Thank you Mr. Chairman.
Dr. Cohn, members of the Standards and Security Subcommittee. Good morning!
I am Sandy Fuller, senior vice president for the American Health Information Management Association, AHIMA. On behalf of the Association, its more than 40,000 members and myself, thank you for the opportunity to provide input into your efforts to advance standards which apply to patient medical record information.
Some of you are very familiar with AHIMA, I know, but for those who are not, may I offer this brief overview:
AHIMA is a professional association representing more than 40,000 members who – on a daily basis – manage health information in provider, plan, and government facilities throughout our nation’s healthcare industry. Our members work with the challenges of managing information in today’s healthcare environment that consists not only of paper records, but electronic records and data, multiple coding systems, and numerous transaction requirements that result from government and private specifications.
AHIMA has been an active participant in a number of standard development organizations, including HL7 and ASTM. In addition, AHIMA has actively pursued initiatives to improve the quality of documentation, and advance the electronic capture, storage and dissemination of health record content.
In response to the current challenges in health information management, AHIMA is crafting a new definition of the legal medical record, promulgating best practices in health information management, commissioning studies into the future of coding and its relationship to documentation, and we have – in conjunction with other groups – begun the process of assuring that new and emerging health-related terminologies will address the demands of existing and future classification systems.
You will see examples of this involvement in my further testimony and in the attachments that I have provided.
This morning, I want to address the questions you have asked about standards for patient medical records including:
Given the plethora of record-keeping systems extant in the healthcare industry today, messaging standards are absolutely critical to the implementation of electronic patient medical record systems.
Whether it’s deploying a comprehensive healthcare information system, creating a “best of breed” records solution, or coordinating care across multiple delivery systems, the transmission of information from one system to another is an absolute requirement in today’s environment.
The development and deployment of standards has decreased the number of individual interface programs required, decreased the time of installation, and improved the availability of data.
And, we believe it is logical to assume that collecting data at its most logical point and then transmitting it as required to other systems improves not only the transmission and sharing of data but the quality of the data as well.
The groups which have developed and promulgated these standards – ASTM, DICOM, HL7, IEEE, and NCPDP, among others –have done a tremendous amount of work to advance the healthcare industry’s ability to deal with the reality of the new electronic world of medical records and information.
The subcommittee’s approach to messaging, as described, should yield a description of the current state of standards deployment and the extent to which these standard development organizations (SDOs) are succeeding in their goal to create a standard. That is, to have one messaging protocol which can be applied to a given set of data and used without required modification.
To the extent that the SDOs have – or can acquire – information about the implementation of these standards, they should be encouraged to address perceived barriers to uniform adoption of their protocols.
AHIMA believes that the creation or formalization of such a feedback loop between SDOs and vendors (or other implementers) may be an area NCVHS can affect in the future.
As Dr. McDonald noted in committee documents dated November 25, 2000, regulatory oversight of the application of standard messaging protocols will be extremely difficult.
The questions that remain include:
In most other areas of our economy, the marketplace has demanded standards that result in decreased costs and increased service.
We believe that rather than using penalties and sanctions as a motivating factor, the National Committee on Vital and Health Statistics (NCVHS), and the Secretary of the Department of Health and Human Services could better assist the promotion of standards by:
Your next question addresses the criteria for selection of Patient Medical Record Information (PMRI) message format standards.
Certainly the eight criteria:
respond to new requirements, and are appropriate for consideration while developing standards for messaging.
AHIMA respectfully suggests that the Committee may want to consider establishing measurement standard for each of those eight criteria which summarizes the SDOs’ response to the criteria such as:
The Committee may even want to ask the SDOs to self-grade their responses to the criteria with detailed answers to the supporting questions that document their grade.
The next question addresses the questionnaire itself.
Comments related to the draft questionnaire are probably best answered by the SDOs which are expected to complete the proposed document. However, to AHIMA, the questions seem appropriate to the categories, even though we believe the information may eventually turn out to be difficult to assemble.
Again, by having the SDOs self-evaluate and complete the assessment grids the Committee discussed in November, 2000, the amount of analysis and interpretation required after the questionnaires are completed may be reduced.
We realize that such an approach begs the question – will the outcome of the process justify the work required to complete the questionnaire? That value proposition will undoubtedly come under scrutiny.
