Local terminologies pose barriers to change

They've all agreed to drive on the right side of the road, but to implement the change gradually. That's how one might characterize the national drive to adopt standards for public health IT, according to specialists in the field.

Implementing standards for transferring data among public health agencies holds out the hope for improving the national response to diseases both familiar and exotic, as well as preparing for possible bioterror attacks, officials agreed. But scanty funding and the large size of existing investments in incompatible systems are slowing the process of adopting standards.

John Loonsk, associate director for informatics of the Health and Human Services Department's Centers for Disease Control and Prevention, pointed to CDC's Public Health Information Network as the framework for national standards in public health IT.

'As such, PHIN involves both data and technical standards and a certification process to assure that the systems can interoperate,' Loonsk said.

The standards comprise both the terms used in medical vocabularies and the metadata associated with them.

'PHIN also involves technical standards,' Loonsk said. 'When you have identified the terms and the [packet] envelope, you need to securely exchange the information and make sure the machines can shake hands.'

PHIN's sponsors in the CDC and other medical community organizations have chosen several types of technical standards for medical data exchange, covering public-key infrastructure, Web services, encryption and authentication as well as the Electronic Business using Extensible Markup Language.

'There are many challenges, but I think the environment is right for [standards implementation] to happen,' Loonsk said.

One of the most daunting obstacles is incompatible local terminology, Loonsk said.

'In many cases, they don't implement the national standards but use local codes. Let's say the task at hand is to identify a lab test,' Loonsk said. 'One way of describing it is to use the Logical Operations Identifiers Names and Codes term, but another way is to use a term that has meaning inside your organization but does not have value outside your organization.'

Converting installed technology to comply with the standards is expensive and difficult, Loonsk said. 'In addition, the incentives in clinical care do not always support the exchange of records.'
Privacy and security concerns are other areas of potential difficulties, he said.

PHIN has been in full operation for about two years and is the framework for connections among thousands of systems, according to CDC. In fiscal 2004, Congress appropriated $10 million to HHS for the project. Lawmakers followed by earmarking an additional $5 million this year for PHIN, Loonsk said.

Scanty funding for state public health agencies is another significant factor slowing adoption of PHIN standards by state public health laboratories, according to Patina Zarcone, information technology director for the Association of Public Health Laboratories.

Tall order

A study by Zarcone's organization estimated that a public health laboratory would need a staff of 62 for a small state, 116 for a midsize state and 260 for a large state.

'Our estimate for acquisition of hardware and licenses as well as implementation and interfacing in the first year for the model lab is in the range of $600,000 to $935,000,' Zarcone said.

About a quarter of the states now are adopting new systems that incorporate the national data transfer standards, Zarcone said.

'The biggest barrier is the funding for obtaining the systems,' Zarcone said. 'Our state public health laboratories often do not have the funding to obtain state-of-the-art systems.'

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