Connecting the Dots: Outlining the Organizations Involved with EHRs and HIE

by Dan Rode, MBA, FHFMA

This column and other Journal articles often cite various government and industry organizations involved in work on a standard electronic health record (EHR), electronic health information exchange (HIE), and the standards needed to accomplish both. It can be a challenge to keep these organizations straight and connect the dots in the quest for a standard EHR and HIE. There are literally hundreds of groups involved in the development of health IT and data standards to some degree. This article highlights some of the most active groups involved with HIE and EHRs.

Standards: ANSI, HL7, ASTM

Standards development organizations (SDOs) have existed since the nineteenth century and affect all aspects of our daily lives, from lightbulbs to ATM cash transfers to the ANSI X12 837 electronic claim format. Congress authorized the American National Standards Institute (ANSI) to be an accrediting body for SDOs in 1918. Therefore, many of the current SDOs are essentially franchised by ANSI; this means that ANSI outlines the processes that these groups must follow to achieve industry consensus standards. In most industries, an industry council has been established to determine what standards will be used and how they will be used in that particular industry. The healthcare industry has lacked a similar entity.

Most HIM professionals are familiar with SDOs such as Health Level Seven (HL7), ASTM International (originally the American Society for Testing and Materials), the Accredited Standards Committee X12 (ASC X12), and the National Council for Prescription Drug Programs (NCPDP). These are voluntary standards groups.

In such groups, individuals, businesses, and government agencies join and voluntarily develop and adopt needed standards for a task or function. The industry councils previously noted then determine what standards will be used (in the case of competing standards), how they will be used, and for what purposes. With the 1996 passage of HIPAA, Congress selected the National Committee on Vital and Health Statistics (NCVHS) to serve as a healthcare industry council of sorts.

In addition to these data standard groups, other similar public and private groups exist for the development and maintenance of standards for terminologies and classifications. Some of these organizations, like some of the SDOs, are international organizations.

The International Classification of Diseases (ICD) is under the auspices of the World Health Organization (WHO), and the SNOMED standards development organization is becoming an internationally governed body. A national group oversees the use of the standard when a terminology or classification is affected by use or regulation. How the US will relate to the SNOMED SDO is currently under discussion.

Currently ICD-9 and -10 classification standards are controlled by the federal government via the National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS). Public input comes from the ICD-9-CM Coordination and Maintenance Committee. Several cooperating parties are also involved with ICD-9-CM, including AHIMA, the American Hospital Association, NCHS, and CMS, which determine the guidelines for ICD-9-CM use.

Other data standards commonly used include the Common Procedural Terminology (CPT), a private classification system maintained and licensed by the American Medical Association, and the Healthcare Common Procedure Classification System (HCPCS) maintained by CMS. Diagnosis and procedure classifications are complicated by the use of federally and privately controlled classifications and the heavy use of such classifications for reimbursement purposes.

There are around 100 terminology and classification developers, and AHIMA and the American Medical Informatics Association are currently working on a project to develop uniform coordination of these standards.

In addition to terminology and classification standards, a variety of potential quality measurement standards are being developed by other groups and collaboratives, which will be covered in a future column.

HIPAA: NCVHS, OESS, OCR

NCVHS predates the HIPAA standards and was established more than 55 years ago by Congress as an advisory body to the Department of Health and Human Services (HHS) on health data, statistics, and national health information policy. Unlike voluntary industry standards, HIPAA provides for regulated use of standards. NCVHS advises the HHS secretary regarding what standards and versions to use for what functions, designated by HIPAA.

The HIPAA charges to NCVHS resulted in the establishment of additional subcommittees related to confidentiality and privacy as well as security and standards. NCVHS also deals with data related to population health, quality, and as the author of the original model for a national health information infrastructure (NHII), an NHII work group. NCVHS has also made recommendations related to the federal government’s use of standards (the Consolidated Health Informatics standards) and, more recently, projects with the American Health Information Community and Office of the National Coordinator for Health Information Technology (see below).

