My name is Michael Beebe. I am the Director of CPT Editorial and Information Services for the American Medical Association (AMA). It is my pleasure to appear today on behalf of the AMA before the Subcommittee on Standards and Security of the National Committee of Vital and Health Statistics. I would like to thank you for the opportunity to testify.
My statement will summarize the views of the AMA on Patient Medical Record Information (PMRI) Terminology. The following comments will address the questions we have been asked to discuss before the Committee as well as other issues of concern to the AMA.
A graphic of PMRI terminologies was presented to the speakers representing the scope of PMRI Terminology. It was derived from the NCVHS Report on PMRI Standards that was delivered to the Secretary of the Department of Health and Human Services (HHS) in August 2000.
a. What new groups or subsets do you suggest?
b. Should any new PMRI terminologies or groups be added?
c. Should any PMRI terminologies or groups be deleted?
The AMA believes that a patient’s medical record should include sufficient information for physicians and other appropriate health care professionals to assess previous treatment; to ensure continuity of care; to decide upon further treatments and clinical activities, and to avoid unnecessary or inappropriate tests or therapy. The medical record is the primary source of information for a patient’s overall health care, meeting all clinical, legal and administrative requirements. In essence, PMRI is medical and health care data about an individual, including facts, observations, interpretations, plans, actions and outcomes. This description should apply to either paper or electronic formats of patient medical record information. Moreover, the strictest protections of patient privacy must apply to such information.
Comparable and accurate PMRI will assist in realizing the clinical utility of such information. It can also enhance the value of such information for clinical research and epidemiological purposes. At the same time, efforts to enhance comparability and computer operability must not detract from the fundamental clinical purpose of such information as outlined above, which will focus first and foremost on the needs of patients, their physicians and other health care professionals, and the institutions and facilities in which they receive their care.
In addition, the AMA believes that the terminology supporting PMRI should be comprehensive and include all the clinical terms used by all members of the health care team involved in record writing. Despite the need for sufficient terminology breadth to accomplish all the varied purposes of PMRI, the AMA believes that the terminologies selected must be limited to discrete and non-overlapping functional areas. That is, only one terminology per area. The AMA is also concerned about the accurate and consistent implementation of terminologies. Standard implementation guidelines for terminologies are essential for uniform national application of the code sets. If health plans and providers are permitted to implement and interpret medical data code sets as they see fit, the purpose of Administrative Simplification will not be achieved. In addition, the AMA recognizes the limitations on the human element of code application and is concerned about the need for education on all the code sets or the development of computerized tools to achieve semi-automation in applying the codes. The AMA believes that the terminology supporting PMRI should be able to be cross-referenced with other terminology listings currently in use and those used in the future.
Health care continues to be on the threshold of change. The medical and information technology advances in the last decade have been incredible and the pace of innovation is unlikely to change. The terminologies necessary to support current and future PMRI will continue to evolve. Therefore, the graphic provided seems to identify a good foundation for the NCVHS to create a work plan to select PMRI terminologies, but should remain flexible to accommodate future developments.
a. Which categories or subsets should receive the highest priority for the PMRI selection process?
b. Why did you give these categories or subsets a high priority?
c. What groups or subsets of PMRI terminologies should be a low priority?
Two years ago the AMA commissioned a study to develop a report identifying a comprehensive list of core clinical data elements that an electronic medical record system should have the capacity to record. The study was conducted by Medical Systems Development, a firm specializing in market analyses of electronic medical records and practice management systems and was conducted for the AMA’s Council on Medical Service and adopted by the AMA’s House of Delegates. The data elements identified were derived from a large number of diverse resources including uniform data sets, accrediting and licensing agency requirements, industry standards, selected electronic medical record literature, and electronic medical record vendor system specifications.
The AMA believes that the components of the electronic medical record that are of most concern to practicing physicians are in the area of core clinical data elements. Moreover, this is the area where practice management software vendors continue to fall short in development of their products.
The core clinical data elements identified included:
a) Patient Identification and Demographic Data
b) Special Patient Health Conditions
c) Allergies
d) Immunizations
e) Health Promotion/Disease Prevention
f) Past Medical History
g) Family and Social History
h) Encounter/Visit Administrative Information
i) Encounter/Visit Clinical Information
j) Laboratory Test Orders and Results
k) Other Diagnostic Procedure Orders and Results
l) Therapeutic Services and Procedure Orders and Results
m) Medications Prescribed and Results
n) Consultations and Referrals
o) Correspondence/Release of Information
The AMA realizes that the terminology for recording all of the clinical core data elements does not exist in compatible formats among electronic health care records generated in the United States. Therefore, the AMA believes that the Committee should prioritize the PMRI teminologies based on current use, practical applications, acceptance in the marketplace, as well as benefits of the system.
The AMA believes that the criteria identified are acceptable for selecting appropriate PMRI terminologies. However, it should be divided into essential criteria and desirable criteria.
a. Do the criteria need to be modified?
b. If so, what modifications are needed for different groups or subsets?
