A key issue is whether EHRs should be certified in Stage 3 to generate electronic public health reports using a new, standardized approach. The Public Health Reporting Initiative is finalizing both a harmonized data element profile and a Clinical Document Architecture implementation guide in the next few weeks.* These are based largely on the Cancer Registry reporting standard that appears in Stage 2 MUse rules and on implementations already in place for the National Healthcare Safety Network (NHSN) and recommended for Stage 3. Adopting the PHRI approach need not require change to existing MUse reporting activities like electronic laboratory reporting, immunization registries or syndromic surveillance. However, it provides a reusable, modular, and extensible methodology that could be leveraged by these and many other types of reporting (for example, communicable disease case reports, product safety reports, birth and death reports) into the future.
The public health (and health IT) communities should examine the PHRI documents to decide if they represent an achievable step toward more generic interoperability between EHR and public health surveillance systems. If so, they will have to make their voices heard during the comment period, because MUse Stage 3 certification is NOT recommended by the HIT Policy Committee (rather, it is recommended for some future, unspecified time).
The Centers for Disease Control and Prevention (CDC), which funds much US public health surveillance, needs to decide and announce whether it will support pilot implementations, full-scale implementation, and health department migration to the new approach going forward.
The Office of the National Coordinator and CDC need to ensure that PHRI products are harmonized with similar initiatives across the ONC Standards and Interoperability Framework, and curated and maintained over time.
Other important issues in the Stage 3 recommendations include EHR data capture of information like occupation and disability; whether NHSN hospital reporting should be included as a new objective; and whether additional public health registries should be offered as choices in the incentive program.
Unfortunately, these decisions are being made at a time of significant vacancies and uncertainty in the decision-making structure at CDC. Representatives of local and state health departments, who are critical stakeholders in this process, will need to study, act and advise CDC, rather than depend on the agency. But the CDC Meaningful Use program is sponsoring a half-day Virtual Conference on public health and Meaningful Use Tuesday, December 18 beginning at 12ET. This should provide a good orientation to Stage 2 changes, and set a foundation for discussion of Stage 3.
Meanwhile, the urgent deadlines of MUse and ONC (sometimes labelled the “Office of No Christmas” for its December demands) loom. Inaction over the holidays might lead to a lump of coal in the public health stocking for Stage 3.**
* Disclosure: Author was a lead team member of the of the Public Health Reporting Initiative from October 2011-September 2012.
** References to Christmas are for humorous purposes only and do not imply an endorsement of any particular holiday or religion. Happy holidays to all, whichever you celebrate.
While healthcare providers and public health departments continue to study how Stage 2 of the Electronic Health Record (EHR) Incentive Program, or “Meaningful Use,” will affect them beginning October 2013, the Health Information Technology Policy Committee has issued a Request for Comment (RFC) on proposals for Stage 3 and beyond that may shape the program after October 2015. Comments are dueJanuary 14, 2013. At least some of these proposals, shaped by comment, will re-appear in a Notice of Proposed Rule Making (and yet another round of public comment) next year.
The RFC unexpectedly pushed back a proposal for electronic case reporting of reportable conditions to an indefinite time AFTER Stage 3 (see below). Because the two Population and Public Health objectives targeted “after Stage 3” have been to focus of rapid and intensive work in the Public Health Reporting Initiative, they will likely merit further discussion as to timing.
Some items of public health interest for Stage 3 (by my own arbitrary criteria–you should read the RFC!) include:
Adding the capability to record occupation & industry codes, sexual orientation and gender identity (optional fields) and disability status to EHR certification requirements (while not setting goals for provider capture of these elements)
Using vital signs and lab results to support up-to-date problem lists (e.g., to use vital signs to signal potential hypertension on the problem list)
RETIRING requirements to capture blood pressure, BMI and smoking status because recording is already at high levels (<80%, data source unstated). Progress will be tracked through hypertension and tobacco use quality measures instead.
Increasing clinical decision support interventions from 5 to 15, including preventive services and chronic disease management, especially hypertension control and dosing of drugs for renal impairments.
Change recording family history to recording high priority (unspecified) family history
Educational materials made available in at least one non-English language based on which of the top-five non-English languages in US are spoken locally
Transitions-of-care now specifically include referrals. Care summaries should include the identity of care team members like care coordinators, and EHR certification includes the ability to populate a referral form for specific referrals including smoking quit-lines.
Notifying care coordinators (when appropriate) of significant healthcare events like emergency department visits or hospital admission or discharge.
EHR importation and use of structured historical immunization data from immunization information systems (registries), and to receive, generate or access age-, gender-, and immunization-history-based immunization recommendations. The EHR certification criteria would requires the EHR to use standard rule sets and patient data to recommend immunization.
Continuation without change to electronic laboratory reporting and syndromic surveillance reporting.
Adding other mandated jurisdictional registries beyond cancer registries for which Eligible Professionals (and now Hospitals) may perform successful ongoing data submission to achieve a menu (optional) objective. In other words, cancer registries could be replaced by other registries in the menu objective for Eligible Professionals (and Eligible Hospitals would be offered a menu option for registry reporting for the first time).