You have asked us to comment on the proposed list of PMRI transactions to be considered in HIPAA standardization recommendations.
Given the Committee’s approach to message format standards, this list is reasonable. It reflects those systems most affected by the current standards.
However, we believe it may be beneficial to consider the data and documents that will be integral to the claims attachment standards. Messaging standards for claims attachments will be required, but in their current form, they do not address the completeness of the data for either the purposes of evaluation of the claim, or the privacy standard relative to minimum necessary information. Until the data sets – or document sets – can be better defined, significant variability will exist in the data which is sent in support of claims.
You have asked us to provide additional comments or critiques and The American Health Information Management Association appreciates the opportunity to suggest additional NCVHS activities that will enhance the development of computer-based patient records.
By way of background, we all know how the healthcare profession has increased its acceptance and adoption of standards – particularly messaging standards.
The best example of this may be seen in the adoption of NCPDP standards by 90 percent of community pharmacies.
We believe that continued adoption of messaging protocols will contribute to advancement of electronic patient medical records. However, as the Committee has recognized in its report to the Secretary in July, 2000, messaging protocols are only part of the solution.
Additional standards in areas of medical terminologies, data quality, accountability, and integrity should be pursued. The report identifies seven Healthcare Terminology domain areas including:
There is considerable standards work being done in these areas, but its adoption lags behind, and development is significantly more complex.
In the Committee report to the Secretary you describe the advantages of collecting information once – and then making it available for use for multiple purposes.
AHIMA strongly supports that approach – both for its affect on quality data and gained efficiency. To advance this premise, more attention should be focused on creating clinically relevant data sets that would improve documentation and enable automation.
Work has begun on the definition of data sets, however it has not been coordinated. Examples of current data sets include:
However, there is only limited data consistency across these data sets, at the data element, definition, and category levels.
In addition to the work begun on data sets, efforts also have been made to standardize what we currently think of as documents or reports. In 2000, ASTM’s E31.22 worked on a Draft Standard Specification for Healthcare Document Formats: History and Physician Examinations and Similar Documents
The use of the HCFA/AMA Documentation Guidelines for Evaluation and Management reporting by physicians has created more structure in physician records.
In the past, progress notes contained only information physicians needed for continuing patient care. To meet the requirements for professional service reporting and to justify billing or reimbursement, HCFA and the AMA have identified seven elements that should appear to support the stated service level.
These are:
Comprised of History of Present Illness, Review of Systems, Past Family and Social History
Comprised of the body/organ systems that are examined during the encounter.
Comprised of the amount of physician work due to the complexity of the service taking into account the number of diagnoses or management options, amount and complexity of the data to be reviewed and the risk of significant complications, morbidity and/or mortality.
Comprised of documentation indicating the severity of the condition(s) involved.
We also know that efforts have been made by many specialty medical associations to address documentation requirements for their specialty. For instance, the Professional Review Organizations (PROs) have identified documentation guidelines as part of their PEPP program.
The examples I have just cited point out only some of the work to date in identifying data standards and documentation guidelines.
Terminologies provide the foundation for the language of medicine and therefore may be the most dynamic and challenging piece of the computer-based patient medical record puzzle. Substantial work has been done on terminologies, and several groups continue to advance clinically specific terminologies.
Included with this testimony is a table of all such systems and developers of which AHIMA is aware.
In your report to the Secretary you identified a number of healthcare terminology domains, of the seven categories reported, only diagnoses and procedures codes are currently addressed by HIPAA regulation. The work of standards development in data sets, structured documents and terminologies, with a few notable exceptions, is also occurring largely outside of the SDO structures and therefore may be overlooked, duplicated, or not advanced quickly enough to impact the PMRI development.
Mr. Chairman, I would like to summarize our comments by making some more specific recommendations that address both your current plans to evaluate message standards and our suggestion that there is a challenging and necessary role for NCVHS to play in advancing the always challenging work of advancing standards in terminologies, data sets and structured documents.
We believe that to advance the message standards work the committee should consider:
We believe that to advance the standards in terminologies, data sets, and structured documents, the committee should consider:
Mr. Chairman, we again thank you for the opportunity to comment. AHIMA is committed to working with the NCVHS and the industry to advance the state of health information. Your work is clearly integral to that goal. I would be happy to respond to any questions you might have.