Updated Health IT Standards Can Help Harness Data to Limit Disease

Public health agencies nationwide rely on timely and complete data from health care providers to detect infectious diseases and environmental hazards, helping to protect their communities from harm. But the electronic health records (EHRs) used by doctors’ offices and health systems do not consistently send timely, granular, and complete data to these agencies. As a result, they don’t always get the information they need in formats that they can easily analyze and act on.

New rules from the federal office that certifies health IT products, the Office of the National Coordinator for Health Information Technology (ONC), are an important step toward improving the flow of data. Effective March 11, ONC finalized a rule—known as HTI-1—that updates standards for electronic case reporting and requires health IT developers to report on the proportion of immunization data that is submitted electronically. The Pew Charitable Trusts supported these changes during the rulemaking process and offered other recommendations that the agency should continue to consider.

Improving interoperability of electronic case reporting

Case reports from doctors, hospitals, and other providers supply data that public health agencies need to detect and respond quickly to emerging threats, such as the seasonal flu or foodborne illnesses. ONC’s final rule advances electronic case reporting—the digital transmission of reportable data between health care providers and public health agencies—by requiring that EHR systems support one of two common technical standards for that reporting. The standards are known as HL7 Clinical Document Architecture (CDA) and Fast Healthcare Interoperability Resources (FHIR).

HL7, or Health Level 7, is a standards development organization that developed CDA and FHIR. CDA enables the exchange of clinical summaries—high-level reports on an individual’s health condition—and has been adopted by many public health agencies for electronic case reporting. FHIR, meanwhile, is a newer, simpler standard, but not as widely used as CDA. Pew supports ONC’s decision to adopt these consensus-based, industry-developed standards, which are critical elements for improving data quality, timeliness, and completeness of the case reports sent to public health agencies.

In its final rule, ONC signaled that it intends to transition solely to a FHIR-based approach for case reporting in future rulemaking. Although some public health agencies are interested in leveraging FHIR for data exchange, others can only accept HL7 CDA documents at this point. Going forward, ONC should give public health agencies adequate time to ensure that they can receive FHIR-based electronic case reports before requiring their systems be FHIR-based.

Measuring the interoperability of EHRs for immunizations

Public health agencies rely on immunization data to tell them how protected their communities are against specific illnesses, and to help identify and respond to potential population-level threats. Many states require providers to report immunizations to confidential databases known as immunization information systems (IIS).

As with case reporting, using EHRs to automatically report immunizations can increase how much critical data public health agencies receive. Yet no one knows precisely how widely providers use EHRs to share data on the immunizations they administer. This measure would allow ONC to quantify, for the first time, the volume of administered immunizations successfully submitted (e.g., without errors) to IISs overall, including the proportion of immunizations that are reported electronically to each IIS and the proportion by age category (i.e., adults and children/infants). That should help ONC and other federal agencies better identify areas where more resources are needed.

Pew recommends that ONC add a timeliness component to the measure (e.g., having data reported within 24 hours) and stratify the information received by timeliness (e.g., less than or equal to 24 hours versus greater than 24 hours). This metric could clarify whether electronic reporting is happening in a time frame that enables public health agencies to identify vulnerable populations during an outbreak. ONC agrees on the importance of timeliness: “[T]his plays a critical role in data quality and utility” and states in the final rule that it may consider adding such a metric.

ONC noted that the proposed measure goes beyond the two Medicare reporting programs that incentivize clinicians and hospitals to report whether they routinely submit immunization data to public health agencies. As noted by ONC, neither Medicare program requires these providers to “indicate the volume of data successfully transmitted to public health agencies.” Pew recommends ONC analyze and interpret its immunization measure in tandem with the corresponding Medicare measures to explore how often these providers are successfully submitting vaccination data to an IIS.

Additional opportunities

Going forward, Pew recommends ONC consider additional measures to assess public health data exchange beyond immunization—namely, for electronic case reporting, syndromic surveillance, and electronic laboratory reporting. In the final rule, the office signaled that it will “consider other areas of public health information exchange to include as part of the [ONC Health IT Certification] Program.”

ONC also should continue to collaborate with the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) on advancing interoperability and ensuring better alignment across U.S. Department of Health and Human Services regulations. Collaboration with CMS should include working with Medicare reporting programs to build incentives into its reporting programs for eligible providers, hospitals, and critical access hospitals to measure the extent to which they share data with public health.

ONC’s collaboration with CDC should include sharing data with the agency on the extent to which data is exchanged with public health agencies. Doing so could then help inform CDC’s strategy and technical assistance efforts.

Sheri Doyle works on The Pew Charitable Trusts’ public health data improvement project.