Adding a second menu option for standardized reporting to a second registry, which could include those from professional societies, public health jurisdictions or other aggregators (e.g. Accountable Care Organizations). It is a new requirement that such reporting use a national standard (“e.g., consolidated CDA”).
Sending healthcare associated infection reports to the National Healthcare Safety Network (at least 10% of all reports sent from the certified EHR)
Two items of interest are pegged for “future stages” (i.e., after Stage 3). While it seems likely that HHS will continue to add future objectives and repairs to the program, the timing and nature of such activity is currently undefined.
EHRs should determine when a case report of a reportable condition need be sent to a public health agency, and should send at least 10% of initial case reports electronically. [“Case report” means clinical information on a case for which a laboratory report of a reportable condition may or may not have been sent separately. NOTE that in earlier discussions by the HIT Policy Committee this objective was slated for Stage 3.]
Reporting of adverse event (related to, e.g., vaccines, devices, EHRs, drugs or biologics) reports to FDA and/or CDC.
Dr. Thomas Frieden, Director of the Centers for Disease Control, can see satisfaction of his request that Stage 3 tackle improved clinical hypertension control, support for tobacco quit line referrals, and bidirectional communication with immunization information systems. Other voices, inside and outside CDC, have had additional goals, and many of these are reflected as well. Some of the key questions the public health (and larger Health IT) community must answer:
Should at least some form of public health case reporting be pushed forward into Stage 3? Will the necessary message or document standard be ready in time, AND will a meaningful number of health departments be ready to receive it? [Look for a post on this topic shortly.] Is it necessary to have a national public health knowledge system that provides rules for public health reporting, or could jurisdictional requirements be manually programmed into EHRs? And who will drive to these answers and assure needed tools are created? [Disclosure: I served as a co-chair of the Public Health Reporting Initiative for a year until September, 2012.]
Should cancer registries be demoted to just “one of” a variety of public health disease registries?
If a standard format is created to report to disease registries, will public health (and non-public health) registries be able to convert in time?
Will state health departments have adapted to receiving and managing CDA documents for Cancer Registries in Stage 2, and can they apply this to other use cases (possibly case reporting or additional disease registries) for Stage 3?
And the perennial question: will health departments be drowning in data from Stage 2, or will they successfully harness the many new ongoing data streams into more effective and efficient case management and health surveillance systems?
Answers to these questions must come in large part from health departments themselves. Many track developments using CDC’s Meaningful Use webpage. The Joint Public Health Informatics Taskforce of the Association of State and Territorial Health Officials, the National Association of County and City Health Officials, and seven other national public health associations, will doubtless be crafting a consensus response to RFC, and would likely welcome your thoughts as they do so.
Several more posts on Stage 2 and Stage 3 Meaningful Use objectives will follow.
Hard on the heels of my own departure from the US Centers for Disease Control and Prevention (CDC) on September 30 comes a clean sweep of high-level informatics leaders in the organization. Sources now confirm that James Buehler, MD the current Director of the Public Health Surveillance and Informatics Program Office (PHSIPO) will depart before year’s end. His supervisor, PHS Rear Admiral (ret.) Steven Thacker, a long-time advocate for cross-cutting integration, is also slated to leave his post as Director of the Office for Surveillance, Epidemiology and Laboratory Services (OSELS). These departures follow at least three years of marked funding reductions at CDC’s informatics core.
[Update 12/11/12: We’ve learned Dr. Buehler is departing for family reasons, and Dr. Thacker for health reasons. Friends and colleagues of Dr. Thacker can connect with him and his family here.]
Few signals indicate the future direction for informatics at the Agency. Acting leadership for OSELS will be placed in the hands of Denise Cardo, MD, director of the Division of Healthcare Quality Promotion, and Dan Jernigan MD, MPH of the National Center for Immunization and Respiratory Diseases (NCIRD) as her deputy. While Buehler and I were recruited from outside CDC, both of the new OSELS leads come from powerful National Centers in CDC’s Office of Infectious Disease. This may (but also may not) indicate a plan to redistribute the OSELS portfolio across the National Centers (sometimes called “Silos of Excellence”).
The timing for an apparent leadership vacuum and dwindling resources could not be worse. It comes in the middle of a massive one-time Federal investment of tens of billions of dollars in healthcare information technology and exchange. Standardization engendered by the “Meaningful Use” electronic health record incentive program could enable major progress in public health programs if two conditions are met. First, cash-strapped local and state public health agencies must make it a priority to migrate to new, more uniform standards and must have the resources to do so. Second, critical public health requirements for information exchange must be successfully negotiated with cost-averse healthcare providers and their information system vendors. Neither can be accomplished without dedicated leadership and resources. The need for a confident, skillful, flexible and funded approach to public health information exchange with healthcare providers has never been greater. We anxiously await the announcement of both new a new informaticsvision and stable leadership at CDC.