In reviewing the NCVHS letter sent to the Secretary of HHS earlier this year regarding PMRI standards, the AMA believes that the four criteria derived from the PMRI guiding principles should also apply to PMRI terminologies. The four criteria include market acceptance; interoperability; comparability of data; as well as ability to support data quality, accountability and integrity. In addition, as the Committee stated, market acceptance is by far the most important because it identifies standards that are implementable, cost justified and flexible enough to meet the needs of most of the relevant marketplace.
For example, the following demonstrates that the CPT procedure codes meet all the above mentioned criteria (e.g., market acceptance; interoperability; comparability of data; as well as ability to support data quality, accountability and integrity):
a. be accredited as an ANSI Standard developer?
b. not be ANSI-accredited, but maintain a practice of open meetings for all standards development activities?
c. not be ANSI-accredited, but maintain a practice of timely and public notification of all standards development meetings?
d. not be ANSI-accredited, but use the ANSI consensus process for voting/balloting on the acceptance of new versions of each standard?
The AMA believes that all coding systems adopted as HIPAA standards should have an open updating process and any interested party should be eligible to submit proposals for additions and modifications. In addition, a responsible panel or committee of experts that are representative of a broad cross-section of the relevant stakeholders should maintain the terminology. The AMA does not believe that it is necessary for the PMRI terminology developers to be ANSI accredited, however the organization maintaining the code set should ensure continuity and efficient updating of the standard over time.
The AMA believes that the PMRI terminology maintainers should meet the guiding principles that were expected of all the current maintainers of the selected HIPAA standards. It may be helpful to emphasize these guidelines to those organizations that would like their terminologies recognized as HIPAA code sets.
The HIPAA guiding principles are: (1) Improve the efficiency and effectiveness of the health care system by leading to cost reductions for, or improvements in benefits from, electronic health care transactions. (2) Meet the needs of the health data standards user community, particularly health care providers, health plans, and health care clearinghouses. (3) Be consistent and uniform with the other standards required under this part--their data element names, definitions, and codes and the privacy and security requirements--and with other private and public sector health data standards, to the extent possible. (4) Have low additional development and implementation costs relative to the benefits of using the standard. (5) Be supported by an ANSI-accredited standard setting organization or other private or public organization that will ensure continuity and efficient updating of the standard over time. (6) Have timely development, testing, implementation, and updating procedures to achieve administrative simplification benefits faster. (7) Be technologically independent of the computer platforms and transmission protocols used in electronic health transactions, except when they are explicitly part of the standard. (8) Be precise and unambiguous, but as simple as possible. (9) Keep data collection and paperwork burdens on users as low as is feasible. (10) Incorporate flexibility to adapt more easily to changes in the health care infrastructure (such as new services, organizations, and provider types) and information technology.
The AMA recently conducted a survey of physicians to determine their opinion of the HIPAA regulations and other issues related to HIPAA. The topics covered in the survey included:
Eighty-four (84%) percent of the responding physicians indicated they currently submit claims electronically either through their own practice vendor or through a billing service. However, the responding physicians indicated that they have a number of concerns regarding HIPAA. For example, 20% of the physicians commented that the privacy regulations are of greatest concern to them, followed by 15% of the physicians indicating that their greatest concern was the cost to comply with HIPAA. Ten percent of the physicians indicated that they were concerned with the penalties for non-compliance as well as the adverse effects they believe HIPAA will have on the delivery of patient care.
Eighty percent of physicians have plans to revise office policies/procedures and 57% are planning to upgrade their computer technology. More than two-thirds of the responding physicians have obtained HIPAA educational resources thus far. Nevertheless, 40% of them were not satisfied with the information and indicated it was incomplete, not clear, vague, and too complex. More than seven out of ten physicians indicated that they and their staff need more information on the transaction standards, privacy and security standards. Furthermore, 72% of the responding physicians do not believe HIPAA will save their practice money in the long run because of billing and other processes being “simplified”.
Although we have long held that increased use of electronic financial and administrative transactions could increase the efficiency of physicians’ practices as well as of the health care system overall, the results of our survey indicate that physicians are extremely frustrated with the impending HIPAA regulations. The development of PMRI terminology standards must build on this lesson by focusing on market acceptance and clinical needs.
The AMA understands that the responsibilities of the NCVHS are to evaluate and recommend patient medical record information standards and applicable terminology. However, it is important to note that NCVHS’ responsibilities on this issue are fundamentally different than those for HIPAA administrative transactions. There is no federal legislation requiring implementation of patient medical record information standards or the code sets that would apply to such standards. Moreover, it is not at all clear if the HIPAA model for administrative transaction standards, which is intended to address inter-enterprise communication, is fully applicable to patient medical record information standards that involve a large intra-enterprise focus.
We all need to keep in mind that if used uniformly, PMRI standards must first and foremost meet the needs of the clinicians where the care is being provided. Standardized terminology could be extremely beneficial to the primary users, which would be the physicians providing medical care to patients. However, other uses such as research and fraud detection would be secondary. Therefore, the HIPAA standards for transactions, privacy and security should first be implemented and demonstrated to be effective before PMRI standards are established.
Therefore, the AMA believes that the government should limit its focus to broad recommendations for medical terminology frameworks, with the specific code sets maintained by the private sector.
Thank you for this opportunity to present the views of the American Medical Association on these extremely important issues.