When the Veterans Affairs and Defense departments began testing health information sharing for their joint virtual lifetime electronic record (VLER) project, they could not initially exchange patient data successfully using the very standards specified by the Office of the National Coordinator for health record formatting.
The popular C32 standard format for sharing information about a patient's health status allows some flexibility in how organizations use it to accommodate their different needs. Ironically, that same feature limited the exchange of patient information between VA and DOD.
Dr. Doug Fridsma, acting director of ONC's standards and interoperability office, used the experience of VA and DOD as an example of the trickiness of getting standards right so healthcare providers can exchange health information properly. C32 is among the requirements of ONC's recent final rule on standards and certification of electronic health records (EHRs).
"The VLER project continues to be very important, in large part because it foreshadows many of the things that we can expect coming up in stage 2 of meaningful use certification," Fridsma said at a meeting of the federal advisory Health IT Standards Committee July 28.
"I see it as our interoperability or exchange "˜beacon community' because they are really trying to answer some of the hard problems," he said, referring to an ONC grant program to set up community-based health IT test beds.
VA and DOD use the C32 document format for summarizing a patient's medical status, which includes medication and problem lists. It is part of the Health Level 7 Continuity of Care Document standard, which the agencies were using in May to test the exchange of data for the VLER project.
In its certification and standards final rule, ONC added more details on patient care summaries and public health laboratory reporting to the standard formats. In doing so, it achieved a balance between being specific on some standards that promote interoperability and those that support flexibility and innovation by data sharing partners.
"On content and vocabulary, they have been very specific," said Dr. John Halamka, co-chairman of the Health IT Standards Committee and chief information officer of Beth Israel Deaconess Medical Center at the meeting. "On transmission, they have been quite general, but making sure that security is protected with encryption."
Fridsma emphasized the trade-offs that occur in taking a standards-based approach to health information exchange. "There are lots of challenges because things that are underspecified can sometimes get us into trouble when we get to the level of interoperability," Fridsma said.
With the first stage of meaningful use, "we pushed the ball a little further down field. But I don't think we have sufficient specificity to guarantee interoperability," he said. At the same time, too much specificity can preclude innovation. "We're still trying to get this right," he said.
For instance, the C32 may be suited for the exchange of information at one level but not be specific enough for exchanging information in other ways. "When we think about interoperability, we think of it as a binary construct, you're either interoperable or not. We may have to have a more nuanced approach to what we expect interoperability to be," Fridsma said.