ONC: Progress outlines barriers for HIE governance

A May 10 conference call on health information exchange had more than 1,000 registered callers, which Farzad Mostashari, MD, ScM, national coordinator of health IT, said indicated the high level of interest in the topic.

“Clearly, the challenges are more sharply drawn than ever before. We know more and more about what we need to do.”

Several obstacles must be addressed, however, he said. For example, while Meaningful Use Stage 2 has been a “big step forward for transport, messaging and content standards” surrounding interoperability. “Software developers are working very hard to implement interoperability standards to reduce cost and complexity. We need to improve the business case for information exchange so that it’s profitable to share information not hoard.”

Mostashari said the industry needs “mechanisms where the rules of the road, interoperability, privacy and business practices are standardized to the extent possible so that information can flow without the need for protracted, painful, expensive contract negotiations.”

However, “the more progress you make,” he pointed out, “the more sharply drawn the challenges and issues.”

The Office of the National Coordinator of Health IT (ONC) is working on HIE governance that establishes a common set of behaviors, policies and standards that enable trusted electronic health information exchange among a set of participants, said Jodi G. Daniel, JD, MPH, director of the ONC’s Office of Policy and Planning. “This is what and how we’re thinking about this suite of activities.”

While the agency applauds the wide range of local activities, she said, “we’re focusing on the national level, to address challenges to exchange information between different exchange organizations and across state boundaries.”

Following the recent announcement of a grant issued to two organizations to further HIE governance, David C. Kibbe, MD, MBA, president and CEO of DirectTrust, said there already is progress to report. His organization has established an accreditation program in partnership with EHRNAC. The group also is working on a trust anchor, version 1.0.  “One very basic issue that makes this somewhat complicated is the idea that there needs to be a mechanism to establish sufficient trust between HISPS and users,” he said. “There is more than technology involved. The technical aspects are quite straightforward but trust between two parties involves clarity, transparency, as well as assurances as to how to rely on parties operating in their environments.”

Kibbe said the top priorities are increasing interoperability, decreasing cost and complexity and facilitating trust among participants using Direct for the exchange of PHI for healthcare improvements. They also hope to design, build out and operate at scale a trust anchor bundle distribution service that transparently identifies attributes of anchor certificates from accredited HISPs and distributes these anchors to the public, thereby permitting trust relationships to grow at scale and remove the need for costly, time-consuming one-off contract negotiation between HISPs or their users/subscribers.

The goal, he said, is to have 50 entities fully engaged in the accreditation program by end of the year. “We’re well on our way but it’s going to take more work.”

Plug-and-play compliance testing also is underway, Kibbe said. They tested specifications last year and partnered with Healtheway and jointly selected CCHIT as a testing partner to do actual engineering testing. “At this point, products from the initial vendors are on their way through the testing processes and the pilot. The end goal was for provider communication to not need to know what technical standards mean.”

The group has designed a certification seal for proof of plug-and-play capability.

Mostashari said the two streams of activity—structured, codified data and standards for the future to make queries also work as well—are both critically important.

Steven Posnack, MHS, MS, director of ONC’s federal policy division, discussed the four principles of the agency’s HIE governance framework--organizational, trust, business and technical. The framework “identifies milestones and outcomes and reflects ONC’s current thinking.”

The common conceptual foundation expresses principles that ONC believes are most important for HIE governance, he said, and serve as a pillar for “how we approach governance issues with respect to HIE. It draws from a wealth of ONC’s prior expertise that crosscut this issue. Over time, we expect to update these and do so in response to comments.”

Posnack said they chose to frame the trust principle from the patient perspective to help create an environment in which patients can do things such as access notice of data practices; receive explanation of privacy and security policies; be provided with meaningful choice; request exchange limits based on data type or source; access and request corrections to their information; and be assured their information is consistently and accurately matched when exchanged.

The business principles “are not necessarily to tell HIE governance entities how to run their business, but more to frame from their perspective of how exchange can take place with patients’ interests in mind, set standards of participation that promote collaboration, provide open access to exchange services, publish statistics, and maintain and disseminate information.”