AHIMA Leading and Influencing International Standards for HIM Practices

By Anna Orlova, PhD; Diana Warner, MS, RHIA, CHPS, FAHIMA; and Sheryl Reyes, RHIA, MPH, MSMIS

AHIMA has been leading the development of international standards for health information management (HIM) practices at the International Organization for Standardization (ISO)—the world’s largest developer of international standards.

In the AHIMA comments on the 21st Century Cures Act Trusted Exchange Framework and Common Agreement, AHIMA representatives emphasized that “technical standards, policies and best practices around use of and adherence to technical standards are imperative to a trusted exchange framework and to a common agreement for trusted exchange¹. These technical standards are chiefly focused on transmission and security. While these standards are of course imperative, they alone do not ensure the accuracy/trustworthiness of exchanged data and information. Adoption of standards critical to the “use” side of the interoperability equation held within Section 4003 of the 21st Century Cures Act definition of interoperability must be required.²

Standards that support the “use” of exchanged information include those falling into the categories of:

• Functional Interoperability (Business, Functional, and Safety Standards)
• Semantic Interoperability (Data and Information Content Standards)
• Technical Interoperability (Transport and Security Standards)³

Figure 1 below shows AHIMA’s standards development activities and its partners—standards development organizations (SDOs).

At the level of a National Trusted Exchange Framework, the healthcare industry will be exchanging enormous amounts of granular data and individual record sets generated/captured at the local level by thousands of electronic health record (EHR) systems, ancillary systems, and mobile applications, largely without best practices for data and information governance in place—according to the results of AHIMA’s information governance (IG) surveys in 2014, 2015, and 2017. If the industry does not address standards and best practices for data and information capture, use, exchange, and reuse (i.e., functional, semantic, and technical interoperability standards all together), then providers cannot trust information for safe, quality care of the individual or for use in improving the health of patient populations.

AHIMA is focused on standards for trusted information sharing—standards for functional, semantic, and technical interoperability. These health informatics standards categories, as defined by the US Healthcare Information Technology Standards Panel in 2006, include:

• Functional Interoperability (Shared Rules)
  • Business Standards (business rules, guidelines, practice checklists)
  • Functional Standards (interoperability use cases, HIM practice standards)
• Semantic Interoperability (Shared Content)
  • Data Standards
  • Information Content Standards
  • Identifiers Standards
• Technical Interoperability (Shared Infrastructure)
  • Information Exchange Standards
  • Privacy and Security Standards
  • Health Information Technology (HIT) Safety Standards

Why AHIMA is a Leader at ISO

In 2011, AHIMA was designated by the American National Standards Institute (ANSI) to serve as a Secretariat to ISO/TC215 and the ISO/TC215 USTAG. AHIMA was selected by ANSI because AHIMA’s best practices for coding, information management, IG, clinical documentation improvement (CDI), operational informatics, and data analytics serve as invaluable resources for standardization of HIM practices and HIT products that support these practices at both the national and international level. AHIMA was also selected because the association has an established record of participation in various standards development organizations (SDOs), such as:

• Health Level Seven (HL7), where AHIMA develops standards for EHRs, personal health records (PHRs), and mHealth
• Integrating the Healthcare Enterprise (IHE), a collaborative of HIT vendors, users, and associations of healthcare professionals, where AHIMA develops US standards for HIM practices
• ISO/TC215, where AHIMA has elevated the US HIM, HIT, and informatics standards into international standards

AHIMA’s standards development activities are carried out in collaboration with the SDOs listed above. Informed by the Practice Briefs and best practices identified under the Volunteer Leadership Development (VLD) activities (AHIMA Practice Councils (PCs), Task Forces (TFs), and Ad Hoc Committees), the AHIMA Standards Task Force of over 60 volunteer HIM subject matter experts (SMEs) work on developing HIM, HIT, and informatics standards, as depicted in Figure 2 below.

Through these efforts AHIMA has positioned itself as an important participant in the national and international HIT standardization activities and has built institutional competencies for standards development and use to support trusted information exchanges for providers, information managers, and researchers.

Why AHIMA Focuses on ISO/TC215

The AHIMA Standards Task Force and Practice Councils have become the drivers to identify the need for standards and to develop HIM standards for electronic information exchanges nationally and globally (see Figure 2 above). Understanding that multi-stakeholder collaboration is needed to build and adopt standards, AHIMA, through multi-national and multi-sector cross-collaboration offered by the ISO/TC215, focuses on the effective proliferation of standards-based HIM practices in the US as well as in the global healthcare market. The stakeholders for ISO/TC215 standards include governmental agencies, healthcare organizations, clinical practitioners, health information managers, public health and research organizations, academia, developers and integrators of HIT applications and services, and various SDOs.

AHIMA selected ISO/TC215 as a primary partner in AHIMA standards development efforts because of its high visibility across SDOs, international focus, HIT users as a primary target audience, and unique role in developing interoperability standards that combines all three components of interoperability (semantic, technical, and functional), as well as for AHIMA’s established leadership role in various workgroups and overall Secretariat role to both the US delegation (USTAG) and the ISO/TC215 at large.

AHIMA Priorities at ISO/TC215

AHIMA standards development efforts at ISO/TC215 are focused to address interoperability challenges experienced today by HIM professionals, clinicians, researchers, and public health professionals who continue to face overwhelming difficulties with usability of the health information systems due to their shortcomings in supporting user needs.^4,5,6,7 Specific examples of some challenges when using health IT are provided in Table 1 below.

