This is the second commentary in a series about the recent “Report to the President - Realizing the Full Potential of Health Information Technology to Improve Healthcare for Americans – The Path Forward” from the President's Council of Advisors on Science and Technology (PCAST). The recommendations have broad implications for the “Meaningful Use” criteria of the HITECH incentive payments for physician adoption of Electronic Health Records (EHRs).

The first commentary focused on the high-level recommendations for health IT, such as a substantial acceleration of health information exchange and an increased focus on population benefits of health information technology like public health and research.

This second article focuses on the report’s technical suggestions to help achieve their high-level recommendations. As described previously, the technical suggestions come from technology -- not health information technology -- experts who are members of the PCAST. As such, the report articulates the technical suggestions in language that is not always aligned with current terms and efforts. PCAST does recognize the need to build on, and not wholly replace, relevant health IT work that has been done.

But it is not clear that the authors were fully aware of what has been done in health IT. A careful analysis suggests that while the PCAST technical vision seems, on the surface, to be revolutionary there is actually a great deal to leverage from existing health IT to meet the high-level PCAST recommendations.

PCAST Technical Recommendations

· A Universal Exchange Language (UEL) – This central PCAST recommendation suggests advancing a shared method for exchanging health data and metadata in a “tagged data element” form. The idea is to use an extensible markup (XML)-like language to embed access control markup for each “small” element of data. “How small is PCAST small,” which has been controversial, has been clarified in the hearings to be more like segments of datarather than individual data elements. There is little controversy that PCAST is suggesting greater prominence for information about data (metadata) and that embedding access control information at a granular level in XML is new. Concerns have been expressed about the feasibility of this approach for health data security as well as about the details of how such XML should be structured. This purely technical PCAST suggestion has also generated churn about whether direct healthcare quality outcomes can be associated with it (probably not) and whether all relevant policies have been developed first. Both of these considerations have figured prominently in each step of the work of the current national coordinator.

Some are considering the UEL to be a completely new direction for health. People have interpreted “a damning with faint praise” for the principal “markup” effort in health – the Clinical Document Architecture (CDA) from Health Level 7 (HL7). PCAST, however, generally recommends evolution and building-on what exists and not wholesale change. The CDA and the more constrained Continuity of Care Document (CCD) represent a huge amount of work to align health requirements and specify data. We do not think that PCAST and the CDA are fundamentally in conflict. PCAST suggests adding “markup” to data structures and the HL7 CDA is one of the guiding factors for how those data structures are defined. There is a lot to build on in the HL7 work on data segments and even documents that can be so “marked-up”. A bigger issue is being able to provide incentives for the result of its use to accelerate exchange – which is why PCAST is fixated on meaningful use stages 2 and 3.

· No Unique Patient Identifier – PCAST does not suggest a unique patient identifier for the United States. PCAST suggests that identifying patients through probabilistic matching of demographic data is adequate now and can become more capable with time. The committee has thus skirted one of the most contentious health IT issues even though there is a tacit acknowledgement that this may be for political necessity.

Probabilistic matching has been a basic element of the nationwide health information network (NHIN) Exchange and other efforts. While some question whether any false positive or false negative matches are acceptable, the NHIN work has shown that there is promise in improving probabilistic matching not only through the availability of more data, but also through the standardization and exchange of “definite links” and “definite do-not-links” in and among registries.

· Patient Data Retrieval – In another recommendation, PCAST promotes what they call Data Element Access Services (DEAS) to support finding and retrieving patient data wherever they reside. This is clearly a recommendation for doing more than the current approach to “push” data from provider to provider in meaningful use stage 1 and the “Direct” project. Essentially, PCAST says “pushing” or “secure emailing” data will not accelerate exchange adequately to meet the president’s goals nor scale adequately. They suggest needs for a “retrieval” approach to support full longitudinal records, secondary data uses, and flexibility in reporting. They also suggest it would increase data liquidity and encourage others to join in (“network effects”).

Essentially PCAST seeks a reduction in “bi-lateral” data exchange and more movement toward a common network that will allow data to be retrieved from anywhere. Of course, such an approach would be dependent on limiting those who have access to data and more “teeth” for inappropriate access and use. While it is not clear PCAST was familiar with Integrating the Enterprise’s (IHE) Cross-Enterprise Document Sharing(XDS), Cross Community Access (XCA) work and its implementation in NHIN Exchange, there is a lot to build on there to meet the PCAST goals. These efforts include “look-up,” a focus on metadata, and a flexible architecture for the size of the data included (even if they are always in XDS called “documents”).

PCAST is a shot across the bow of the current health IT agenda. ONC has established a high-level working group and hearings to analyze the report and determine implications. CMS will be evaluating the recommendations as well. Regardless of the technical approach, the biggest question is whether they respond to the high-level PCAST demand for substantial acceleration in health information exchange through the remaining leverage in stages 2 and 3 of meaningful use or if, because so much leverage has been expended in measurement and reporting, they respond to the report with only “pilot” projects that test the activities, but do not incentivize a broad step forward in health information exchange.

John Loonsk, MD FACMI, is chief medical officer for CGI Federal. From 2006-2009, he was Director of Interoperability and Standards in the Office of the National Coordinator for Health Information Technology.