HI300 Unit 5 Standards for Electronic Data and Data Interchange -.docx

HI300 Unit 5: Standards for Electronic Data and Data
Interchange - Discussion
Standard Development Organizations
Identify and research standard development organizations listed
in the text on pp. 165–166
.
Select one of the organization’s websites and identify at least 3-
4 facts about this organization and explain what it does.
Do not duplicate your classmates’ information. Note: You may
explore the internet for recent articles about the organization
and include this information as well.
When responding to your classmates describe similarities and
differences between the organizations you researched.
Discussion responses should be strictly on topic, original with
scholar references, and contribute to the quality of the
discussion by making frequent informed references to lesson
material.
NO PHARGIARISM!!
Below is the Chapter 4 reading for this assignment.
Standards for Electronic Data and Electronic Data Interchange
The original uniform data sets such as the UHDDS and the
UACDS were created for use in paper-based (manual) health
record systems. They were not designed to accommodate the
data needs of the current healthcare delivery system or the
demands of EHRs and clinical information systems.

Standards are needed in order for data to be easily, accurately,
and securely communicated and exchanged electronically among
various computer systems. This is referred to as
interoperability. Without standards for interoperability, EHRs
and the NHIN will not realize their full benefits (Thompson and
Brailer 2004).
Many types of standards are being developed to support the
EHR and health information exchange. Some involve defining
record structure and content, others specify technical
approaches for transmitting data, and still others provide rules
for protecting the privacy and security of data.
Public and private organizations have been actively engaged in
the process of developing healthcare informatics standards to
support EHR development, interoperability, and information
exchange. The federal government supports this work in a
variety of ways. One example is the S&I Framework. According
to Fridsma (2010 slide 4), the Framework “is the mechanism by
which ONC will manage the implementation of specifications
and the harmonization of existing health IT standards to
promote interoperability nationwide.”
Definition of Data Standard for Electronic Data Exchange
Data standards provide the ability to record a certain data item
in accordance with the agreed upon standard (Giannangelo
2007). Data content standards are “clear guidelines for the
acceptable values for specified data fields” (Fenton et al. 2007).
Data exchange standards are protocols that help ensure that data
transmitted from one system to another remain comparable.
One of the purposes of HIPAA’s Administrative Simplification
rules was to standardize information exchange and in August
2000, the Department of Health and Human Services (HHS)
published regulations for electronic transactions. These
regulations apply to transactions that occur among healthcare
providers and healthcare plans and payers (Rode 2001). The
long-term goal of the transaction standards is to allow providers
and plans or payers to seamlessly transfer data back and forth
with little intervention. To do this, HHS adopted the electronic

transaction standards of ASC X12 Insurance Subcommittee
(Accredited Standards Committee Health Care Task group
[X12N]). The standards adopted for EDI are called ANSI ASC
X12N.
The HIPAA standards also include code sets standards for the
electronic exchange of health-related information. To illustrate
how the adoption and utilization of standards for data
representation and data exchange facilitates billing functions,
consider the codes sets are data standards used to identify
specific data elements such as the diagnosis on a claim. The
compendium of data elements on the claim form make up a data
set. In order to send the diagnosis and other items that make up
the data set electronically, the healthcare provider uses the ASC
X12N 837 messaging standard. The 837 specifies the format for
each data element. For example, one specification for the format
of the diagnosis would be that diagnosis codes have a maximum
size of seven (7) characters.
A new version of the standard for electronic healthcare
transactions (Version 5010 of the X12 standard) was approved
in 2009 and implemented in 2012. This new version is essential
to the use of ICD-10-CM and ICD-10-PCS codes that are slated
for implementation in 2013.
Data Needs in an Electronic Environment
As discussed in chapter 16, healthcare organizations often have
several different computer systems operating at the same time.
For example, a hospital’s laboratory system might be entirely
separate from its billing system. In fact, the various
departments of large healthcare organizations often use
different operating systems and are serviced by different
vendors. In addition to operating multiple systems, it is an
ongoing challenge to integrate information from legacy (older)
systems operating on old platforms with state-of-the art
information systems.
Healthcare organizations must integrate data that originate in
various databases within facilities as well as in databases
outside the facility. They also must be able to respond to

