Monday, July 12, 2010

An Alternative Approach for how to use the NIEM

In Adopting the NIEM for Health Information Exchange Joel Massou talks about replacing the current set of standards that many of us have been working on over the last decade years with new XML content.  While he makes many key points (e.g., concept naming and software development requirements), I disagree with the overall approach.

The key approach that I think is important from the NIEM is not the current set of data models, but rather the approaches used in harmonization.  I'm told that the key here in the NIEM is to engage committed stakeholders and in the processes used to obtain consensus.  Having seen how some of these processes played out in NHIN Direct, I think that NIEM may be on to something, but more work is clearly needed.

If you've read this blog before, you've seen me reference Glen Marshall's excellent article on the Standards Value Chain.  The point is that it takes time (sometimes as longer than five years) to go from the development of a standard to release in a product.  It all depends upon market demand.  ONC has already created a demand for the CCD and CDA standards in the Interim Final Rule.  Changing that would be a disaster at this stage of the game.  Too many have already headed down the path because providers need products using these standards yesterday.

Changing standards in the middle of this process will take even more time.  There should be an evolution in the standards along the lines that Joel suggests, rather than a revolution.  In fact, this is an ideal time in HL7 to address this needed change.  The Structured Documents Workgroup is presently working on the next release of CDA and on Green CDA, the ITS workgroup is reviewing several simpler ITS forms including hData and MicroITS, Clinical Decision Support is searching for models, and everybody is trying to simplify.  An evolutionary path will be sustainable.

My father's imparted wisdom comes to mind again, this time, about trying to change horses in midstream, and the effects that it has on both schedules and quality of work.


  1. Keith,

    I am not suggesting using NIEM for stage 1 of Meaningful Use. I agree with you that it will take time to switch to NIEM. The CCD and the CCR have been retained for Meaningful Use Stage 1 and I believe that's the right approach because of time constraints.

    I believe the NIEM data model is a strong candidate for harmonizing standards for stage 2 (beginning 2013) or stage 2 (beginning 2015). And as I said the NIEM approach can leverage what has been done with HL7, HITSP, and CCR.

  2. Joel and Keith,

    Great comments and perceptions on the current state of standards. While HL7 "standards" are used broadly many of the standard factions with healthcare have been allowed to take their own paths promoting a level of standards choices. Having a single harmonized model for health will provide tremendous future value that promotes transparency, stronger interoperability and reuse.