how it related to standards organizations, ONC, and what I would have done differently if I could start over.

David