requests to transfer data to other facilities, payers, accrediting
and regulating agencies, quality improvement organizations, and
other information users. These goals can only be accomplished
when every database system is either operating on the same
platform or using common standards.
Benefits of Data Exchange Standards
Healthcare informatics standards describe accepted methods for
collecting, maintaining, and/or transferring healthcare data
among computer systems. These standards are designed to
provide a common language that makes it easy to:
Exchange information
Share information
Communicate within and across disciplines and settings
Integrate disparate data systems
Compare information at a regional, national, and
international level
Link data in a secure environment
Having the ability to exchange, share, communicate, integrate,
compare, and link data is important to healthcare delivery.
These activities make possible important activities such as:
Disease surveillance
Health and healthcare population monitoring
Outcomes research
Decision making and policy development
The long-term vision is to enhance the comparability, quality,
integrity, and utility of health information from a wide variety
of public sources through uniform data policies and standards
(NCVHS 2001). Thompson and Brailer (2004, 13) expressed the
federal commitment to standards in their statement that “A key
component of progress in interoperable health information is the
development of technically sound and robustly specified
interoperability standards and policies.” In 2010, states, eligible
territories, and qualified State Designated Entities received
awards from ONC to assist them in facilitating the secure
exchange of health information in order to advance state-level
health information exchange while moving toward nationwide

interoperability. The ONC expects the funding to be used to
increase connectivity, enable patient-centric information flow to
improve the quality and efficiency of care, and ensure
healthcare providers and hospitals meet national standards
(ONC 2011b).
Many types of standards are necessary to implement EHRs and a
health information technology infrastructure that supports
connectivity, interoperability, and seamless data interchange.
International, national, state and regional or local standards
ensure communication and efficiency and minimization of
duplication of effort along the continuum of healthcare. It is
especially important to note that healthcare is provided locally
and standards must be adopted at the local level to achieve the
full benefit of an EHR.
American Recovery and Reinvestment Act
Officially known as the American Recovery and Reinvestment
Act (ARRA P.L. 111-5) and Health Information Technology for
Economic and Clinical Health Act (HITECH), the “Stimulus
Law” was signed on February 17, 2009. ARRA provides $19.2
billion in spending on health IT. Title XIII of ARRA, given a
subtitle, “Health Information Technology for Economic and
Clinical Health Act (HITECH),” deals with many of the health
information communication and technology provisions.
Office of National Coordinator
ARRA includes the statutory authorization of ONC, which
makes ONC a permanent office under HHS (Asmonga 2009). Its
charge is to help develop a national health IT infrastructure to
improve the quality and efficiency of healthcare and the ability
of consumers to manage their care and safety. ARRA stipulated
$2 billion to ONC for use as follows (Asmonga 2009):
$20 million: to advance healthcare information enterprise
integration through technical standards analysis and
establishment of conformance testing infrastructure to be done
by the National Institute of Standards and Technology (NIST)
and coordinated with ONC
$300 million: to support regional or subnational efforts

toward health information exchange
Remaining funds: to the immediate implementation assistance
to support:
— Health IT architecture
— Development and adoption of certified electronic health
records (EHRs) for categories of healthcare providers not
eligible for support under title XVIII or XIX of the Social
Security Administration for the adoption of such records
— Training on best practices to integrate health IT
— Infrastructure and tools for the promotion of
telemedicine
— Promotion of the interoperability of clinical data
repositories or registries
— Promotion of technologies and best practices
— Improvement and expansion of the use of health IT by
public health departments
The ONC published a final rule establishing standards,
implementation specifications, and certification criteria for the
certification of EHR technology to support the achievement of
meaningful use Stage 1 by eligible professionals and eligible
hospitals under the Medicare and Medicaid EHR incentive
programs in 2010. Stage 1 standards, which took effect in 2011,
fall into three categories: content exchange, vocabulary, and
privacy and security (ONC 2010). Transport standards were
proposed but removed in the final rule. These standards will be
discussed later in this chapter.
Health Information Technology (HIT) Policy Committee and
HIT Standards Committee
Two official HHS advisory committees established as a result of
ARRA are the HIT Policy Committee (HITPC) and the HIT
Standards Committee (HITSC). The HIT Policy Committee
provides recommendations to the National Coordinator on a
policy framework for the development and adoption of a
nationwide health information technology infrastructure that
permits the electronic exchange and use of health information as
is consistent with the Federal Health IT Strategic Plan and that

