Critiquing EHR Interoperability PlanHIMSS Executive Assesses Presidential Council's Report
The report from the President's Council of Advisors on Science and Technology, which endorses the use of extensible markup language in electronic health records, "almost makes it sound like this XML approach will be the magic bullet" that solves interoperability and exchange issues, Sensmeier says.
"That does a disservice to those who have been working on this challenge for a long time," she adds. "It if was that simple, we would have solved this problem a long time ago.
In an interview (transcript below), Sensmeier:
- Praises the council for calling attention to the importance of making EHRs interoperable to facilitate health information exchange among providers while maintaining privacy.
- Criticizes the council's suggested approach of using XML to tag specific data elements within EHRs with descriptive information, such as relevant privacy protections. She points out that individual data elements "rarely have meaning outside of their context."
- Calls for additional work on existing standards and processes for interoperability, including Health Level Seven and IHE, or Integrating the Healthcare Enterprise, rather than starting from scratch on a "universal exchange language" as the council recommended.
- Labels as unrealistic the council's call for requiring use of an XML-based universal health language in future stages of the HITECH Act EHR incentive program.
At HIMSS, Sensmeier is responsible for the areas of clinical informatics, standards, interoperability, privacy and security. A registered nurse, Sensmeier became board certified in nursing informatics in 1996, earned the Certified Professional in Healthcare Information and Management Systems in 2002, and achieved HIMSS fellowship status in 2005. She is an adjunct faculty member in the school of nursing at Johns Hopkins University.
HOWARD ANDERSON: The President's Council of Advisors on Science and Technology has called for the use of a universal exchange language based on XML within electronic health records. Do you think that such a language could play a valuable role in future generations of EHRs?
JOYCE SENSMEIER: I think the report has a lot of interesting and good ideas within it, and I certainly support the idea of heaving a language that we can use for interoperability. Also, I love the idea of thinking of innovative ways to approach this. We as an industry have not yet solved the interoperability problem, and we have been working on standards and other efforts for more than 20 years. So I think it is really important to do a wake-up call and ask: Are we working in the right ways? Are we looking at the right things? And is there a better and simpler way to approach it?
My challenge with the primary recommendation that they make is it simplifies things greatly to a point that it almost makes it sound like this XML approach will be the magic bullet. That does a disservice to those who have been working in this space for a long time. If it was that simple, we would have solved this problem a long time ago. So that is my initial reaction.
Using XML Tags
ANDERSON: The council said that XML could be used to pair data elements in electronic health records with metadata tags that describe, among other things, the required security and privacy protections. Do you think that is a good approach?
SENSMEIER: The challenge with the data element approach is that a universal XML-based language implements, but does not inform, the tags, and data elements rarely have meaning outside of the context of other elements that they need to relate to. ...
So, for example, a lab result or lab report, or even a radiology image ... is something that is important to be explained and have the context. So to me, the challenge is you need the information model to support this, and to see the document or the information in its perspective and with human interpretation is also an important component.
So let me just give you an example. You have vital signs for a patient and you might see the heart rate, the respiration, the temperature. Putting them together in a chronology would give you information about what is happening over time with those vital signs, and then you need to look longer term at the patient's situation and in context with other reports. To me, that is what you are losing when you just take a data element approach. Even with the metadata and the tagging, it would be extremely difficult to pull out what you need to get a picture of the patient's situation with that approach.
ANDERSON: So are you suggesting that existing standards should be leveraged rather than creating a new universal exchange language?
SENSMEIER: Absolutely. I think it is great to take a fresh perspective, and it's possible to use the council's report and the comments the Office of the National Coordinator for Health IT gets back on this report to take a look at what has occurred. But to me, to reinvent the wheel at this point would cause more damage than help.
Take these comments, the recommendations, consider the body of work that is out there available and make it better; improve on it. That is the ultimate solution. ...
Health Level Seven Standards
ANDERSON: What standards that already exist could play a role in all of this?
SENSMEIER: Well certainly the Health Level Seven standards are critical. In the report they talk about CDA, the clinical document architecture standard from HL7, which helps to bring data elements together into the form of a document that you can parse out in different ways.
There is a reference information model within HL7 that also should be used to give the context of the data elements that they are describing, and the XML approach is a part of that work.
And then, finally, what the Integrating the Healthcare Enterprise project does is profile those standards and provide implementation guides for how the users can implement them to maximize the ability to exchange information consistently. So those are three ideas that I would ask them to consider.
Role of Middleware
ANDERSON: The presidential council said that healthcare organizations would not have to replace their EHRs to accommodate a new universal exchange language because the EHRs could be made compatible with the new language through middleware. Is that realistic?
SENSMEIER: To me it is not completely realistic. The idea of using middleware is an important concept, and the EHR vendors and the middleware vendors are working very collaboratively to move the interoperability agenda forward, which is great. We are seeing at the interoperability showcase at the HIMSS Conference where those partnerships are critical, especially from the infrastructure perspective, which is basically what this report is talking about.
To say, though, that it wouldn't require any changing of the EHR systems is, in my opinion, naive because there are touch points between the EHR systems and the data and the middleware accessing the data that are certainly critical. ...
It is extremely important to make sure that the patient's information is protected and that the systems are secure. But it is going to be very complex to do that at the data element level and at the tagging level. That, to me, is a huge, huge undertaking. I don't want to minimize its importance, but I think that is part of the restructuring of the current systems that would need to take place.
The use of middleware is not going to enable us to just separately address this without affecting the current systems that are in place. There will need to be work done to connect those two components and to really get at the interoperability exchange that they are seeking.
ANDERSON: So many healthcare organizations are still making the move from paper to electronic records, or expanding their use of EHRs. So is moving to a next generation of EHRs that accommodate a universal exchange language realistic in the near term for stage two or stage three of the HITECH EHR incentive program?
SENSMEIER: The chief information officers and the physicians practices are right now tearing their hair out trying to make sure that they are thinking of all that they need to do. ... As many of them consider the incentives and the mandates ... there is just so much that they need to manage and think about and they have their hands full with the systems implementations that they currently have going on. ... So my hat is off to them. And certainly, from HIMSS' perspective, we are trying to provide them with some tools to help.
They cannot even begin to think about what this (universal exchange language) might mean. It is great that ONC is asking for comments on this report so that we can better understand what the implications are. But I can't imagine that healthcare organizations are able to even begin to consider what this might mean to them.
Moving forward to stage two or stage three, hopefully we can get some clarity around this topic and they can better understand what it might mean to them and if there is a way to provide simpler solutions for them. So the innovative approach and the creative thinking is important, but we also need to marry that with the body of work that is available, the efforts that have moved forward already and that are in place to realize health information exchange.
I want to mention one other example. We talked about the acute care environment in physicians practices a little bit, but the idea of statewide health information exchange is another component that will be impacted by this. The states that have received funding for their programs are beginning the implementation of those efforts. So for them to now go back and reinvent the wheel is going to be a pretty challenging thing. Many of them have gotten their business plans and technical plans approved by ONC, and they are marching forward to realize the statewide health information exchange. So for them to now stop and reassess their processes and consider what this means for them, that is another potential disconnect that I foresee.