1. HIT Standards Committee Vocabulary Task Force Report From Task Force Hearing Sept. 1-2, 2010 Jamie Ferguson Kaiser Permanente Betsy Humphreys National Library of Medicine 21 September, 2010

2. 22 Vocabulary Task Force Members ChairOrganizationCo-ChairOrganization Jamie FergusonKaiser Permanente Betsy HumphreysNational Library of Medicine Members Donald BechtelAccredited Standards Organization X12 Chris BrancatoHHS/ONC Lisa CarnahanNIST Christopher ChuteMayo Clinic Bob DolinHL7 Greg DowningHHS Floyd EisenbergNational Quality Forum Doug FridsmaHHS/ONC Marjorie GreenbergHHS/CDC Patricia GreimVeterans Affairs Amy GruberCMS John HalamkaHarvard Medical School Stan HuffIntermountain Healthcare John KlimekNCPDP Clem McDonaldNational Library of Medicine Stuart NelsonNational Library of Medicine Marc OverhageRegenstrief Institute Marjorie RallinsAmerican Medical Association Dan VreemanRegenstrief Institute Jim WalkerGeisinger Andrew WiesenthalIHTSDO (SNOMED)

3. 3 Review: Subject of Hearing General questions: 1.What are the requirements for a centralized infrastructure to implement “one-stop shopping” for obtaining value sets, subsets, and vocabularies for meaningful use? 2.Which requirements or functionalities are urgent, i.e., absolutely required to support “meaningful use”? Which would be most useful immediately? What would be a staged approach over time to get to the desired end state? Detailed questions: –15 detailed questions addressed the panelists’ operational experience and views in support of the general questions

4. 4 Review: Structure of Hearing Panel 1, Value Set Publishers Panel 2, End User Implementers of EHR technology Panel 3, EHR Vendors and Canadian Perspectives Panel 4, Providers of Terminology Services 24 Panelists represented a mix of the public and private sectors including developers of health measures, standards organizations, academic researchers, small office providers, large health systems, EHR vendors and terminological specialists Format: Short introductory presentations by panelists, followed by one hour to two hours Task Force Q&A discussion with the panel

5. 5 Hearing Results: Major Themes 1 Clarity is more important than simplicity and harmony (but not by much) –Government must provide clarity, stability and predictability for vocabularies –Clarity about what is required, of whom, for what intended purpose –Clarity of future direction and vision is important –Simplicity for users should be an overriding goal of the infrastructure –Simplicity must be balanced by mechanisms for handling exceptions A comprehensive plan does not mean it should be done all at once –Prioritize the most immediately useful content sets (value sets, subsets and cross-maps) including maps of SNOMED CT to ICD-9-CM & ICD-10-CM –Providing an enumerated list of codes is not enough for any value set implementation, but not everything is needed at first because attributes may be added over time to cultivate a more complete system –Prioritize establishment of a US extension to SNOMED CT for rapid additions needed by value set developers Intellectual property (IP) issues can be a significant barrier to adoption and use of vocabulary content sets –More on this later, hold discussion for now

6. 6 Hearing Results: Major Themes 2 Strong version management is absolutely critical for distribution of vocabulary content sets, and expiration dates should be considered System performance, uptime, and security characteristics must define infrastructure requirements –Explore the possible uses of cloud technology and distributed solutions Value set context is important and unique – controls may be needed –The intended use of a value set establishes suitability for a specific purpose –“Off-label” use of value sets is sometimes highly problematic –Information about “off-label” uses may be helpful –Value set context and intent must be documented consistently Multi-stakeholder, cross-functional involvement in the development and review of content sets should be facilitated by the one-stop shop

7. 7 Hearing Results: Focus on IP (1 of 2) Despite a diversity of individual views, every panel cited Intellectual Property (IP) restrictions and licensing as a barrier to vocabulary implementation in MU The scope of vocabulary IP issues in MU encompasses all uses of vocabulary IP that may be involved in complying with MU regulations: –Vocabulary standards and extensions to standard vocabularies –Derivative works including crossmaps and value sets –Messaging standards that specify vocabularies, including HIPAA and MU Alternative solutions suggested by panelists were all over the map: –Don’t allow monopolies for vocabularies/code sets that charge fees –Government should pay national license fees for all standards it adopts –Provider fees should recover a portion “X%” of national license costs Plea from hospitals and clinicians: “Make this simple for us.”

8. 8 Hearing Results: Focus on IP (2 of 2) For IP issues, simplicity appears to trump both cost and mere clarity “I understand the need to pay for the standards I use in my EHR but I am not in the business of tracking IP in my [medical office] practice.” “Of course free is better …[but] we do not mind mind a reasonable fee for IP – we are used to that model – but you have to make it simple.” “Just tell me how much it costs but it has to be one check made out to one place. Don’t make me figure it out [the IP] or I’ll never do it, it’s not worth it.” Panelist comments suggest a possible alternative solution: –The Government or its agent could centrally administer license payments for intellectual property it adopts and uses in MU. Separate from the question of national licenses, this could potentially involve federal negotiation of license fees on behalf of regulated entities and federal payment processing. Each meaningful user would know his or her obligation and where to send their one single payment for all MU-related IP.

9. 9 Next Steps HITSC discussion, input and guidance for the Task Force Task Force meetings are scheduled to develop our recommendations and next steps HITSC may make recommendations to ONC