includes recommendations on the areas in which standards,
implementation specifications, and certification criteria are
needed.
The HIT Standards Committee provides recommendations to the
National Coordinator on standards, implementation
specifications, and certification criteria for the electronic
exchange and use of health information for purposes of
adoption, consistent with the implementation of the Federal
Health IT Strategic Plan, and in accordance with policies
developed by the HIT Policy Committee.
Standards Development, Coordination, Testing, and
Harmonization
Developing, coordinating, testing, and harmonizing healthcare
standards is a complex process in which many organizations are
involved. The following definitions provide further information
on standards and harmonization (HITSP 2009):
The term standard … is a well-defined approach that supports a
business process and:
has been agreed upon by a group of experts
has been publicly vetted
provides rules, guidelines, or characteristics
helps to ensure that materials, products, processes, and
services are fit for their intended purpose
is available in an accessible format
is subject to an ongoing review and revision process.
Harmonization is the name given to the effort by industry to
replace the variety of product standards and other regulatory
policies adopted by nations, in favor of uniform global
standards. Usually used in the context of trade agreements,
harmonization has recently been adopted by the United States
government to refer to information technology standards.
Most standards are created through a voluntary consensus
process that involves identifying the need for a standard,
negotiating the content of the standard, and drafting a proposed
standard. The final standard is published after undergoing a
comment and revision period. This process facilitates wide

adoption and improved utility. Figure 4.5 describes the
standards value chain.
Figure 4.5. Standards value chain
Standards typically go through several stages in a process that
can take three or more years. It begins with developers, who
draft new standards or update existing ones. Profiling
organizations select among applicable standards, combine the
work of multiple developers, and create use scenarios for how
to apply them. Typically, independent, neutral organizations
test the standards, and implementers put them to work.
Advocates
Advocacy organizations influence and facilitate the value chain
at every step. National governments are prominent
standardization advocates, often sponsoring, funding, and
staffing standards activities. Private-sector stakeholders include
advocacy organizations such as health IT and finance advocates
and software vendors, implementers, and users. Consumers also
have a stake in standards, although they are underrepresented in
standards advocacy.
Market Stakeholders
Software vendors, implementers, and users are economic
stakeholders. They influence standards development and
implementation through participation and funding. Their
balance of interest is both strategic and tactical.
Source: Marshall 2009.
Organizations referred to as standards development
organizations (SDOs) are involved with the creation or
revisions of standards. HL7 and ASTM, for example, are both
accredited SDOs. Table 4.1 provides a list of several
organizations that are actively involved in developing standards
for health-related information management.
Table 4.1. Standards development organizations
Resource
Description

Source
AIIM
AIIM is an ANSI (American National Standards Institute)
accredited standards development organization. AIIM also holds
the Secretariat for the ISO (International Organization for
Standardization) committee focused on information management
compliance issues, TC171.
http://www.aiim.org
Accredited Standards Committee (ASC) X12
ASC X12 is a designated committee under the Designated
Standard Maintenance Organization (DSMO), which develops
uniform standards for cross-industry exchange of business
transactions through electronic data interchange (EDI)
standards. ASC X12 is an ANSI-accredited standards
development organization.
http://www.x12.org
American Dental Association (ADA)
The ADA is an ANSI-accredited standards developing
organization that develops dental standards that promote safe
and effective oral healthcare.
http://www.ada.org/275.aspx
ASTM International
Formerly the American Society for Testing and Materials,
ASTM International is an ANSI-accredited standards
development organization that develops standards for healthcare
data security, standard record content, and protocols for
exchange of laboratory data.
http://www.astm.org

