Testimony of 3M Health Information Systems provided on May 29, 2002 to the National Committee on Vital and Health Statistics, Subcommittee on Standards and Security, Hearings on HIPAA Code Set. Presented by Keith C. Mitchell, Ph.D., Knowledge Architect, Clinical and Economic Research Department, 3M Health Information Systems.
Hello and good afternoon. On behalf of 3M HIS I would like to thank you for the opportunity to provide comments on the system issues that may arise from implementation of new code sets.
Our testimony will focus on the implementation issues of introducing a new code set that may be confronted by vendors, potential impact to customers and transition issues to consider. In the interest of time, I will be providing an overview of key points. The written testimony distributed earlier contains additional details.
The current code sets have been embedded into virtually every portion of healthcare systems. It is in our vocabulary, software and processes. We use the code sets for a number of purposes including clinical edits, care pathways, classification systems, compliance audits and of course medical records coding. Logic has been developed to leverage the clinical relationships of the code sets and provide the industry with solutions to improve accuracy and efficiency within healthcare processes. Databases have been designed to store the current code sets using the current characteristics to support these processes. Finally, software has been developed to deliver specific functionality and contains specific assumptions as to the type, length, and structure of the current codes sets. Changes to screens, algorithms, and prompts will need to be considered based upon the characteristics of the new code sets. In short, all aspects of current systems will need to be reviewed and potentially updated to reflect the new code sets.
Interfaces and Electronic Data Interchange
Of particular importance is the issue of electronic interchange of data and system interfaces, a core focus of HIPAA. In order to implement the new code system, all interfaces between systems that transmit coded patient data must be reviewed to assess the impact of the new code sets and, as needed, changed.
Interfaces consist of two different components, the first being a communication method and the second is data formats. Communication methods allow two applications to share data. Some examples of communication methods are Dynamic Link Libraries, TCP/IP network communications, or a simple file on disk. New code sets have very little if any affect on Communication methods.
Data formats contain patient data, help identify each piece of data and therefore are likely to change to support the new code sets. Some examples of data formats are HL7, X12, Fixed Format, Tag-Value pairs, and XML. Depending on the changes needed to implement the new code set and how the new code set differs physically from the current code sets will determine which data formats must change and the scope of the changes. For instance, the current procedure code sets (ICD-9-CM and CPT) contain numeric characters only. New procedure code sets will likely contain alphanumeric characters to increase specificity and support future expansion. The new codes will also potentially have more characters, again to increase specificity and expansion. Both these changes would require different data storage methods within a database and adjustment of any interface that depends upon type or length of fields for accurate transmission of data. Further, during the transition phase from an old code set to a new code set, there may be a need for both code sets to be stored in a database which will require database redesign and interfaces may need to simultaneously support both new and old codes for the same patient.
Once the new code set is documented, new data formats created and market requirements understood, vendors must update their applications to interface the new data. Use of industry standard data formats can greatly simplify this collaboration process. 3M Health Information Systems encourages and supports the use of industry standard data formats such as HL7.
Summary
Changing code sets will be an industry-wide challenge but a doable task. Every vendor that elects to continue to support the new code sets will need to systematically review every facet of their systems to determine where dependencies upon the current code set exist. Any necessary changes must be designed, developed and installed within customer systems.
The new code sets will inevitably provide the opportunity for new functionality within systems and processes so not only will the new code sets be retrofitted to support existing system functionality, systems will potentially be enhanced at the same time. The amount of change will be substantial and as addressed in prior testimony, the benefits of change clearly must warrant the costs.
The NCVHS Subcommittee on Standards and Security heard testimony on April 9, 2002 regarding the 23 year old inpatient (ICD-9-CM) code set reaching its expansion limits. On April 9, 2002, the Subcommittee heard testimony about identified gaps in code sets. The need to recognize and code new advances in medical technology and treatment is an absolute requirement for both research and payment purposes. So while the effort to implement the changes will be substantial, the benefits derived from improved coding systems will outweigh the costs. The sooner decisions are made, and direction and timelines set, the better prepared providers and vendors will be -- and the sooner medical providers, consumers, and insurers will benefit.
