Hubert Humphrey Building
200 Independence Ave., NW
Washington, DC
DR. STARFIELD: Let's get started. I am Barbara Starfield. This is a meeting of the Subcommittee on Health Data Needs, Standards and Security, of the National Committee on Vital and Health Statistics.
These are the hearings on claims attachments, as you all know. I think most of you were here yesterday, and we heard from providers and from payers, and state health perspectives as well.
We wound up the day with some intimation on the claims attachment project that is being carried out in HCFA.
We would like to try to be a little early today, at least stay on time, but maybe adjourn even a little bit early. So, we are going to move ahead.
I want to give a few minutes at the beginning to Steve Barr, who has a few words of follow up from his presentation yesterday afternoon. Steve?
MR. BARR: Good morning. I would like to make a few comments. We have a request from the committee to try to help us.
We have tried to do outreach on this project to various components. We have gone to outreach to the commercial insurers at X12, Blue Cross and Blue Shield caucus, WEETI, NUBC, NUCC, and various other organizations.
As you have heard yesterday, this project yesterday is very involved, very intensive and it involves a lot of different concepts that were never ever discussed before regarding any other HIPAA transaction.
I was wondering whether the committee couldn't suggest a method that we could go get additional outreach to other industry components that would aid us in informing other people of this transaction.
We can only go when invited. A lot of people aren't even aware of this transaction or what it is going to involve.
If we don't get outreach, it is our opinion that when this does come down the road, people are going to be absolutely flabbergasted and stunned by the entire project.
If the committee could make any suggestions how we can get additional outreach, we would like to do that.
In addition, yesterday we discussed the utilization of two standards, the X12 and HL7. In addition to HL7, we discussed the utilization of LOINC codes.
We were wondering, since before the committee has taken under advisement to look at the X12 transactions, they could also look at the HL7 and the utilization of LOINC codes throughout the industry to make sure what the industry really feels about the utilization of HL7 and LOINC codes, and its utilization within the project. Thank you very much.
DR. STARFIELD: Thank you, Steve. I am going to shortly turn over the floor for the morning session to John Lumpkin, who chairs our working group on our work for administrative simplification.
I guess we need to go around the room, mostly for the people on Internet. We pretty much know each other by now within the room, but for the sake of electronic media, we will sort of start introducing ourselves.
MS. BALL: I am Judy Ball from HHS.
DR. COHN: I am Simon Cohn, Kaiser Permanente, a member of the committee.
MS. GREENBERG: I am Marjorie Greenberg from the National Center for Health Statistics and executive secretary to the committee.
MR. MOORE: I am Bob Moore from HCFA, and staff to the committee.
DR. BRAITHWAITE: Bill Braithwaite from ASPE at HHS, and staff to the committee.
DR. STARFIELD: I am Barbara Starfield from Johns Hopkins and chair of the subcommittee.
DR. LUMPKIN: John Lumpkin from the Illinois Department of Public Health. I chair the work group.
MR. BLAIR: Jeff Blair, Medical Records Institute. I am a member of the committee.
DR. JANES: Gail Janes, CDC, Atlanta, staff to the subcommittee.
MR. BLANCHARD: I am Barry Blanchard with EDS, and one of the original co-chairs of the 837 transaction.
MS. ROBINSON: Krista Robinson, with EDS, Medicare Part B Systems.
MR. FOLCKEMER: I am Jeff Folckemer from Mede America, vice president of claims processing and adjudication and clearing services.
MR. RODE: Dan Rode from the Health Care Financial Management Association.
MS. O'BRIEN: I am Sue O'Brien from Physician Computer Network.
MR. ZUBELDIA: Kepa Zubeldia from ENVOY-NEIC.
(Other introductions made around perimeter of room.)
MS. ABERNATHY: Susan Abernathy from the National Immunization Program.
MR. CAGE: Michael Cage(?), American Dental Association.
MR. OWENS: Bob Owens, American Dental Association.
MR. MAYES: Bob Mayes, Health Care Financing Administration.
MS. NERSISI: Jean Nersisi, American Medical Association.
MR. CONWAY: Tom Conway, American Medical Association.
MS. CARTER: Gail Carter, ANTHEM, Blue Cross/Blue Shield.
MR. ARGES: George Arges, American Hospital Association.
MR. HENRY: Jerry Henry, chair of the Kentucky State Uniform Billing Committee.
MR. BARR: Steven Barr, HCFA.
MS. WARREN: Marie Warren, Blue Cross/Blue Shield of Illinois.
MS. STALIKER: Christine Staliker, Empire Blue Cross/Blue Shield.
MR. WATKINS: Larry Watkins, Mede Computer Systems.
MS. HAMMOND: Cheryl Hammond, UASI.
MR. STANICK: Dan Stanick, National Council for Prescription Drug Programs.
MR. HAMMOND: Ed Hammond, Duke University, representing HL7.
MS. LOMBARDO: Michele Lombardo, the Health Care Financing Administration.
MR. WALDEN: Dan Walden, Westat.
MS. GILFOY: Helene Gilfoy, Catholic Health Initiatives.
MS. ESTARIO: Grace Estario, Department of Defense.
MR. SHANKS: Paul Shanks, St. Claire's Hospital in New York City.
MS. SINYOFSKA: Sidassa Sinyofska, ASTM.
DR. STARFIELD: Anybody who hasn't spoken their piece? Okay, John, it is yours.
DR. LUMPKIN: Great. We will go to the first panel, the panel of vendors. Since you are not sitting in the order of my list, we will just start to my right and proceed to the left.
MS. ROBINSON: Good morning. I am Krista Robinson representing Electronic Data Systems. I would like to thank the subcommittee for the opportunity to testify on health care claims attachments.
EDS is a professional services firm that provides consulting, information and technical expertise to over 9,000 clients worldwide.
We shape how information is created, distributed, shared, enjoyed and applied for the benefit of enterprises and individuals alike.
In the health care industry, EDS serves over 250 clients, including 71 insurance carriers, 18 state Medicaid programs, Medicare Part B carriers for the entire country, clearinghouses, as well as many HMOs, federal health care programs, employers and pharmaceutical organizations.
EDS processes over 2.4 billion transactions each year and processes claims for one in every four Americans, or 123 million lives, 80 percent of which are electronic.
The EDS health care industry serves and participates in several professional industry organizations such as X12, AFEHCT, WEETI, NCPDP and HL7.
In addition, EDS has formed a HIPAA virtual team to assess the impacts of the legislation, not only in our own corporation, but for our customers as well.
Although I am here today to represent EDS as a corporation, and the HIPAA virtual team, my background revolves around Medicare Part B claims processing.
Because I would like to assist the subcommittee to the fullest extent, I have with me Barry Blanchard, who co-chaired the development of the X12 837 Health Care Claims Transaction, to help answer any additional questions the subcommittee may have on this important topic.
Electronic claims attachments is a complex, dynamic matter, and there are several issues that should be addressed, as we have indicated in the testimony to follow.
Based upon our knowledge and experience in health care, we are planning to address the following items concerning health care claims attachments:
The definition of a claim versus an attachment; appropriate information for a claim; appropriate information for claims attachment; the positive and negative impacts on existing systems with the inclusion of X12 and HL7 in one standard; the integration of information the systems currently have with health care data; and the problems of implementing standards for health care claims attachments.
In order to differentiate information that is appropriate in a claim versus information that is appropriate for claims attachments, it is important to understand the differences between the two transactions.
In the industry there is much debate over what constitutes a claim versus what constitutes an attachment. Many feel that the electronic claim current contains information that is considered an attachment.
Others believe that the electronic claims should contain more information in order to adjudicate a claim without having to request additional information.
In its simplest definition, a claim is a request for reimbursement of a health care product or service provided to an individual by a provider.
It contains administrative information along with pertinent medical record information that is needed to validate the claim.
A claim can be submitted through a paper form or by an electronic format. In today's environment, a claim attachment contains supplemental information required by a payer to adjudicate a claim.
Most often, this information is additional patient information concerning their medical record, documented on primarily non-electronic media.
In the future, the information that should be included in a claim is data that can be codified and does not require intervention for interpretation.
The attachment should include supplemental information related to the processing of a patient's claim, that is not necessary for most types of claims, but may be requested by payers for further clarification of a submitted claim.
As mentioned yesterday by Steve Barr, there is a proof of concept team that HCFA is guiding to define a transaction format and content for providers to return requested Medicare medical information to payers.
The request for the information would come in an X12 transaction, the 277 request for additional information, from the payer to the provider.
The proof of concept would require the response to come from another X12 transaction, the 275 additional patient information, and possibly an HL7 message embedded within a segment of the X12 transaction.
The combining of the two standards development organizations is an excellent idea for a concerted effort. Significant impacts to existing systems are involved.
Because this is new to the EDI software industry, an initial negative impact is the ability to recognize and interpret different syntax in the same data stream.
Currently, most systems do not use X12 or HL7 for electronically processing claims or claims attachments. For those that do, HL7 is typically used for processing clinical information between medical delivery systems, or X12 is used for processing medical billing and encounter systems which are financial in nature. Most systems are designed for one or the other.
In today's environment, payers, health plans and claims processing systems do not have common integration of information across departments.
It is more common in the institutional provider community to have a system integrater with HL7 than it is on the professional, dental and provider community.
Typically, these providers do not have an electronic mechanism in place to process clinical information.
The latter has typically focused their efforts in the development of claims payment systems, and put little automation in the business processes surrounding the development of claims, the review of the claims, or the resolution of the claims.
The EDI industry is currently working on the technical feasibility of reading, processing and interpreting different types of formats.
Translators can process both HL7 and X12, but the payers current systems may not be able to interpret the data.
In addition, the various entities involved with these transactions will need to evaluate other business issues such as cost of implementing such issues and related business processes and work flows.
In addition to the technical impacts, there are data dictionary issues that would need to be resolved.
Each standard, X12 and HL7, use different data dictionaries, which would need to be referenced in the same data stream.
The proof of concept stream has done an excellent job of codifying the information used in attachments for the limited number of attachments they are using for this project.
This team has identified attachments, giving them reference numbers as well as the data elements within each attachment, assigning codes for each data element.
They are currently trying to cross reference these codes with link codes along with HL7, to come up with a universe of codes for each element in their test attachments.
The issue then becomes who is responsible for this code list. Where can providers, needing to send an attachment, payers needing to receive an attachment, and systems needing to integrate the codes into the system to alleviate human intervention find this list, and who can update it?
We believe that if X12 and HL7 are combined, then there should only be one code set, with a cross walk of the code list in a single source of information.
The industry should decide on how this is done and who should maintain this list. This would provide the least impact for providers to identify the necessary information.
If the technical and business process data stream issues can be resolved, then electronically submitting attachments becomes a positive impact.
Until these issues are resolved, we believe that one of two situations will occur. One, providers will continue to submit paper attachments or, two, providers will catch on to what payers request for additional information in order to process a claim, and will submit as much information as possible with the claim every time, in order to adjudicate their claims as quickly as possible.
This will make it more difficult for the payer and/or system to process the original claim.
In addition to the impacts noted above, we believe that the following challenges could occur:
Different types of work stations may be required, coupled with data storage that would be needed in order to retrieve information;
Cost benefit analysis will be required by all entities involved, related to business flows, processes and systems upgrades;
There will be individual privacy and confidentiality issues of electronically transmitting additional patient information;
Changes will be required in federal and state laws and mandates.
This is a complex challenge. It will take flexibility and compromises to implement such a task by all entities involved.
The standards for attachments should be an industry-led consensus with government participation.
The EDI industry is still in the process of developing software capable of interpreting multiple types of formats.
We would encourage the proof of concept team to include a viability and feasibility study, along with cost savings and a benefits analysis, on their work with the X12 standards and the HL7 messages.
Until this is done, it may be premature to make any decisions on how and when electronic attachments are implemented.
If standards are developed that limit the use of attachments, it could infringe on a payer's ability to continue with their current business decisions. It also may require payers to upgrade their current EDI software.
In conclusion, the industry, along with the government, should define a standard, allow a framework to be established that will allow payers and providers to move forward with the electronic attachment, and allow an economic model to define when to move forward with the implementation.
Thank you for the opportunity to provide the testimony to the subcommittee, and I will open this up for any questions that you may have.
DR. LUMPKIN: I think we will take the panel, although I do have a couple of questions that will help me to understand your testimony.
EDS, do they produce systems for both vendors and providers?
MS. ROBINSON: Yes, and for payers.
DR. LUMPKIN: That is what I meant to say.
MS. ROBINSON: That is what I thought.
DR. LUMPKIN: Payers and providers?
MS. ROBINSON: Right.
DR. LUMPKIN: Do you have a computerized patient record in operation?
MS. ROBINSON: I can speak currently for what we have in Medicare and we use NSF and we also use ANSI. Is that what you were meaning?
DR. LUMPKIN: No, you don't have a computerized medical record?
MS. ROBINSON: We do not have that right now, no.
DR. LUMPKIN: Okay, thank you.
MR. BLANCHARD: A further answer to the question. EDI's major business is to manage payment. I don't know any hospital that has an EDS sole system. That may be a new plan.
I would just like to clarify that, because you said payer, and that maybe gave you the wrong impression. I don't think they are equally on both sides of the fence.
MS. ROBINSON: It is more on the carrier side, that is correct.
DR. LUMPKIN: Great; that helps.
MR. FOLCKEMER: Thank you. Again, my name is Jeff Folckemer. I am the vice president of Mede America claims and clearinghouse services and operations. Thank you for the opportunity to speak to the subcommittee.
I am really going to present more facts than disclose information on Mede America. I would rather give the subcommittee an idea of what we see out there, and open it up for debate.
Mede America is in the business of health care EDI. To that end, we clean and clear claim information and claim attachment information from the provider to the payer.
We do work closely with the payers, though, in the instances of California and our relationship with WildPointHic-10(?), where we provide software to the payers to give to the clients.
Our core business, though, is working with the clients, hospitals, large clinics, large physician groups, providing them software to translate information from their practice management systems, their hospital information systems, convert on download,
Whether it be ANSI, X12, Print Image, NSF, MNSF, version 4 or proprietary, we convert that into a proprietary custom data base that we convert back to our clearing service. From our clearing service, we ship out the various formats, depending on what the payer requires.
Our definition of a claim is an encounter or episode at a health care rendering facility that is recorded in a standard that is consistent with the specified electronic format.
This information uses standard coding methods as defined by the third party payer across all lines of business.
Our definition of an attachment is additional information required by a third party payer that is not defined in the standard claim submission, across all lines of business, in order for the third party payer to adjudicate the episode or encounter.
To differentiate information that is appropriate for the claim versus information that is appropriate for the claim attachment, we must use the current electronic standards as a guide.
Our past experience can only tell us where we have been and where we need to go.
Version 4, national standard format, X12, NE 37 and variations of these formats encompass what we know today as a claim.
Claim attachment information is taken on nearly all other data that cannot logistically be placed in the above-stated formats or variations thereof.
That means, if you cannot put it into one of those fields -- that is, one of those record layouts -- it is considered by us to be an attachment.
Claim attachments supported by Mede, Mede America supports various electronic claim attachments. Our electronic format attachments are physical therapy, speech therapy, occupational therapy, respiratory therapy, cardiac rehabilitation, medical social services, psychiatric therapy, skilled nursing, substance abuse, pacemaker, ambulance, and the emergency room services.
These attachments have non-standard electronic formats. They are electronic, but are typically not part of version four, the national standard format, or X12 837.
We have found that an electronic attachment is usually manually keyed at the provider site into the third party payer's specific format.
This eliminates paper, but puts the manual labor on the shoulders of the provider. This method is preferred over the submission of paper by all involved.
Our software allows them to actually key into screens that are windows based, that require the information that is needed by the payer to adjudicate the claim.
Scanning attachments. Mede America also supports scanned images that can be attached to a claim. We receive an electronic claim that is serialized to an electronic scanned image, that it is married to.
We can take the electronic claim, take the electronic image, and when we do the conversion back into our own proprietary formats, we tie them together.
From this point, we print the claim and scan images for mailing to the third party payer. This is a costly solution that still produces paper output, but it is needed due to the increased requests for claim attachment information and an increase in third party payers that do not support electronic submission.
What has occurred over the last year or so that has really affected our central print shop is that managed care organizations, PPOs, IPAs, they have been popping up like crazy.
What it is doing to our business is, claims that we used to be able to process electronically to Medical, Medicaid, Medicare, they are converting the customer base or client base, who are insured, into these managed care organizations.
These organizations are small enough that they get by the rules and regulations, that they do not need to accept electronic claims.
What it is forcing us to do is to print these claims. So, we are actually regressing and moving backwards.
We are seeing our electronic business come to a halt and we are actually seeing our paper business increase.
DR. LUMPKIN: Let me just clarify that. You are not seeing a decrease in the number of payers who accept electronic transfers. You are seeing an increase in those who do not.
MR. FOLCKEMER: That is correct.
DR. LUMPKIN: So, these are new players on the market that don't. Okay.
MR. FOLCKEMER: That is correct. That is actually one of our biggest stumbling blocks. The other part that has actually changed the way we do business is that, as a clearing service, we cannot get to a lot of these payers because they will either have one commercial hook-up to Envoy, and you have to go through Envoy, and they will not let us connect directly to them.
So, we do not have the ability to use our clearing services when we actually are working so tightly with the provider to get to the payer.
So, what it has forced us to do is to work closer to the payers. We have formed a new corporation called ShareNet, where we have taken all the clearinghouses that want an open and free communication market out there, to utilize their connections, our connections, and share, so we are not forced into a non-democratic clearing service.
The scanned images that are usually emergency room reports or medical records. Commercial payers tend to require their information as well as managed care organizations.
Our scanned attachments can be JPEGS, TIPS, MTMAPS, GPEGS. Basically what it does for the provider, it allows them not to ship paper. The cost of a stamp alone saves them a lot of money, as well as stuffing and printing the paper.
What we can do is, if they have an optical storage system, we can actually take that optical image and tie that to the claim.
We are taking it electronically, but we are still shipping out paper.
Detailed attachments. Mede America supports detailed attachments. These attachments contain line items detailed to the UB92 billing form.
When I say UB92, as everyone well knows, we are talking about Version 4 right now.
This detail is captured in a text format that is married to, or sterilized to, a claim. From this point, we print the claim and the detailed line item information for mailing to third party payers.
This is a costly solution that still produces paper output. Again, this follows our scanning routine. We take an electronic download of the line item detail -- let's say it is a 270 or 250, which is drug detail or itemized items, supplies, that a hospital needs to disclose to the payer.
We take the detail on that revenue code and we actually list three band-aids, five aspirin, whatever it possibly can be.
When the payer takes a look at it, the emergency room, they have justification for the payment of it.
This is a costly solution that still produces paper output, but it is needed due to the increased request for claim attachment information, and an increase in third party payers that do not support electronic submission.
Commercial payers tend to require this information as well as managed care organizations.
Standardization is the only acceptable means. If claim attachments will be required, we must have a finite list for claim attachments that have succinct, clear and concise definitions.
I think if we just would take and make a master list that we would apply to all payers, all providers, and say, these are the claim services that will always need attachments, and we do not break away from that, we will then be able to justify having a standardized, codified submission method that will make sense, and everyone will be able to actually do.
It will actually open up the claim clearing and submission of electronic information more to the ATM market, where anybody can get into the market, everybody can exchange transactions, everybody can use the network.
We must balance the need of the third party payer to the need of the provider. Forcing providers to a custom and proprietary format will force many of them to completely revamp their internal data transfer methodologies.
Forcing third party payers to accept these same special formats will have the same drastic effects.
We have worked with many agencies that set standards for data exchange. NUBC, NUCC or ANSI, all have the capability to set the standard.
The agency that is tasked to set the standard needs to have full representation from providers and payers to set a standard that is fair to both the provider and the payer.
Notice I did not include vendors in there. The vendor is the middle man. We should not be included in that.
What needs to be done is we need to try to be sure that the providers and the payers can work together without a vendor in between.
What the vendor brings to the table is the value added pieces, additional pieces to that clearing function.
We need to examine what we are trying to standardize. We need to determine whether the data is needed for immediate use, or if a yearly audit could be conducted to verify that compliance standards are met.
I know that Bob Davis spoke yesterday. I have worked with Bob and SPARCS and some various other things. There are some things that are done with New York Medicaid where prior to really Version 4, they required paper attachments, always, abortion, sterilization consent forms.