European Committee for Standardization (CEN)
CEN contributes to the objectives of the European Union and
European Economic Area with voluntary technical standards
that promote free trade, the safety of workers and consumers,
interoperability of networks, environmental protection,
exploitation of research and development programs, and public
procurement.
http://www.cenorm.be/cenorm/index.htm
Clinical and Laboratory Standards Institute (CLSI)
A global, nonprofit, standards development organization that
promotes the development and use of voluntary consensus
standards and guidelines within the healthcare community. Its
core business is the development of globally applicable
voluntary consensus documents for healthcare testing.
http://www.clsi.org
Clinical Data Interchange Standards Consortium (CDISC)
CDISC is an open, multidisciplinary, nonprofit organization that
has established worldwide industry standards to support the
electronic acquisition, exchange, submission and archiving of
clinical trials data and metadata for medical and
biopharmaceutical product development.
http://www.cdisc.org/
Designated Standard Maintenance Organization (DSMO)
The DSMO was established in the final HIPAA rule and is
charged with maintaining the standards for electronic
transactions, developing or modifying an adopted standard.
http://www.hipaa-dsmo.org
Health Industry Business Communications Council (HIBCC)

HIBCC is an industry-sponsored and supported nonprofit
organization. As an ANSI-accredited organization, its primary
function is to facilitate electronic communications by
developing standards for information exchange among
healthcare trading partners.
http://www.hibcc.org/
Health Level 7 (HL7)
An ANSI-accredited standards development organization that
develops messaging, data content, and document standards to
support the exchange of clinical information.
http://www.hl7.org
Institute of Electrical and Electronic Engineers (IEEE)
A national organization that develops standards for hospital
system interface transactions, including links between critical
care bedside instruments and clinical information systems.
http://www.ieee.org
International Organization for Standardization (ISO)
ISO is a nongovernmental organization and network of national
standards institutes from 157 countries.
http://www.iso.org/iso/en/ISOOnline.frontpage
National Council for Prescription Drug Programs (NCPDP)
A designated committee under the Designated Standard
Maintenance Organization (DSMO) that specializes in
developing standards for exchanging prescription and payment
information.
http://www.ncpdp.org

National Information Standards Organization (NISO)
An ANSI-accredited, nonprofit association that identifies,
develops, maintains, and publishes technical standards to
manage information. NISO standards address areas of retrieval,
re-purposing, storage, metadata, and preservation.
http://www.niso.org
National Uniform Billing Committee (NUBC)
A designated committee under the Designated Standard
Maintenance Organization (DSMO) that is responsible for
identifying data elements and designing the CMS-1500.
http://www.nubc.org
National Uniform Claim Committee (NUCC)
The national group that replaces the Uniform Claim Form Task
Force in 1995 and developed a standard data set to be used in
the transmission of noninstitutional provider claims to and from
third-party payers.
http://www.nucc.org
Source: AHIMA 2007.
Private or government organizations involved in the
development of healthcare informatics standards at a national or
international level.
Because so many organizations are developing standards, there
needs to be coordination. Therefore, some organizations play
key roles in coordinating the efforts of other SDOs. The
American National Standards Institute (ANSI) is one example.
It coordinates the development of voluntary standards in a
variety of industries, including healthcare. Most SDOs in the
United States are members of ANSI. ISO coordinates
international standards development. ANSI represents the
United States at the ISO.

Some other projects that coordinate healthcare standards are the
National Library of Medicine’s Unified Medical Language
System (UMLS) and the USHIK.
The UMLS’s Metathesaurus is a centralized vocabulary database
that includes more than a hundred vocabularies, classifications,
and code sets. Source vocabularies found in the Metathesaurus
include those designed for use in patient-record systems such as
SNOMED CT as well as those used for healthcare billing such
as ICD-9-CM. The code sets mandated for use in electronic
administrative transactions in the United States under the
provisions of HIPAA are found in the Metathesaurus with the
exception of the National Drug Codes (NDC) which are
available from the FDA.
The USHIK is a computer-based health metadata registry funded
and directed by the AHRQ with CMS and the Veterans
Administration as strategic inter-agency partners. It is
populated with the data elements and information models of
SDO and other healthcare organizations in such a way that
public and private organizations can harmonize information
formats with healthcare standards. The knowledge base also
contains data element information for government initiatives
supporting the use and implementation of data standards (for
example, HIPAA) and the federal health architecture program.
ARRA called for ONC, in consultation with NIST, to recognize
a program for the voluntary certification of health information
technology as being in compliance with applicable certification
criteria to meet defined meaningful use requirements. In
collaboration with ONC, NIST has developed the necessary
functional and conformance testing requirements, test cases, and
test tools in support of the health IT certification program. The
NIST is a non-regulatory agency of the U.S. Department of
Commerce.
At present, one of the most challenging aspects of the standards
movement is the area of standards harmonization. In 2011, the
HITSC Clinical Quality Workgroup and Vocabulary Task Force
were tasked with selecting the minimum number of vocabulary

