Testimony to the

National Committee on Vital and Health Statistics

Subcommittee on Standards and Security

August 28, 2002

J. Marc Overhage, M.D., Ph.D.
Associate Professor of Medicine, Indiana University School of Medicine
Senior Investigator, Regenstrief Institute for Health Care
On behalf of the
eHealth Initiative Foundation’s
Public-Private Sector Collaboration for Public Health

Good morning. My name is J. Marc Overhage and I am an Associate Professor of Medicine at Indiana University and a Senior Investigator at the Regenstrief Institute for Health Care in Indianapolis, Indiana. I am testifying today on behalf of the eHealth Initiative and its Foundation to help the subcommittee understand its efforts to bring together public and private sector stakeholders to promote and coordinate the national adoption of health data standards and systems interoperability to meet clinical and public health needs. The eHealth Initiative and its Foundation, which I shall subsequently refer to as “eHI”, is sponsoring one such effort, which is called the Public-Private Sector Collaboration for Public Health (or the “Public-Private Sector Collaboration”). In addition, it is providing significant staffing support to the Markle Foundation’s initiative—Connecting for Health…a Public-Private Collaborative which Dr. William Edward Hammond spoke about, earlier in this panel.

What is the purpose of your initiative? Briefly discuss your initiative’s objective, priorities, and strategies to succeed.

Purpose and Objectives

The mission of eHI is to drive improvement in the quality, safety, and cost-effectiveness of health care through information technology. Its membership represents many of the stakeholders in the health care community, including:

• Health Systems and Health Care Providers
• Health Care Information Technology Suppliers
• Payers
• Non-profit Organizations and Professional Societies
• Pharmaceutical and Medical Device Manufacturers
• Practicing Physician Organizations
• Research and Academic Institutions

eHI’s strategic priorities are as follows:

• Increase awareness of the role of information technology in driving greater quality, safety and cost-effectiveness within health care;
• Lay the foundation for an “interconnected, electronic health information infrastructure” by promoting the adoption of clinical data standards and enhanced connectivity;
• Build the case for public and private sector economic incentives for better quality health care enabled by information technology.

Overview of the Public-Private Sector Collaboration

In order to address the subcommittee’s questions, I will use a specific example of a recent eHI initiative – the Public Private Collaboration for Public Health. The Collaboration’s purpose is to:

• Develop and communicate strategies to efficiently and securely capture and transmit standardized electronic data of public health importance, including lab results, microbiology results, orders and chief complaint data;
• Facilitate the transmission of such data by building upon and integrating recommendations within the CDC’s National Electronic Disease Surveillance System (NEDSS);
• Leverage existing provider health care information systems and data sources to enhance public health surveillance processes;
• Achieve rapid results that can be applied within six to twelve months;
• Lay the foundation for a national health information infrastructure.

Critical Success Factors

There are many organizations and initiatives that have worked to drive the adoption of clinical data standards and lay the foundation for a national health information infrastructure. With these goals in mind, eHI and the Public-Private Sector Collaboration focused on the following critical success factors:

• Bringing together the public and private sectors, who, by working together, can leverage complementary expertise and competencies and achieve optimal results;
• Focusing on the need for standardized, electronic data to support a specific, well-defined, and highly visible need (e.g. public health) as opposed to trying to focus on a broader goal, such as the adoption of all data standards--so that results could be achieved and demonstrated quickly;
• Focusing on data that is, for the most part, already in electronic formats and therefore more likely to be converted and transmitted quickly;
• Aligning efforts and data needs with existing funding sources (e.g. emergency supplemental funding related to bioterrorism);
• Leveraging the work of experts and “those in the trenches” who have already been performing this work across the country, to build upon lessons learned and best practices;
• Involving key stakeholders, including those that produce data and those that use data, in strategy development efforts;
• Driving the usage of the standards and strategies developed within “real world” demonstration and implementation projects, to demonstrate feasibility and success;
• Aligning efforts with national initiatives, such as those related to NCVHS.

What organizations or professional societies are participating in your initiative? Briefly discuss the membership commitment considered within your initiative’s organizational structure.