Because HIPAA rules also have a compliance aspect, CMS’s Office of E-Heath Standards and Services (OESS) is the coordinating office for HIPAA standards and security maintenance, development, and compliance. The HHS Office for Civil Rights (OCR) is charged with handling privacy rule compliance. These offices serve as staff to the NCVHS subcommittees.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) coordinates the activities of NCVHS, some federal-only healthcare data projects, and a variety of other tasks. Until recently, ASPE also coordinated the Consolidated Heath Informatics program and the initial NHII development. Currently, ASPE is examining the work force implications of EHR and NHIN.

Electronic Records and a National Network: ONC, HITSP, CCHIT, AHIC

With President Bush’s 2004 call for a standard EHR by 2014, an executive order was released, and the Office of the National Coordinator for Heath Information Technology (ONC) was established. The HHS secretary and ONC then developed a new approach to adopting and implementing healthcare industry standards with the goal of achieving a standard EHR, HIE, and nationwide health information network (NHIN).

ONC initially awarded four contracts that established the Health Information Technology Standards Panel (HITSP), the Certification Commission for Healthcare Information Technology (CCHIT), and four architecture proposals for an NHIN. It also worked in conjunction with the Agency for Healthcare Research and Quality (AHRQ) and the Health Information Security and Privacy Collaboration (HISPC) to study the privacy and security barriers to HIE.

Essentially, HITSP is set up to harmonize or determine what sets of national standards (developed by the SDOs) will be used for what purposes or function in the US. Once HITSP determines these standards or groupings of standards, they are then reviewed by the American Health Information Community (AHIC, see below).

AHIC and the HHS secretary then must determine which standards should be used for what purpose in the healthcare industry. These standards and the criteria that are used are then forwarded to CCHIT, which is charged with reviewing health IT products to determine if they include the standards or the capacity to accommodate these selected standards. While HITSP and CCHIT are currently under ONC contracts, both are intended to become self-sustaining. Just how HISPC will evolve will become more apparent later this spring as its initial investigational projects are completed.

AHIC

AHIC was established by the HHS secretary in the fall of 2005. Made up of nine public and eight federal representatives plus the secretary, AHIC is a federal advisory body chartered to “provide input and recommendations to HHS on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected.”1 AHIC’s goal is to address EHR and NHIN adoption by addressing the issues of standards harmonization, product compliance certification, health information exchange, privacy, security, and the health IT agenda.

Work groups were formed to establish breakthroughs in the areas of biosurveillance (now population health), consumer empowerment, chronic care, and EHRs. Recently, additional work groups began to address quality, confidentiality, privacy, security, and personalized healthcare (the use and storage of genetic health information in the EHR). Except for confidentiality, privacy, and security, these groups are developing use cases that require standards. Once these use cases are developed, HITSP will provide the standards for each use, and after AHIC and HHS approval, CCHIT will incorporate them into the certification requirement.

To make this process work, the secretary has charged the federal representatives (e.g., the Department of Defense, Veterans Health Administration, and the Indian Health Service) to use adopted standards in the future. It also has actively recruited employers and other healthcare purchasers to do the same. If this approach works, healthcare entities working with these federal agencies will be affected and their needs will potentially spur software development for federal use and then private use in the industry. CCHIT certification will allow vendors to indicate to purchasers that their products meet the requirements being imposed.

On the long road to reach the goals of EHR, HIE, and NHIN, AHIMA and HIM professionals will continue their involvement with the organizations mentioned above as well as many others. In the months to come we will report on these and other organizations involved with these goals.

Note

1. US Department of Health and Human Services. “Secretary Leavitt Takes Steps to Advance Health IT.” Press release. June 6, 2005. Available online at www.hss.gov/news/press/2005pres/20050606.html.

Dan Rode (dan.rode@ahima.org) is AHIMA’s vice president of policy and government relations.