A five-year study published by the US National Institute of Standards and Technology on usability of EHR systems identified the following four issues with adoption that may negatively impact patient safety:

1. Clinically relevant information is not available for the task at hand
2. Inadequate documentation
3. Inaccurate information
4. Irretrievable information¹⁰

Healthcare is moving to greater patient participation and personalization in care that requires trusted information capture, sharing, use, and reuse between patients, providers, and healthcare organizations. This must occur during not just information access but also scheduling, referral, decision-making, and general management of the patient’s health and care. Standards-based interoperable HIT solutions are becoming fundamental building blocks and are driving healthcare delivery transformation to enable a financially sustainable and well-resourced healthcare system. In addition, the need for a competent workforce to support standards development as well as implementation, operation, and use of standards-based HIT solutions is overwhelming—specifically, for workers skilled in standards-based services integration, cloud computing, cybersecurity, and information safety.¹¹ AHIMA standards development efforts at ISO/TC215 are focused on addressing the challenges summarized above, all of which are semantic, technical, and functional interoperability challenges.

To date, ISO/TC215’s portfolio of standards and projects (standards under development) includes over 230 health informatics standards: International Standards (IS), Technical Specifications (TS), and Technical Reports (TR).¹² These standards are developed by the ISO/TC215 Work Groups (WG) and Joint Work Groups (JWG) as follows:

• WG1 – Architecture, Frameworks and Models
• WG2 – Systems and Device Interoperability
• WG3 – Semantic Content
• WG4 – Security, Safety and Privacy
• WG6 – Pharmacy and Medicines Business
• JWG1 – Traditional Chinese Medicine
• JWG7 – Health Software, HIT Systems and Medical Devices (abbreviated name)

AHIMA standards development activities are mainly conducted in WG3 (semantic interoperability standards), WG4 (functional interoperability standards), and WG2 (technical interoperability standards).

Workforce standards have been developed in WG3 and WG4, while HIT safety standards have been developed in JWG7. Table 2 below provides examples of standards developed with AHIMA participation.

Source: ISO/TC215. “ISO/TC 215 Health Informatics Standards Catalog.” 2017. 

AHIMA Partners at the US Delegation to ISO/TC215

AHIMA’s partners in developing interoperable HIM, HIT, and informatics standards at the US delegation (US Technical Advisory Group) to ISO/TC215 include various SDOs and national leaders in HIT adoption, including but not limited to (in alphabetical order):

• Association for the Advancement of Medical Instrumentation
• American Dental Association
• BD
• Clinical Data Interchange Standards Consortium
• Experian Healthcare
• Health Level Seven
• Healthcare Information and Management Systems Society
• Kaiser Permanente
• Medtronic
• National Council for Prescription Drug Programs
• Philips Healthcare
• US Department of Veterans Affairs
• US Food and Drug Administration

AHIMA built a foundation for ensuring ISO/TC215 standardization efforts have direct value for AHIMA members and HIM professionals at large. AHIMA is working with its members to be recognized as the national and global leader to influence the US position on HIM, HIT, and informatics standards across the globe. AHIMA’s goal is to help set the national and international HIT standardization agenda and establish HIM leadership and influence on standardization of electronic health data, information, and knowledge.

Resources

Those interested in learning more about ISO/TC215 standards development can visit the following resource links for additional information:

• ISO/TC215 Standards and Project Catalog
• ISO/TC215 Website at AHIMA
• ISO/TC215 Website at ISO

Notes

^[1] AHIMA. “AHIMA Comments on 21st Century Cures Act Trusted Exchange Framework and Common Agreement.” August, 25, 2017.

^[2] House.gov. “21st Century Cures Act.” November 25, 2016.

^[3] Orlova, Anna. “Overview of Health IT Standards.” Journal of AHIMA 86, no. 3 (March 2015): 38-40.

^[4] Bowman, Sue. “Impact of electronic health record systems on information integrity: Quality and safety implications.” Perspectives in Health Information Management (Fall 2013). 

^[5] Nguyen, L., E. Bellucci, and L.T. Nguyen. “Electronic health records implementation: An evaluation of information system impact and contingency factors.” International Journal of Medical Informatics 83, no. 11 (2014): 779-796.

^[6] Kuhn, Thomson et al. “Clinical Documentation in the 21st Century: Executive Summary of a Policy Position Paper from the American College of Physicians.” Annals of Internal Medicine. February 17, 2015. 

^[7] Bouamrane, Matt-Mouley and Frances S. Mair. “A study of general practitioners’ perspectives on electronic medical records systems in NHS Scotland.” BMC Medical Informatics and Decision Making 13, no. 58 (2013).

^[8] Mitcheff, M. “A Case Study: The Association of Interoperability of Health Information and Potential Patient Safety Concerns.” Presentation at 2016 AHIMA Convention, October 15 to October 19, Baltimore, MD.

^[9] Miller, M. and D. Young. “Supporting Functional Interoperability through Standards for Information Management Practices for Healthcare.” Presentation at 2016 AHIMA Convention, October 15 to October 19, Baltimore, MD.

^[10] Lowry, Svetlana Z. et al. “Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization.” US National Institute of Standardization and Technology (NIST). October 7, 2015.

^[11] International Organization for Standardization (ISO) Technical Committee 215, Health Informatics (ISO/TC215). “Strategic Business Plan.”

^[12] AHIMA and ISO/TC215. “ISC/TC 215 Health Informatics Standards Catalog.” 2017. 

Anna Orlova (anna.orlova@ahima.org) is senior director, standards, Diana Warner (diana.warner@ahima.org) is director, standards, and Sheryl Reyes (sheryl.reyes@ahima.org) is senior manager of standards at AHIMA.