What they did was, they just created the electronic field in their Version 4. So, you can check the box to say you have it on file.
Then if Medicaid feels, well, it is time for an audit on this place, let's make sure they really do have these on file, Medicaid can actually go out and audit and stop the transfer of all that mass paper.
Impact. Mede America realizes that change is difficult but necessary with claims and claim attachments. We need to mandate electronic claim submission, not only at a federal level, but at the state level as well.
We need to require, without exception, that Workers Compensation, no-fault insurance companies, PPOs, MSOs, HMOs and IPAs accept electronic claims in the X12 837 Version 4, or the national standard format.
We need to pick the standard for claims attachments and have a finite list that all parties involved can accept as necessary to adjudicate a claim.
The impact from following these guidelines will be positive. We will reduce the cost of administration and allow for timely payment of claims.
We can eliminate the manual intervention that causes the majority of payment errors or the inappropriate denial of claims. We can stop the request for paper altogether.
Point of view. Recently, Mede America has been experiencing an increase in our central print center. We have been experiencing a growth in managed care organizations that will only take paper claims and paper attachments.
These attachments are medical records, detail medical code breakdowns, emergency room reports, treatment plans, and various mandated forms.
We seem to be moving away from the electronic requirement back to paper.
Whether we choose HL7 X12 with 275 pilot, or look to ways to eliminate attachments altogether, we must require electronic claim submission and electronic claim acceptance by all.
Allowing paper claims and paper claim attachments will only increase health care costs to all of us. Thank you.
DR. LUMPKIN: Just a quick question. You described what Mede America does. You don't do office management, software? Do you service the back end or do your customers do direct data entry into your system?
MR. FOLCKEMER: We serve as actually both. They can actually do direct data entry into our windows based software, or they can actually download. We take downloads.
We have relationships with SMS, HBOC, Meditech, all the major HIS vendors. We actually accept their formats, convert them into our format, and then we do the final conversion into what the payer needs.
DR. LUMPKIN: You also serve as a clearinghouse?
MR. FOLCKEMER: We serve as a clearinghouse.
DR. LUMPKIN: Thank you. Okay.
MR. RODE: Good morning, again. My name is Dan Rode. I am sandwiched in here with the vendors, but I am with the Health Care Financial Management Association.
We are not a vendor, at least, I think, in the definition this morning.
We are a professional association of some 35,000 members who work in various payer and provider areas, work across the spectrum of the providers and the payers, also consultants and some vendors, and probably a good number of people in this room.
HFMA has been involved with this issue for about 30 years. We worked with the NUBC in its early formation, worked with the X12 and the health care task force as well, and also worked with a task force some five or six years ago on claims adjudication and claims audits, since some of what we are talking about is the data that goes into that.
I am not going to read from the prepared text that you have. I don't want to strain your eyes and there is too much there, with all the questions that you asked. The comments that I will make this morning are essentially the same as what you have in front of you.
When I testified about a year ago about the data and transaction standards, I talked about uniformity. Much of what I said then still applies.
The request for additional information or attachments has plagued our claims process for many years.
Some will argue that the additional information sought by the payer is not needed and is just a stall tactic used by payers to delay the pay of a claim.
Some payers will claim that they need additional information to process the claim accurately and ensure that the claim is clean.
They will tell you that the uniform claim, whether it is the UB92 or the HCFA 1500 or the X12 837, just doesn't do it. There is a hint of the truth in both statements, both from the payers and the providers.
The uniform bill has essentially failed to do the job because the uniform bill is based on a paper transaction.
The NUBC, the NUCC have added codes. They have added fields. Over the years, they have attempted to meet as many of the data demands as possible.
Each time that they have met them, there have been other data demands that have come along. So, we are faced today with the situation the same as we were five years ago, seven years ago, 10, 20 years ago. What do we do with the additional information and what do you do to make this standard invoice work.
When we started the UB82, actually, we thought we had finally arrived at a solution, only to find that, for those of us like myself who comes from an academic health center -- the University of Minnesota -- we quickly were asked to have an itemized attachment of our bill to the electronic claim, very difficult to staple to an electronic tape at the time.
In many cases, since we were a tertiary care center, we would send hundreds of pages of itemized statements along with the bill.
Of course, on top of the itemized statements are the other attachments you have been hearing about for the last couple of days, various kinds of reports, operating room reports, emergency room reports, results of different tests.
In your handout, I have listed about a page and a half of common handouts which were identified when we worked with the peptide project a few years ago.
The payers who want information generally are doing that either on a proprietary form such as the HCFA forms that we used in home health in some of the therapies.
They are asking for it on a free format. They are asking for part of the medical record or, on occasion, for all of the medical record.
When we work with Medicare, some of the Medicaid programs, some of the Blue Cross/Blue Shield programs, obviously we have gotten a relationship, in many cases, where we know what the format is going to be, we have known when it is going to be demanded, and we have either been able to make it electronic, or at least know when to submit it.
When we deal with other insurers, we are generally on a basis of trying to determine -- as I think Paul Cheng said yesterday -- what it is that they want and how often do they want it. Of we wait until they tell us.
Many times the attachment does not go in with the invoice. Many times the attachment follows when a request has come for additional information.
So, we have got two different situations, one where it can accompany the transaction and one where it cannot.
We have the capability, with the X12 approach, to add data to the invoice or to electronically staple the data to the electronic invoice.
Whichever we choose really requires some work from the technical folks of what is the best way to submit the data and how would you do that.
We have that flexibility. We have transactions you have already heard of, the 275, the 277, the 278, that allow us to both format data and send it across, or scan data and send it across digitized.
How we do it, when we do it, becomes one of the tasks for you or a group that you work with as we go forward with these claims attachments.
We have, on behalf of HFMA, essentially four recommendations this morning.
The problem we really have is knowing what data to collect, and then having the process to transmit it. If we don't know what data to collect or in what format to collect, it becomes very difficult, no matter how well our systems work, to get the data back and forth.
It eliminates our ability to use these vendors that you see here, and we go back to a paper process. So, we really need to consider that.
3. We believe that the Secretary should establish a group consisting of the health care industry representatives, to consolidate the activities conducted by the NUBC and the NUCC, along with oversight and coordination of attachment information.
Whether this is yourselves or a subgroup of yourselves or a separate group that works with the Secretary, we believe it is time to consolidate the NUBC, the NUCC, the code sets that they maintain for claims, as well as the code sets that are currently maintained by the Blue Cross/Blue Shield Association for the 835.
We have got to have the same data across all the X12 transactions. We have to have the same data sets. We have to be able to have uniformity.
These groups have a significant amount of expertise. We don't want to eliminate the expertise, nor do we want to continue this kind of a process of testimony once, twice, three times a year.
There needs to be an ongoing dialogue for the group that is going to work with this attachment process, and with the claims process.
This is not the same as the X12, which sets up the best way to transmit this information back and forth, but the group that works with you to decide what information do we really need, when do we send it, how do we send it, through the X12 transactions and perhaps the HL7 transactions.
4. Finally, the process for collecting data by state or local data groups should not be included as part of the claims process, even if it uses claims data and data sets.
Coming from Minnesota, I have worked with data groups for more years than I really hope to imagine. I have some horror stories I can tell you off line at some point in time.
The transaction for the claim and for these attachments is for the purpose of payment. You heard yesterday that some people will throw every piece of data at you that they can to get the claim paid.
We have also heard that the data comes quickly. In many cases, what you are looking for in quality data and in data that you are looking for coming out of the medical record requires a complete and accurate medical record.
Those of you who work in academic health centers and others know that our billing forms do not require a complete medical record. It requires that data be collected and substantiated by the record.
We have found in Minnesota very successful use of the UB92 as a data form for quality information and for employer information, but one that was collected in a different transaction, not the claims transaction.
As we become more electronic in our industry, we have the capability of using X12 transaction sets for reasons other than billing.
I would urge you not to consider putting the collection of the kind of organizations that the NADA organizations collect into the claims transaction itself. It just adds another segment to the whole process of administration and I would like to see you keep that separate so that we can keep the administrative processes moving.
Finally, it is important to recognize the role of this committee and any other group that we put together on attachments.
We are talking about clinical data as part of these attachments. We are talking about data that is not standardized.
As we move ahead in this process, we may have to initially use a transaction like the 275 to submit data that has just been scanned and sent over.
Eventually it would be nice to see a standardized operating room report, a standardized emergency room report, and some of these other functions, so that the payers can actually judge, on a consistent basis, what the information is.
Those of us on the provider side can actually know what information to prepare in these reports.
Recognize right now, that when we put an operating room report together or an emergency room report together, we do it under our own systems. We don't do it on any kind of a national basis, except if it is required in some condition of our certification or accreditation.
That is a lot to take on, and I would be glad to answer any questions you have. There is a lot of detail in the questions you asked, and I suspect there may be questions after today. We certainly would stand ready to answer those as well.
Let me indulge your patience for just one more moment on a personal note. I heard Steve this morning talk about the need to get additional buy-in to the work that his group is doing, and we certainly support the work that they are doing with regard to the transaction.
We have a situation right now, where we don't have the initial work that you all have been doing out yet, through the Secretary and through OMB.
I would like to urge you, as a separate agenda item, to consider recommendation to the Secretary and to the Congress, to delay the implementation of these transaction sets, both the other nine as well as the attachments.
Our industry currently is going through not only preparation for the year 2000, which many of us are behind on if we recognize it even exists, and we are going through a significant change in the way in which we handle Medicare and Medicaid transactions, because of the balanced budget act.
This requires a lot of data processing. We are putting in new prospective payment programs over the course of the next two years, and we are using the same systems people that are expected to put in all the changes that we would like to see with the HIPAA attachments.
I have been working on this project for almost 25 years. It hurts me to say delay. I sure would not like to see us push this stuff through for the sake of meeting a legislative time table, and do it in such a way that we have an incomplete process, and one which is jump started and re-jump started.
I would urge you to consider that as a separate agenda item, but I did want to bring it to your attention, and I thank you for the extra time.
MS. O'BRIEN: My name is Susan O'Brien. I am the EDI product manager for Physician Computer Network.
Physician Computer Network is an information technology vendor for office-based physicians of all types.
We are the practice management system for, and represent approximately 20,000 installations, supporting over 100,000 physicians, which translates into an estimated 25 percent of the office-based physicians in the United States.
We provide computer solutions for both financial and billings aspects of a physician's office, as well as clinical information systems.
On behalf of Physician Computer Network, I would like to thank you for allowing us to participate in this hearing on health care claim attachments.
Once a standard has been decided upon, we as a vendor will be tasked with the engineering, development, installation, training and support necessary to fulfill the electronic computer requirements being set forth.
As the vendors are responsible for a significant proportion of the responsibility surrounding this claims attachment standardization initiative, we appreciate the opportunity to express our concerns.
Speaking to the question posed regarding the positive impacts of the inclusion of X12 and HL7 messaging in one standard, we believe that any standard adopted which facilitates the sharing the data would be positive. This would be true of virtually any format.
The negative impact, as a software vendor, would be the reengineering and development necessary to capture the data by a specific mandated date.
The primary reason for the anticipated difficulty in fulfilling the electronic needs of our customers would be because the integration of clinical information across departments in the office-based physician arena is extremely uncommon.
Less than one percent of our entire customer based is actually doing this now. It is common for physicians offices to have computers to handle the financial aspects of their business alone.
Not only do they not share this information across departments, but it is not currently common for physicians offices to capture clinical information electronically at all.
There are various software programs on the market to address the clinical aspects of the business. We are currently continuing to develop and have installed at numerous sites a clinically based electronic medical records system called Health Point.
Physician Computer Network is heavily involved in this joint venture with Glaxo Wellcome to provide electronic medical record technology.
The development of the Health Point product has made us truly aware of the challenges involved in computerizing clinical information.
This technology is still undergoing metamorphosis and is not readily available for all specialties. The clinically based technology, at this point in time, could be considered cost prohibitive to the smaller-sized practices.
However, it could be stated that within the available clinical systems arena, it is common functionality for the clinical software to provide to the financial practice management system information for billing purposes, information such as procedure codes, diagnosis codes, provider, place of service, et cetera.
Theoretically, the same could be accomplished for submission of a health care claim attachment form.
An implementation of an initiative such as this is an enormous undertaking. Assuming a standard has been decided upon, we as vendors must engineer the capturing the data.
Whether it be through a full-blown electronic medical record systems such as Health Point or perhaps a more theoretically simple method, we know that it is not being formally captured now, except for the few offices that have invested in the electronic medical records systems.
If we, for example, for adopting a seemingly simpler method, were to provide for text capture of surgical notes or progress notes generated on a PC using Microsoft Word or some other industry standard text-based software program, providers will still have to purchase some type of incremental technology.
Amazingly enough, we have found that within a certain faction of our customer base, consisting primarily of the smaller customers or rural areas, that the PC is not common.
They typically use older technology purchased some five or ten years ago not conducive to meeting current industry standards.
For instance, we often use third party software such as Procom Plus to facilitate the communications piece of claims transmission, or to provide access to payers' bulletin board systems.
As we struggle to keep up with mandates such as NSF 301 and CLIA number submission, we implement the use of PC software with our programs.
As recently as last week I was speaking with a representative from Blue Cross and Blue Shield of Nebraska. She was explaining to me the demographics surrounding the physicians they service, and specifically how they do not have PCs and their reluctance to pursue incremental technology, citing the costs associated with this type of movement as being the primary reason.
Once the product and technology are sold to the provider, we must provide for the installation, training and ongoing support to the office personnel in the field.
The process of installing the capability alone can be analyzed as follows. Of our 20,000 physicians offices, approximately 50 percent bill electronically.
A simple, straightforward installation could be estimated at requiring two man hours to complete. For 10,000 offices at two hours each, it would take approximately 20,000 man hours or 500 weeks.
One man could complete approximately 80 installations a month, or 960 per year. Implementing an initiative such as this would necessitate our organization to hire and devote at least 10-1/2 people full time for an entire year for this project, for the installation phase alone. This alone would cost as much as $500,000 to $1 million.
Obviously, billing initiatives have potentially devastating effects on vendor organizations. The development and implementation alone will be very expensive.
As a vendor, we will seek payment from our customers, the providers.
As recently as December 1997, implementing a simple change to facilitate the CLIA number mandate for Medicare lab claims brought out organization to its knees just by virtue of the sheer number of sites impacted, and an aggressive drop dead date for claim denial imposed.
In closing, the more swiftly we can obtain a format decision, the better. It is imperative that the providers and health care organizations are made fully aware of the specifics surrounding this initiative.
It is also extremely important that an incremental approach with a time line appropriate to the task be addressed.
DR. STARFIELD: What specialties have you worked with most with patient records?
MS. O'BRIEN: With patient records? You know, I am not positive.
DR. STARFIELD: Which ones are the hardest?
MS. O'BRIEN: Orthopedics is very difficult, I think, and there are a couple of them. I am not very much associated with that at all.
DR. LUMPKIN: Family practice, general internal medicine, ob/gyn, I think are the ones that Health Point is done on.
MS. O'BRIEN: I think you are right. Those are the easier specialties.
DR. LUMPKIN: No, they are not, but they are the most common.
MS. O'BRIEN: The most common, I guess.
DR. LUMPKIN: Jeff, did you have an informational question, because we will get to the deeper probing questions when everyone is done.
MR. BLAIR: Let me wait, then.
DR. LUMPKIN: Okay. Kepa.
MR. ZUBELDIA: Good morning. My name is Kepa Zubeldia. I am vice president of technology with ENVOY NEIC.
I guess that makes me the non-democratic member of the panel. But I am coming today representing the Association for Electronic Health Care Transactions.
Preparing today's presentations, we have had meetings, conference calls, and e mails with a number of clearinghouses, large and small, as well as payer and practice management vendors, members of AFEHCT
I want to point out that both EDS and Mede America sit on AFEHCT's board, as well as Mede Computer Systems, sitting behind me.
In spite of a large number of members of AFEHCT being competitors with each other in the market, AFEHCT members share a common view with regard to the needs, benefits, expectations and potential pitfalls of administrative simplification.
I want to thank Bill Braithwaite for putting this testimony on the Internet as an attachment to the meeting agenda.
We also want to thank Steve Barr, the Bureau of Program Operations of HCFA, the Department of Health and Human Services, and the NCVHS for having this hearing, bringing the attachment issue to the spotlight, and inviting us to testify.
Although we have known that this issue was coming, the invitation to testify created a critical mass, for a fact.
We have worked our way through the issue, and it occurred to us that this scenario in which the private sector should come together and take the initiative to develop a consensus among payers, providers, clearinghouses and others, we in effect would start moving in this direction. We welcome the participation of all interested parties.
Some feel that the contents of this document steps on their toes, or the toes of others. Please know that that is not the intent.
Please regard this document as an invitation to come together and address the attachments problem. The industry needs to reach consensus before the government makes policy in this area.
The Association for Promoting Health Care Transactions is a voluntary trade association comprised of health care clearinghouses, practice management companies, provider business management services, software vendors, credit card issuers, value added networks, health insurers, reinsurers, stop loss underwriters, and health data processors. A complete list is available on request.
What is an attachment? In the paper claims environment, an attachment is any information used in the adjudication of the claim that is not part of the basic claim form.
This additional information must be conveyed in a piece of paper different from the claim form itself, and attached to the form.
Since the paper claim form contains a limited number of fields for standard information, the standard attachments take a number of formats:
Reprinted forms of several kinds; certifications; answers to questions; letters, reports, copies of parts of the medical records; evidence of X-rays or tests or dentures or orthopedic devices.
In the electronic environment, it is a lot more difficult to define what an attachment it. This difficulty comes from the fact that over the years the electronic format has been enlarged to include many items of information that do not fit on the paper form.
Therefore, they would be attachments when filed on paper, that are part of the electronic claim format.
One characteristic that they both have in common is that attachments may be necessary before the adjudication can complete.
At least one of the parties -- payer or provider -- perceives that they are necessary for adjudication.
Why are they necessary? The fundamental question is one of a lack of trust. The provider is compelled to demonstrate that he or she can show proof that the service was rendered as claimed, and a payment is due.
Some providers are more trusted. Therefore, they are compelled to produce fewer attachments. Other providers are not so trusted, and produce many attachments.
Now, the payers are caught in the middle of this war. Payers collectively must, by contract, administer hundreds of thousands or millions of different health care benefit plans.
We know the struggles that the payer ID group is having with this issue.
Many of these plans conditionally or universally require administrative or clinical data that is not part of the classic claim form.
Accordingly, providers routinely send universally required data as attachments to the basic claim, and in an attempt to anticipate health benefit plan contract requirements, also attach any perceived conditional data to expedite payment.
It is also appropriate to acknowledge the responsibility of all payers as fiduciary agents to minimize abuse and/or fraud in the health care system.
Attachment data is used to ensure that proper payment is made, which currently produces abuse and fraud.
Let's define some demarcation lines for attachments. Traditionally, the claim form contains mostly administrative information. There is very little room for clinical information.
Therefore, clinical information has been considered an attachment. However, a substantial number of attachments are in the gray area between administrative and clinical, for example, certificates of medical necessity, prescriptions, ambulance information, others. They are both clinical and administrative content.
Another dividing line is whether it is up front or on demand. Some attachments are required in all cases in order to adjudicate certain claims.
Other attachments are only produced after the payer requests it. In some cases there are statutory requirements for certain attachments, like consent forms.
In other cases, a business practice, probably linked to health plan benefit issues, or previous experience with fraud, requires the attachments.
In a few cases, the attachments document unusual medical circumstances. Most, if not all, payers request attachments or supporting documentation after the claim exceeds certain financial thresholds.
In those cases where the provider knows the attachment will be required, like DME or ambulance, the attachments will be filed at the same time as the claim. This expedites the claim processing and speeds up the reimbursement.
The cost of filing these attachments is relatively low. When the attachment is requested by the payer after the claim has been filed, the provider must retrieve the file, produce the attachment and send it under separate cover.
This process becomes much more expensive in terms of both money and time. These cases are not traditionally called attachments, but requests for additional information.
It can easily be argued that a request for additional information may include the same data as an attachment.
However, a request for additional information requires a much more costly procedure to produce and process.
Another division of attachments can be made along the line of formatted data versus unformatted data, or free text information.
