Kathy McCaffrey, RRA, MA

Deputy Director Data Division
CALIFORNIA OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT

DESCRIPTION

The Office of Statewide Health Planning and Development (Office) is a department of the Health and Welfare Agency of California State Government. Its responsibilities vary from seismic safety regulation, manpower planning and health data collection and dissemination. The Office collects data on hospitals, long-term care facilities, home health agencies and licensed clinics within the state. The largest and only confidential database is the Patient Discharge Database which includes individual patient information for discharges from all hospitals licensed in California. There are approximately 3.6 million discharges per year in California which has been a stable volume for approximately 5 years.

The 18 data elements collected by the Office for each patient record are outlined in statute with accompanying regulations providing detailed definitions. They are similar but do not match the specific elements on the UB-92 billing document that is used by most other states for hospital discharge data reporting. The data elements that are defined as patient identifiers include the patient social security number and actual date of birth. The social security number is converted to an encrypted record linkage number and the date of birth is converted to age for the public datasets.

The discharge data are used in aggregation primarily for trend analysis and outcome studies. The highest volume users are the hospitals for the purpose of evaluating market share and service utilization in their communities. Researchers are also high volume users along with consultants/vendors who use the data to provide trend information for use within the healthcare industry. The legislature uses the data to evaluate bills and amendments during the legislative session. For example, annually the Office provides an update to a member of the legislature for the number of hospitalizations resulting from motorcycle accidents. This information is used to evaluate the motorcycle helmet laws that are challenged periodically.

There are a number of laws that address patient confidentiality in California. They are included in various statutes dealing with insurance, providers, health plans and research. California state government has it's own Committee on Protection of Human Subjects under the Health and Welfare Agency. This group reviews the requests for any state controlled patient identifiable information regardless of prior approval by an educational institutional review board.

The Office uses ICD-9-CM as the primary medical coding scheme for describing diagnoses and procedures for all discharges. The psychiatric DSM-4 codes are also accepted. Currently no CPT coding schemes are collected.

HIPAA Impact on the Office: Data Standard

The Office continues to seek interpretation of the details in order to assess the impact of HIPAA. The overall purpose for the law is acknowledged and recognized as a step forward toward electronic communication and reduction of administrative costs. The impact of implementation, however, creates concern related to the cost and policy issues raised by the transition from the current systems defined in state law or regulation to the adoption of national standards.

For example, recently I was informed that the National Uniform Billing Committee had decided to eliminate the state-defined fields on the UB-92 claim form. Although the Office does not currently use the UB-92 as the vehicle for data transmission, the important data elements captured in that set of fields include race and ethnicity as well as secondary E codes. Will these data elements be captured in the enrollment or encounter datasets? How will these data be pulled together for reporting of the inpatient discharge dataset which includes payment information?

It appears that states can capture additional information if it "is necessary for State reporting on health care delivery or costs". Currently the Office captures an additional field on each diagnosis to indicate if the condition was present on admission or occurred after admission. Will this data element be deemed outside the standards? Who will make that decision since this is not a payment related data element. If it is deemed outside the standard but the Office assesses this data element to be valuable, will the state be liable for requiring information outside the standard? Which committee, such as the National Uniform Billing Committee, will have oversight?

In order for the Office to clearly anticipate the impact of this law we need to be more fully informed about the details of implementation. Our experience in dealing with a variety of hospitals from sophisticated urban medical centers to rural hospitals with long-term care facilities and the corresponding variety of computer support systems obliges us to develop exception modifications to reporting requirements. The exceptions outlined in the HIPAA will need further interpretation in order to determine if the Office will need to use them to carry out the data collection for the State.

HIPAA Impact on the Office: Confidentiality

California has a wide range of stringent laws that address confidentiality for the health care environment. The Office has statutory authority to collect the patient discharge data but the patients do not specifically authorize release. A specific clause in the statute assures confidentiality of the specific patient information. This clause is used as the guidepost for addressing requests for data other than in the public format.

The Office has been engaged in projects where linking data has proven valuable and has in no way compromised patient confidentiality. The primary outcome study performed by the Office is the AMI, Acute Myocardial Infarction, Outcome study. The outcome that was measured in this project was mortality. It was important to be able to identify the patients who died 30 days after the AMI. This was not possible when only the hospital discharge database was used. Thus, the discharge database was linked with the death certificate file in order to obtain the actual date of death. This information enhanced the reliability of the measurement in the study. Our policy is that any data linkage project needs to be reviewed by the State Committee for the Protection of Human Subjects.

Currently a Joint Senate Task Force of the California Legislature is reviewing all aspects of confidentiality for the citizens of California. They have had hearings related specifically to health care and are addressing patient authorizations for releasing and sharing patient identifiable information. It is unclear how the HIPAA will impact the confidentiality laws in California.

HIPAA Impact on the Office: Coding Changes

The Office has anticipated the conversion from ICD-9-CM to ICD-10. The concern lies in the tools that will be available for conversion and cost for implementation. We have identified a need for a mapping scheme between ICD-9-CM and ICD-10 that would make the conversion less costly and cumbersome for the operations of the Office. A bigger concern is the difficulty that the hospitals will have with the conversion and the responsibility the Office will assume.

The ICD-10-PCS conversion will involve the same issues including a mapping scheme from ICD-9-CM. No one on staff has had the opportunity to review the ICD-10-PCS schematics to understand the impact on conversion. Currently, the Office does not collect data using the CPT procedure codes. There is concern about using two different procedure coding schemes, ICD-10-PCS and CPT, for outpatient settings in the future. It would be optimal to settle on one single coding scheme that fits the goal of standardization.

The implementation for ICD-10 and ICD-10-PCS needs to be universal or the basis for standardization is lost. The timing could not be worse, however, given the concerns about the impact of the "Year 2000". There may be some modification considered for the implementation timeframe requirements.

Conclusion

The Office supports the goals of the Administrative Simplification sections of HIPAA. During the last two years, the Health Information Committee of the California Health Policy and Data Advisory Commission (Commission), the primary advisory body to the Office, has been engaged in reviewing all aspects of the Office operations and future goals for health care data collection. The Commission released its recommendations for expanded data collection and improved technological processes in December 1996. These recommendations included adopting standards to reduce cost and improve quality of the data transmitted to the Office. The Office looks forward to making the improvements to the Office databases from the Commission recommendations and implementing the national standards set for by HIPAA.