standards with the minimum number of values to meet the
requirements of meaningful use stages 2 and 3. Content
exchange standards are being reviewed as well with the same
goal to harmonize HIT standards. It will take the cooperation
and collaboration of many, especially the HIM profession, to
harmonize HIT standards and implementation guides for the
purpose of interoperability and health information exchange
HIE.
Types of Standards
Many types of standards are necessary to implement EHRs and a
health information technology infrastructure that supports
connectivity, interoperability, and seamless data interchange.
While progress with standards harmonization and consolidation
has occurred, there are still hundreds of standards. Thus, it is
impossible to discuss them all in this chapter. Those better-
known standards HIM professionals may work with are
addressed here. Other chapters, such as chapter 5 Clinical
Vocabularies and Classification Systems, provide additional
information on specific standards.
Record Structure and Content Standards
Structure and content standards establish and provide clear and
uniform definitions of the data elements to be included in EHR
systems. They specify the type of data to be collected in each
data field and the attributes and values of each data field, all of
which are captured in data dictionaries.
ASTM Standard E1384-02a 07
ASTM International is an SDO that develops standards for a
variety of industries in the United States. The ASTM Technical
Committee on Healthcare Informatics E31 is charged with the
responsibility for developing standards related to the EHR. E31
works through subcommittees assigned to various aspects of this
endeavor.
The ASTM Subcommittee E31.25 on Healthcare Data
Management, Security, Confidentiality, and Privacy developed
ASTM Standard E1384-02a 07. This standard identifies the
content and structure for EHRs. The scope of this standard

covers all types of healthcare services, including acute care
hospitals, ambulatory care, skilled nursing facilities, home
healthcare, and specialty environments. It applies to short-term
contacts such as EDs and emergency medical care services as
well as long-term care contacts.
HL7 EHR-S Functional Model and Standards
HL7 provides a comprehensive framework and related standards
for the exchange, integration, sharing, and retrieval of
electronic health information that supports clinical practice and
the management, delivery, and evaluation of health services. It
provides a reference list of functions that may be present in an
EHR-S (http://www.HL7.org). Figure 4.6 shows the HL7 EHR-S
Functional Model. HL7 developed the HL7 EHR-S Functional
Model and Standards that address the content and structure of
an EHR. The purpose of the functional model is to provide a
foundation for common understanding of possible and useful
functions of EHR systems.
Figure 4.6. ANSI/HL7 EHR System Functional Model, R1-2007
Content Exchange Standards
Content exchange standards complement record content and
structure and vocabulary standards. These standards provide the
rules, often called protocols, of how data are actually
transmitted from one computer system to another. Content
exchange standards supply the specifications for the format of
data exchanges, thereby providing the ability to send and
receive medical and administrative data in an understandable
and usable manner across information systems.
CCR, CDA, and CCD
The CCR standard is a core data set of relevant current and past
information about a patient’s health status and healthcare
treatment. The CCR was created to help communicate that
information from one provider to another for referral, transfer,
or discharge of the patient or when the patient wishes to create
a personal health record. Data from a CCR may also be
incorporated into a personal health record. Because it utilizes
XML codes, it enhances interoperability and allows its