Some argue that formatted or field oriented data belongs in the claim and non-oriented data belongs in an attachment.
However, there is a gray area in clinical information that could be expressed in a well-defined format, such as HL7 or free text.
A typical example would be lab reports, and the two camps are still battling, where does the data belong.
There are several other boundaries over which the claims versus attachment lines can be drawn. There seems to be little consensus in the industry for what is actually an attachment, as we know attachments today.
Most players seem to agree that some of the items of information currently sent up front with the electronic claim are traditional attachments.
Also, there seems to be agreement that more attachments need to be sent and processed electronically than what is happening today, and the pendulum should not swing too far in the opposite direction, where everything on the claim becomes an attachment to a minimalistic claim.
Let's see how the system works today. Currently, using the NSF, UB92, or 837, there are three ways to send attachments.
All three are in widespread use in different segments of the industry. It is important to understand this, so we don't break a process that works today. These forms I will describe in a moment.
A substantial percentage of the claims filed today are either filed with attachments or, in fewer numbers, will need additional information filed at a later time. These claims are being processed and paid today.
Having the ability to file more attachments electronically will not lower the cost of insurance, but it is nothing new. It is something that is happening today.
Some sectors of the industry -- and correctly -- perceive that without the ability to file electronic attachments, the goal of achieving 100 percent electronic claims will never be reached. This is a mistake. That goal can be reached without electronic attachments.
Although AFEHCT recognizes that electronic attachments can generate a substantial savings, we also believe that, with proper education of the industry in this matter, the goal of 100 percent electronic claims is not linked to 100 percent of electronic attachments.
A substantial number -- let's take a look at electronic attachments inside the claim today. A substantial number of DME, home health, ambulance, home infusion, PEN, chiropractic, podiatry, oxygen and other claims are filed electronically with information inside the electronic claim format that has no equivalent on the paper claim.
The electronic claim format, over the last few years, have been expanded to cover these paper attachments inside the electronic formats themselves, not as a separate attachment, but as information in the electronic claim that only applies to certain specialties.
That has no correspondence on the paper claim form, and if filed on paper, it would certainly be considered an attachment.
There are millions of these claims being processed today. Medicare has certainly been the leader in this area, and the rest of the industry is following Medicare's footsteps, as they try to automate new lines of electronic claims businesses.
If this attachment information was to be pulled out of the electronic claim format in the immediate future, the cost and damage to the industry would be substantial.
Another way of sending attachments is attaching something outside of the electronic claims transaction. All current electronic claim formats allow for an attachment indicator, that links the electronic claim with an external attachment.
Typically it can be an attachment control number or reference control number of some sort. There is a mechanism in use today for cases where the attachment is needed in every instance, but it is not possible to convey it electronically as part of the standard claim.
For example, this is used by dentists to send X-rays or denture casts, by DME suppliers to send original prescriptions, or by surgeons to send releases and consent forms.
The claim can certainly be filed electronically, even when the attachment, by its nature, can't be sent electronically.
Both claim and attachment can be tied together by a reference or control number.
It is likely that this category will continue even after attachments are automated, since the nature of these attachments requires either an object or an original signature on a piece of paper as the transmittal method.
Number three, attachments after the claim information. This could properly be termed additional information sent upon the payer request, rather than attachments.
In the last few years we have seen a mass migration of the commercial payers to this type of attachment.
It used to be that when filing paper claims, a filer felt compelled to send all sorts of additional information as attachments.
The adjudication cycle was so long that they attempted to get paid on the first try, by sending everything that the payer was likely going to need later.
Most of this attachment information was not needed and caused great expense at both ends. With the reduction of the adjudication cycle from weeks to days through electronic claims, and the ability of payers to communicate electronically with the providers, the commercial payers are now requesting that the claim be sent electronically without attachments, and that attachments only be sent upon request from the payer. Most attachments are sent by non-electronic means.
This new paradigm for the industry, made possible by the communication channel involve the actions that the payers have established with the providers through the clearinghouses.
Even though a sizeable number of electronic claims require that additional information be sent later, the percentage of such claims has dropped dramatically when compared to the claims that were sent with attachments under the old paper paradigms. The savings to the commercial payers are substantial.
What is coming in the future. The work of the attachment support group in X12 in HCFA is progressing and showing very encouraging results.
In the future there will be new classes of attachments that we will be able to file electronically, further reducing some of the paper attachments that have to be sent off line today.
This may constitute a completely new classification of attachments that are sent electronically but detached from the claim transaction itself.
One of the issues with the work being done by the X12 work group concerns the use of an encapsulation technique to include the clinical HL7 message inside an administrative X12 transaction.
This scenario allows the transmission of clinical data over EDI networks, taking advantage of the existing EDI infrastructure, while at the same time using HL7, which is the form most appropriate for clinical data.
As far as the clearinghouses are concerned, we view the bin segments of the 875 transaction as a binary large object that can be transferred by clearinghouses without actual knowledge of the contents.
It may contain an HL7 message or a dicom image. That aspect of the encapsulation will likely be hidden during the clearinghouse processing.
One item that will require further investigation prior to large scale deployment is the economic impact of such large objects.
They consume greater resources than traditional administrative transactions. At this point it is difficult to quantify the resource consumption because there is not a measurable installed base.
As far as the integration of both standards, X12 and HL7, at the provider this will be a new capability for most providers.
Even though HL7 is widely used in hospitals and large clinics, there are fewer than 10,000 of those in the country, as opposed to several hundred thousand small providers.
Those small providers, those few small providers who use HL7 mostly download demographic information from the hospital into a practice management system, rather than to transfer clinical information. The exception may be lab tests and lab results.
In our view, the ability of small providers to use HL7 in a meaningful way to satisfy requests for additional information coming from a payer is, at this time, practically nonexistent. This doesn't mean that it couldn't develop very quickly.
We are not aware of any payers with the ability to receive clinical information in the HL7 format and integrate it into their claims processing system at this time.
Of course, since the 275 implementation guide is still in development, we are not aware of payers with the ability to process HL7 and encapsulate it inside a 275 in a production environment.
The exception to these two statements are those X12 members who are currently participating in the 275 proof of concept.
DR. LUMPKIN: Kepa, can you summarize perhaps the next section and get to your recommendations? We are running out of time.
MR. ZUBELDIA: I could do that, but let me point out two other issues that I think are very important. I won't read it.
The first issue that is very important is that most adjudication systems cannot process attachments electronically, except the Medicare system. They require manual intervention.
Any claim with attachments has to be suspended and the attachment has to be looked up by somebody. This delays payment and increases the cost.
There are no business processes in place to handle the attachments, either by the payers or the providers. It is an ad hoc process and it is extremely expensive.
The payers have a very strong preference to receive fewer attachments or no attachments at all, if it is allowed and still meets their fiduciary responsibility. Any extraneous information causes them to suspend the claim and suspend additional money.
Maybe one of the most important issues is to standardize the request for additional information. We have heard from everybody on that.
A potential big issue is the misuse of attachments, causing attachment overflow. In the past, attachments have been very expensive for everybody to process, both payers and providers.
If that balance was to be tilted, the attachments could be very inexpensive to process by one or both ends. If the provider finds the attachments inexpensive to send, they could overflow the payers with attachments, causing their adjudication systems to collapse because every claim would be suspended.
If the payers had very easy requests for additional information methods, they could overflow the provider systems, that could not satisfy those requests for additional information. So, that balance is critical.
It is also critical to know that there are millions of attachments being processed today as part of a claim form. If that was to be pulled out of the claim form, the system will grind to a halt.
Maybe the biggest issue is that there are no answers for all of these questions today. The recommendations from AFEHCT is, first, to require all electronic claims.
The payer should accept all electronic claims as required by HIPAA. The attachments may be under separate cover, electronic, paper or otherwise. The claim should be filed electronically without excuses that it requires an attachment.
The second recommendation is that the industry should reach a consensus on attachments. Rather than having regulation imposed on them on what attachments to use when, let the industry make that decision.
Attachments are not claims. The claim information that belongs in the claim should not be allowed to escape to the attachments.
The attachment information that is today on the claim could be migrated, over time, to the attachments, but that has a severe financial impact on the immediate business we are doing.
So, don't break the system. That is the fourth recommendation.
The fifth recommendation is that there be a cost/benefit analysis extensively on what are the advantages to having more attachments sent electronically versus fewer attachments, if at all.
Also, the relationship between the attachment and the medical record needs to be defined. There are requests for medical record information that are being viewed as attachments that are not necessary to adjudicate a claim. They are made for other purposes. That needs to be studied.
There needs to be a strong, concentrated effort to discourage the use of attachments whenever possible. Making it easier to file standard attachments electronically has to be accompanied by education so they discourage the use of attachments in the first place.
Then, there has to be a continuous revision of the coding systems that are currently requiring attachments with some specified procedures and specified diagnoses and things like that.
When we see an attachment being requested in a high percentage of cases, then the coding system needs to be reviewed.
The last two sections of this testimony have some more detail on what I talked about and you are free to read it at your leisure. Thank you very much for allowing me to testify today.
DR. LUMPKIN: Thank you. Questions? I have got a ton, so if you guys don't raise your hand now, you may not have the time later.
DR. STARFIELD: This is probably an unanswerable question of the Jeff Blair type. Do any of you have any international business where you work with other health care systems?
I will mention specifically, what about the UK system which doesn't pay fee for service. There is no billing in the traditional sense.
However, there is billing in the UK health system because the physicians are paid money for doing -- they are given incentives for doing certain things.
They apparently use the read system very effectively, but I don't know the details. Do any of you?
MS. ROBINSON: Yes. I will let Barry Blanchard address that a little bit further.
MR. BLANCHARD: As far as the international business, we have systems that are very similar to what we use in the United States that have been put into place in England and into other places.
For the most part, I think they are more similar than different. Again, we are involved more on the payer side, the claims processing.
They are really looking at putting into place a lot of the same standards that we are using in the United States as well, not only in England, but in Australia and other places as well.
There are other standards bodies. Because a lot of the work that has been done here, I think, has proven to be successful, at least so far, they are basically kind of following our lead, I guess.
DR. STARFIELD: Are you familiar with, in the sense of using the read system?
MR. BLANCHARD: No, I am not.
DR. COHN: I can clarify the read question for you, although I am not sure what exactly that has to do with these particular issues.
The read system is widely used in England, but an older version of the read code is what is used, which is a very small subset of what is currently known as the read. I think it is version 3.0.
It is used for, I think, the reporting by family practitioners and others on diagnosis and procedure information, as I understand it, to the National Health Service.
It isn't a transaction standard. It isn't an attachment. It is a piece of terminology within all of this.
DR. STARFIELD: The question is to what extent is a computerized system that is already in effect, could it be used, could it be applied to the kinds of transactions that we are talking about.
MR. BLANCHARD: To make another comment on that, the read codes have not been picked up in Europe, in the neighboring countries, at least not in the older version of it.
It is sort of similar to the SNOMED codes, which are used fairly widely in the United States for many purposes.
MR. ZUBELDIA: We don't do business in Europe, but through the extra work that I do on interactive claim, which is another syntax, we work together with the international health care EDI in Europe.
I was fascinated by the French project in which the provider adjudicates the claim. The provider's computer has the software with all the logic to adjudicate the claim and send, at the end of the day, the claim adjudicated to the French payment system, and to secondary payers, without the payers having to do that. It puts the concept of trust at a different level.
DR. LUMPKIN: Would that require a single payer system?
MR. ZUBELDIA: No, it doesn't. They don't have a single payer system. What it does require is that the software in the provider's system has to be approved by the government. It has to be reviewed and approved by the government.
MS. FYFFE: A question for Jeff and also comments from other members of the panel. You talked about the decrease in automation related to managed care. I would like you to elaborate upon that a bit. I would welcome any comments from other panel members if they have seen a similar trend.
MR. FOLCKEMER: I will start with some of the recent things that we are doing with our -- I am addressing one state in particular, California.
What we are doing out there is, we are converting every hospital to use our software package. We have an alliance with Health Care Transaction Network.
In that, we are trying to clear all claims that a hospital or a large clinic can handle. From that point we can handle the Medicare, the Blue Cross, the Blue Shield, and some of the bigger HMOs.
The smaller HMOs that are popping up and the smaller SMOs and MCOs, they cannot take electronic claims.
With some of the new acts that have been imposed in California, especially with the Medical program, where Medical is forcing all their enrollees into managed care, they are scrambling right now to figure out how they are going to take claims. Right now it is actually reverting back to paper.
MS. FYFFE: Let me make a point of clarification here for the committee. A few years ago I was somewhat involved in this issue. I think it is the same thing and let me just try to frame it here.
Hospitals would typically have large main frame systems that were designed to bill Medicare, Medicaid, the Blues and maybe the commercials, although you had to do some manual interventions for the commercials.
Suddenly, all these managed care contracts came about and there were some software companies out there that would allow you to buy a software package that you would piggy back on top of your main frame system so you wouldn't have to go through the manual intervention to prepare a bill for a managed care company.
I know when I was a director of patient accounting, I would have to take these bills that were intended for Medicare or the Blues and hand them to a biller.
He would go through a manual sheet and prepare the bill to go to the managed care company.
So, are you talking about the automation of these different types of contract terms for the variety of managed care companies or are you talking about something else?
MR. FOLCKEMER: It is actually a combination of both. We are trying to do some things with LA Care and a few other agencies out there.
Right now they cannot take electronic claims in the format for these MCOs, MSOs, those managed care organizations that are strictly for Medical enrollees. They don't know how to do it yet. They are debating it.
We are actually seeing an increase in paper claims because that is what they will take.
MR. ZUBELDIA: Beyond Medicaid, in California we are also seeing a large number of IPAs and other provider organizations that are themselves at risk, especially large provider practices that take risk. They can't take electronic anything, patient advice, eligibility, nothing.
MR. FOLCKEMER: They cannot process electronic claims themselves. They are actually telling you that, we cannot take electronic claims. So, we have to put them back to paper.
MS. FYFFE: They haven't matured yet to the point where they have automated.
MR. ZUBELDIA: Right. In a lot of cases they think they don't need to automate because it is a group of physicians that are taking their own risk.
So, they see their own patients, so they are not going to send any claims to anybody. But they do send referrals.
MR. FOLCKEMER: And secondary claims.
MR. ZUBELDIA: And secondary claims. There are all kinds of issues that I don't think they understand what business they are in.
MS. O'BRIEN: Yes, they do. We have a full risk managed care package that we are currently working on and developing. It is being installed in a few places, and that is a part of it.
I am working on an interface piece with a managed care group to be able to accept claims.
MR. ZUBELDIA: You need to hurry up.
MS. O'BRIEN: They do know that there is the need for that.
MR. FOLCKEMER: Kathleen, my point is that currently we can accept the ANSI 837 4010 as a download and we can convert and we can put out 4010 and we can put out 3070.
If these new payers, as they are certified, they should be mandated to accept electronic claims, so that we don't reverse the cycle. It is increasing the cost definitely to the providers. There is no doubt. We charge them for those paper claims.
MS. FYFFE: When you say certifying, who is certifying them?
MR. FOLCKEMER: That is what I am requesting, that they be certified, that to become a new managed care organization or to become an IPA or an MSO or an HMO, part of that requirement should be that you take electronic claims in a format that is governed by the state, by the federal government.
DR. BRAITHWAITE: First, a point of clarification. Jeffrey, you realize that the HIPAA law requires every single payer to accept electronic claims in the standard format in the year 2000.
MR. FOLCKEMER: Yes, I do.
DR. BRAITHWAITE: At least there is a time limit on your problem.
MR. FOLCKEMER: I need year 2000 tomorrow.
DR. BRAITHWAITE: Then all the computers would be stopped and we wouldn't have to worry about these claims.
Several of you have mentioned the use of attachments for the purpose of conveying some text with a signature attached.
Since the HIPAA law also includes a requirement for a standard for electronic signature which supersedes state law requirements for paper signatures, I am wondering what proportion of attachments are there solely because you need this paper signature, and whether the electronic signature standard would resolve that problem. What size is that problem?
MR. ZUBELDIA: I can't answer that question, how many require the signature. Those that do require the signature, most of the time would be the patient's signature.
In order to obtain the patient's electronic signature, then the patient would have to have a certificate, and that is not practical today; maybe in a few years.
MR. MC DONALD: Along those same lines, that whole signature thing could stymie the whole process. There are really two kinds of things.
You want to know that it exists. In a lot of other environments it is the on file. Is that on file mechanism available?
You know, I checked out today and if I get a bill tomorrow and I call and they say my signature is on file --
MR. FOLCKEMER: That is currently in the V4, the NSF and that is also in the ANSI.
DR. MC DONALD: What I really mean is, does that suffice and could all the signature requirements -- because the electronic one creates a lot of other burden -- if you are just yanking a text report out of their word processor, they won't have any kind of electronic signature at the end, and the on file rule could be applied to all of these.
I think it would be important to work through these and see if it could be.
MR. RODE: I don't know if it comes under the HIPAA legislation, but it is certainly one that the federal government could look at, the state governments.
Blue Cross has used an on file system for years. So, there is no reason to think that it couldn't be done. It gets back to the trust level that Kepa talks about and the ability to know that it actually is on file and it can be audited.
MR. FOLCKEMER: I used to work at Blue Cross/Blue Shield, and signature on file was sufficient for all lines of business.
MR. ZUBELDIA: Some states have a statutory requirement that the claim has the provider's signature. The statutes sometimes are not clear and they say electronic signature rather than digital signature.
The electronic signature can be just their name typed or printed with a computer, so it is not clear.
Digital signatures would be beneficial for providers, pharmacists, that kind of environment. But I don't see them for patients yet.
DR. LUMPKIN: I guess I am a little bit confused. When I went to the container store, when you go to Sears, Best Buy, they all use a little signature pad. So, it seems to me that that technology ought not to be --
I am assuming that Sears doesn't really go into very expensive stuff.
MR. ZUBELDIA: Yes, you are confused. That is not a digital signature. That may be a digitized signature, but that kind of signature could be lifted from one document onto another with, I don't know, a graphics package, if you want.
Everybody, once they have your signature, could make millions of copies of it. The digital signature we are talking about is a cryptographic mechanism that binds the document with the identity of the signer.
If the document is changed or the signature is changed, the signature is invalidated.
DR. LUMPKIN: Trust.
MR. BLAIR: This is more security stuff.
DR. MC DONALD: If we are talking about doing something in the next epoch, like for some of us, while we are still alive, assuming that you could get hand pads of a given type so it works through, it would be really very difficult.
It really sounds like it is not necessary for almost all these kinds of signatures we are talking about. Already in place, in all of industry including health care, is this notion of on file.
There is always going to be an audit requirement on all these things anyway. I would just like to make sure that as we work through the HIPAA stuff that the regulations facilitate this, so that we can make it grow as fast as possible in as many environments as possible.
DR. LUMPKIN: I have a couple of questions that were raised by some of the discussion. Perhaps this may be a difficult question to ask.
We had some discussion about the proof of concept committee and the use of the LOINC codes in generating the requests for attachments.
In your knowledge of some of the models that are out for computerized patient records, could a LOINC code then generate automatically a retrieval of the information that is requested?
MS. O'BRIEN: Technically, yes. I don't see why not.
DR. LUMPKIN: Technically it could. Then, if that were to be the case, and you set in the system what kind of checks that ought to be in place in that kind of system.
One could envision a full technology where the payer could query the provider's system and retrieve information which the provider may not choose to send.
Would you expect that there would be some human intervention in the billing process?
MS. O'BRIEN: Probably not a whole lot different than there really is for receiving a payment transaction or a reconciliation transaction, where they receive it, they put out an audit report and review it and they can make exceptions to it prior to running the transaction.
MS. ROBINSON: You could put controls in place that would monitor that. I think that the whole point of making it electronic is to eliminate the use of human intervention.
Computer systems can put controls in place that would allow people who are not supposed to have access to it to have access to it, or to allow only certain information to be provided, maybe a query system or something like that, so you couldn't update it. You couldn't have access.
DR. MC DONALD: A little clarification. The proposal at hand is not to have a direct access query into the local system.
It is to send a message to the receiving system. It defines what you want and then the receiving system does the query. This is not a remote distributed data base model that is being proposed.
The receiving system actually has complete control over what it does with that message, and whether it acts on it and how it acts on it.