Participants in eHI and the Public-Private Sector Collaboration

With the support of the Joseph H. Kanter Foundation, participants in eHI and/or the Public-Private Sector Collaboration include the following:

• Federal agencies such as the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services and NCVHS;
• State and local public health agencies and partner organizations such as the Association of Public Health Laboratories, the Association of State and Territorial Health Officials, the Council of State and Territorial Epidemiologists, the National Association of County and City Health Officials, the National Association of Health Data Organizations, the National Association for Public Health Statistics and Information Systems, and the Public Health Data Standards Consortium;
• Health care technology suppliers (representing 80% of the nation’s health care systems) including Cerner, EDS, IBM, McKesson, SAIC, Siemens and others;
• Health care providers and provider groups such as CareGroup HealthCare System, Cleveland Clinic, Duke University Health System, Kaiser Permanente, MedStar Health, New York Presbyterian, Partners HealthCare System, and VHA Inc.;
• Holders of large sources of health care data such as Advance PCS, 4Medica, Quest Diagnostics and Quintiles;
• Academic and research institutions such as the RAND Science and Technology Policy Institute, the Regenstrief Institute for Health Care, and the University of Pittsburgh Center for Biomedical Informatics;
• Standards organizations such as Health Level 7, SNOMED, and LOINC;
• Non-profit associations with interests in this arena, such as the American College of Emergency Physicians, the American Health Information Management Assocation, the American Medial Informatics Association, and the Workgroup on Electronic Data Interchange.

Commitment of Members of the Public-Private Sector Collaboration

The Public-Private Sector Collaboration includes both members and non-members of eHI. Work was performed by participant volunteers within seven working groups, who focused on the following areas:

• Architecture
• Chief complaint data
• Lab results
• Microbiology results
• Orders
• Security
• Vocabulary

The work was performed under eHI’s Foundation for eHealth and supported by the Joseph H. Kanter Foundation, CDC (through in-kind support), and eHealth Initiative contributions.

Accomplishments to Date

Since its inception in November of 2001, the Public-Private Sector Collaboration produced the following outcomes:

• Proposed additions to CDC’s Implementation Guide for Transmission of Laboratory Based Reporting of Public Health Reporting Information including standard formats and specification of data types that have not yet been addressed;
• Alternative methods and responsibility models for integration brokering functions;
• Conceptual framework for specifying the components of microbiology results reporting;
• Summary of scope, methods, and findings to date of sites currently performing syndromic surveillance;
• Identification of focus areas for demonstration projects.

As noted above, the Collaboration developed a model of the components of an integration brokering function. The purpose of this model is to define methods and tools that can be applied to data that is not currently standardized, in order to produce standards-compliant message formats and content. The graphic below provides an overview of the integration brokering framework.

The Collaboration has recommended the application of these integration brokering tools and methods as one means of accelerating the migration to a standards-based messaging environment.

Next Steps

Over the next 30-60 days, the Collaboration will release draft implementation guides for the following:

• Lab results
• Microbiology results
• Orders
• Chief complaint data.

These implementation guides will specify message formats, minimum data content, and considerations for coding specifications.

In addition, the Public-Private Sector Collaboration will focus on promoting widespread adoption of the standards and strategies developed through a wide range of communications, education, outreach, and other vehicles, targeted to providers, laboratories, public health agencies, and other key stakeholders that can drive change.

How do your activities interact with the NCVHS’ Patient Medical Record Information (PMRI) standards and terminologies?

eHI’s Interaction with NCVHS’ Patient Medical Record Information (PMRI) Standards and Terminologies

Central to eHI’s mission and strategy is increasing clinical data standardization and interoperability within the health care system. eHI’s members and Collaboration participants support standardization in both their product development and delivery of health care services. eHI’s commitment to the Public-Private Sector Collaboration is premised on the concept of applying PMRI standards to public health reporting. The Collaboration working groups used as their starting point, the application of standards and terminologies to enable the timely and efficient reporting from health care providers to public health agencies.

Demonstration projects will enable eHI to identify issues and provide feedback to NCVHS on the application of standards and terminologies in operational environments. We also believe that the demonstrations will provide an opportunity to validate the value of a standards-based approach to building an interconnected health care system. eHI would be pleased to have the opportunity to share our experiences and lessons learned as the demonstration projects are implemented.

Briefly discuss your initiative’s present level of use of PMRI standards and terminology, any gaps your initiative identified with them, and your plans for future involvement in filling those gaps.

eHI’s Use of PMRI Standards and Terminologies

Consistent with NCVHS’ recommendations, eHI’s Public-Private Sector Collaboration has recommended HL7 2.x as the format for:

• Orders
• Lab results
• Microbiology results
• Chief complaint data.

To support the implementation of these recommendations, the Collaboration is in the process of completing public health-specific implementation guides for each of these message types, with the support of the CDC.

Gaps Identified and Plans for Involvement in Filling Gaps

The Public-Private Sector Collaboration identified several key areas that require additional development or implementation.

