Metadata standards would support health data exchange,
but developing, testing, and implementing them in time for
stage 2 would be a tall order.
48 commenters supported the use of metadata (two did not;
one made no recommendation).
There is consensus on the need to exchange health information and conduct clinical decision support to increase quality,
improve patient care, and reduce costs. With the shared savings program, a provision outlined in the Affordable Care Act,
accountable care organizations will need to work in concert to
reduce costs associated with Medicare beneficiaries. This serves
as an excellent backdrop from which to build community health
Comments to ONC acknowledged the value of leveraging
metadata standards to improve data usefulness and liquidity in
support of health data exchange. ONC was applauded for embracing the recommendations and vision outlined in the PCAST
report: to enable the ability to share and understand data from
disparate systems; develop uniform standards; and promote interoperability among health IT systems.
However, there is a common concern in the industry over
rushing the required use of metadata. Metadata—and the standards governing metadata use—have not been widely implemented within the healthcare community to date. Some commenters expressed misgivings about implementing metadata
requirements through the federal rulemaking process.
ONC’s summary of the comments noted that many wanted
industry standards development organizations to set metadata
standards. Nine of the 51 commenters stated specifically that
metadata standards were not ready for inclusion in stage 2 of
Apart from the need to further develop metadata standards,
testing and implementing metadata standards in time for stage
2 would be a tall order. The healthcare industry is not ready
or capable of supporting regulatory requirements to integrate
metadata standards, as its bandwidth is stressed with transitioning to ICD- 10, creating accountable care organizations, and
preparing for other requirements in stage 2.
Barriers and Considerations
Although ONC received general support for moving the PCAST
recommendations forward, many of the comments it received
on the advance notice emphasized barriers and challenges to
In its report, PCAST acknowledged that the industry lacked
standards on metadata use. It noted the need to develop initial minimal standards for the metadata associated with tagged
data elements and a road map for a more comprehensive set of
standards over time. ONC, it recommended, should “facilitate
the rapid mapping of existing semantic taxonomies into tagged
data elements, while continuing to encourage the longer-term
harmonization of these taxonomies by vendors and other stake-
The providers, payers, vendors, and policy organizations
submitting comments on the advance notice raised additional
challenges associated with implementing metadata standards
in the current health IT environment.
Data sets. Before the industry can begin development of metadata standards, ONC must identify a uniform and unambiguous
data set. In the advance notice ONC described a proposal that
metadata be expressed according to the requirements in the
Clinical Document Architecture, Release Two header, a recommendation put forward by its HIT Standards Committee. CDA
R2, a document format standard developed by HL7 International, provides wide coverage across metadata elements, and
working from a single standard would make implementation
easier, the committee reasoned.
However, the proposal has perceived drawbacks. CDA R2 inextricably merges data and presentation in the same format.
Secondly, as ONC acknowledges, the standard does not support
some of the metadata elements outlined in the proposed rule,
such as the patient’s “display name,” which ONC proposes be
included in the header.
An argument for not managing metadata as proposed is that
success will be better achieved by making the standardized data
set widely adopted through multiple, flexible implementation
The American Academy of Family Physicians commented that
by restricting the metadata to a single implementation ONC
would reduce the ability of the market to innovate. AAFP firmly recommended that ONC separate the data definition of the
metadata needed to support health information exchange from
its representation in a particular standard. The important work
is to define an unambiguous data set. How to represent it, such
as in XML, is unimportant or, more accurately, fertile ground for
Other commenters also recommended that ONC specify only
the metadata elements to be used, not the representation structure for those elements. If ONC focuses on the data required to
support health information exchange, the presentation of the
data will follow and should not be prescriptive.
Pilots and demonstrations. Many of the industry responses
called for the need to conduct further evaluation, analysis, and
testing of the metadata approach before incorporating it into the
rulemaking process for stage 2. Current metadata standards are
not mature and robust enough to support HIE at this time, and
it would be premature for ONC to incorporate them into stage