Tuesday, September 7, 2010

The Vocabulary Task Force Hearings

On September 1 and 2, the Vocabulary Task Force of the HIT Standards Committee held a public hearing to get input on requirements for the infrastructure to make vocabulary content (including taxonomies, value sets, subsets and crossmaps) available to support the Meaningful Use program.

Our previous hearing on vocabulary governance resulted in a set of recommendations, particularly centering on a theme of establishing �one-stop shopping� for Meaningful Use vocabulary content. This new hearing encompassed four panels. First we heard from developers and publishers of vocabulary value sets and subsets; the second panel was made up of hospital, clinical and academic EHR implementers and end users of the vocabularies; the third panel included large and small vendors of EHRs sold to care delivery organizations and small office physician practices, and Canada Health Infoway; finally the fourth panel covered the full range of public and private sector terminology services providers and vendors.

The task force engaged in many hours of rich and far-ranging discussion such as different models of one-stop shopping including �Nordstrom� vs. �Costco� vs. �Boutique.� There were a few major themes woven throughout all the panels from different perspectives.

What started out as a plea for simplicity and harmony turned into broad cross-stakeholder agreement that clarity is more important and more urgent than simplicity. It was agreed that the government must provide clarity, stability and predictability for Meaningful Use vocabularies in terms of what is required, of and by whom, and for what intended purpose.

Other areas where clarity is needed are the responsibilities for ownership, stewardship, validation, review, and support of vocabulary content.

The absolute criticality of versioning for all vocabulary content, and version controls including expiration dates on content sets, was heard loud and clear.

Providing enumerated lists of codes that comprise value sets is not enough for value set implementation. Panels discussed different context mechanisms to establish unique suitability for purpose for the intended use of content sets, and the task force also explored issues surrounding the �off-label use� of value sets.

Infrastructure has to provide good performance, scalability, security, uptime, etc. and the panels mentioned different approaches to achieve these goals.

Not to be left off any summary are the issues around intellectual property as a barrier to adoption and use of vocabulary content - which were part of every panel discussion. A variety of views and possible solutions were considered including legal prohibitions against monopolies, national licensing alternatives, and rights management schemes.

Although the hearing was focused on vocabulary issues, some of the comments regarding intellectual property were clearly focused on message standards - which despite their relative low cost can still be more expensive than some local public health authorities (for example) can afford. Here's a few examples of the kinds of freely available resources that help accelerate interoperability.

SNOMED CT to ICD-9-CM - There are two free mappings from SNOMED CT to ICD-10-CM, a basic "conceptual" mapping which is released with SNOMED CT (free to all US users under the UMLS license) and a draft rule-based mapping for the reimbursement use case. The rule-based map includes IF-THEN rules for selecting the appropriate ICD-9-CM code for a condition in those cases when a SNOMED CT concept could map to more than one ICD-9-CM entry. For example, in order to select the appropriate ICD-9-CM code for infertility, you must look elsewhere in the patient's record to determine whether the patient is male or female. Having received modest feedback on the draft mapping, the next step is to produce a current rule-based map that covers all entries in the SNOMED CT CORE problem list subset, which we hope to complete by early 2011.

SNOMED CT to ICD-10-CM - NLM is currently inserting ICD-10-CM into the UMLS Metathesaurus, which will create the synonymous mappings between SNOMED CT and ICD-10-CM. When this step has been completed (by November 2010), we will work on a rule-based mapping between the SNOMED CT CORE Problem list subset and ICD-10-CM. This should become available in later in 2011.

Next, the Task force will review what we heard and consider making recommendations to the HIT Standards Committee.

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