DR. LUMPKIN: Well, actually it does. When we talk about a current system, let's start off with paper. Generally, the clinician has an idea what kind of information is leaving their office when they do a paper bill, because they have to train or work with their staff.
When you do an 837 transaction, you can conceptually understand what is going from your system to their system.
Now, if you include an electronic transaction and you say, I want to bill for a laparoscopic procedure, depending upon the standards that may be set by that receiving company, you may say you want to send a bill and not really understand that in that process it is sending a copy of the medical record, a history of any procedure that you may have done related to the female GU tract for 10 years.
MR. MC DONALD: That is not the model that is being proposed. The model being proposed is that there is a fixed, defined set of what these things are.
When you get your system in, you configure it for how it is going to behave, just like when you are training your office staff.
There is not a model proposing that this thing is going to come in and say, give me what you have got. It is going to be all predefined in terms of, if you have an ambulance attachment, this is what it is.
It will be a configuration issue as to when you send it, to what vendor you send it to. It is just like they configure some of these systems now to automatically send a bunch of attachments, send the whole record.
It is automated through people, but that is not the doc looking at it, if this insurance company asks me for it.
I mean, we heard that yesterday, that there are certain insurance companies that they just copy the whole thing and send it to them.
DR. LUMPKIN: Well, given that, I just really raised that issue because I think that one of the things that will be important to the committee is to conceptualize how providers, as we go into this new electronic media, understand the options.
By and large, PCN will go in and set up the system with the office staff. I can conceive of five years down the road, with the provider who provides the service not really being able to understand how much of the clinical information is leaving our office without us making sure that there is some way for them to understand, particularly for those who are not computer literate, but went to medical school to treat patients. I just think that may be a future challenge.
MS. FYFFE: I don't mean to belittle your concerns, but I think it is a management issue in the physician's office.
MR. ZUBELDIA: I don't think that will fly while Bob Gelman is alive. Bob Gelman would just -- he would kill everybody in that room if that flies.
MS. ROBINSON: You can put audit capabilities into systems to be able to control that from a management perspective.
MR. BLAIR: I had three warnings to us and I want to understand each of the three of them better. One is the inability of small physician offices to be able to deal with the automation that would be necessary to send, it seemed like, not only attachments but maybe even claims.
The second was with respect to payers that might be receiving the binary large objects, that there is a large -- I don't know whether you said all, but a large number of the payers that would have to implement new systems, to be able to handle those.
The third comment that I would like to pursue and understand better is the degree to which the time frames may impact adjustments to the year 2000 problems.
Let me hit the first one. Susan, I think you made a comment that many of the small physician offices that you are dealing with -- let's isolate it on attachments, since that is what we are talking about now.
They literally would have to make a major investment to step up to meet this requirement. Could you elaborate on that? If there is anyone else, could you please also indicate whether you have perceived the same problem, or whether you see it differently?
MS. O'BRIEN: I am not really sure how much it is going to cost. I don't know what we are going to capture and what we are going to require and in what order we are going to require this stuff to be sent.
I kind of set up a model thinking of just the most simple thing that I could think of is surgical notes that a dictation person will type out in word perfect or microsoft word, capture as a data text format, and then will transmit it.
They would have to buy a PC and get trained on it and it wouldn't be huge sums of money for that particular data set, but they still would have to purchase something.
We would have to train them and we would have to install it and we would have to support it. It is going to cost them money. It really depends on what we do and what order we do it in, how I can capture that data.
DR. LUMPKIN: Did the other folks that are here have comments on that subject?
MS. ROBINSON: Yes, I do. We have done some preliminary analysis on what it would cost to implement all of HIPAA, including the attachments, from a payer's perspective.
Although I don't have exact costs right now, I could provide that for you. It is in the multiple millions of dollars per carrier.
DR. LUMPKIN: So, you can provide your estimates to us?
MS. ROBINSON: I can provide that to the committee, if you need that.
DR. LUMPKIN: You switched to the payers. What about any other comments about small physician offices or small group practices in terms of the burden that this would have on them?
MR. MAYES: Jeff, this is Bob Mayes. I just want to clarify to everybody that HIPAA does not require any providers to send anything electronically. It only applies to those providers who choose to do electronic business. In that case, they must use the standard.
There is absolutely no requirement for a single provider in the country to do claims or anything else electronically.
The payers do have to comply. They must be capable of accepting that in electronic form. Providers do not.
DR. LUMPKIN: It is a little bit more complex than that. If you take, for instance, an operative report, generally operative reports are made at facilities. So, the hospital or the surgery center would be the one. Primarily they are dictated.
If we are conceptualizing for operative reports, making those attachments, then it is not too big a leap to go from that being provided, but the bill gets sent from the physician's office.
It would require a lot more communication electronically, not only between the payer and the provider, but between providers and the institutions where they work.
MR. MAYES: But the institutions are providers as well, for part of the law. A hospital would not be required to send this electronically either.
A provider is not defined as just a single individual provider. It is anyone or any organization that provides care. It is just a point of clarification that the regulation will not require any provider -- whether they be individual or institution -- to send things electronically.
MR. RODE: Getting the information, though, to an electronic format is a change from getting it right now to a paper format.
If the committee can come up with a standardized format for some of these things, then you have the potential that physician offices or hospitals or home health agencies could do it one way instead of having to do it a different way, depending on who is asking for the information.
If somebody wants to dictate a report, the next person wants highlights of the dictated report, and a third person wants it printed out on a format, we still right now have to have somebody sit down and do this on paper.
Yes, it will take money to convert to electronics, of someone wishes to go that direction.
What the committee can do is certainly standardize the way some of this stuff is captured. That allows us, even when we dictate some of these reports, to make sure that as we are dictating the report we have covered the things we know are going to be asked for, both for billing as well as for some of the quality data we want to capture.
MR. EMERY: Jack Emery with the American Medical Association. I would just like to clarify that it may not be government policy to require electronic processing, but the administration's own proposal for this year says they are going to penalize, by charging a user fee, every claim that is not submitted electronically.
That burden will be felt by the medical profession, by the small physician offices, laboratories, more than anyone else.
That is a burden, then, that is being placed on the profession and that is a penalty that we have been talking about.
In addition, they would actually charge an additional user fee if you submitted a duplicate claim to the program. All of these are burdens that will be felt more strongly by the small physician offices than by others.
MR. BLAIR: Could I get back to the third part of my question? I am sorry, were there some other folks who were going to answer? Okay, I am sorry.
MS. GILFOY: This is Helene Gilfoy from Catholic Health Initiatives. I have looked at seven of our hospitals on the east coast. I don't have a full report yet.
Of the 50 systems that four hospitals have reported to me so far, of the 50 systems -- this is not a complete report -- 29 of those systems cannot accommodate the identifiers and the two major code sets that are proposed to be changed.
So, 29 of the 50 systems that we have looked at so far cannot accommodate the HIPAA changes.
MR. BLAIR: Did they give you any information as to what is preventing them?
MS. GILFOY: The field sizes will not accommodate the changes. The field sizes are hardened in the system. So, the field sizes have to be enlarged and we have no way to do that without having our vendors come in and do it for us.
As far as cost goes, I have no idea, because I am not going out to my vendors until the final rules are published, to say how are you going to change this.
As far as the cost to us, all of our vendors are required, because this is federally mandated, they are all required to make the change, unless Bob's thing that we don't have to do it electronically. I don't think that is realistic for any of us.
Does that address some of the --
MR. BLAIR: Let me ask you a follow-on question on that. That is, do these folks have systems that are old, where they are also winding up having to deal with the year 2000 problem as well?
MS. GILFOY: No, we are up to date with all of our releases. These are not old systems. These are not legacy systems that I am talking about.
MS. FYFFE: Helen, these 50 systems, name a generic type.
MS. GILFOY: HIS, LAB, Medical Records Systems, you name it, it is across the gamut. This survey that I am doing at this point is only for the identifier changes and the two major code sets.
There is other information that I shared with Simon as far as the code sets that are required within the 837 transaction.
There are 37 code sets that I have looked at. The majority of those code sets do not have a concurrent code set within UB.
The code sets that do have concurrent code sets, the codes are not the same.
DR. LUMPKIN: We are getting a little bit far field. We need to get back to attachments.
MS. GILFOY: The point that I wanted to me, though, is that we are not even talking about attachments.
DR. LUMPKIN: We got your point. We understand that it is not going to be small. Jeff, did you have one other question about attachments, or you have caused enough trouble?
MR. BLAIR: I am already overwhelmed. Let me try asking a relatively focused question. John, like you, I have been hearing a lot of stuff today. It is hard to differentiate what is unique to claims attachments, like what has to do with HIPAA standards.
That is what I kept hearing over and over again from discussion of the balanced budget amendment coming down the road, which I am painfully well aware of, but which does get transmitted by HIPAA standards, to the year 2000, to everything else in the world.
DR. COHN: Now, I guess what I wanted to hear from each of the speakers in bulleted fashion, like one, two, three and hopefully not repeating each other, is the unique additional issues that have to do with claims attachments that are different somehow from the other standards that are already pretty far down the pike.
If you could do that for me, that would be very helpful to me, to help me understand the additional risks involved with claims attachments that need to be somehow dealt with, that the committee needs to consider. Can you do that for me? Send us a note afterwards of things we have missed.
MS. O'BRIEN: I have one. We don't currently capture that data electronically. We don't capture it.
MR. ZUBELDIA: There is a lot of low-hanging fruit that has been already automated. It is maybe incorrectly in the claim but it works today.
The things that have not been included in the claim are things that could not be processed automatically. There may be a few exceptions, but in general they could not be processed automatically when they reached the payer in the adjudication system.
If they are going to suspend the claim, they might as well get it on paper, because they are going to have to look at it. Let's not delay the claim because there is a need for attachments.
Let's send the claim electronically and send on paper the things that need to be sent on paper, or things that cannot be automated.
We can save by sending them electronically. We can save by sending a word perfect report electronically. If we are sending an X-ray electronically, no payer would be able to see it. That may be an advantage, but we need to look at what are the real cost benefits.
MR. RODE: I would add to that the data that is existing in the 837 is a combination of previous work by the NUBC, NUCC and the consensus of the industry, of data they could agree upon.
What we are looking at is attachment data that we have not agreed upon common definitions of the data or the data set. The other two bullets kind of go from there.
MR. FOLCKEMER: From the larger hospital information systems and the small hospital information systems and the clinical systems that we deal with, we do not capture the electronic data, as Susan has said.
The only way we capture it is by roster, download or scan. It ends up on paper. By the time it gets to the payer, it is paper again. It may come to us electronic, but we will convert it to paper. If we had a standard electronic format or if you did a bin wrap with the 275, we can do all that.
We just need to know what to do with that detail when we get it. If it is just going to be free form, I will take that scanned image and throw it into a format and pass it on. But the payer won't be able to do anything with it.
MS. ROBINSON: I would say that there are some concerns about electronic storage of the data and being able to retrieve that data and display that data.
That is not out there today, concerning attachments, changes in the clerical business practices and changes in the business processes that are currently revolving around the paper and making the attachment electronic.
DR. MC DONALD: I would just like to make a comment because the way the question was asked, the comments all came out very negative.
If we talked the same way about the UPC codes in 1986 or something like that, we would say, it is going to cost $2,000 a device and it is going to cost all this money, and we could make it a $20 million expense per grocery store.
All it was, was an enabling technology. It didn't make anyone do anything. Within five years, the whole place was using it because it cost them a huge bundle on the other end.
If you send a person to each office and it is $200 or $500, but they have an employee who is costing them $15,000 forever ongoing, I don't see how these things have any relevance. It is the cost and a benefit.
MS. ROBINSON: That is why we said a cost savings.
DR. MC DONALD: I appreciate what you said. I just want to change the tenor a little bit.
MR. BLAIR: What I am hearing is that unfortunately it seems that we almost have the cart before the horse.
If we don't have the electronic medical record that captures the data which can efficiently feed into claim attachments, then we are in a situation where the claim attachments is trying to drive things.
I think we are also hearing that the motives for payers requesting attachments is questionable in some cases. That may not be the way to drive us toward computer-based patient records.
We have other reasons, like patient care and quality, and improved clinical processes that we want to drive computer based patient records, as opposed to claim attachments.
DR. MC DONALD: I would like to make a side bet to anybody in the room, maybe for a Hershey bar or something. If a reasonable, technical implementable standard comes about well before the time frame, there will be vendors out there hawking like crazy, the things that are in computers everywhere in the universe.
I am saying discharge summaries, operative notes, they are all dictated and they are sitting in computers, and laboratory reports.
You will see a whole shift in this whole phenomenon, oh, we are going to save two FTEs, is what should happen if it works. If it doesn't work, then the standard just sits there.
MR. RODE: You have the ability as the committee to make some limits on these, and standardize them so that can happen.
When it happens and when the final regs are out, then the computer community and the provider community can recognize what you want to do and start moving on it. Right now, no one knows what you want to do, so they are not moving on it.
MS. O'BRIEN: It just feels so big.
DR. LUMPKIN: Right, but I think the issue that is raised, and it is something we can discuss when we meet a little bit later, I think we need to better understand the market forces.
Those market forces on the front end, where there is potential for cost savings versus on the back end where we have to weigh the conceptual model of the cost of paying the bill efficiently versus the cost of receiving tons of stuff because the provider wants the bill to be paid in a short time frame.
I think it may be helpful if we can figure out a way to do that. It is probably not going to be in a hearing format. We may need to look at some more in-depth analysis of some of the market forces here, as a committee.
MR. FOLCKEMER: I think a finite list, from a vendor's perspective, once I have that list, and have that format, I can start.
MR. ZUBELDIA: I would like to make a comment because AFEHCT also represents payers. As part of the testimony, we had a lot of contribution from payers.
One concern is that this will not be a standard that just sits out there unused because nobody wants to use it.
The concern is that the payers are mandated by HIPAA to implement whatever attachment standard is defined. All payers will be mandated by HIPAA because there is one provider in Montana that wants to send attachments electronically, all payers in the country have to be able to receive it.
The payers' preference would be to define what attachments need to be sent electronically through an industry consensus, and possibly define that no attachments should be required electronically, and only certain information upon demand, rather than having a standard format that everybody has to implement with all the graphic displays to display this X-ray and only that one provider in Montana is going to use it.
I hope not. I hope everybody uses it. There is a concern.
DR. LUMPKIN: Actually, he is in North Dakota. We are going to take a 15-minute break. I just want to sort of advise everyone about the schedule this afternoon.
It is the committee's intention to break by 4:00 o'clock, if not a little bit before. So, we are going to take a short break now. We are going to hear our last panel, and then we are going to take lunch. I am going to ask you to shave some time off lunch. I am just going to tell you ahead of time to make your plans that way.
(Brief recess.)
DR. LUMPKIN: The final panel is on content experts. George?
MR. ARGES: Good morning. My name is George Arges and I am the chairman of the National Uniform Billing Committee.
On behalf of the National Uniform Billing Committee, I would like to thank the Committee on Vital and Health Statistics for the opportunity today to speak on the important subject of attachments.
My brief statement is intended to provide a framework for a process that can begin tackling the problem of attachments.
Let me preface my remarks with an acknowledgement of the support from all the members of the NUBC that have and continue to act with passion and responsibility to achieve the vision of uniform claim standards.
It is their actions that help to bring about administrative simplification. So, any criticism that I may direct toward providers, payers or other third parties are not necessarily intended to apply to these members.
Today the growing number of requests for attachments is unpredictable, unstructured and unrelenting.
The result is a claims processing system that is burdensome, costly and inefficient. Generally the most frequent reasons for requesting attachments stem from two distinct needs.
One need is for additional information to control the reimbursement being made, while the other is to request attachments to arrive at an understanding of a specific aspect of the delivery system.
Recently we heard the President of the United States, in his state of the union speech, talk about strengthening the special relationship that exists between patients and their physicians.
Clearly, this special relationship has eroded, with more decision making going to third parties that request additional information that goes well beyond processing a claim or simply managing the care of the patient.
In many of these cases, a request for an attachment occurs because third parties seek to first manage their financial risk rather than manage the patient's case, basically a reimbursement issue.
Health care providers often receive requests for additional information from third party reviewers when they bring into question the medical necessity for some services delivered or even the medical necessity for the entire episode of care.
In these situations, providers receive requests for additional information about the clinical decisions made on behalf of the patient.
These requests for additional information are often unstructured or insufficiently defined as a standard document.
This becomes problematic for providers' information systems designed around specific routines.
The lack of specific definitions, structure and methods for handling and reporting the additional data results in a process that cannot capture the data in the most efficient time and place; namely, when the care is being ordered and rendered.
As many of you know, providers create a medical or patient record to track the significant events or services during the patient's stay at their health care facility.
The creation of a medical record involves many information gathering routines. Yet the process that yields the creation of a medical record is, itself, unique. If you have seen one process, you have seen, basically, one process.
Since the delivery of health care services is done on a credit basis, many providers find themselves forced to gather more information and jump through many administrative hoops to receive payment.
Their reimbursement for services rendered becomes a hostage of third party payers until the additional data demands are satisfied.
There is no question that a high degree of accountability is needed to safeguard the financing of the health care system.
We believe that the UB92 data set provides a structure and a level of accountable detail needed, and can further serve to improve claims processing efficiency.
There are already many claim details included on the UB92 data set. Much of the detail is codified and intended to provide specific information as abstracted from the medical record.
The purpose of the codes is to allow for further development of the claim and to allow any necessary edit logic to be programmed into automated claims processing systems.
Unfortunately, many people who request attachments do not know how to derive the information from the UB92, or do not keep current with the data sets codes.
Consequently, the primary purpose for the creation, namely to reduce the need for an attachment, is lost as a result of their inaction.
As I mentioned earlier, there are also other reasons for requesting additional information besides reimbursement.
The other reasons are the needs of the public health or health care researchers to examine with more specificity certain types of services delivered with each episode of care.
These requests are in essence used as a means to gauge the pulse of health care delivery within and across communities.
For instance, the need to track pacemakers is one example. The need to report sexually transmitted diseases is another example.
These requests, however, are more defined and structured. Therefore, it is easier for providers to establish routines and methods for gathering and supplying this information.
Providers know when they need to collect this information and the frequency of when to report this information.
However, there still need to be controls at a national level for these requests, particularly when providers must deal with bordering states.
The NUBC realizes that there are specific circumstances for providing additional data or information. The process for evaluating the merits of the request should be coordinated through a national oversight body like the NUBC, that already has established a method to evaluate the best course for gathering and reporting this information.
The process should set clear policies and procedures for when and how to report additional claim attachment information.
This could be through the establishment of a code to the UB92 data set, or perhaps establishing a separate electronic record or document designed around specific events or circumstances.
Committees like the NUBC have a proven management process that balances the viewpoints of providers and third payers alike.
In addition, we have recently extended an invitation to include the National Center for Health Statistics as a member.
This was done in light of the growing use of the UB92 as an instrument used by public health and health services researchers, and primarily to gain their perspective for the management of the claims transaction.
At the November meeting of the NUBC, we heard from HCFA representatives about the proof of concept model. We were looking at the X12 transactions as a process.
While the design of the X12 transactions is promising as a transport mechanism for carrying attachment information, it can become meaningless and expensive if we neglect the policy and related management processes which evaluate and establish the business needs for the attachment information in the first place.
At that meeting, the NUBC questioned the creation of some claim attachments being presented. From our perspective, the request for attachment information should only be supplied in extraordinary circumstances. They should be the exception and not the rule.
We would urge the NCVHS to consider whether the attachment data is needed as a result of a deficiency in the information contained in the claim, or whether it is a result of the inability of users to accept and use the information already contained in the claim data set.
As I mentioned in one of the earlier NCVHS hearings, if we are going to achieve administrative simplification, then each transaction identified in HIPAA should fulfill its intended purpose.
Attachment information should not be routinely prepared for each claim. If specific information is needed, then those organizations requesting the data should go before committees like the NUBC to make their case. Otherwise, we will not have a standard for a claim transaction.
Finally, I would urge the NCVHS to establish a management process to oversee, examine and evaluate and handle any attachment requests for information to be supplied with a claim.
The NUBC stands ready to serve in this capacity. Our protocol is structured to be sensitive to the needs of the provider, payer and public health research community.
NUBC meetings have, and will continue to be open to the public, so that the review and deliberation process for any request for additional data receives a fair hearing.
