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Interoperability Roadmap Public Comments

ONC accepted public comments on Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft Version 1.0. The comment period ended on April 3, 2015.

The draft Roadmap proposes critical actions that need to be taken by both private and public stakeholders to advance the nation towards a more connected, interoperable health IT infrastructure and was drafted by ONC based on input from private and public stakeholders. The draft Roadmap outlines the critical actions for different stakeholder groups necessary to help achieve an interoperable health IT ecosystem.


Charles Ishikawa
Executive Secretary
Joint Public Health Informatics Taskforce
Dear Office of the National Coordinator for Health IT: On behalf of the Joint Public Health Informatics Taskforce (JPHIT), we are pleased to submit comments on the Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft Version 1.0 (henceforth “the Roadmap”). As a taskforce of nine national public health associations, JPHIT’s comments are informed by a broad perspective on federal actions that impact public health informatics capacity and practice in the United States of America. Relative to the Roadmap, JPHIT’s view encompasses stakeholders who: • Support the public good; • Generate new public health knowledge; • Operate and connect health and public health IT capabilities; • Govern, certify and/or have oversight; and • Develop and maintain standards. JPHIT is committed to supporting ONC’s efforts to protect and improve our nation’s health with interoperable electronic health information. JPHIT supports the draft Roadmap’s overall goal, objectives, and approach. Public and private efforts to build an information ecosystem must advance toward the Learning Health System (LHS) to maximize public health benefits. Data flow among healthcare and health-related service settings to generate population-level insights is fundamental for a LHS. JPHIT, therefore, strongly supports actions that prioritize the development of interoperability building blocks for public health purposes. JPHIT finds, however, significant gaps in the Roadmap to health information system interoperability for population and public health. The gaps are at both strategic and tactical levels. Strategically, JPHIT believes that clinical and public health information interoperability must be advanced concurrently, allowing for optimal coordination in development, implementation, and interactions. When actions are prioritized to benefit direct patient care first and then only later benefit community health, the overall benefit to the public and the patient is unnecessarily diminished and delayed. We recommend that the ONC adopt a strategy that prioritizes actions that have mutual, immediate benefit to the quality of clinical and public health services. At a tactical level, adoption of this recommendation would, at a minimum, entail the following: 1. Stakeholders: Recognize and address the interoperability needs of public health agencies, other essential public health service providers (e.g., NGOs), and other population health actors as data providers, as well as data consumers. 2. Governance: In any governance body and its component working groups, industry-led or otherwise, ensure balanced representation for the public good’s interest in setting policy and standards for interoperability. The governance body should include representation from local, state, and federal public health as these three entities have unique and vital roles in the exchange of health-related data. 3. Priority use cases: Public health use cases, mutually beneficial to patients and their communities, should be prioritized in the first three years of the Interoperability roadmap implementation plan. Doing so will promote near-term returns on federal Health IT investments that are population-wide, solutions to core legal barriers that constrain interstate public health data exchange, and information technologies with baseline functionalities for the public good. JPHIT recommends use case #2, "Clinical settings and public health are connected through bi-directional interfaces that enable seamless reporting to public health departments and seamless feedback and decision support from public health to clinical providers.” 4. Core technical standards and functions: The common “clinical” and patient-matching datasets must be further standardized and grown for public health purposes. JPHIT supports and refers ONC to the individual comments of our member organizations for further technical details on these matters. JPHIT values the inclusive leadership and bold vision ONC exhibited in drafting the Roadmap. Public health agencies at local, state, and federal levels are partners in the process and essential components of the vision. Moving forward, JPHIT will continue to support all stakeholders in advancing health IT interoperability for more healthy and resilient individuals, families and communities. Sincerely, Marcus Cheatham, PhD JPHIT Co-Chair, NACCHO representative Stephanie Mayfield Gibson, MD, FCAP JPHIT Co-Chair, ASTHO Representative
Debi Willis
PatientLink Enterprises, Inc.
