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Shahla Yaghmai, Ph.D. |
Daniel Essin, M.D. |
With an estimated population of more than 9.4 million, Los Angeles County is the most populous metropolitan area in the United States. By the year 2000, the population is expected to exceed 10 million, more than 42 of the 50 states.
As one of the most ethnically and culturally diverse areas in the nation, Los Angeles County residents are also increasingly poor. The County's poverty population numbers over 2 million people, including 850,000 children and 110,000 elderly living below the federal poverty level, with an estimated 43,000 to 77,000 homeless men, women and children. There has been a dramatic increase in the medically uninsured and underinsured in the County over the past several years which has been further complicated by recent legislation placing restrictions on the care of legal immigrants.
The health care system operated by the Los Angeles County Department of Health Services (LAC-DHS) is the second largest public health care system in the nation, and is the County's health care safety net for the indigent population. Through the 1115 Waiver Demonstration Project, LAC-DHS seeks to increase access to ambulatory care services by 50% and to decrease inpatient beds by almost 40%. Increasing access to ambulatory care services will be accomplished, for the most part, through expansion of services at LAC-DHS facilities and through public-private partnerships.
Currently, the LAC-DHS system includes 6 hospitals, 6 comprehensive health centers, 26 publicly operated health centers, 8 privately operated health centers, 5 jointly operated health centers, and 72 private community clinics. The County's three trauma centers and four emergency departments, located within the LAC-DHS hospitals, are critical components of the emergency medical services system in the area. LAC-DHS' services are distributed throughout the County's 4,752 square miles.
Although the federal government requires most health care providers to submit itemized billings, the LAC-DHS has operated for a number of years with a waiver from Medi-Cal billing, allowing it to bill Medi-Cal on a fee-for-service basis, using an all-inclusive rate for its staff model inpatient facilities and outpatient clinics. Any standardized data coding, collection, and/or reporting system must continue to include codes appropriate for all-inclusive billers. DHS currently uses UB-92 codes for all-inclusive billing purposes.
The LAC-DHS has historically assigned a low priority for tracking detailed outpatient services by either the International Classification of Diseases (ICD) or the Current Procedural Terminology (CPT) coding schemes. As a result, the Department has not incurred the necessary capital outlays to allow it to keep pace with the rest of the industry as it relates to data gathering and information systems.
L.A. County is continually operating with fewer and fewer resources. Next fiscal year, in fact, the LAC-DHS is faced with a structural deficit of approximately $123.1 million. Any increase in administrative reporting requirements will compound the Department's looming financial difficulties. The State's expansion of managed care in the Medi-Cal market, however, is changing past practices, and requires the LAC-DHS to provide detailed encounter data to the HMOs and other payor groups. In addition, the proposed standards for specified transactions to enable health information to be exchanged electronically will further compound the LAC-DHS financial difficulties without some source of additional financial relief.
LAC-DHS uses the following coding schema for clinical data collection:
1) International Classification of Diseases (ICD), the ninth edition (ICD-9) Diagnosis codes
2) Diagnostics Related Groups (DRGs) are derivatives of ICD-9 codes. These codes are maintained by the World Health Organization (WHO).
1) International Classification of Diseases (ICD), the ninth edition (ICD-9) Procedure codes is used for research purposes to document procedures.
2) Current Procedural Terminology (CPT) Procedure Codes
3) HCFA Common Procedural Coding System (HCPCS), a listing of services, procedures and supplies, and their associated codes, used by physicians and other providers in billing for services.
The Systemized Nomenclature of Human and Veterinary Medicine (SNOMED) This code structure is maintained by the College of American Pathologists (CAP) and is widely accepted for describing test results.
This code is maintained by the Food and Drug Administration (FDA).
LAC-DHS has adopted and is implementing the use of the following standards for data transmission standards:
2) Digital Imaging and Communication (DICOM) - This standard is developed by the American College of Radiology - National Manufacturers' Association (ACR-NEMA). It defines the message formats and communication standards for diagnostic and therapeutic images. DICOM is supported by most radiology Picture Archiving and Communications Systems (PACS) vendors.
3) Health Level Seven (HL7) - HL7 defines transactions for transmitting data about patient registration, admission, discharge and transfers, insurance, charges and payors, orders and results for laboratory tests, image studies, nursing and physician observations, diet orders, pharmacy orders, supply orders, and master files.
4) NCPDP - The National Council of Prescription Drug Pharmacies has developed the leading standard for passing pharmacy information.
5) X12N - The Accredited Standards Committee has developed the leading standard for passing insurance/business related information.
Several years ago, LAC-DHS recognized the need for a comprehensive Information System (IS) "blueprint." Prepared with the assistance of a consultant, LAC-DHS recently adopted the Enterprise Information Architecture/Computer-based Patient Record (EIA/CPR) Final Report. This serves as the framework of IS technology acquisitions, policies, and standards. The EIA/CPR Final Report consists of the EIA and CPR models, and Migration Strategy.
The EIA Model is the overall IS schema for LAC-DHS and is directed towards:
LAC-DHS facilities are currently using HCFA-1500 and UB-92 claim forms.
LAC-DHS believes that the privacy and confidentiality of an individual's medical records are vital. It has developed policies and procedures to ensure, preserve and protect patients' privacy and medical records confidentiality, department-wide.
1) Given the structural deficit, LAC-DHS does not have resources to comply to HIPAA requirements because of its fixed revenue base. Any significant changes in operational procedures, systems modifications, etc., will impact patient care due to limited budgetary resources.
2) Although electronic data interchange (EDI) has been used in financial and commercial applications for quite some time, the use of this technology for patient-specific applications still leaves concerns about data security. LAC-DHS' commitment to patient privacy and confidentiality can be compromised by this legislation.
3) Obtaining resources qualified to address implementation and on-going maintenance requirements are issues that could impact implementation timelines.
1) Implement a pilot program to identify that this approach is measurably cost-effective and efficient in achieving administrative simplification goals.
2) Provide necessary financial assistance/incentives for implementation of the required changes to information systems and operational procedures and policies.
3) Establish a reasonable timetable for nation-wide implementation.