As chair, I am required to include, on the NUBC agenda, those requests that come to my office. All I ask is that the requests be properly filled out in terms of purpose, what it hopes to accomplish and, if known, the UB92 data set element that would be affected.
The committee will then review the request at the next meeting. At that meeting we discuss and deliberate how best to handle that particular information.
It is important to note that there are important steps that take place between the time the request comes into our office and before the meeting actually takes place.
Once a request is properly documented, it is added to the NUBC's meeting agenda, and material is sent to each of the state uniform billing committees.
This action is undertaken so that each major advocacy organization and HCFA's Medicare and Medicaid programs have an opportunity to formulate their opinion.
This process allows us as a committee to gain the various perspectives of the different constituencies, on whether they support the request.
Finally, these viewpoints help the NUBC members to formulate their opinion.
If a data request is rejected by the committee, the committee will explain its rationale and will usually make a recommendation on alternative actions that should be followed.
Our operational protocol does not limit or prevent the resubmission of a request. We do ask, however, that a resubmission be accompanied with a rationale which explains why the NUBC should reconsider the request, and to include any new information that would help alter the committee's thinking regarding the collecting and reporting of this information, or if there are any special circumstances that pertain to the request -- for instance, legal requirements, state law, federal law, et cetera.
With regard to the questions, there wasn't a category of questions geared to committees like the NUBC. Therefore, we did not attempt to answer them.
However, the first two questions are probably the most important for the committee to answer. Coming to terms with a definition of a claim and a claim attachment is extremely important.
Webster's Dictionary refers to an attachment as a physical connection by which one thing is attached to another, or the process of physically attaching.
Is this the same view that Congress had in mind when it created the HIPAA legislation? If so, what is it that we are attaching to the claim.
One of our payer representatives gave an apt definition of a claim. It is a formally defined series of structured data elements used to request payment for the rendering of health care services to the patient.
It should be noted that the key term here is formally defined, and structured data elements. For my purposes, this defines the claim as a document.
A document, according to Webster, is an official paper, proof or evidence relied on as a base of proof or support.
If the claim then is construed as a document that serves for the basis of seeking payment or describing the services rendered to a patient during an encounter, can the same be said of the term, claim attachment.
Does claim attachment then mean the process of adding another document to the claim? What document, again, is being added.
Some have described the use of the X12N attachment transaction not as a document per se, but rather the process of adding other data to the claim.
If we assume that this is the process of adding more data to the claim, then the administrative simplification benefits outlined in HIPAA would be lost.
I do not believe this is what Congress had in mind when it identified attachments as part of the administrative simplification provisions in HIPAA.
Each of the transactions outlined in HIPAA are distinct and specifically referenced. Even the sections that deal with compliance to the administrative simplification provisions treat them as separate and distinct transactions.
The law made no reference to attaching additional data to each transaction in order to embellish it and make it suitable for processing purposes.
Instead, the attachment section of the law specifies the creation of attachment at a later date when the business case warrants the use of attachment transactions for the inclusion of separate documents.
Again, what are these documents and for what purpose do they serve?
Identifying these documents can be a daunting task. However, the process has already begun. An inventory has already been established for some of these documents and many are unique to a particular health plan or program.
If the documents are to be part of the claim, then committees like the NUBC, the National Uniform Claim Committee, the ADAs, or the NCPDPs, which are responsible for managing the data content of the claim as it pertains to their sector of the health care delivery system, should review and evaluate them, and identify how best to handle these documents as national standards.
That means removing any variations that may exist for each of the health plans.
Finally, I would urge that a bold plan be put in place, so that these committees can work outside the traditional lines that have encumbered us in the past, so that they can be creative in their approach for creating these attachments and achieving the goals of administrative simplifications.
My recommendations are, number one, to establish a process which includes a designated oversight body to review claim attachment requests.
Second bullet is to define a claim attachment as a document with specific purpose, definition, structure and methods for capturing and transmitting the data.
Then, strengthen the requirement for all health care participants to primarily utilize the already-established claims data sets like the UB92, make that a first criterion.
Establish state agencies reporting requirements on a national basis. We heard yesterday of the benefits that would derive if we were to do this.
Have oversight bodies work in conjunction with X12 work groups to develop appropriate electronic transaction sets and implementation guides when necessary.
Establish a sunset date for existing attachments. This would allow for a period of time for organizations to review their existing attachment requirements and to determine whether there is, in fact, a legitimate national need for them.
If there is, the organizations could begin looking at the specifics on whether the purpose and definition and structure and methods for capturing them are identified, and then to begin cataloguing them. Thank you for the opportunity to comment.
MR. HAMMOND: My name is Ed Hammond. I also would like to thank the committee for the opportunity to appear as a representative of HL7.
I am the immediate past chair of HL7. I am the co-chair of the HL7 special interest group on vocabulary, and I am the chair of a government relations committee, in which I am performing this role.
I have noted, as well as George, that no questions were specifically asked of us, but we have opinions on some of those questions, and I have answered those.
I have created a claims attachment to my comments here and will make both of these available to this subcommittee.
HL7 itself is in its 11th year on developing data interchange standards.
DR. LUMPKIN: I hope you are comfortable if we deny payment on it.
MR. HAMMOND: Actually, what I am trying to do is to work out a process that enhances both of those processes for us.
I, myself, have spent my entire career working with standards and in creating a computer-based patient record, both in terms of the design perspective, the implementation perspective, and the operational support.
I have been in the pits of a lot of the issues that are being talked about here. Part of that is what has been the driving force behind my activity with HL7.
HL7, current version, version 2.3, was approved in 1997 as an American national standard.
The current membership of HL7 includes approximately 500 organizational members that represents an almost equal balance between the vendor community and the health care provider community.
I might mention as an aside here that when I think provider, I think of somebody who clinically delivers care. I have become attuned to the fact that provider also includes the billing components of what we are talking about.
In addition to the dominance of vendor and provider community, there are consultants, payers, government organizations and a number of special interest categories.
Those 500 organizational members translate to about 1,800 members of the organization itself. The majority of all of the clinical information system vendors provide an HL7 interface.
Most of the gateway systems that put these systems together accommodate the HL7 standard.
HL7 now has seven international affiliates, which I think has significance in terms of the broad marketplace, and will entice the vendors even more in support of the HL7 standard.
There are three more that we anticipate will become international affiliates in 1998.
In 1996, Hewlett Packard conducted a survey at the HIMSS meeting, related to standards and what standards most met the needs of that particular person's organization.
Sixty-eight percent of the respondents indicated that HL7 was their choice. The next closest organization was 19 percent.
I think this represents both the kind of people that go to HIMSS, which represents a lot of the larger institutions with clinical involvement, but also the penetration of HL7 into that group.
The activities within HL7 have grown immensely during the past two years. I think HL7 has now recognized that it needs to address more issues than the simple transmission of data from one place to the other. It has to take responsibility for the larger environment and all the components that are necessary to successfully make those transactions occur.
HL7 is addressing issues that relate to the broad exchange of data within an institution, within an enterprise, within a geographical integrated delivery system and, in some cases, within a national system.
New activities in HL7 include a special interest group or SGML or XML or HTML. I think these are mark-up languages that I think will play a significant role in the future, particularly in terms of the use of the internet, intranet and extranet to transmit data.
I think that we will see an increasing use of those standards as part of the exchange of clinical data.
Security, privacy and confidentiality have become a very key activity within HL7. We are working very closely with the Internet people, taking advantage of the expertise and the dominance of those standards within what we have to do.
HL7 is not only addressing the transmission of the data from point A and point B, but looking at the encryption of data within the HL7 standard, which applies an additional degree of security, privacy and confidentiality through exchange of detailed information, including authentication of sender and receiver, as well as accommodating digital signatures.
I think a critical event is the vocabulary special interest group, which is working to define vocabulary in terms of use and content, and specifically takes advantage of existing vocabulary systems, which include LOINC, SNOMED, the read classification systems, IDC-IX and X, CPT and other coding systems.
The vocabulary itself will be mapped into UMLS, and will be defined specifically as it relates to HL7 messages. So, we are defining vocabulary in terms of message content.
A subset of this group will meet in March to create the model for naming prescription drugs and other drug-related products.
Four of the major drug knowledge based drug groups -- to my knowledge, that is all the knowledge-based drug groups -- have contributed their models to this process and, at this meeting in March, these models will be harmonized along with input from NCPDP, and we are also using work coming out of Europe's standards group, TCT51.
HL7 has also created a reference information model that defines the health care data objects that will be used in Hl7 messages.
The vocabulary is being referred back into this reference information model and we have invited all interested parties to join HL7 in the harmonization of defining those data models.
I think that is particular significant in terms of the activities of the claims attachment.
The claims attachment special interest group, that you have already heard about, is one of the new activities. Not only does this special interest group represent an effective coalition of two standards development organizations working together, but the leadership of this group is shared across those two organizations.
I think that it has been interesting watching the development of the proposals that you have heard about in the proof of concept. In fact, as the groups become accommodating and understanding of what the other positions are, I think we are able to produce a proposal that was significantly more powerful than either of the two groups would have done by themselves.
I think that is particularly important in recognizing the fact that there are the providers on the one hand and the payers on the other hand, who have a very different perspective of what they are trying to accommodate.
I think one of the frustrations that I have suffered sitting back listening for a day and a half is, I keep hearing the words of someone and they, and expressions of they don't know what they are doing or they aren't proposing anything.
That makes me very, very nervous because if they have not been represented by the people who have come before this group in the last two days, I think we are in major trouble and really need to identify who those people are.
HL7 also has a new activity in decision support, which includes the Ardin Syntac Medical Logic Module Standard.
We have conformance and certification special interest groups now. At the last meeting we created an audit quality of care and outcomes special interest group. So, I think we are addressing this broad spectrum of requirements.
HL7 also has active products with NCPDP, ASTM, X12 and NACR NIMI, DICOM, and the IEEE standard efforts now meets with HL7.
Duke Medical Center has about 100 different HL7 interfaces that is accommodating the interchange of all types of administrative and clinical data.
That includes activities both within the inpatient setting and the outpatient setting, and includes a group that we call the Duke University Affiliated Physicians, which is a group of community physicians that are linked back into the overall network.
These community physicians do not have a full computer-based patient record system. They do have computers and, through those computers, access to clinical data including laboratory data, drugs that have been prescribed, and various reports.
I would like to reiterate the statement that was made, that there is a tremendous amount of data that is now electronically available. Most things that are dictated end up in electronic form.
Most laboratory data is reported electronically. So, for small expenditures of money you can create, not a computer based patient record, but you can create a tremendous amount of data, much of which is part of the claims attachment electronically.
The forms of data interchange include structured data. By this I mean codes from some coding system, and their values.
It includes text streams. It includes text blobs such as image interpretation, progress notes, discharge summary, operative notes.
The standard itself supports the interchange of demographic data, laboratory orders and results, pharmacy orders and dispensing, drug allergies, procedures and diagnoses.
We now are defining an envelope that will include images using the DICOM standard.
HL7 supports automated data waive forms. I have used HL7 to exchange all components of electronic medical record, and in fact, the entire medical record. I think these components are what, in large, will provide the content of claim attachments.
The task of this subcommittee is not an easy one, but I think that the difficulties that you encounter must be faced.
I think taking the easy way out or a quick way out, that only accommodates today, would be a major mistake. I think you absolutely need to look at what is going to happen over the next three to five years, in terms of the expansion of the number of facilities that will be capable of supporting some type of electronic record, and also the ability to be able to derive the claims attachment from these data bases.
From yesterday's testimony and discussion, it is clear that there are many different perceptions of what is needed, and why we do what we now do, does not exist.
I think that it is necessary to have a clear cut understanding by both the payers and the providers on what we are trying to accomplish, and each must accommodate the other, I think, to make this successful.
I think that we now use the concept of claim attachments to control hidden agendas. I think that we use the ambiguity of what is requested to exercise some level of control.
Paper forms are static and I think we are now going into a transition in which we are using electronic forms that are dynamic.
I think we need to look at what happened on the Internet with HTML, and recognizing that we started out with static forms.
As people began to use it very quickly, we are finding out a number of ways of dynamically altering these forms. I think we need to take that under advice.
We now support a number of multiple data bases. Most institutions will probably have a financial data base that is separate and different from the clinical data base.
Then on top of this there are research data bases. And in addition to those categories we have different groups of people, such as public health, state requirements and others, that have copies of the same data bases, but these are all created independent.
At least at Duke, I can assure you that there is a difference between what is contained in the financial data base and what is contained within the clinical data base.
There is always a loss of information in the translation, and there is also the loss of information due to the different timing delays between the creation of those data bases.
I think in what you do for the future, it is extremely important to recognize that we need one data model, that we derive both the reimbursement as well as the clinical care off the same data model.
I think it is too expensive to try to maintain multiple models, and my experience has been that everything that we charge for is legitimately part and parcel, and is part of the clinical record itself.
One comment on confidentiality and privacy, I think that one of the things we need to recognize is that we don't always need to know the identity of the patient to be able to do what we need to do with the patient data.
As long as a computer knows how to link a patient with a particular care plan and a particular reimburser, then the person who is actually reviewing that claim does not need to know the identity of that person and where that person lives and other characteristics. I think we can solve some of those kinds of problems.
In closing, I would say that HL7 is committed to working with X12N and the combined group of the claim attachment SIG.
We have committed a time line that is very rapid to define the messages and the segments and create the data elements that support the claim attachment.
I am excited about this process. I think that my first recommendation to this group is that there needs to be a clearly stated directive that this framework that has been proposed as part of the proof of concept presentation is the way that things are going to be done.
If you don't do that, what you are going to do is, everybody is going to sit down and have a wait and see attitude.
You are going to have other things that are beginning to happen. So, I think independent -- I think this point was made maybe by Clem -- I think independent of legislation that requires this to be implemented across the board at some period of time, if we clearly define what is going to happen, you will find a number of people beginning to make the commitment to make that happen.
Furthermore, I think that what is proposed can very easily be turned into componentized software at an upperware level, in which you can find gateways, if you will, that will interface between systems that are overwhelmed by the year 2000 problems, taking that data from there, accommodating what is being proposed by the claim attachments.
I think some other requirements are necessary before what is proposed will work. The first thing is, I think it is absolutely necessary to clearly define what is required, to validate the appropriateness of health care and what will be reimbursed.
My view of the current system is that we view reimbursement as more of an art than a science, and the circumstances of what actually is done in terms of the approved set of charges, is a function of the individual that reviews those charges, moreso than what actually happened is inappropriate. I think we need to move more and more in that particular direction.
The payers appear to be afraid of clearly defining what is required to justify reimbursement for fear that the providers will catch on.
I am naive enough to believe that that is exactly what we really want to happen if we are going to eliminate the games that are being played between the other organizations.
I think that we need to make sure that all the experts now participate. I think the significance of what is proposed as part of the proof of concept project is the fact that there is a proposed framework that is generic in the sense of the detail that is contained within that framework.
The point was made yesterday that this was an evolutionary process. When we first start out, the system is going to have lots of problems.
One of the things that should happen, that should evolve out of that, since you are forcing everybody to go back and reexamine all the detailed components, is that you will learn what is important and what is not important.
Over a short period of time, I think you will be able to get a standard that has an adequate set of stability.
I think finally that we need to recognize that this process will take place over a period of time. We need to recognize the fact that there are delays in terms of creating concepts and ultimate implementation of that concept.
We need to recognize that those delays occur in a period of time in which technology is changing at an absolutely unbelievable rate.
The point has been made in terms of HL7's use by small providers. I think what is critical to note is that, one, the HL7 standard itself is capable of accommodating the exchange of data that small providers need, that most of the clinical commercial systems that provide a computer-based patient record for small providers are HL7 compliant.
To me it is an awful lot like color television and now high density television. When do you buy a color television?
You didn't buy it as long as there was only one program that came in in color every night. So, you have got to get this balance where it is worth my while to do it.
I think one of the exciting things about what is proposed in terms of the accommodation of claim attachments is the fact that this may be the added incentive that will make it now profitable for small providers as well as large providers to begin to capture this data electronically.
I find it interesting that the motivation for doing this is the fact that we think it will save money, both for payers and for providers.
So, we need to recognize that part of what we are doing is to spend some money to get there. Buying a car is one of the most difficult task that I face. It usually takes me two years to do it because I don't know where that transition occurs.
At some point I spend the extra money to do that and I think that is what we are faced with in this particular case.
We can't define a system based on what is, but what we need to do is base it on a system of what we need, what will be, and I think that will provide the incentive to get there.
MS. NERSISI: I am Jean Nersisi, director of the Office of Electronic Medical Systems at the American Medical Association and secretary of the National Uniform Claim Committee. It is my pleasure to appear today on behalf of the NUCC.
In response to the question regarding the definition of a claim versus an attachment, the NUCC would define a claim as the submission of information by a provider or covered person to establish that health care services were provider.
The submission may be made either electronically or on paper to a third party payer.
The claim includes a request for payment or reimbursement to the provider or covered person.
An attachment would be other information that may be included by the provider at the time of the claim submission to provide further supporting details, or additional information that is requested by the payer prior to the claim being adjudicated.
In response to the question related to differentiating information that is appropriate for the claim versus information that is appropriate for the claim attachments, the NUCC believes that a non-institutional health care claim and equivalent encounter information should be based on the uniform minimum/maximum data set.
The data set should be equivalent across all products, contracts and government programs. The data set should also include a limited set of additional data elements intended to serve as replacements for attachments, for example, additional information to specify any extenuating circumstances, or justifications that may assist the payer in the review.
In addition, the data set should standardized optional or statutorily required elements.
The NUCC further believes that the number of attachments required should be reduced. The process for handling attachments should be improved and the data required on an attachment should be clarified.
In addition, the NUCC believes that the non-institutional uniform data set and associated attachments requirements should constitute the data required by any public or private payer to process a claim.
In response to the question regarding what types of claims attachments and formats are requested, payer representatives to the NUCC have stated that they ask for a variety of information in order to adjudicate a claim.
Some of this information can be found in the patient's medical record, such as operative notes, test results, reports, et cetera.
Government payers also request information using standard forms to reflect patient consent, medical necessity, duration of drugs, et cetera.
Some of the requests require administrative billing and clinical content, such as ambulance claims, outpatient rehab, emergency room reports and records, referrals, EOBs, et cetera.
Also, payers look for information on supplies such as drugs and duration, or supplies and their price.
Payers also request information about contradictions on the claim, such as seemingly incorrect coding and information to substantiate claims, such as certificate documentations and assignment of benefits information.
The method of requesting and receiving this information depends upon the relationship a payer has with the provider and their technological capabilities.
Some providers are also able to receive and respond to these requests electronically.
Payers also request and receive information from providers via the mail, fax and telephone systems.
In response to the questions related to the purpose of the attachments, from the NUCC perspective, attachments serve many purposes.
Payers may request additional information to determine medical necessity. Some attachments are required for contractual arrangements or government mandates.
Attachments are sometimes used for internal audits, such as pre- or post-adjudication review, and requests for information may also be made because of a dollar threshold on a patient's plan.
Additional information may often be requested if there are concerns regarding possibly fraudulent claims.
Information may also be collected in order to help the state rate settings and to determine cost benefit analyses.
Payers may also request attachments to manage changes in care patterns as a result of the additional data.
Regardless of whether claims are received on paper or electronically, many must be reviewed manually. According to a 1996 report of a survey conducted by the Health Insurance Association of America, 18 percent of claims are pended for one of several reasons, including coordination of benefits, cost containment purposes, and other reasons.
They may also be pended for inadequate data on the claim form, which may initiate the request for attachments.
The data suggests that, in addition to standardizing the transaction protocol and claim forms, the minimum maximum data requirements must apply to all payers and providers and cover both paper and electronic transactions.
In response to the question related to the process that would be aided by standardization, the NUCC believes that standardization and electronic exchange of attachment information could reduce the workload for all the key parties affected by the health care electronic data interchange, those at either end of the health care transaction, generally the payers and the providers.
It is essential, however, that the types of requests for information, the expected content and the format be standardized.
This means that the types of requests and the corresponding data elements need to be defined and then these parameters should constitute the data required by any public or private payer to process a claim.
For the question related to the process not conducive to standardization, the members of the NUCC have indicated that there are many proprietary systems for attachments in use today.
There are also many mandates by public payers, at both the state and federal level, that may be difficult to standardize.