C2. Providers and technology developers supporting individual empowerment Call to action: Providers and technology developers should provide a majority of individuals with the ability to send and receive their health information and make decisions with the providers of their choice, including but not limited to their existing care team based on their preferences COMMENT: To enable patients to send their health information to a provider of their choice, barriers must be removed which currently prohibit patients from sending data to their provider. Enabling Bidirectional communication using Blue Button should be mandatory in EHR technology.
PatientLink is a technology company who has been in Health IT for 18 years. The recent advances in regulations which empower patients to engage and participate in their own healthcare has been very encouraging. We are participating in workgroups with other technology companies who desire to enable patients to be contributors and active participants in their health care. However, if EHR companies are not required to enable bidirectional communication with patients via a standard such as Blue Button, they will continue to hinder the ability of patients to communicate with any provider of their choice. We are willing to participate actively in advancing bidirectional communication via Blue Button and overcoming the barriers currently preventing this ability.
Jake Galdo
Assistant Professor
Samford University
Sean Kelly, MD, FACEP
Chief Medical Officer
General Comments to "Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap; DRAFT Version 1.0" We applaud the ONC for developing the interoperability roadmap. Over the last few years, billions of dollars have been spent in the development of our electronic health records system. Until we have a guide in place, we will not be able to fully realize the potential of this revolution. We agree with the ONC that interoperability of healthcare IT systems and the secure, efficient sharing of electronic health information are important to improving patient care and reducing healthcare costs. The ONC’s “Roadmap” provides the vision and framework to realize this potential. We are grateful for the opportunity to provide insight and comment. As a general matter, Imprivata strongly recommends that the ONC continues to consider the importance of security and data protection, as critical to the success of interoperability. The bi-directional flow of information between healthcare organizations and, in time, between patients and care providers relies on the integrity of health information. This can only be accomplished if the proper security policies, process, and technology measures are integrated at each step in the process – and if those security measures do not interrupt clinical workflows. For interoperability to succeed on a broad scale, the entire healthcare community—including patients, care providers, hospital administration, policymakers, payers, and technology vendors—must be assured of the authenticity and validity of the information itself, as well as the identity of the individuals accessing and sharing the data.
Specific Comments to "Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap; DRAFT Version 1.0" 1. Proposed addition of EPCS (Electronic Prescription of Controlled Substances) as a “prioritized workflow". The current draft of the Roadmap presents a call to action (in Table row D.4): "e-prescribing of controlled substances with concurrent availability of PDMP data”. We applaud this goal as an essential part of increasing patient safety and public health. We are, however, concerned that this call-to-action, as presently written, could inadvertently delay the broad adoption of EPCS by causing providers to wait until PDMP-based workflows are developed before adopting EPCS. As is eloquently described in Appendix F of the Roadmap, the use of EPCS -- even in the absence of PDMP -- significantly reduces abuse, and acceptable workflows that enable its adoption today are available. Further, the broad adoption of EPCS will result in more complete and reliable PDMP data. On the other hand, we believe that the development of PDMP-based workflows that put the prescribing physician in an enforcement role will take longer. Such workflows will need to go beyond the technical challenge. They will require the resolution of sociological and ethical issues in balancing patient-doctor trust with the wishes of law enforcement. We therefore propose that the current call-to-action: • E-prescribing of controlled substances with concurrent availability of PDMP data be replaced with two calls to action along the following lines: 1. E-prescribing of controlled substances (EPCS) with integrated reporting to PDMP systems. 2. Availability of PDMP data when e-prescribing controlled substances. We also propose that “EPCS” be added to the glossary. 2. Section M (Accurate identity Matching): Motivate use of authentication data in matching. We believe that the use of authentication data, including biometrics, has the potential to improve the accuracy of matching by several orders of magnitude. We also believe that the availability of such data will increase as identity proofing of patients becomes more prevalent as proposed in section F of this Roadmap. The roadmap appears to agree, as evidenced by critical action M2.3 ("ONC will coordinate with industry stakeholders to study voluntary collection of additional identity attributes …”), but there is no introductory text motivating that action. In fact, the current draft seems to dismiss authentication as being distinct from identity matching (“Identity matching should not be confused with authentication”) and by implication, not relevant. To dispel that implication and to be consistent with the critical actions suggested in table row M2, we propose that Section M, “Moving Forward and Critical Actions” be enhanced. We propose inserting as the second paragraph the following text: We must use all means available to improve the accuracy of matching. To that end, it may be fruitful to study the use of authentication data in the matching process. As we move forward, patients will acquire “proven” identities that can be securely attached to biometric or other identifying data. It is important to study the use of authentication data in the matching process as it could, when available, improve the matching accuracy by orders of magnitude.