• First, terminologies pose significant challenges. Existing terminologies do not support concepts of importance for public health surveillance, such as that related to chief complaint data. There are also instances where available and well-defined terminologies have limited implementation (e.g. LOINC).
• Second, implementation guides are essential in order to realize the benefits of standards and terminologies.
• Third, standardized approaches to defining and communicating rules associated with data usage would be of great value. One example of this is the need to know the public health rules for selecting lab tests, associating them with specific diseases, and determining the reporting requirements. Public health has attempted to systematize this manually through the development of the Dwyer tables. In the current environment, the rules implicit in the Dwyer tables must be translated and implemented for each application to provide automated reporting of lab results to public health agencies. A standardized approach to rules would allow vendors to develop automated “engines” that could translate the rules into routines for taking specific actions based on the rules parameters.
• Finally, while full adoption of the PMRI standards and terminologies may take significant time, current data can be leveraged in the nearer term by using integration strategies, such as format converters and code translators.

Recognizing that a number of ongoing efforts to coordinate PMRI and terminology standards exist, please discuss any lessons-learned by your initiative as well as your relationship with the activities of the other health data standards initiatives.

Lessons Learned

The success of the Public-Private Sector Collaboration demonstrates that the health care industry is ready to move beyond discussion into action.

The Collaboration has also demonstrated that a short-term intensive effort can produce significant and tangible results in a short period of time. This was due to several factors including: the high level of commitment among the participants, the current level of standards development, and the focus on solving a specific problem, i.e., public health reporting. Replicating this model could produce valuable advances in the movement toward adoption of standards.

The Collaboration further demonstrated the value of collaboration between the public and private sectors. Within our work groups we were able to partner the knowledge of public health requirements with the expertise of system suppliers and providers to identify strategies that could be rapidly deployed to produce significant improvements in public health reporting capacity. Throughout this effort it was evident that the private sector system developers were and continue to be willing to contribute their resources and expertise to developing standards-based approaches to meeting public health and other health care reporting requirements.

Relationship With the Activities Of Other Health Data Standards Initiatives

eHI was established to bring together the broadest range of participants in support of its mission, which is to improve the quality, safety and cost-effectiveness of health care through information technology and help to lay the foundation for a national health information infrastructure. Its membership and Collaboration participants include those who produce data, those who use data, those who enable the transmission of data, and those who develop the standards for data transmission (e.g. providers, health care IT suppliers, payers, national standards organizations, manufacturers, public health organizations, and Federal government agencies).

eHI seeks to work with all the other organizations focused on health data standards, through concrete alignment of activities and overlapping membership across the Steering Committees and membership of the various groups, to facilitate a coordinated approach to clinical data standards adoption. Communication lines are open, documents are shared, and attempts are made to align outcomes and work products. A summary of the organizations that eHI is either working with or has reached out to includes the following:

• Markle Foundation’s Connecting for Health ….a Public-Private Collaborative
• Federal Government’s Consolidated Health Informatics Initiative
• CDC’s National Electronic Disease Surveillance System
• Public Health Data Standards Consortium
• National Alliance for Health Information Technology
• National Committee on Vital and Health Statistics
• Data standards development organizations such as HL7, LOINC, WEDI and SNOMED.

Discuss what the National Committee on Vital and Health Statistics could do to assist with your initiative’s commitment to advancing PMRI standards and terminologies.

National Committee on Vital and Health Statistics Assistance

NCVHS can support eHI’s efforts by focusing on the following activities:

• NCVHS can continue to create a clear and consistent message that there is a set of “operable” standards and terminologies that can and should be adopted in the near term. This message will assure the participants in our initiatives that their decision to adopt specific standards will be validated and sustained by the overall health care community.
• NCVHS can encourage and support demonstrations that implement NCVHS recommendations or provide test beds for addressing the gaps in current standards. In some cases, these demonstrations may not require additional funding. For example, the funding for enhanced public health reporting can provide a significant demonstration of the value that standards adoption can provide. NCVHS can gain the benefit of these initiatives by monitoring their progress, providing visibility for their successes, and applying the lessons learned.
• Collaboration and coordination between NCVHS and other Federal agencies has the potential to advance standards adoption. If reporting and other record-keeping requirements are consistent with NCVHS-recommended standards, the health care industry will be able to move with confidence to adopt standards and realize tangible savings and efficiencies by doing so.
• NCVHS can leverage the work performed by eHI’s Foundation to bring together public and private sector stakeholders to accelerate the adoption of clinical data standards and interoperability, including that related to the Public-Private Sector Collaboration for Public Health and the Markle Foundation’s Connecting for Health—by incorporating results and lessons learned into NCVHS’ recommendations;
• Finally we would like to encourage NCVHS to undertake the development of a model for migration from the current environment to a PMRI standards-based environment. A realistic approach to migration will reassure the industry that standards adoption will be an orderly and considered process. We would encourage NCVHS to include in this migration plan, strategies and incentives that, if adopted, would accelerate the use of PMRI standards and terminologies.