Standardization may be even more difficult in the private sector, where contractual provisions vary across and within specific companies.
Some NUCC members have acknowledged that another aspect inhibiting standardization is the fact that providers are at various levels of electronic capability, and that it may be too cost prohibitive for many of them to purchase new equipment in order to handle the requests for attachments in a standardized format.
Given the fact that providers are using thousands of different versions of clinical and administrative software systems, and that the percentage of electronic medical systems remains very low, the standardization of claim attachments information should be limited to a well defined set of possible attachments.
Automation of clinical data will occur at different rates throughout the health care industry. Larger health care delivery systems, such as hospitals, integrated health networks and managed care settings, will continue to lead the trend in automation.
This trend will occur slower in the ambulatory setting, with the larger practices automating first.
All of these factors must be considered when defining the requirements and developing the standards.
Therefore, in order for administrative simplification to be realized, the claims transactions must consist of a uniform data content. The claims data set should include a limited set of additional data elements intended to serve as replacements for some attachments.
The data requirements outside the claim need to be limited to a defined number, and the payers must standardize their processing methods.
In response to the question regarding the relationship between claims attachments and the medical record, the NUCC believes that claim attachments, as specified in HIPAA, are not synonymous with the patient medical record or detailed clinical information, although some attachment information may be derived from a patient's medical record.
The NUCC is fully supportive of ongoing efforts to develop standards for computer-based patient records. However, the NUCC believes this is an issue which is most appropriately viewed as largely separate from the insurance transactions currently being considered, and beyond the specific mandates of HIPAA administrative simplification.
For the question related to the request for medical records, the NUCC payer representatives have stated that they may require the entire record in certain circumstances, if the entire record is necessary to adjudicate the claim.
However, the provider may send the entire record along with the claim without such requests in order to expedite the payment of the claim.
If the entire record is requested, only the information necessary to adjudicate the claim should be extracted and confidentiality safeguards must be assured.
In response to the organizations responsible for the content of the claim attachments, the NUCC believes that there should be an organization other than those entities currently responsible for the development of the messaging transactions, responsible for managing the content of claims attachment transactions.
As a general principle, the development and the maintenance of the content and the messaging architecture are two distinct roles. Although the functions must be coordinated, they should remain independent of each other.
It is logical that the organizations responsible for claims data content and similar HIPAA transactions are also responsible for the claim attachments content.
These organizations should be formally representative of all parties affected by health care EDI, such as providers, payers, standard development organizations, and regulatory agencies.
Based on their structure and current and anticipated responsibilities, the NUCC and the NUBC are fully appropriate to assume this responsibility.
The NUCC has an official operating protocol that addresses modifications to claims data content. This protocol provides full due process, open meetings, and the ability of non-members to generate agenda items.
It is being revised to broaden the parties represented on the NUCC, and to address the need for an additional appeals process.
Fundamentally, data content should be maintained through committees like the NUCC and the NUBC that focus on formal representation of key parties to the transaction for which they are responsible, by using a consensus approach to decision making.
Data content maintenance is an activity that should be conducted through the kind of public/private partnership that these two committees exemplify, and not viewed as a primarily technical communications standard.
The NUCC recently coordinated a meeting with all of the content committees pertinent to the HIPAA transactions, the NUCC, NUBC, ADA and NCPDP, to discuss future coordination activities.
Although some individual committee members participate on more than one committee, it was agreed that data sets must be coordinated and that the committees must work closely to this end. Thank you for the opportunity to present the NUCC's perspective on critical issues associated with administrative simplification.
DR. LUMPKIN: Thank you.
MR. OWENS: My name is Bob Owens, I am associate executive director, information technology, and chief information officer of the American Dental Association. It is my pleasure to appear again today.
I am just going to go through. You have my brief statement. I am just going to go through and highlight some of the key factors in ADA's position as content person, if you will.
As Dr. Rosa's testimony stated yesterday, we have as a strategic goal the elimination for the need for claim attachments.
If we are going to get to an interactive world, which we hope we will get to very quickly in dentistry, it is our intent to be able to online adjudicate the claim, similar to Dr. Lumpkin's comments earlier relative to claim information and attachment information exchange, if you will, to do that online, real time, and to have adjudication immediate.
There are about 30 percent of the dentists today that have a claims processing system, period. In today's world, a very smaller, probably a much smaller number than that, zero to the thirty percent that we talked about yesterday are the claim attachment related.
The fact that we will find in dentistry is that claim attachments do not assist in the adjudication generally. All they do is really add cost to the claim filing.
Those different payers that have done studies that went to no attachments for a period of time, other than for some financial impact on their bottom line relative to faster pay, there really hasn't been any real negative benefit as far as fraud or non-payment of claims for more information, if you will.
If you have to have attachments in this interim process, some guidelines need to be looked at from the content perspective.
Payers need to be required to pay all claims. If a provider is able to meet and satisfy the need for information, there should be no second guessing. There should be no additional pending or bits and pieces. It shouldn't be piecemeal.
If you need additional information, then state what that is. When we satisfy that, then we expect payment, not this back and forth stuff.
It should be, again, very specific, not I need a doctor's notes, or I need dentist's notes. Define what doctor or dentist notes or hygienist notes really mean. Get that down to the very specifics so that we can provide that.
It should be, again, without exception. If you look at the paths in the ADA, we have become the source of dental information for the profession of dentistry.
We have done this through surveys, focused clinical studies and electronic capture of data. We have become the best source, typically, for public health and other similar information requirements.
That is usually based on the existing claim transaction or what is in the claim currently. Again, we are a very simplified operation when it comes to collecting information.
If you want to look long term at what we can do to improve the pool of data, it is the clinical medical record.
Clearly, that is the direction that we are again looking to go to. Our practice management vendors have already started with a very good base of clinical systems.
We have made significant progress in the development of a clinical record, computerized health record. In fact, we will probably be there very shortly.
We anticipate that this record, when it is implemented, will be in fact the best source for clinically related dental information.
Again, keeping those two needs separate, we recognize that there is a need for public health and other types of clinically based information.
When we talk about basically doing services and adjudicating the claim, those are two very different pieces for us.
Since clinical claims and other types of patient data is created or generated from the provider, providers really should have the leading role in determining the data content.
Privacy and confidentiality of patient data should take precedent over any possible uses of the data. Again, if you start looking at the identifiers and you start passing those identifiers very quickly, the record will start to unravel and you will be able to go to patient-specific information.
We are uniquely positioned as a professional organization. We are representing 74 percent of the practicing dentists in the United States.
It is also important to note that we are also an ANSI accredited standards organization in certain areas, and we provide content for both the national and international standard-setting activities.
In fact, we have been doing that in the ANSI world for over 30 years and, for the rest of organized dentistry, far longer than that.
We provide industry access, and basically we have an open environment. If you have information or requests, bring it to us and we will try to accommodate that.
We have appropriate representation, try to maintain and ensure that the different segments of the marketplace are appropriately represented, timely development, keep costs disciplined, coordination.
It is not our intent to develop all standards internally at the ADA. In fact, we develop the content and go and participate in a lot of organizations, such as X12, and SNOMED and the like. So, we are very active in getting our information content together and then going out to the different standards organizations to do that.
We do that for all of organized dentistry's needs and information content.
It is our experience that if you are going to have meaningful standards and business processes, you have got to begin with the most responsible for creating the information.
In an organization such as ours, that is flexible enough to meet changing demands and has a fundamental principle of stewardship, if we look at what we are required to do as dentistry, we are not required to dictate. We are simply stewards of the information and are required to be able to coordinate across what is the industry, what is truly best for organized dentistry as a whole.
We believe that our proven ability to develop the content puts us in the best position to facilitate content development activities, and our responsibility as stewards of organized dentistry requires it.
Given that, our number one goal would be no claims attachments. However, if we can't get there, clearly our position is that the ADA is the best organization responsible there to coordinate the content. Thank you, again, for the opportunity.
DR. LUMPKIN: Thank you for capping off our discussion. Questions?
MS. FYFFE: Thanks for the presentations. First of all, I have a question for Ed Hammond. I would like to comment that a couple of decades ago, I was a student in one of Ed's lectures at Duke, and he hasn't changed a bit. Neither have I.
DR. HAMMOND: What grade did you get?
MS. FYFFE: Ed, you said something that I didn't quite follow. You were talking about the Internet and HTML and dynamic forms.
You used some sort of analogy but it sort of went past me. Perhaps you could elaborate on that.
DR. HAMMOND: A part of it may be the definition of claims and claim attachments. We have heard a number of people say that they would like to eliminate claim attachments.
My interpretation of what they really mean is the fact that they would like the claim itself to be dynamic, to really address what is specifically needed.
This was the analogy that I was trying to use, in terms of the dynamic pages, that what we send contained within a particular claim is algorithmically or dynamically derived from what is required to validate the claim, so that it is not separate; it is part and parcel.
DR. LUMPKIN: I get the feeling that in this process it is kind of like -- I think it is for one of the sport utility vehicles there is this commercial where the guy goes in the vehicle and starts driving and this voice in the sky booms and says, go further.
Then a little while later the voice says, go further, and he is about ready to go off a waterfall and it says, too far.
I think many providers think that is kind of the way we see claim attachments. We just don't know what to send. Then when we send a lot, it is too much.
DR. BRAITHWAITE: I gather from the discussion and this panel that we shouldn't try to set up the NUAC. We should stick with the NUBC and the NUCC and the ADA and all those other alphabet soup things.
In a previous panel there was an indication that maybe we should go to the NUDC and kind of integrate all of this stuff from the various content committees.
I know you all have your own sort of bailiwicks here. But how do you feel about the need to more closely integrate, if not form sort of one data content committee.
MR. OWENS: We have looked at that. Again, looking at what we do is very different from what you have typically in the physician area or the institution area.
It doesn't mean that they don't have to be coordinated and we don't get together periodically to ensure that we do have coordination.
As far as organized dentistry is concerned, we find it imperative that we develop and get the content together for dentistry, and then work with the various groups.
They are not just the other content folks. They are all the different standards organizations, not just in here in the United States for HIPAA, but internationally across the world, to make sure that dental standards in general do have a level of consistency throughout the world.
From that standpoint, we feel very strongly that we should be coordinating but not part of a supergroup. We have enough of those in the industry today.
DR. NERSISI: The NUCC pulled all the groups together to discuss this issue. Each of the individual groups were looking at somehow the transactions need to be coordinated, the data sets need to be coordinated.
However, right now they serve such different functions, so it probably wouldn't be necessary at this point in time to have any kind of a formal structure, but to continue to work together in that way, and also set up some joint committees.
You have to remember that the people who are chairing some of these committees probably aren't the ones that are actually involved in the subcommittee work.
As far as pulling together an actual overall structure, we felt that the work would be best done at the subcommittee type level with the joint working groups working together.
DR. HAMMOND: I think one of the observations I had is if you look at ICD-IX, it turned out that there is also an ICD-IX for orthopedics and there is an ICD-IX for oncology.
There is overlap and there is some conflict in the process of doing that, and then there is some new value in this.
What I am concerned about is that we are trying to solve a lot of our problems in a piecemeal fashion. I think the opportunity has been made available to us to really try to do this across the board.
The comment earlier on whether the computer based patient record, and what is derived from the claims attachment, to me the answer to that question is an obvious yes, simply because I define the computer based patient record as what I need to do to handle the whole process of health care.
The source of that data is the person who knows the answer to the question of where they put it in.
I think the same thing is really true here. What you are faced with is groups that exist with a focus on a particular piece of the problem itself.
To change from that structure into a different structure in which a lot of this is consolidated together is, I think, a very difficult task. It may be impossible to do.
Insofar as possible, I think what we really need to do is to bring these groups together. I think electronically it is a lot easier than it was before the existence of that, in such a way that we do harmonize and create a single product that accommodates all the groups.
Anybody working in the seams between these groups has an easy answer to their question.
DR. ARGES: Actually, about two years ago I wrote a paper for the AHA, the American Hospital Association, on basically creating a national uniform data committee, with the express purpose of kind of bringing this all together.
At the December NUBC meeting we also kind of discussed that option again. There was a lot of interest by the members of the committees to kind of pursue that, basically to hold a summit.
I think we met the following week at the AMA offices with the ADA and in conference with the NCPDP.
I think this is evolutionary rather than revolutionary and that we are going to have to learn to walk before we can start running in this process; actually, probably crawl first.
I do think eventually the outgrowth will lead us toward that pathway.
DR. MC DONALD: Jean, I want to direct this toward you. You made a comment or an assertion that what we have to do is define the -- firstly, I think everyone has said, get rid of attachments or minimize them, and I can support that.
We have to define them and then set minimums maximums on the variables included in them. You also said paper or electronic.
I would like to just kind of reinforce that. The principal work that is needed is not message standards. It is really what is the semantic content that we are trying to get across and boiling it down to a minimum.
Now, having said that, I was thinking that you would be much more positive about some organization that charged ahead and made that happen.
This is very difficult and it is probably almost -- it may be impossible for some committees as they are constructed.
You have the senior leadership of an organization who don't know squat -- not in general, but in the specific of how to do these semantics. I am sorry. It has gone out on the net, and it is too late to pull that one back.
They aren't the people who know how to fashion these kinds of things, and you end up with what we see on the forms now, which is not meaningful at a certain level except by local lore.
I don't know how to get beyond that, but that still is a critical area.
Now, the other side, to make this more possible, as we heard the huge number of questions and all these attachments, there aren't hundreds. There are probably only 10 major form-like attachments. They only have 30 or so questions on them.
It is really a realizable task, if you have the right group in the room, to make a straw person -- a straw man, I don't know how you say that any more.
DR. LUMPKIN: If you are going to kick it, it is probably a straw man.
DR. MC DONALD: Get a proposal and then get it revised by these committees and the leadership. They won't do the homework and don't know the tactics to make these straw proposals.
I don't think that is an impossible task. I think that could be done in a number of months with the right kind of energy on it.
Then you have the other kinds of things, which are sort of like any lab test or any note, which have a different set of problems, but on the one hand, those codes kind of exist.
Given that we want to constrain attachments, maybe those aren't issues so much. But I would still like to see a way that we get toward, let's take the top 10. Some of the ones in the pilot project that are listed as items aren't really single form attachments.
There are maybe five or six. Actually, a couple of them, a handful are already done in X12. We may not have that much work to do. If we focus on what work has to be done -- you know, we could have endless meetings.
I guess that may be good for the people who want this to progress, but --
MS. NERSISI: Could I just respond? The proof of concept project that has been initiated, the NUCC is very supportive of what has been happening.
In fact, at the March meeting, the NUCC will discuss how they want to participate formally with this POC.
In the discussion that they had at the January meeting, members felt that what really needs to be done, that would be a process or a method for sending attachments or, in the future, clinical information.
What really needs to be defined are those, let's say, the questions that will be sent from the payer to the provider, and the possible attachments that will be sent back.
That is what needs to be defined, these policy types of questions, and that is how the NUCC, I think, will want to participate.
DR. MC DONALD: When they are needed and when they are not?
MS. NERSISI: Exactly.
MR. ARGES: The purpose for when you collect them, why you collect them.
MS. NERSISI: Exactly.
MR. ARGES: One of my concerns is that a lot of the requests for information basically involve utilization review.
The problem is that there aren't any utilization review standards. So, you have this gamut of playing the documentation end game where I will keep asking until you can't provide and I can deny. That to me is just not where we ought to be.
DR. LUMPKIN: No value statement there. Simon?
DR. COHN: Perhaps this is slightly off point from what we have just been talking about, but I am struck that, especially as I listen to some of the discussions around minimum maximum data sets and all of this other thing, that we have a very complex 837 transaction currently.
The reason it is complex is because it has lots of attachments in it already and people have already gotten to the table, have already stuck their stuff into it as an option.
In a sense, the 837 has lots of pieces in it. Recognizing that there are a number of people at the table here, who have some view of the 837, if you had a preference of how we handle this other data that we are talking about, recognizing it sort of by definition and attachments of one sort or another, does it make more sense to try to somehow enlarge the 837 standard, and make it bigger are more complex?
Are we really taking the right tack in moving off toward an attachment? Thoughts from the panel?
MR. OWENS: Looking at the 837 as it is currently constructed, there is a paperwork segment that if you are looking at just attaching a binary file or an X-ray, you could do that physically today.
The issue is that when you look at what is information that you need to adjudicate a claim, that is something totally different.
So, do you want to keep it separate? I guess first you have to define what is the information that you need, and then determine is that an attachment separate. Is it electronically tied to that original claim or not.
You know, again going back to dentistry, we have already gone through and set up all the varying committees. We have had discussions of attachments at the highest levels, including the ADA board of trustees.
From our perspective, we kind of know what we want long term in attachments. Obviously it is nothing, but we also look at realistically if we have to put some information together, what is the information that it needs to be in order to get collected as it is defined by the payers.
From that perspective, we don't sit at the ADA and say, this is yet another attachment standard. We physically go and participate in the X12 organization to ensure that the 837 houses everything that is necessary to adjudicate a claim.
We are also physically participating in the X12 group in the joint HL7 work group relative to attachments, to ensure that any information that is relative to dentistry is, in fact, reviewed appropriately and controlled appropriately for content.
MS. NERSISI: The 837, the monster transaction as we have been calling it, includes a lot of data elements that were probably put into the 837 because of specific needs, and they are probably typically attachments.
The NUCC data set maps to the 837, and it probably covers about two thirds of the data elements that are in there.
The NUCC data set includes a few elements that wouldn't probably be defined specifically as a claim, but includes some additional thing, ways to send additional information. Like we talked about the EPO yesterday. That would be included.
The rest of the 837 is designed to be able to send certain types of attachments. I guess what I think should be done, since there is a lot of business that may be done currently today using that current transaction -- I know a lot of the Medicare business currently uses, for instance, some of the additional elements that are included in the 837 -- I think those things should be identified.
Maybe eventually they should be considered not used in the 837. There could be some kind of a sunset date, and then a new methodology used to send that.
I think you are always going to have the case where the claim will include this, and this supporting information should be included along with that claim, and that could be --
DR. MC DONALD: The question you are asking, should you expand the 837, nobody has really said yes or no.
MS. NERSISI: No, you should not expand it.
DR. MC DONALD: Okay.
MR. OWENS: As hard as it is to complete a claim, leave the information in there necessary to adjudicate a claim, period.
Now, if you need clinical information for other purposes outside of that, that is a whole different transaction and a whole different approach that should be used.
DR. LUMPKIN: You have to understand that he drills down to the issue from the dental point of view. We got that the short answer is no.
MR. HAMMOND: The problem is that words never mean what we want them to mean. What I hear everybody answer is in a very compartmentalized way.
We think 837 and we think claim attachments. I think that the payer industry has probably been give a bit of a disservice in not being able to respond to the fact that everybody wants to get of claim attachments.
I think that is a compartmentalized thinking. What I think would be interesting to find out is whether there is need to have supporting data along with part of a claim for reimbursement.
Whatever you then create to accommodate that is a different matter. But I think you need to face the raw issue here of what is it that you are trying to do and what is the justification for doing it and is it justified.
I think it is justified for them to ask for a little more data than a vanilla submission of a claim.
MR. ARGES: Could I answer that? I think the requests should always be considered by the committees. I also think that part of the problem has been that the payers have not really come before these committees to a great extent to make the request.
They have gone outside and around it. In basically nine years that I have basically been involved with the NUBC, I have seen maybe two commercial requests, and the rest basically HCFA requests or Medicaid requests of CHAMPUS requests for data.
DR. LUMPKIN: Let me clarify and redefine the question. The question is, if we make the assumption that there are legitimate business reasons for payers to request additional information that is considered to be within the realm of that information that is collected by the provider, should that be, as has been historically, added to 837, or should it be someplace else.
What I heard you say it, it should not be added to 837.
MR. ARGES: No, 837 is really a transportation vehicle, if you will, to carry the information. It really ought to be the committees, like the four of us, basically, evaluating whether it needs to be part of the claim data set.
That claim data set can be rolled into the 837 as a transport vehicle.
DR. LUMPKIN: So, you are saying that as long as it does meet external review and is accepted as being a valid piece of data to be carried, then it should be rolled into the 837.
MR. ARGES: It will be identified in the 837 instructions for carrying purposes, yes.
