Article by Hammond

Creating a better health care system requires a complete and comprehensive electronic health record. This involves using data which must be built upon common words, structures, and organization--interoperability. Interoperability requires standards. Department systems were stand-alone applications. For example at Duke Medical Center, lab results came back in paper form and had to be entered manually into TMR (the medical record)—this lead to an increase of data, excessive use of human resources, and high error rates. Steps to create a standard begin with the need for a standard. The expertise is likely to come from a vendor; however, the ideal standard is “vendor-neutral”. The standard must be marketed for adoption and then implemented. Standards may created by my methods such as 1. a group of interested parties can come together to create an ad hoc standard; 2. the government can mandate a standard; 3. marketplace competition and technology adoption can introduce a de facto standard; or 4. a formal consensus process, such as ANSI (the American National Standards Institute) can be followed.
Developing health data standards began in the 1980s. There are other important standard-making organizations that contribute to standards use in healthcare which include : the World Wide Web Consortium (W3C), Internet Engineering Task Force (IETF), the Object Management Group (OMG), and the Organization for the Advancement of Structured Information Standards (OASIS) bur business standards. ANSI coordinates the U.S. voluntary standards activities. Interoperability means that all necessary standards must be defined, adopted, and implemented. There are several concerns dealing with health data standards. There has been no clear set of definitions or instructions. No one has defined all the standards required to support interoperability for a NHIN. This is an important issue that is not being resolved because there has not been any effort to create a set of guidelines for health data standards. There needs to be “just-in-time” standards. These standards have the ability to produce effective standards quickly. Creating “just-in-time” standards will help implementers make progress toward interoperability.
Competition among SDOs have led to further issues in adoption health data standards. The competition forces implementers to choose between the competing SDOs. There is also overlapping in some areas. For example, the scripting standard created by the NCPDP (National Council for Prescription Drug Programs and the medication messaging standards defined by HL7. This causes conflict. Many users and vendors will use this particular conflict as a reason not to implement any standard until the situation is resolved. ANSI defines a process (including balloting rules) that support the creation of American National Standards. The ANSI process is governed by a set of rules and procedures for reaching consensus on technical decisions. Ninety percent of those voting must approve a ballot for it to advance to the level of a national standard. The ANSI balloting process can be accelerated by initial ballots for a Draft Standard for Trial Use (DSTU). Standards are very important in the health IT industry. Vendors want a standard that is favorable to their products because they are concerned that their products might not conform with standards. For this reason, almost all vendor participants in the standard-making process take part to protect their proprietary interest.
Standards within health information management are constantly changing. Hammond states, “New versions of standards are coming out even before older versions reach the final ballot stage. This process results in confusion and instability and creates a moving target for standardization.” He also suggest that the balloting rules need to be reevaluated and definitely shortened. HIPAA (The Health Insurance Portability and Accountability Act of 1996 was the first large-scale mandate of standards related to IT. There were major problems including the expense of processing claims, lack of data standards and identifiers, and the frequent changes in reimbursement rules. There are also several issues that must be dealt with concerning health data standards. These include : competition among SDOs, efforts to identify and create required standards are poor or do not exist, effective integration of clinical expertise into the process of making standards, a more effective approval process, a method to “fill the gaps”, balanced involvement of vendors, and many more. Hammond shows that these must be dealt with first before attempting to create a successful data standard. In order to deal with the above issues he recommends the creation of a neutral, nonprofit organization in the private sector with the authority to manage all aspects of health data standards. The work would be coordinated at that level and standards would be developed as single integrated efforts governed by process rules. Hammond suggests creating an environment where interested parties work together as one to produce a single set of standards.

There has been no effort to create a set of guidelines or instructions concerning health data standards. There are many gaps that have not been identified and will only be identified as progress is made toward a NHIN. There is also competition among the SDOs which further complicates the standard process. This causes implementers to choose among multiple operations and requires an additional step of mapping between standards using an interface engine for interoperability. Data Standards have also become an ever-changing process which makes them difficult to adopt and implement.
Each area in healthcare needs a set of standards. There needs to be a common language for all areas so that communication about a patient is efficient.
Interoperability means using data that is built upon common words, structures, and organization. It is imperative to use this so that multiple organizations can share and use data. Using interoperability can support for a national health information network (NHIN). In order to create a NHIN, there must be a set of common rules/structure which is called interoperability.
Standards for the content of EHR include functional requirements, HER models, continuity of care records (CCR), patient summary record, and personal health record.
SDO is standards-development organizations. Every standard does not necessarily need its own SDO. SDOs were created for general topics. General Standards were created by the SDOs—W3C, IETF, IEEE, OMG, HL7.