The document discusses the future of healthcare standards and interoperability. It outlines the standards committee's 2014-2015 workplan focusing on topics like image exchange, quality reporting, and care management. The presentation notes that content, vocabulary, and transport standards need further development. Specifically, it calls for abandoning proprietary approaches and adopting common web standards like JSON, REST, and OAuth for exchanging health data. The presentation envisions a future where FHIR replaces older standards and certification focuses on true interoperability using modular, implementer-friendly standards.

1. The Future of
Standards
John D. Halamka MD

2. Agenda
•
The requirements based on the Healthcare Reform
timeline
•
The 2014-2015 Workplan for the Standards
Committee
•
•
•
Care Management goals
Reflecting on where we are and where we need to go
Questions

4. Workplan Activities
Topic
Image Exchange
Data Transport
Topic Description
and Notes
Standards to support image
exchange
Status
Assigned to the Clinical
Operations WG
Additional standards to support
transport of data to and from
TASK COMPLETED
patients
Result
High
High
Standards which support flexible
platforms for measuring and
reporting quality
High
Standards to support closed
loop referral workf1ow
High
Record Locator
Services
Standards which support
Record Locator Services
High
Care Plans
Standards to record care
plans/care team
High
Quality reporting
and measurement
Referral Workflow

5. Workplan Activities
Topic
Topic Description
and Notes
Status
Result
Content Gaps (Lab Orders)
Clinical Operations WG reported out
during June HITSC
Medium
Standards Supporting Digital
Signature
CMS presented to HITSC on July
17;
Medium
Medium
Parsing and record
sharing
Improvements to standard to
facilitate unambiguous parsing,
longitudinal record sharing, and bulk
record sharing
Medium
Advanced Directives
Standards to record advanced
directives/care preferences
Medium
APIs
Standards for application
programming interfaces supporting
modular application integration
Medium
CDS
Standards for clinical decision
support, both knowledge
representation and application
programming interfaces (APIs) for
query/response to knowledge
resources
Medium
Lab Orders
Digital Signature
Terminology
Content Gaps (Terminology)

6. Workplan Activities
Topic
Topic Description
and Notes
Defect Reporting
Standards which support defect
reporting to PSOs
Medium
Standards needed for registry
support including structured
data capture and transmission
to third party repositories
Medium
Registry Support /
SDC
Query/Response of
PDs and Patient
Identity
Status
Standards which support
query/response of provider and
patient identity in directories
Result
Medium

7. Workplan Activities
Topic
Topic Description
and Notes
Status
Standards which support consent in
a query/response architecture such
Query/Response Consent as granular patient privacy
preferences hosted in a managed
Management
service ("pull") and sent as part of
the request for records ("push")
Data Segmentation for
Privacy
Standards supporting data
segmentation for privacy
P&S WG and COWG reviewed DS4P
Project, which upon completion was
handed work over to HL7 to develop
standard; DSTU scheduled for Sept
release.
Standards for clinical documentation
Clinical Documentation supporting new payment models
for New Payment Models (includes ICD10, smart problem lists,
computer assisted coding)
Local and Targeted
Queries
Standards which support query of
data within organizations and
targeted query for patient data
Result
Medium
Medium
Medium
Medium

8. Care Management Goals
• Identifying cohorts and creating queues with
rules
• Managing queues with guidelines/protocols
• Real time alerts and reminders
• Scheduling/Registration decision support
• Test results tracking

9. Measure
Expectation
11/11/13
EHR
Capability
99

10. M
R
od
H
Ex i f
E s
Standards
d ie
p e ie d
e lit
c i
ct D
n b
at at
a a
h p
io a
n a
ns
E C
Measure
Expectation
11/11/13
Usability &
Workflow
EHR
Capability

11. Patient Profile Screen

13. Self Service Web Interface

14. Patient-Level Information Assets
BIDPO
QDC
- -

15. Provider Measure Scorecard
Slide title
Massachusetts eHealth Collaborative
© MAeHC. All rights reserved.
- -

16. Decision Support Service Providers

17. Where we are
• Content
• Vocabulary
• Transport

18. Content
•
The HL7 RIM is important for creating content standards
but should be invisible to implementers
•
A 16 year old without healthcare domain knowledge
should be able to create an arbitrary structured content
document with novel data fields
•
In the near term, CCDA and FHIR must co-exist. In the
future FHIR may supplant CCDA
•
•
JSON is easier to generate and parse than XML
HL7 3.0 is not going to be widely used for messaging in the
US

19. Vocabulary
• The Value Set Authority Center has
collected almost all needed vocabulary and
code sets
• There are a few gaps - uniform adoption of
LOINC for allergy/severity/reaction, UCUM
for units of measure, EHR support for
structured data capture

20. Transport
• RESTful approaches that use OAuth2 and
OpenID are easier to implement than
SMTP/SMIME or XDR with PKI.
• Trust fabric solutions are still evolving and
trust anchor exchange is what is working
now
• Push, Pull and View are all valid
interoperability architectures

21. “Healthcare is not special”
• We need to abandon the idea that
healthcare needs unique approaches to
exchanging payloads of data.
• HTML and HTTP = FHIR and
REST/OAuth2/OpenID
• Simple and functional is more important
than addressing every edge case

22. Where We Need to Go
•
Certification needs to be redesigned to focus on
interoperability using real clinical scenarios
•
Optionality needs to be eliminated (OR means AND
and destroys in interoperabilty)
•
•
Modularity needs to be enabled
•
How do we create an “app” ecosystem in a world of
EHR consolidation/attrition?
Implementation Guides should not be based on
“indirection” but should stand alone

23. The Next 3 Years
•
For now, continue version 2.x for messaging transactions in
the US - ADT, orders, results until it can be replaced by FHIR
•
For now, continue CCDA for transitions of care until it can
be replaced by FHIR
•
Aspire to a future of FHIR over REST using JSON with
OAuth2/Open ID authentication
•
•
Reduce optionality - OR means AND
Focus on the building blocks and not narrow fixed use cases
i.e. require APIs in all EHRs as part of Meaningful Use Stage 3

24. Questions?
• jhalamka@bidmc.harvard.edu
• http://geekdoctor.blogspot.com