preparation, transmission, and viewing in multiple ways. The
CCR is designed to be organized and transportable. It is
sponsored by a consortium of healthcare organizations,
practitioners, and other stakeholders. The CCR is the other
content exchange option available for meeting the requirement
for EHR Technology to be certified as being capable of
electronically exchanging a patient summary record for stage 1.
HL7 is a SDO that provides standards, guidelines, and
methodologies that make data exchange possible among
hospitals, physician practices, and other types of provider
systems. For example, the standards consist of rules for
transmitting demographic data, orders, patient observations,
laboratory results, history and physical observations, and
findings. They also include message rules for appointment
scheduling, referrals, problem list maintenance, and care plans.
The HL7 CDA provides an exchange model for clinical
documents (such as discharge summaries and progress notes)
and brings the healthcare industry closer to the realization of an
EHR. The CDA standard makes documents machine-readable so
that they can be easily processed electronically. It also makes
documents human-readable so that they can be retrieved easily
and used by the people who need them.
ASTM and HL7 negotiated a memorandum of understanding to
bring ASTM’s CCR initiative into line with HL7’s EHR
functionality and CDA standards. The CCD was developed as a
collaborative effort between ASTM and HL7 to leverage CDA
with the CCR specifications. As the use of the CCD increases, it
is likely to become the common health information exchange
(HIE) methodology between the EHR and PHR systems.
Institute of Electrical and Electronics Engineers 1073
The Institute of Electrical and Electronics Engineers (IEEE)
1073 provides for open-systems communications in healthcare
applications, primarily between bedside medical devices and
patient care information systems, optimized for the acute care
setting. The IEEE 1073 series was adopted as a federal health
information interoperability standard for electronic data

exchange (ONC 2006).
The IEEE 1073 series of standards pertains to connectivity. The
standard specifically addresses the requirement for two devices
to automatically configure a connection for successful
operation, independent of connection type. The standard defines
a device-to-device internal messaging system that allows
hospitals and other healthcare providers to achieve plug-and-
play interoperability between medical instrumentation and
electronic healthcare information systems, especially in a
manner that is compatible with the acute care environment.
Digital Imaging and Communication in Medicine
Through a cooperative effort between the American College of
Radiology and the National Electrical Manufacturers
Association (ACR-NEMA), Digital Imaging and Communication
in Medicine (DICOM) was originally created to permit the
interchange of biomedical image wave forms and related
information.
DICOM is used by most medical professions that use imaging
within the healthcare industry, such as cardiology, dentistry,
endoscopy, mammography, ophthalmology, and orthopedics.
DICOM was adopted as the federal health information
interoperability messaging standard for imaging in March 2003
(ONC 2006).
Vocabulary Standards
Vocabulary standards include vocabularies, code sets, and
nomenclatures. These standards go hand in hand with other
health informatics standards such as those for information
modeling and metadata. Vocabulary standards establish common
definitions for medical terms to encourage consistent
descriptions of an individual’s condition in the health record.
Having established standards for clinical data enables consistent
definition of data elements. These systems are explored
thoroughly in chapter 5.
Privacy and Security Standards
HIPAA mandated the adoption of privacy and security
protection for identifiable health information. HIPAA privacy

standards have been implemented throughout the healthcare
industry to protect personal health information and define
appropriate use and disclosure.
Security standards ensure that patient-identifiable health
information remains confidential and protected from
unauthorized disclosure, alteration, or destruction. Effective
security standards are especially important in computer-based
environments because patient information is accessible to many
users in many locations. Many standards organizations—most
notably, the ASTM and HL7—have developed security
standards, but no single standard currently addresses all of the
HIPAA provisions. Privacy is addressed in chapter 13 and
security is addressed in chapter 17.
Check Your Understanding 4.2
1. Which of the following best describes an SDO?
A. Coordinates standards groups
B. Develops standards
C. Develops data sets
D. Develops best practices
2. Which of the following should be used to communicate
information from one provider to another for referral, transfer,
or discharge of the patient?
A. CDA
B. CCR
C. HL7
D. ORYX
3. Which of the following was adopted as the federal health
information interoperability messaging standard for imaging?
A. DEED
B. DICOM
C. IEEE
D. NHIN
4. Which SDO develops messaging, data content, and
document standards to support the exchange of clinical
information?
A. IEEE

