1. Interoperability Roadmap Compiled Comments Architecture, Services, and Application Programming Interfaces (APIs) Workgroup David McCallie, Jr., co-chair Arien Malec, co-chair March 12, 2015

2. HITSC - Architecture, Services & APIs WorkgroupArchitecture, Services & APIs ONC FACA WG Lead(s)Debbie Bucci Chair / Co-Chairs David McCallie, Jr., Chair, Cerner Corporation Arien Malec, Co-Chair, RelayHealth Clinical Solutions General Questions (as they apply to the assigned Roadmap section) Are the actions proposed in the draft interoperability Roadmap the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Roadmap SectionK. Standard, secure services L. Consistent, secure transport technique(s) Charge / Question(s) Does the roadmap advance towards the architectural and architectural patterns identified by ASA? Do the standards selected in the standards advisory advance towards the same? What changes to the roadmap are suggested to better meet the roadmap’s goals? 2

3. Interoperability Roadmap Section K API’s 3 Questions for Workgroup Discussion General Questions Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Workgroup Charge / Questions Does the roadmap advance towards the architectural and architectural patterns identified by ASA? Do the standards selected in the standards advisory advance towards the same? What changes to the roadmap are suggested to better meet the roadmap’s goals? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS K1. API’s Workgroup Member(s): 1.Through the coordinated governance process, health IT developers, SDOs, ONC and others should implement a coordinated approach to developing and standardizing a targeted set of public APIs for nationwide interoperability 2.HIT developers & SDOs should develop public APIs for (i.e., sending, receiving and finding a common clinical data set) 3.Certification bodies (including ONC) should develop certification approaches to encourage the adoption of specific or consistently functioning APIs as to reduce switching costs but that does not prevent the adoption of innovative new APIs 4.SDOs should advance and accelerate the development of standardized RESTful APIs 5.Health IT developers should work with SDOs to develop standards for interoperable electronic health devices 6. Stakeholder input requested7. Stakeholder input requested

4. 4 Charge QuestionsComments Does the roadmap advance towards the architectural and architectural patterns identified by ASA? (J. Campbell) In some cases, but not entirely. To advance toward the architecture and patterns identified by this workgroup, the government would be better served by coordinating governance and testing tools around the waist of the interop hourglass. Activities around the periphery should be minimal, light touch, and focused around new use cases or incentivizing adoption. (G. Cole) Yes, somewhat with the coordinated approach towards a targeted set of standard APIs. Do the standards selected in the standards advisory advance towards the same? (J. Campbell) Yes, actually. (G. Cole) Not really, but since it is a 2014 survey it should not be expected to provide that content. What changes to the roadmap are suggested to better meet the roadmap’s goals? (J. Campbell) The roadmap should not focus on the specifics of the “how” of interoperability (e.g., a prioritization of REST). The roadmap should focus on the activities necessary to produce a vibrant and multi- use-case ecosystem that can flourish on a foundation of uniformity. (G. Cole) Include the concept that maintenance, and versioning of APIs is as paramount to long term interoperability. Change the focus from certification to testing and the development of testing tools. Interoperability Roadmap Charge Questions

5. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 5 2015-2017 Send, receive, find and use a common clinical data set Comments (Section K, API’S) 1. Through the coordinated governance process, health IT developers, SDOs, ONC and others should implement a coordinated approach to developing and standardizing a targeted set of public APIs for nationwide interoperability (J. Campbell) Many coordinated approaches to such APIs (interfaces / use cases / whatever) already exist. It would be preferable for ONC, if they feel that such avenues are inadequate, focus on modifying or augmenting existing activities, rather than creating even more bodies and processes. As mentioned, such activities provide the most return on investment at the narrow waist of the interop hourglass. (G. Cole) Include the concept that maintenance, and versioning of APIs is as paramount to long term interoperability. Unclear where and how a governance process across such a disparate group would convene, or work over time. 2. HIT developers & SDOs should develop public APIs for (i.e., sending, receiving and finding a common clinical data set) (J. Campbell) Many public APIs for sending, receiving, and finding a common clinical dataset already exist. It is preferable to identify deficiencies and augment as necessary, rather than developing a new approach, unless a new approach is truly warranted. Indeed, HIT developers and SDOs are developing public APIs for (?? there seems to be a word missing here). Perhaps this item should say that work should continue. (G. Cole) Probably needs to define precisely some set as the minimal set, e.g., the 2015 Common Clinical Data set.

6. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 6 2015-2017 Send, receive, find and use a common clinical data set Comments (Section K, API’S) 3. Certification bodies (including ONC) should develop certification approaches to encourage the adoption of specific or consistently functioning APIs as to reduce switching costs but that does not prevent the adoption of innovative new APIs (J. Campbell) It’s unclear what the “switching costs” refer to here. If this is about the “switching cost” of moving between EHRs, it’s possible that an “API” as commonly perceived (a real-time business action or CRUD function restrained to a single workflow or piece of data) would be inadequate and inefficient, given that you eventually want to get rid of the old EHR. A onetime “move everything” batch job might be preferable. I appreciate that the ONC recognizes this is one use case of many, but it should at least be pointed out that mandatory certification tends to lock in and ossify approaches, deincentivizing efforts to come up with other approaches. (G. Cole) Disagree with this statement on developing an approach thru certification……many feel that there is an enormous gap in testing tools and that the existing certification program is not meeting the stated goals. Reword this to focus and relate to I. Testing tools (pg 76) 4. SDOs should advance and accelerate the development of standardized RESTful APIs (J. Campbell) It’s not appropriate to mention a technology stack here. That’s what the Interop Standards Guide is for. (G. Cole) No comment 5. Health IT developers should work with SDOs to develop standards for interoperable electronic health devices (J. Campbell) Agreed. I would suggest “continue to work” and that electronic health device manufacturers might also benefit from being involved in this conversation. (G. Cole) Why do we call out electronic health devices? Interoperability is fostered by standardized content over secure, standardized transports. It is easy to understand, given the technology movements towards mobility and connectivity, that we may see additional opportunity to collect and disseminate healthcare content via devices, but this does not seem to belong here in the APIs piece of the roadmap.

7. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 7 2018-2020 Expand interoperable health IT and users Comments (Section K, API’S) 6. Stakeholder input requested(J. Campbell) No comment (G. Cole) No comment 2021-2024 Achieve nationwide LHS Comments (Section K, API’S) 7. Stakeholder input requested(J. Campbell) No comment (G. Cole) No comment

8. Interoperability Roadmap Section L1 Common Transport Standards 8 Questions for Workgroup Discussion General Questions Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Workgroup Charge / Questions Does the roadmap advance towards the architectural and architectural patterns identified by ASA? Do the standards selected in the standards advisory advance towards the same? What changes to the roadmap are suggested to better meet the roadmap’s goals? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS L1. Common Transport Standards Workgroup Member(s): 1. ONC will identify, and health IT developers should adopt, a minimum set of common transport standards to enable priority learning health system functions. 2. SDOs should update standards and health IT developers should adopt standards as needed. 3. SDOs should update standards and health IT developers should adopt standards as needed. 4. Stakeholder input requested

9. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 9 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L1, Common Transport Standards) 1. ONC will identify, and health IT developers should adopt, a minimum set of common transport standards to enable priority learning health system functions. (J. Campbell) Hardly anything objectionable here, although I suggest that identifying and prioritizing learning health system functions should come before the identification of the standards. (G. Cole) “Minimum” should be emphasized here – the current meaningful use standards did not address transport in certain public health cases, and the proliferation of approaches resulted in extra and unnecessary development and testing work for all parties. General comment: the focus throughout the document has been: send, receive, find and use….however the workflow patterns almost always follow the write once read many paradigm, suggesting that more emphasis should be put on Find and Use. Yes, stepwise it is easier to think about Send and Receive as early, perhaps even easy steps to take, but it is Find and Use that are of paramount importance and they actually do not require that either send or receive has happened. 2. SDOs should update standards and health IT developers should adopt standards as needed. (J. Campbell) Always a sound plan. (G. Cole) No comment

10. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 10 2018-2020 Expand interoperable health IT and users Comments (Section L1, Common Transport Standards) 3. SDOs should update standards and health IT developers should adopt standards as needed. (J. Campbell) No comment (G. Cole) No comment 2021-2024 Achieve nationwide LHS Comments (Section L1, Common Transport Standards) 4. Stakeholder input requested (J. Campbell) No comment (G. Cole) No comment

11. Interoperability Roadmap Section L2 Send 11 Questions for Workgroup Discussion General Questions Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Workgroup Charge / Questions Does the roadmap advance towards the architectural and architectural patterns identified by ASA? Do the standards selected in the standards advisory advance towards the same? What changes to the roadmap are suggested to better meet the roadmap’s goals? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS L2. Send Workgroup Member(s): 1. Public health agencies should converge on the use of standardized web services to support data submission as well as data query from registries and other systems. 2. Providers (including hospitals, ambulatory providers, long- term care centers and behavioral health providers) should adopt and use DIRECT to reach critical mass. 3. Providers and health IT developers should provide individuals with the ability to easily and securely transport their health data to a destination of their choice. 4. Stakeholder input requested 5. Stakeholder input requested

12. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 12 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L2, Send) 1. Public health agencies should converge on the use of standardized web services to support data submission as well as data query from registries and other systems. (J. Campbell) Again, specific technical approaches belong in the Standards Guide, not the roadmap. I appreciate and stress that a single mode of transport would be preferable, especially compared to the current approach. (G. Cole) Are 1, 2, 3 in some priority order? Is this saying that the focus of getting data sent to public health registries is priority number one? If we really want to have a Send 3, 6, 10 year plan, then work on writing the general Send goal, and have the 3 (or more) specific groups of public health, providers, and healthIT developers be broken out as targeted measurable environments with specific measurements that may vary over the timeframe. 2. Providers (including hospitals, ambulatory providers, long-term care centers and behavioral health providers) should adopt and use DIRECT to reach critical mass. (J. Campbell) This is one case in which I might abandon my “no standards in the roadmap” cause, because Direct was already mandated as a part of Stage 2. Regardless of whether it was the right technical choice, certified EHRs support it, so maybe it’s time to do the necessary lifting (a resource location service keyed by NPPES, for example) to support it. (G. Cole) No comment

13. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 13 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L2, Send) 3. Providers and health IT developers should provide individuals with the ability to easily and securely transport their health data to a destination of their choice. (J. Campbell) In general this seems reasonable. Standardizing approaches to this use case / pattern would be useful, since it might incentivize those destinations to support such patterns, thereby making it a smaller technical effort to support a wider range of destinations. (G. Cole) No comment 2018-2020 Expand interoperable health IT and users Comments (Section L2, Send) 4. Stakeholder input requested(J. Campbell) No comment (G. Cole) No comment

14. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 14 2021-2024 Achieve nationwide LHS Comments (Section L2, Send) 5. Stakeholder input requested(J. Campbell) No comment (G. Cole) No comment

15. Interoperability Roadmap Section L3 Receive and Find 15 Questions for Workgroup Discussion General Questions Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? What, if any, gaps need to be addressed? Is the timing of specific actions appropriate? Are the right actors/stakeholders associated with critical actions? Workgroup Charge / Questions Does the roadmap advance towards the architectural and architectural patterns identified by ASA? Do the standards selected in the standards advisory advance towards the same? What changes to the roadmap are suggested to better meet the roadmap’s goals? Category 2015-2017 Send, receive, find and use a common clinical data set 2018-2020 Expand interoperable health IT and users 2021-2024 Achieve nationwide LHS L3. Receive and Find Workgroup Member(s): 1. Health IT developers, providers and researchers should increase use of national standards for query functionality 2. Health IT developers, providers and public health agencies should increase use of national standards for publish/subscribe functionality. 3. SDOs should pilot, assess and refine standards for RESTful web services. 4. Health IT developers should widely implement national standards for query. 5. Health IT developers should widely implement national standards for publish/subscribe. 6. Health IT developers should implement national standards for RESTful web services as they are available. 7. Stakeholder input requested 8. Stakeholder input requested

16. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 16 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L3, Receive and Find) 1. Health IT developers, providers and researchers should increase use of national standards for query functionality (J. Campbell) As this was an option in Stage 2 and as many EHRs already support it, I think it’s appropriate to include it here, although unlike Direct, it wasn’t mandatory. (G. Cole) No comment 2. Health IT developers, providers and public health agencies should increase use of national standards for publish/subscribe functionality. (J. Campbell) I have concerns about this item and especially its timing, given that pub/sub has not been a part of any certification work to date. To me, it better belongs in the library of “other” patterns that are all really goo ideas but not yet a part of certification and maybe should be approached differently. (G. Cole) It looks like this is really about Find, even with the introduction of publish/subscribe (which I think can be viewed as just another mechanism by which to Find).

17. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 17 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L3, Receive and Find) 3. SDOs should pilot, assess and refine standards for RESTful web services. (J. Campbell) Discussion and naming of specific technical approaches is better left to the Standards Guide. (G. Cole) No comment 4. Health IT developers should widely implement national standards for query. (J. Campbell) What’s the difference between “increase use” (#1) and “widely implement”? Assuming they are different, then maybe we should do the same thing in “Send” (L2). (G. Cole) No comment

18. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 18 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L3, Receive and Find) 5. Health IT developers should widely implement national standards for publish/subscribe (J. Campbell) See my comments for #4, for the appropriateness of this item, and #2, for the appropriateness of pub/sub. (G. Cole) No comment 6.Health IT developers should implement national standards for RESTful web services as they are available. National standards for publish/subscribe National standards for RESTful web services (when available) (J. Campbell) Does this really say that Health IT developers should implement national standards for RESTful services, specifically national standards for RESTful services? That seems unnecessarily redundant. Or is it saying that pub-sub should be RESTful? Regardless, I recommend removing this one. (G. Cole) No comment

19. 1. Are the actions the right actions to improve interoperability nationwide in the near term while working toward a learning health system in the long term? 2. What, if any, gaps need to be addressed? 3. Is the timing of specific actions appropriate? 4. Are the right actors/stakeholders associated with critical actions? 19 2015-2017 Send, receive, find and use a common clinical data set Comments (Section L3, Receive and Find) 7. Stakeholder input requested (J. Campbell) No comment (G. Cole) No comment 2021-2024 Achieve nationwide LHS Comments (Section L3, Receive and Find) 8. Stakeholder input requested (J. Campbell) No comment (G. Cole) No comment