Rob Gingell
EVP Product Development
Resilient Network Systems
See uploaded comments file.
See uploaded comments file.
Bruce Wilder
Interprofessional Systems, Ltd.
A second file is attached, an intended to accompany the previous comments.
Bruce Wilder
Interprofessional Systems, Ltd.
I have reviewed NATIONWIDE INTEROPERABILITY ROADMAP – DRAFT VERSION 1.0, and the Quick Reference Factsheet (both of which I will refer to hereafter as the “Interoperability Roadmap” ), and would like to provide comments. In addition, I have attached two files that provide background and additional details for the comments provided here. The “Interoperabiity Roadmap” appears to be unnecessarily and complicated, and its goals more aspirational than achievable, unless a radically different approach is employed. Although comment regarding problems with patient safety, security and privacy, widespread physician dissatisfaction, and other issues relating to the current state of EHRs has not been requested, I mention these issues because I believe that in large part they have a similar root cause as does the poor progress being made with regard to interoperability. In my view, there are two things that are easily achievable (technically, but perhaps not politically), and that could bring about the desired result (namely interoperability and a nationwide health learning system) more simply, and more cost-effectively for the taxpayers. First, an open source EHR (VistA, e.g.) should be made available to any provider (physician, group practice, hospital, public health agency, e.g.) at nominal cost. Second, the above-mentioned open source EHR (there could be several versions for adaptation in different environments, but all with the same architecture) needs to be licensed so as to optimize innovation by the actual users, and patients. Of course, a properly constituted governing authority (such as was contemplated in HR 6898 of 2008, referred to in the attached documents) would be (as would open source code) an essential part of such an environment. The widespread use on an EHR with open source code would enable, and in fact strongly incentivize (if not require for survival) proprietary vendors (not only of EHRs, but of medical device makers) to make their products interoperable.
Development of publications, and availability for dialog with policy-makers
Steven Kelmar
Executive Vice President, Corporate Affairs
Aetna, Inc.
Attached please find Aetna, Inc.'s comments on the Interoperability Roadmap.
Pamela Lane, MS, RHIA, CPHIMS
Deputy Secretary, HIE and Director of CalOHII
CA Health and Human Services
CalOHII appreciates the opportunity to comment. Please see attached letter.
Mary Ann Chaffee
Senior Vice President
Eric de Jager
Vice President, Product Management
Databound Solutions, Inc.
Please see the attached document.
Our company delivers data automation and interoperability solutions for healthcare providers. We would welcome the opportunity to be included in the discussions on the development of data standards for electronic health records and patient billing systems. Beginning in 2015 we will be exploring the interoperability of commercial, wearable and other "tele-health" devices into EHR systems as a means to reduce re-admissions and improve patient outcomes.
William Rich, MD
Medical Director, Health Policy & President Elect
American Academy of Ophthalmology
Please accept the attached comments on behalf of the American Academy of Ophthalmology. For comments or questions, please contact Rebecca Hancock at rhancock@aaodc.org.
Outlined in the attached comment letter.
Mary Ann Chaffee
Senior Vice President
Nathan Seth
Vice President - Emerging Technologies & Solutions
Kforce Government Solutions, Inc.
KGS will support ONC with interoperability testing, implementation, pilot study, and evaluation. KGS is willing to serve as an industrial committee member that contributes to the ongoing interoperability efforts between the federal government agencies and their partners.