We thank you for the opportunity to speak today and look forward to continuing this dialogue with NCVHS.

Public-Private Sector Collaboration for Public Health
Steering Group
As of May 2002

Delton Atkinson, MD, Executive Director, NAPHSIS

Thomas Balzer, PhD, Senior Vice President, Quintiles Transnational Corp.

Claire Broome, MD, Senior Advisor, Integrated Health Information Systems, Office of the Director, CDC

Rachel Block, Director, Finance, Systems and Quality, Centers for Medicare and Medicaid Services

Carol Brown, MS, Senior Strategic Oversight Coordinator/Anjum Hajat, MPH, Senior Research Associate, NACCHO

Bradley Douglas, Director, Cerner Corporation

Floyd Eisenberg, MD, Physician Consultant, Siemens Corporation

Seth Foldy, MD, City of Milwaukee Public Health Commissioner, Head IT Committee, NACCHO

Marjorie S. Greenberg, Chief, Data Policy and Standards Staff, National Center for Health Statistics, CDC and Representative for Public Health Data Standards Consortium

William Edward Hammond, PhD, Professor, Duke University, President of AMIA

C. Martin Harris, MD, Chief Information Officer, Cleveland Clinic

Jeff Kang, MD, Chief Clinical Officer and Director, Office of Clinical Standards and Quality, CMS

Brian F. Keaton, MD, FACEP, Attending Physician and Emergency Medicine Informatics Director, Summa Health System, American College of Emergency Physicians

Alana Knudson Buresh, PhD, Senior Director, ASTHO

John Loonsk, CDC

Denise Love, Executive Director, NAHDO

John R. Lumpkin, MD, MPH, Director, Illinois Department of Public Health and Chair, National Committee on Vital and Health Statistics

Yves Lussier, MD, Assistant Professor and Associate Deputy Director, Department of Medical Informatics, Columbia University

Janet Marchibroda, Chief Executive Officer, eHealth Initiative

M. Jane Markley, Corporate Vice President, SAIC

Clement J. McDonald, MD, Director Regenstrief Institute, Leader LOINC Project

J. Marc Overhage, MD, PhD, Regenstrief Institute

Gianfranco Pezzino, MD, MPH, President-Elect, CSTE, State Epidemiologist, Kansas Department of Health and Environment

Helen Regnery, PhD, Program Manager, NEDSS; Association of Public Health Laboratories

Russell J. Ricci, MD, General Manager, IBM Global Healthcare Industry, Board Chair, eHealth Initiative

Helga Rippen, MD, PhD, MPH, Director of RAND Science and Technology Policy Institute

Wes Rishel, Board Chair of Health Level Seven, Vice President, Research Director

Gartner Research, Gartner Healthcare, Inc.

Charles Saunders, MD, President, Health Care Global Industry Group, EDS

Randy Spratt, Senior Vice President, Technology and Standards, McKesson Corporation

Mike Wagner, MD, PhD, RODS Laboratory, Center for Biomedical Informatics, University of Pittsburgh

Andrew Wiesenthal, MD, Associate Executive Director, Permanente Federation

Public-Private Sector Collaboration for Public Health
Organizational Participants
As of May 2002

Advance PCS

American College of Emergency Physicians

American Medical Informatics Association

Apelon

Association of Public Health Laboratories

CareScience, Inc.

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

Cerner Corporation

Cleveland Clinic

Columbia University

Duke University

EDS

Emergint

ESRI

Health Language

Health Level Seven

IBM Corporation

Illinois Department of Public Health

Kaiser Permanente

Kansas Department of Public Health

Mayo Clinic

McKesson Corporation

4Medica

National Association of Health Data Organizations

National Association of County and City State Officials

National Association for Public Health Statistics and Information Systems

National Committee on Vital and Health Statistics

National Association for Public Health Statistics and Information Systems

New York State Department of Health

Public Health Data Standards Consortium

Quintiles Transnational Corp.

RAND Science and Technology Policy Institute

Regenstrief Institute

RODS Laboratory, Center for Biomedical Informatics, University of Pittsburgh

Quest Diagnostics

SAIC

Siemens Corporation

Washington State Department of Health