Our customers expect us to solve business problems through software and consulting that address fundamental issues involved in the business and delivery of healthcare. These issues exist independent of the current code sets and indeed; significant research effort has been spent in adapting the current code sets to support these fundamental issues. For instance, the process for assigning a DRG using diagnosis and procedure codes was first defined by Dr. Robert Fetter while at Yale. The objective was to improve the tools available for administration of acute care hospitals in the area of analysis and process control, a need that continues to exist today. DRGs were later used by CMS to address another fundamental aspect of healthcare, payment. These two activities, using DRG for administration and using DRGs for payment, have been replicated multiple times around the world using different code sets and algorithms than those originally used by Dr. Fetter and CMS.
While the new code sets will require extensive changes to systems, the fundamental reasons customers purchase our solutions have not changed. Encoding will still be required; editing for accuracy will still be required; training and education will still be require; process improvement will still be required. So, unless the business problems significantly change due to the new code sets, our practice has been to update and upgrade our solutions within existing customer support contracts.
Change does bring about opportunity. So while our existing software and consulting solutions will continue to be updated and enhanced to support the new code sets, we anticipate new opportunities and services will be needed by the market to fully implement any new code sets.
One opportunity that may require multiple solutions for the market will be in the support of historic code sets. This issue will be important for trending of data over time, use of public datasets, and provider and hospital comparisons. For instance, in the case of ICD-10-PCS, CMS has already published a mapping from ICD-9-CM procedures to the proposed ICD-10-PCS procedure coding system and this mapping is available on the CMS web page. This mapping may provide a portion of a solution for the market assuming ICD-10-PCS is implemented. How the issue will be resolved is yet to be determined as until the new code sets are identified and documented, the implications to the market can not be fully determined. 3M HIS expects to survey the market and our customers and continue to be the preferred supplier for healthcare solutions.
As stated earlier, it is 3M HIS’s opinion that the benefits derived from improved code sets outweigh the costs of implementation. We encourage the committee to set a clear direction and timeline for change to allow providers and vendors the opportunity to effectively prepare for the change. The sooner the new code sets are in place the sooner medical providers, consumers, and insurers will benefit.
HIPAA has currently defined 8 standard transaction formats that will use the new code sets. More transaction formats may be defined prior to full implementation of HIPAA. The implementation dates for transaction formats and code sets are linked. However, the implementation dates for other HIPAA regulations such as security, national identifier and privacy are different. Transaction formats and code set changes can occur without significant changes to the infrastructure and processes currently used for information interchange other than those changes needed to support the characteristics of the new code sets. Implementing the changes needed for other HIPAA requirements will potentially require investment in infrastructure changes and process changes; changes that tend to be costly and time consuming to implement. While there is a definite advantage to minimizing the number of cycles of change that will be required of providers, we recommend that the committee be vigilant to the risks of combining the code set issue with other HIPAA issues that require significant changes to infrastructure and processes. If combined, a delay in infrastructure development would result in a corresponding delay in implementation of the new codes sets, which would result in a delay to medical providers, consumers and insurers of the benefits of the new code sets.
We would recommend that notice be provided at least one year in advance of implementation and that two years lead-time is preferred. At the time of notice, all details related to the new code set should be publicly available and fully documented. Changes to the new code sets prior to implementation should be kept to the barest minimum. This advance notice will allow thorough review of existing systems, collaboration with partner vendors on embedded components and interfaces, and will provide ample lead-time for customer implementation, testing and certification. Less than 1 year is too quick to coordinate the necessary activities.
This recommended lead-time has been sufficient for other implementations of clinical modification (CM) code sets elsewhere in the world. Both Canada and Australia recently implemented CM code sets and provided vendors 1-2 years advance notice with final modifications being made in the year prior to implementation. Even with the late changes, vendors successfully updated products and providers made the necessary changes and upgrades to systems in order to comply with government regulations. These experiences indicate that with sufficient clarity and notice, the necessary system changes can be made in a timely manner. However it is worth noting that the financial consequences of converting to a new code set in a foreign country may not be as great as in the US as a result of our prospective payment system.
In closing, 3M HIS would like to express its support of this committee and look forward to its recommendations. 3M HIS remains committed to making the transition to new code sets as efficient, effective and trouble-free for the industry as possible. If there is any additional information that the committee would like 3M to provide, please do not hesitate to contact us. Thank you very much for this opportunity to express our views.