B. DSMO
C. NUBC
D. HL7
5. Which of these standards is a standard for communication
between bedside medical devices and patient care information
systems?
A. ASTM Standard E1384-02a 07
B. LOINC
C. HL7 CDA
D. IEEE 1073
6. One of the two official HHS advisory groups established
as a result of ARRA responsible for making recommendations to
the National Coordinator is:
A. Certification Commission for Health Information
Technology
B. HL7
C. HIT Policy Committee
D. Accredited Standards Committee Health Care Task
group
7. Which standard assists in the sharing of information from
one provider to another for patient care?
A. ASTM CCR
B. LOINC
C. HL7 CDA
D. DICOM
8. What organization coordinates the efforts of other SDOs?
A. ANSI
B. HL7
C. ASTM
D. ARRA
9. What type of standard establishes common definitions for
medical terms?
A. Content exchange
B. Interoperability
C. Record structure and content
D. Vocabulary

Emerging Health Information Standards
The development of healthcare informatics standards is far from
complete. The task is critically important to the development of
EHR systems and, ultimately, to implementation of a national
health information infrastructure. Leading standards groups are
continuously working to reach consensus on a variety of
standards, but many issues remain unresolved.
Extensible Markup Language (XML)
A key technology tool for enabling data sharing is called
extensible markup language (XML). XML was developed as a
universal language to facilitate the storage and transmission of
data published on the Internet. Markup languages communicate
electronic representations of paper documents to computers by
inserting additional information into text (Sokolowski 1999).
For example, the CCR standard specifies XML coding that
allows users to prepare, transmit, and view the CCR in multiple
ways such as in a browser, as an element in a HL7 message, or
CDA compliant document, or as a word processing document
(ASTM 2009).
Another XML-based standard, the Structured Product Labeling
(SPL), is a document markup standard approved by HL7 and
adopted by Food and Drug Administration (FDA) as a
mechanism for exchanging product information (FDA 2012).
Metadata Standards
AHIMA (2012) defines metadata as “Descriptive data that
characterize other data to create a clearer understanding of their
meaning and to achieve greater reliability and quality of
information. Metadata consist of both indexing terms and
attributes. Data about data: for example, creation date, date
sent, date received, last access date, last modification date”
(221). Metadata standards would be standards that support
descriptive data that characterize other data to create a clearer
understanding of their meaning and to achieve greater reliability
and quality of information.
CDA documents are also encoded in XML. CDA is cited
throughout an ONC advance notice of proposed rule making

published on August 9, 2011. This notice solicited comments on
metadata standards to support nationwide electronic health
information exchange. Initial categories of metadata under
consideration as a minimum set include patient identity,
provenance, and privacy in association with a patient obtaining
their summary care record from a health care provider (ONC
2011c). Following the notice, the ONC announced the launch of
two pilot programs which will test the metadata standards. At
the time of publication, a determination had not been made as to
whether EHR technology should be capable of applying the
metadata standards as part of EHR certification requirements
supporting meaningful use under Stage 2 of the Medicare and
Medicaid EHR Incentive programs.
Role of HIM Professional
As the domain experts in health record data content, HIM
professionals have a large role to play in overseeing healthcare
data sets and standards for their organizations. As paper
disappears and electronic information environments appear, the
HIM professional will be called upon to coordinate and manage
the organization’s data requirements. HIM professionals have
the opportunity to serve as leaders in healthcare organizations
and in their professional community to ensure data content
standards are identified, understood, implemented and managed.
Specific aspects that fall to HIM professionals include (AHIMA
2008):
Conducting a data content standards requirements analysis
Developing a local data dictionary to support enterprise-wide
interoperability
Advancing the development of data content standards
Contributing to domain knowledge by participating in
relevant professional association work
Contributing to the development and harmonization of
industry and professional standards
Real-World Case
According to the American Academy of Family Physicians
(AAFP), “Continuity of care is the process by which the patient