MR. OWENS: As long as it is part of the claim. If you are asking for non-claim-related information -- if you are asking for non-claim-related information for like public health or other clinical type of activities, non-administrative information, that is different than saying if you want to adjudicate a claim, all the information necessary to adjudicate a claim should be in the claim transaction.
DR. LUMPKIN: I am confused. You first seemed to be saying no, now you are saying yes with all the caveats.
Let's say that I am a payer and I cover for laparoscopes for A but I don't cover for B. It is legitimate for me to ask you why did you do that. That is not going to be covered under the procedure code. I need some additional information.
Is that going to be in an 837 or is that going to be in an attachment.
Let's suppose that we have adjudicated that process through the various committees and, yes, that is a legitimate question to ask. Where would you want to see it?
MR. HAMMOND: To me the question is whether you send them before or after. I mean, if you send them at the same time, then to me it is unimportant as to whether you call it an 837 plus an attachment or not, or whether you add another field to 837 and put that in. I think electronically you have got that freedom.
I think the real question is whether it is sent as part of the claim itself or sent in response to a query.
DR. MC DONALD: I would like to clarify. The attachment as it is conceptualized at large in the field is not defined by whether it comes later. You can send it along with 837. That is not really the defining issue.
What I got a sense from the industrial people on all sides, is that they would like to pare down the claim. They have come up with this name, the monster transaction, the mother of monsters or something. So, that suggests something.
They would like to make it simpler and more fitting to the typical claim, and have some general mechanism to deal with these other things.
Now, there is a separate thread that is saying kill claims. I buy that, but it doesn't really kill claims to say, okay, we are going to put another 500 questions the provider has to answer for every claim.
That is not going to help the business, by just jamming everything into it. That is sort of the sentiment I have gotten.
MS. NERSISI: I guess I would like to comment on it. The content committee should be the group that decides on if the request is legitimate.
Then it is the technical committees that would decide where that would fit best, whether it would fit in the 275 or the 837, or whether it is already in the 837.
What needs to be defined is what are those requests, and that they need to be standardized and the same questions be asked by all the payers.
MR. ARGES: From a provider perspective I would have to say, are there variables there that would allow you, the payer, to be able to abstract from the information I am giving you to make payment.
My answer would be, if the variables are there, if it is a laparoscopy of some code, or a HCPDP code available or an ICD-IX code available that would help you evaluate whether you can make a differentiation between one payment versus another. That would be the driving factor.
If it is something that you want me to calculate, what your reimbursement method ought to be -- in other words, do the calculation for you -- then we might say no.
MR. OWENS: Going back to the 837, when the 837 was originally developed, it couldn't even accommodate Medicare or HCFA 1500 claims. It could not do that in its first iteration.
So, anyone who went to X12 and offered this bit of information be added, that information be added, to me it is not a monster. It is a very logically defined document.
You just need to know how to work through that, and that is what the implementation guide is for.
If you look at the certifications that were added in there, you look at the procedures and the diagnosis and the numbers of those and you very logically go through them, it is like once that information has been sent to you, the fact that it is not sent on an operative report, the fact that it is not sent on a lab report should be immaterial.
Again, when you talk about whether that information be on the 837 or should it be as a separate attachment, a lot of that information may already be in the 837, but it is not presented in the exact manner that replicates paper.
I think when we started developing the original 837, what we did is we took the UB82, the HCFA 1500, and the electronic versions of those documents, and basically tried to copy them.
I think what we have here now is an opportunity to look at the business process and define what it is that we specifically need to do for a claim.
What is it that we specifically need for additional information to adjudicate that claim, and come up with the best electronic process to meet that, versus trying to replicate a paper environment.
Those are the differences that you have and that is why a lot of people think this is the monster out of control.
MR. ZUBELDIA: I have been working on the 837 since 1989. I am probably one of the grandfathers of 837. I started working on it from the very beginning. So, let me give you a little bit of history of why we did all that stuff, and maybe Barry can help me here.
DR. LUMPKIN: Actually, we are over schedule, so if you could keep your comments relatively --
MR. ZUBELDIA: I will keep them very short. The main reason why all that stuff is in the 837 is so it can be processed by the adjudication system in one shot.
There is, today, on adjudication system that can take a claim as a supplemental to a claim that has been filed before.
If you can process all the attachments with the original claim, then they belong in the 837.
If you need them later, the adjudication systems today will have to get them in a different transactions. If it comes on another claim identical to the previous one, but with more attachments, it is going to reject as a duplicate claim.
That is purely how the business systems work today. I am not saying that is perfect, but that is how they work today.
If you were to design the 837 again from scratch, you would pull all the attachments out of it and build adjudication systems that can take supplemental transactions to a base claim transaction.
That is how we built the interactive claim transaction. I am now co-chairing the interactive claim transaction. It has 15 segments, only 15 segments.
Until two months ago, it did not have a loop. Now it has a loop because the international community wanted to put a loop in it.
It has only claim information that can be adjudicated in real time. If it needs some attachment, it cannot be real time and therefore it does not belong there.
So, the business processes that drive these transactions are totally different. In the case of the 837, it is very complex, because we are trying to process it in a batch mode, one shot, rather than request response mode, which would be more appropriate for an interactive claim.
DR. LUMPKIN: So, what you are saying is that if the information is separated from the basic claim by time, then it needs to be something other than 837.
MR. ZUBELDIA: That is correct.
DR. LUMPKIN: If we determine up front that the information is needed, that it ought to be embedded as some intelligence, whether it be through a coding system or some additional field, as part of the 837, or looped at part of the 837.
MR. ZUBELDIA: That is correct.
DR. LUMPKIN: Is that a fair summary of what we are hearing?
DR. MC DONALD: I don't think so. I don't think it is time to discuss it now. He said something more there than that.
DR. LUMPKIN: Okay, thank you.
MR. MAYES: Since I work for an organization that is probably the one that has gotten the most fields put on this specifically, one of the things that we are finding internally is that the kind of questions we are asking -- you know, it is interesting, because we all keep talking about just a field.
That is one of the problems we are struggling with, is that we can no longer get what we need out of a single field. Yet, we are always constantly trying to fit it into a new field.
When you talk about adjudication of claims, there is the actual payment for that particular claim, but we use all that information for setting payment policy.
Now, that is an extension, if you will. It is still financial. It is not clinical. It is not even quality of care -- to a certain extent it is.
So, I think that is probably not unique to HCFA but probably all the large payers are beginning to struggle -- certainly the managed care plans with there is a lot of information that you need to set sound fiscal policy, if you will, and payment, which is an extension of the claims process but it is not just this is all I need to pay provider A's claim.
So, it is a struggle. I don't have the answer. Bob brought up the EPO hematocrit issue yesterday. We have others, with the adequacy of dialysis, there are a lot of issues that come up internally.
To say, well, do we stick something in the claim or do we go another route because we don't think we can get enough information out of a single field in the claim, but nobody is going to let us go in and put five or six or seven or eight fields about this one thing, I think we have to be careful when we talk about, what do you need to adjudicate a claim.
I think it is a little bit more complex in terms of setting payment policy and other things.
MR. BARR: One of the things I tried to repeat to you is that this issue was brought up at the last X12 meeting a week ago, where there was a two-hour meeting to discuss the migration of data from the 837 to the 275, and whether data should be in the 275 or the 837.
There was a form discussed at a meeting the next night where the three 837 co-chairs -- David Marley, the representative from the X12 -- met with the people working on the 275, where we discussed a form, how to develop the migration of data, if it should be migrated, out of the 837 to the 275, whether it should be left in the 837.
There has been a plan developed where there will be meetings at every X12 meeting now to discuss this migration, and whether the data elements should be considered one data element at a time or they should be maintained in the 837 or the 275.
That is an issue for the 827 work groups. Yes, the data content people have been put to that, and I really appreciate that.
It is the 837 people who do the transaction, who really have an embodying light to really determine whether it belongs in the claim or the 275.
DR. STARFIELD: I have a question about sort of new information, and if there is a quick answer, give it to me and, if not, we will develop another way of getting it.
Another subcommittee of the National Committee on Vital and Health Statistics is dealing with information, clinical information, from other types of settings -- long-term care, home care, mental health settings and stuff like that.
Are all the things that we have been talking about the last two days relevant to those, or do we have to think about whole new systems, in the context of claims attachments for those kinds of settings?
MR. ARGES: I think it is relevant. I do think, though, that I wouldn't necessarily categorize them as claim attachments.
I do think that they may be other transaction that may need development. Whether they are an attachment to another transaction or whether they are independent transactions, I think they need to be established. I think there might be a specific purpose and place for them.
DR. MC DONALD: We sometimes get very constrained. There is a whole set of transactions that are flowing right now that have nothing to do with claims or claims attachments that have clinical data in them.
HL7 is sending all kinds of stuff around. That is a different and a similar subject, I guess is a short answer.
MR. OWENS: Just a comment. The 275 transaction is not a claim attachment transaction. It is a patient information transaction.
To the extent that you require any patient information, that would be the same transaction used. There is also lab reporting transactions within X12. Certainly if there was a specific transaction -- at one point we had an HMO reporting transaction that was actually led by a government agency.
After two years or three years, actually, of no interest we disbanded that work group for lack of interest.
Certainly if there are other informational needs required, X12 would obviously be ready to develop the appropriate standard, if it didn't already exist.
DR. LUMPKIN: According to my quick conference back here, an encounter, that would be reported using the 837.
MR. OWENS: That is correct.
MS. FYFFE: According to the law, it is health claim or provider encounter information.
MR. OWENS: Right.
DR. COHN: We haven't talked about that in the last two days.
MS. FYFFE: No, we haven't.
DR. LUMPKIN: But there is another use for 837 other than to pay a bill.
DR. MC DONALD: It is 10 to 1:00. I just want to know when we are going to schedule coming back from lunch. You were aiming for 1:00, I think.
DR. LUMPKIN: Yes. Actually, we were just wrapping up. I was about ready to suggest that we come back at -- I don't think we will be able to make it back by 1:00. I think we will have to shoot for 1:30.
DR. MC DONALD: Why don't we do 1:15?
DR. LUMPKIN: Can we bring our food down here? So, why don't we bring our food down here and shoot for 1:15, or as close to it as we can. Thank you.
(Whereupon, at 12:45 p.m., the meeting was recessed, to reconvene at 1:15 p.m., that same day.)
DR. LUMPKIN: We want to cover four issues, some in more depth than the others, this afternoon, before we adjourn.
The first is to kind of recap our discussion that we have had here today on claim attachments. As part of that, determine -- my best guess on time frames, that if we are talking about an NPRM in October, that we need to have something to bring before the full committee at the June meeting.
MR. BARR: The NPRM is due from me in August. October was the first date, but it has now been pushed back to August. So, I have to have something to start beginning writing, way before August.
DR. LUMPKIN: So, we need to get something to the full committee at the June meeting. So, we need to talk about that.
The second is we need to have some preliminary discussion on the computerized patient record. We are scheduled to have, or we are planning to have our first hearing on that in the fall.
Maybe we can define a little bit what we intend to do, maybe some thoughts we want to put together before then.
MS. GREENBERG: Also, John, there is supposed to be an initial panel at the March NCVHS meeting.
DR. LUMPKIN: Oh, yes, okay. Who is invited? I was closing down that Twinkie factory when you guys discussed that.
DR. BRAITHWAITE: We were thinking about, since it is just a preliminary sort of knowledge thing, that we might invite the institutes that are working in this area, to give us kind of overviews, like the CPRI and the MRI and perhaps the NLM and the VA, DOD consortium that is working on the government CPR, anyone else we could think of.
MS. GREENBERG: Some of the Davies award winners.
DR. BRAITHWAITE: This is just one panel.
DR. MC DONALD: You are talking about non-profits; right, when you were listing all the things?
MR. BLAIR: Could we perhaps get the chair of the IOM committee to present?
MS. FYFFE: Are we going to have any vendors who actually have up and running computerized patient record systems?
DR. LUMPKIN: I think that would be good.
DR. COHN: Real ones or planned?
MS. FYFFE: They have to at least be through beta tests.
DR. MC DONALD: This is just a preliminary.
DR. BRAITHWAITE: This is a preliminary. We are talking about an hour-and-a-half panel.
MS. FYFFE: That is really not enough.
DR. LUMPKIN: I think this is just let's get ourselves thinking about it. We have been talking all along about having a full two days in the fall, for this subcommittee/work group.
DR. BRAITHWAITE: Then maybe there would be some vendors with some real installations to talk about by then.
DR. MC DONALD: My only thought is that this is such a complex subject area.
DR. LUMPKIN: We are just reviewing the agenda.
DR. MC DONALD: For March?
DR. LUMPKIN: No, today. Actually, we got sidetracked; I apologize. The third item -- then we are going to come back to it. We are going to spend a few minutes on it, but not right now.
The third item is that we need to have some brief discussion on our role once -- and I have heard rumors to this effect, that this is going to happen -- that once the NPRMs on all the other stuff that we have already talked about, like 837s and all those other transactions -- once those are published, there will be a comment period.
So, we need to have some discussion of what the role of the committee should be during that process.
Then finally, just a brief informational point for the committee, which will also be at the March meeting -- maybe I will just leave it until then. Never mind. That will be the last item.
DR. COHN: A secret that you don't want to tell us.
DR. LUMPKIN: No, this is a discussion on quality, but I think we will have that at the March meeting in the subcommittee?
MS. GREENBERG: We are actually having another panel at the March meeting on the underlying quality of the data to look at quality of care, with the idea that there would be a panel or a discussion on actual quality of care.
DR. LUMPKIN: We will cover this last one. The executive committee is looking at the issue of the role of the national committee in relationship to quality, given that the President's Commission on Quality has made the recommendations and they have sort of gone out of business.
MS. GREENBERG: I think they don't want to go out of business.
DR. LUMPKIN: Maybe they don't want to go out of business. But anyway, I have been asked to chair a working something or other, a small committee, and discussing this already with Lisa on the committee.
So, if there are other people who are on the committee who are interested in being involved in these discussions, just let me know.
Those of you with puzzled looks because you can't quite figure out what this is, you can help unpuzzle the rest of the committee as we try to redefine the issue.
Certainly there are significant information and data-related issues in the quality movement that is occurring in health care, and the measurement of quality.
MS. FYFFE: Did an official request come down from somewhere that, because the President's Commission on Quality is over, the work wasn't finished and now we are going to carry on or what is the scope of what we are supposed to do.
DR. LUMPKIN: We are to define what, if any, role we as a committee believe we should play, which is different.
MS. FYFFE: This is beyond data?
DR. LUMPKIN: No.
MS. GREENBERG: It is the relationship to data.
DR. LUMPKIN: No, this is self initiated.
MS. FYFFE: Oh, this is self initiated.
DR. LUMPKIN: You guys haven't asked us yet but maybe you should, we think, but we are not sure, so we have got to think about it some more.
MS. FYFFE: It is part of the charter of this group.
DR. MC DONALD: I have got to leave a little early. I hope we can spend some time on the actual content that we have already got under our belt, before we talk too much about what we might add.
This is coming up at the next meeting. I wonder if we could get back to the substance of what we are going to do at -- you said two things. The NPRMs are going to come out in the comments.
I guess I would like to know from Bill, does the committee automatically get to review sort of the final versions that are adjusted by the comments?
If not, Kathy Frawley and I last night were talking. She thought it was a good idea that we have some look at it, in case it got completely changed around.
DR. LUMPKIN: We are going to do that as the third item on our agenda. We are actually taking the last item first because it is just an announcement and request for names. Then we are going to go back to the first item, which is on attachments.
DR. MC DONALD: Bill almost had a chance to answer that question, except that he had popcorn in his mouth.
DR. BRAITHWAITE: You will get a copy of the finals.
DR. MC DONALD: Is that the same as we get a chance to comment on it?
DR. BRAITHWAITE: You mean before it is final?
DR. MC DONALD: Yes, we make recommendations and then comments come in and it could get completely changed around.
We would at least like to take our names off it if it gets changed around the wrong way. It could get kind of wacko; not likely.
DR. BRAITHWAITE: Your name is on the recommendations that went to the Secretary. Your name is not on the --
DR. MC DONALD: Oh, you already took them off.
DR. BRAITHWAITE: Your name is not on the final, but you will get a chance to comment on the final, along with everybody else.
DR. LUMPKIN: That is what we are going to discuss on the third item. First, on the attachments, if we are going to make some sort of recommendation to the full committee in June, what do we think we need to do to get ready to do that, between now and then?
DR. STARFIELD: The question is, do we have enough information now to make a recommendation or do we need to do more?
DR. LUMPKIN: Yes, or do we need to do more hearings.
DR. COHN: I don't think we need more hearings, but I think we probably need to get a coherent internal perspective.
DR. MC DONALD: We need some time to discuss and I would worry if there was no time allocated at the March 3rd or 4th time that we could discuss the issues and dimensions that we should comment on, even.
DR. LUMPKIN: Do we have a work group meeting scheduled in March?
MS. GREENBERG: Well, we have subcommittee breakouts, although those at the executive subcommittee meeting did not feel that they wanted long breakouts. I think they said only an hour, but I think I will make them longer eventually, but under two hours.
DR. LUMPKIN: Is there something scheduled the night between the two days?
MS. GREENBERG: I did not recommend setting up an evening meeting.
DR. MC DONALD: Let's go at it another way. We probably need three or four hours, I think, to thrash out and get a coherent common view.
MS. GREENBERG: Well, if it starts at 3:30, I think I would just recommend going to 6:30.
DR. MC DONALD: So, it would be the last time slot.
MS. GREENBERG: It is the last time slot for the first afternoon. Right now it says like 3:30 to 5:00, but you could go longer.
MR. BLAIR: This would be on the 3rd, the night of the 3rd. What time will we be starting on the 2nd?
MS. GREENBERG: I don't think that has been set.
MR. BLAIR: I heard that some of the people are coming up, and it takes me an hour and a half to get down here. If it is 9:30, then I might be able to fly up that morning.
MS. GREENBERG: I think we can say that probably 9:30 is reasonable, given that people are coming from various directions.
DR. MC DONALD: Is there any way to plead for earlier than 3:30? What will happen is, especially if there are people living in Virginia, or wherever you are going to be staying -- regardless, people's stomachs start to compete with thought at around 5:30.
DR. LUMPKIN: The difficulty is that we really have a meeting that has quite a full agenda with a number of panels.
MS. GREENBERG: It is a tight agenda. The executive subcommittee basically laid out what they wanted. As I said, I personally felt that this subcommittee would need longer, but also by setting it up at the end of the day, it could go.
DR. MC DONALD: Are we meeting here?
MS. GREENBERG: Yes.
DR. MC DONALD: Can we bring sandwiches in? Does the place close? What will happen is everyone will quit at 5:45 and we will probably start late.
DR. LUMPKIN: Do they deliver pizza? We will work on it.
MS. GREENBERG: We can discuss it afterwards.
DR. LUMPKIN: We could also go early the next morning and start early, for that matter, if we need to go early.
DR. MC DONALD: Listen, I am the only one that matters to.
MS. GREENBERG: Do you really think the 3:30 to 6:30, that people wouldn't just stay?
DR. MC DONALD: I think it is a bad set of hours to deal with complicated issues. That may be all we have.
DR. COHN: I will buy, Clem, that we need to do that and I will agree with you. I don't think that I have come to great clarity out of the last two days of meeting.
I guess as part of that, though, I would wonder if there are things that we can think of to do between now and then that will help with the clarification process.
My own belief is that we are going to need to have some more hearings about this. I think just in terms of due diligence it is very apparent to me that when we talked about X12 we had lots of different people and lots of different interests being represented talking about the X12 transactions.
In a sense, we are here talking about HL7 and LOINC and other things without really a due diligence exercise to make sure that those are really the way people want this to go.
So, that becomes part of it, but I think there is a lot to be done before that. So, I guess the question is what, over the next couple of weeks, do we do.
DR. MC DONALD: How do we get more hearings in between now and when the stuff has got to get written?
DR. COHN: Let's decide that in March, but let's figure out what we need to do between now and March.
MS. GREENBERG: If you actually think you want to have a meeting before the June meeting, we need to start polling for dates immediately. We can't wait until March.
DR. LUMPKIN: The first thing to do is to define what it is that we think we need to hear. That will give us some better position of deciding whether or not we need to do hearings or whether we may need to try to get that information in some other format.