and the physician are cooperatively involved in ongoing health
care management toward the goal of high quality, cost-effective
medical care” (AAFP 2010, paragraph 1). The CCR, an XML-
based health data exchange standard, was created to help
communicate summary health information from one provider to
another for referral, transfer, or discharge of the patient.
Microsoft introduced a personal health record platform that
allows sharing of health information.
Microsoft’s HealthVault allows the user to gather, store, and
share health information online. HealthVault supports the CCR
and CCD standards for exchanging patient data. Not only can
applications use the CCR standard to exchange data with
HealthVault, but a user can extract and reconcile data from a
CCR (Microsoft 2009). Microsoft’s partners include NewYork-
Presbyterian Hospital, Health Partners, Kaiser Permanente,
Aetna, Walgreens, among others.
Summary
According to Brandt (2000), “the vision is clear: a longitudinal,
or lifetime, health record for each person that is computer-
based, secure, readily accessible when needed, and linked
across the continuum of care [is needed]. In reality, we are a
long way from that model.” It is impossible to develop a
longitudinal EHR that meets Brandt’s specifications without
standards that guide its development. The complexity of
technology, the variations in computer platforms from one
system to the next, and the different (and sometimes
conflicting) data needs of users demand flexible health
data/information systems. The systems must be able to store
volumes of data in a standardized format, communicate across
vendor-specific systems, and keep data in a secure manner that
protects individual privacy and information confidentiality.
The need for standardized data definitions was recognized in the
1960s, and the NCVHS took the lead in developing uniform
minimum data sets for various sites of care. As technology has
driven the development of the data/information systems, the
early data sets have been supplemented with healthcare

information standards that focus on EHR systems.
A number of standards-setting organizations have been involved
in developing uniform definitions, data fields, and views for
health record content and structure. Standards for developing
record structure and content, content exchange, vocabulary, and
privacy and security are being created and implemented. These
standards are dynamic and in constant development by various
groups.
Standards development generally takes place as a consensus-
driven process among various interested parties. Implementation
is often voluntary but may be mandated. However, many groups
are involved in standards development and competition exists
among those groups. One of the major efforts of the ONC is
standards harmonization that consolidates standards into a
useful and accepted set of national information technology
standards.
Some data sets and standards have been incorporated into
federal law and are thus required for use by affected healthcare
organizations. For example, in 1983, when Section 1886(d) of
the Social Security Act was enacted, UHDDS definitions were
incorporated into the rules and regulations for implementing an
inpatient prospective payment system based on diagnosis-
related groups (DRGs). These definitions are still required for
reporting inpatient data for reimbursement under the Medicare
program.
HIPAA mandated incorporation of healthcare information
standards into all electronic or computer-based health
information systems. Of particular importance under HIPAA are
transaction/messaging standards for communication of data
across systems, privacy standards that protect individual
privacy and confidentiality, and security standards that ensure
that data are accessed only by those who have a specific right to
access them. The rules and regulations for HIPAA are still in
development, and, to date, the transaction, privacy, and security
standards have been implemented. Other standards are still
under development. For example, in 2005 HHS published a

proposed rule to adopt of a suite of standards for the electronic
health care claim attachment. A final rule was never published.
However, the Affordable Care Act requires the final rule
defining standards and operating rules for claim attachments be
published no later than January 2014 with compliance no later
than January 2016.
The selection of health information standards to support EHR
adoption gained national support through recent federal
initiatives aimed at developing a strategic plan to guide the
nation’s implementation of interoperable health information
technology in both the public and private sectors. The ONC has
been given a mandate to advance the development, adoption,
and implementation of healthcare information technology
nationally through collaboration among public and private
interests and to ensure that these standards are consistent with
current efforts to set HIT standards for use by the federal
government (Thompson and Brailer 2004). As a permanent
office under HHS, the ONC oversees implementation plans for
the provisions of the HITECH Act within ARRA. In 2010, the
ONC published standards, implementation specifications, and
certification criteria for the certification of EHR technology to
support the achievement of meaningful use Stage 1 by eligible
professionals and eligible hospitals under the Medicare and
Medicaid EHR incentive programs. The final rule for Stage 2 is
expected to be released in third quarter 2012 followed by Stage
3 some years later.
Work will continue on the development of healthcare
informatics standards. It is a complex and dynamic task with
constant activity in the development, modification, negotiation,
and implementation process. The rapid growth of technology
and the increasing need for healthcare data/information makes
the task a daunting one. According to Fridsma (2011, paragraph
2) “ONC is identifying the vocabularies, the message, and the
transport ‘building blocks’ that will enable interoperability.
While vendors should be able to flexibly combine them to
support interoperable HIE, these ‘building blocks’ need to be

unambiguous and have very limited (or no) optionality.”
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