MR. BLAIR: I think the first question I have is what is our scope. Can we recommend process and procedure as well as technical standards.
DR. LUMPKIN: That we can probably answer here. So, we will come back to that one. Are there other things that we need to hear outside of this group?
MS. FYFFE: What I was going to suggest, just for logistical purposes, is that on March 2 or 3 we spend two hours trying to frame exactly what the questions are and what the scope is.
That would certainly be enough time for April hearings if you go ahead and schedule the April hearings and then go ahead and let the people know what the questions are going to be the first week in March.
DR. STARFIELD: Why can't we do that this afternoon?
DR. LUMPKIN: The difficulty is not coming up with the questions. The difficulty is scheduling the time and beginning the process of arranging for speakers and trying to fit that all within the busy schedule that the committee has.
That is the reason why we really need to process and determine whether or not we are going to do that. That has to be done today.
We could -- I think it really is more functional if we decide what it is that we need to hear, and then use that as a basis for whether or not hearings may be the best way to achieve that, or some other mechanism.
MR. BARR: I kind of agree -- we talked this over during lunch. We kind of agree with Simon's statement. This concept is so radical that we have already gone through the X12 process and heard the X12 transaction end.
Now, for the first time, we are talking about utilizing HL7 and LOINC code messaging and we are making a very big leap from what is actually being used in industry, and making a lot of assumptions.
What I have heard in two days -- and I am part of the proof of concept -- I am not sure that, one, the industry is agreeing or not agreeing or that HL7 is the way to go or LOINC is the only way to go.
I think that we don't have, or have not received input from the major payers in the country, the Aetnas and the Prudentials.
The major payers have not been here to testify, and a lot of providers have not been here to testify whether or not they can utilize this technology and this scheme that we are suggesting.
I think to make a rational decision and a very valid decision, I think you would have to have, as bad as it would be, another set of hearings, where you bring those kinds of people to the table and have them discuss these issues.
Really, the concept is so radical that I think you need this kind of input.
DR. LUMPKIN: I echo that. I think I am a little bit more comfortable on the provider side because I think basically they do mostly paper right now anyway.
I am a little bit concerned that we don't understand, even just to get down to the scope and other issues, where the payers are, and why they need this and how open they are to an implied standard, which we haven't addressed.
I am not sure that we have authority to, but it seems some standardization on claims adjudication processes would be an important one, and perhaps to ask them where they are in that.
DR. COHN: I was going to comment that as I listened to the testimony, both yesterday and today, I came away feeling really that the payers were going to be the affected group in this one, much more than anything else that we have talked about.
The providers either choose to send things by paper or continue to do, whatever, all that stuff. They can stay in a paper mode with all of this.
What we identify as a standard, the payers have to be prepared to accept that. Now it feels very different from the other things we have done, since they have all been the same, but most of that stuff is already being handled electronically. I think I really need to be querying them in a very specific and active way.
DR. MC DONALD: I feel sort of turned around, in the sense that I thought the legislation said that we have to come up with some kind of a proposal for attachment standards.
Now, what you are saying is that we are going to ask whether anybody wants an attachment standard. Is that right, would they be willing to accept the standard, is what I think you just said.
DR. COHN: No, I actually didn't say whether they would accept, but I think we need their input because they are going to be the most affected group in relationship to the standard, at least the way I was analyzing it.
DR. MC DONALD: Okay, again, this is really Steve's issue, but what in the heck are we going to get done by August if we don't figure out how to change the direction they are going now, today.
I mean, we are on a schedule that is almost impossible as it stands. Now we are going to sort of start over, is what I am hearing, and see what they really want.
I think we either ought to get real honest about it and say, shut down, you guys, don't spend so much time on this until we get a clearer read on where we are going.
I personally am on this committee. I don't want to spend a lot of time on it if it is not going to get --
DR. COHN: Let me make a comment, because I actually don't think that I saw this was a fishing expedition, sort of saying, in your heart of hearts, what would you like in the world in the next few years.
It is more, there is this proposal coming down the road. What do you think. I think that is a very different discussion.
DR. MC DONALD: The words you used were a little different the first time.
MR. BLAIR: I may be trying to close the gap, if I can, between what I am hearing here. What I think Simon was trying to get to -- maybe I shouldn't speak for you here -- I think what a lot of the testimony was telling us is that we may do an absolutely perfect job technically, in coming up with the best job we could for defining the claim transactions.
If we don't also do something to find out what it is going to take to bind the payers to limiting their requests to the standards that we are defining, that they are going to go around the system and we are going to wind up with a set of standards that really aren't reducing a lot of the transaction volumes.
At least that is what I thought I was hearing and I didn't know whether it is within the scope of our committee to start looking at what it might take to get agreement from the employers to agree to use these standards and not go around and create new claim attachments or new requests for information. That is kind of my scope question.
DR. LUMPKIN: I would argue that our charge is that we use standards to achieve administrative simplification, and that our goal is administrative simplification, not standards.
Part of this process that we have been hearing about requires -- I mean, we could probably achieve significant administrative simplification without electronic standards for data interchange related to attachments.
None of these things will be achieved if the payers aren't willing to go along and resolve this problem. We don't really understand, I think, their issues at this point.
DR. MC DONALD: Let me retract my concerns about the hearings -- not so much the concerns, but the time frames.
I think that it is a known fact that the payers will not want to restrict themselves to questions. I have been at enough meetings hearing people talking spontaneously.
This is the way they can get an edge on the economics of the game. So, that is not going to be news. The question is, would we push forward, as the law says, with some kind of a proposal that is constrained enough -- which I really think is what we should be worried about.
How can we constrain it enough that we will be willing to give it a run, and not try to send photo images and some of the most difficult things.
Cut it down to a couple of things that look like they have promise, recognize that the promise may be greatest to big institutions and not providers at the beginning.
I heard a lot of concerns in the testimony today of many kinds.
DR. COHN: Clem, I actually wanted to agree with you. As I look at this, this is an issue of what I would describe as outliers.
By definition, the claim attachments should be the main body of information needed, and every additional piece, question or whatever is obviously not part of the standard transaction, or the previously known standard transaction.
DR. LUMPKIN: Can I clarify? Did you mean the claim or the claim or the claim attachment?
DR. COHN: I meant the claim. The claim is sort of what should be done routinely. Then other things are beyond, what I would describe as outliers.
If we can divide up that outlier area and take 40 or 50 percent of it and structure it in a way that could be automated or otherwise, we haven't solved the 100 percent problem.
We haven't solved answering every question and constraining everyone, but maybe we have reduced the number of things that can be automated by 50 or 60 percent which I think is, Clem, what you are talking about. I think there is a great strategy to advance in this area.
MS. FYFFE: A very gross analogy, if everyone will indulge me. Asking payers to strictly define the types of information they need is analogous to asking providers the types of questions they are going to ask patients.
There is a lot that is unknown. There is a lot of judgement and there is financial risk. That is my only comment.
MR. ZUBELDIA: Maybe hearing it from this side of the table sounds a little different from the other side. I would like to maybe recommend that the committee takes a phased-in approach instead of making standards for attachments year one.
Year one, you go for the low hanging fruit, which is the attachments that can be sent in the 837 that are true attachments. They are not requests for additional information.
Sending them or standardizing them doesn't break anybody's system, doesn't force payers to have new business methods to deal with attachments electronically.
Then in subsequent years you go after standard requests for additional information and standard other transactions that are not in the 837 that will require other business processes.
I think that at first to do a year 2000 plus attachments with the brand new business functionality that they are going to need to process those attachments coming in on a separate transaction, it is very difficult.
I think the mandate to have standard electronic attachments can be fulfilled by standardizing the attachments that can be sent in an 837, including electronic explanation of benefits, or coordination of benefits. That is just a suggestion.
DR. STARFIELD: That was sort of a variant of what I want to say. Basically there are two things that we have to deal with in claim attachments. One is the what questions and the other is the why questions. The what questions are what was done and the other is the why questions, which is clinical logic, which we will be a long time getting automated.
Now, in the what questions are the two kinds that Kathy just mentioned. There are the kinds that can be dealt with in the existing system, and the others are not.
I think that we have to, as a committee, sort of decide that we will not be able to deal with the why questions and just give those up.
Even with the computerized patient question we will never get at the why of the clinical logic. We will do better than we are now.
DR. LUMPKIN: Not automatically.
DR. STARFIELD: Not automatically.
DR. LUMPKIN: You were shaking your head.
MR. BARR: I am shaking my head when it comes to the fact that your proposals will utilize the attachments that already exist in the 837.
The attachments that already exist in the 837 are not data that is being requested by other payers to supplement the claim.
It already comes in as part of the claims set. If it wasn't needed, then they would not have a need for attachment data.
The people who ask for attachment data today cannot get the information off the 837. That is the reason why the payers today come in and ask for all of this information.
So, what have you solved? You have just solved the fact that you have a way to submit the same data you have today. Now all the other information that is in this country that is 50,000 forms and 50,000 versions is going to continue to come in by paper.
So, you have automated a process that is in existence today and that is not a buy off in helping the country.
DR. COHN: First of all, I agree with your comments. This thing will not be improved and we will be facing the same problem in the year 2001, unless we are really looking forward a little bit further.
Now, I don't want to see this effort slow down. I do want to make sure that the discussions are more than the people around this room.
If you were to hold a hearing sometime in April, what would you have to bring to the table that would be something that would provide some substance and might be able to reassure people or at least show them, as opposed to it being an idea.
I know I am speaking up and eating up your time frame here. When would we need to have a hearing that would be useful in terms of the process?
MR. BARR: I guess there are two problems regarding time frames. I am under a mandate to have an NPRM done by August 1998.
If you think about that mandate that I am given, I am already behind the time, because we haven't put pen to paper as yet.
A lot of the information we can take out of existing regulations, but there is this process of explaining what we are doing that has to be done.
Anything beyond April would be way too late for me. I would have to have it at least by April.
One of the things we could do, my only concern -- and the same concern I mentioned this morning -- is when you mention the word claim in this country, everybody runs to the table and wants to hear about their claim because they think that is the way they are going to get paid, and that is the most important thing in their minds.
When you mention the word attachment, people just close their ears and say, it doesn't affect me. I don't care.
One of the questions we asked was how do we get outreach. I think if you bring the big payers into a forum, whether you bring them into sort of an open forum or some kind of a meeting, and have them logically explain to you what they really do on attachments, and what the process really is, and explain again the process we are going through with this standard and what we are proposing ahead of time, maybe they can give us some input into whether they think it is a rational process or not.
The April deadline is just because after that we are already going to be testing the proof of concept the way we are scheduled to do it. We will already be in the testing phase.
To stop and go back and restart, we could never have any testing done by August 1998. What we hope to do is at least prove, for the first set of transactions, because there is no testing of any other transaction, that the concept works and it is a feasible concept and it is rationale. We will prove that doing the proof of concept.
DR. LUMPKIN: Let me just sort of toss in a couple of two cents into the process. I think the reason why this is so important, if you were to sit in the physician's lounge at Little Company of Mary Hospital, which is right outside the City of Chicago, and you were to listen to the kinds of issues that clinicians are raising, billing and those kinds of transactions are given. They have done those for years.
Where they are seeing increased administrative burden are related to attachments. The amount of requests that they are getting for additional information -- not just related to the bill, but related to the policy issues, related to quality of care -- is just stifling.
If, in fact, we believe that we want to have an impact in the clinical care arena by trying to simplify the process, then we need to begin to scratch where it itches.
All the work that we are going to do, that we have done, is really just a small portion.
We had testimony here today that what is being seen, at least in California and in a number of other scenes, is that there is a trend toward fewer electronic submissions, because many of the companies that are coming on are small, are new, and aren't accepting them.
I am just urging us to, in our agenda -- and this problem will not be solved just looking at one end of it. We really need to, in some way, figure out a way to get the payers to the table and to begin to have some discussion about what it is that they are looking for, and how they are trying to address the issue of getting their hands around it, which is not just the issue of is this bill legitimate.
It is not just a fraud issue. They are trying to look at quality. They are trying to justify to the purchasers of care what they are trying to do.
One company could have 700 different product because each purchaser says, well, I only want this in my package.
So, they have to make a determination, is this person eligible. If it is not in the attachment, it is going to be on the eligibility form. It is going to be someplace else. We really need to rationalize this system, and that, I think, is our charge.
DR. MC DONALD: I guess I am going other-worldly at the moment. The payers have been the most present in this whole process all along.
The committee is made up of payers and me. That is what it is. I am the only token provider on the committee.
We had a meeting in Chicago with 40 people, or 50 or 60, of which it was still mostly payers. There is a known phenomenon. Kathleen said it. They need this freedom.
The question is, if the AMA and the other groups of players said, we want to have a defined set and we want to constrain it and we want to be able to anticipate it, and that makes sense to me.
The other side of it is, we want to be free and open. This isn't going to change.
We have to decide whether we have to go forward and do something or not. If we have to go forward and do something, I would like to see us talking about what are those issues that would make them comfortable with the direction they are going, and how could this be tailored or tapered or slowed down or whatever, to get somewhere.
There aren't a lot of choices in the general context. LOINC, schmoink, you could use any code you want to make up. They are just numbers. It doesn't have anything to do with the issues at all, except that there are a bunch of them out there for labs and a bunch of codes. It doesn't have anything to do with the fundamental issue.
HL7, the thing says that we have to do ANSI standards. You are not going to be able to go and make up a whole new standard to send clinical data. That is what the vendors have, at least inside the bigger institutions where there is clinical data.
So, then the question is how can we reduce the anxiety and do this in stages to make it better. I don't know that having hearings with more payers is going to help any because the payers have been the only ones actively involved.
The first big day we had a bunch of providers speaking up and they said, control it. Now, Kathleen, can we actually imagine a world that the payers can live with. If they can't, then the whole thing is moot; some constraints.
MR. MAYES: Let me suggest that we not narrow our focus too much. Even in the existing NPRMs that will be out soon -- any day now -- we have taken a variety of approaches, and I will point to the security NPRM.
In the security NPRM we don't specify specific technology to retrieve what we want. It is really very much of a performance oriented or policy-type procedure.
I would posit that we can actually take a very similar approach, given the extremely short time frames, with this whole claim attachments question.
I think that you sort of hit it on the head, Clem. I would focus, at least initially, on beginning to discuss the issue of standardizing which questions are asked. What makes a particular attachment, and trying to develop a mechanism that says, every time we have a group, a special setting, whether it is the ambulance report or the operative reports or whatever, what is the mechanism that we can get the interested parties together and determine what is the minimum data set, if you will.
That doesn't mean that we can't continue to explore the technological ways of implementing that. Frankly, I think something like XML is going to completely change much of what we are talking about anyway, in terms of whether we go with the 277 or that sort of thing.
I mean, there are new technologies coming on line that in three or four years, or five years, we are going to wind up changing the technical parts of the standard anyway.
I guess what I am saying is, if we have a very short time frame, I think you could meet the mandate under Kennedy-Kassenbaum for promulgating standards by addressing it from a relatively technology-independent point of view, at least initially, and saying, you know, the phase I -- this sort of has to do with what Clem was talking about -- phase I, let's just sort of define what we mean by standards.
That is actually part of what you guys are doing right now. You have taken 14 or 16 or 19, however you count them up and say, okay, we are going to try to combine all the different variations we see on this currently, see what are the core elements in all of those, put those forward as a straw standard, if you will, and then make sure that no one else comes running in and says, no, you absolutely have to have this other element you dropped out.
Some of those you might, in fact, find. Maybe you can incorporate them into the current 837 with some modification.
That doesn't mean, though, that you can't also recognize that no, that route isn't going to work all the way. You just can't expand it out. I think we heard that.
Meanwhile, we have got to work out the technical aspects of how you do that.
I just think that gives us a long way down the road to solving what, as John pointed out, is truly what we are trying to get at, which is administrative simplification, not the introduction of technologies or computers in every doctor's office or whatever, but how do we make things more efficient so that we can put more of our resources toward patient care.
I would just recommend that a phased approach focused initially on process, it doesn't mean that we have to stop work on the technical aspects or the proof of concept, but it allows us to do something meaningful within the extremely short time frame that we are now faced with, in trying to get some language out for regulation in six months.
MS. FYFFE: I think the questions that payers would ask providers are really -- tomorrow's questions really depend on the iterations in the marketplace
I think there are really three themes. One of them has to do with the increased emphasis on fraud and abuse. That is going to continue for a while.
The other theme is cost control. The third theme is quality, but that is not only a payer issue. As payers and providers become one -- and they are beginning to become one in some parts of the market, then they are a provider issue as well, the quality aspects of it.
I am a little bit mystified as to why we are talking about not having the major payers here, when you had some pretty big payers here on Monday.
United Health Care, which bought out Travelers, Empire Blue Cross and Blue Shield --
DR. LUMPKIN: They were not here.
MS. FYFFE: Principal Health Care.
DR. LUMPKIN: That was the working group.
DR. STARFIELD: Of the three you mentioned -- fraud and abuse, cost control and quality -- where does the whole issue of justifiability for payment -- that is, the benefit package -- come into that. Is that under fraud and abuse or where is that?
MS. FYFFE: I am not sure I understand your question.
DR. STARFIELD: The whole scope of benefits. That is a big thing about payment. You know, you are doing something. Is it covered by the benefits. That is a big part of the claim attachments. Where does that come in?
It is not justifiability. It is just, you know, are we allowed to pay you for it.
MS. FYFFE: How the benefits are defined varies widely according to contract and, of course, by state law and, unfortunately in the future, perhaps by federal law.
DR. MC DONALD: We have got one conundrum. What the providers want is a fixed, defined list.
MS. FYFFE: No way.
DR. MC DONALD: It is real clear and it makes sense. What the payers want is no fixed and defined list. If we can't solve that -- I have got to leave anyway, and I am not walking out because of this -- but if we can't solve that, the whole thing is silly. They want the opposite things.
DR. LUMPKIN: No, but I don't think those are necessarily mutually exclusive.
DR. MC DONALD: It sounded like to me they were.
DR. LUMPKIN: If there is some agreement with how certain information will be submitted --
DR. MC DONALD: It is not the how. They want the what; am I right or am I wrong?
MS. FYFFE: You can't have the what.
DR. MC DONALD: So, what can we say? What question are you going to ask and when.
MS. FYFFE: It is gray. It is not black and white. This is not a binary world.
DR. LUMPKIN: For instance, the proof of concept, I think, gets to a certain defined set. What I don't think we have a good handle on are the economics of the provision of care.
At some point we need to know, as the requests for information increase, is it cheaper in the front end, if you are a provider, to just give them everything when you have got the chart in front of you, or is it more expensive to get out the specific afterward, when you have to find the chart, find the record and figure out what things were.
If we can reach some middle ground where we take into account the economics in the care delivery site, and the economics at the payer site -- let me site a real concrete example.
Operative notes. In our current system operative notes, by and large, in my experience, are all dictated. People don't sit down and type them. They don't write them.
If they are dictated, somewhere they are already converted into some electronic format, because almost nobody uses a typewriter any more.
That operative note could be, from what I understand and what I heard today, could be attached as part of the 837 claim as a little ASCI file, rolled into there, and the company can decide whether or not to look at it.
If you build that into the current systems, you may have resolved a big chunk of the attachment problem with no additional work on the front end by the providers, because they already have it in some electronic means, and no additional work by the payers, because they can choose what to look at and what not to look at.
You have eliminated probably a good chunk, 90 percent of the paperwork that is associated with operative claims.
Those are the kinds of solutions that I would suggest we begin to look at.
DR. MC DONALD: That is what we are looking at. The attachment issue, whether it is pre- or post-, is irrelevant to this whole design.
It doesn't have anything to do -- the attachment is defined as that bin thing either place. That is exactly what we are looking at.
DR. LUMPKIN: That is great. Those are the kinds of issues. But we need to ask the payers. In a sense, there are some payers that I think they represent a certain spectrum.
My question is -- and really, if we can get the right folks here -- we need to talk to utilization review folks and some of the folks on the medical clinical side and say, here is what we are hearing from some of the other folks. What do you really need. Can you work with this kind of system.
That may not necessarily work at a hearing. It may be by directing questions in a letter or document to some of those folks, because they are less likely, because it doesn't deal with claims, it deals with attachments, to want to participate in a hearing.
MR. BARR: Either way we go, I mean, the question becomes, if you need additional hearings or additional data, I guess we need a recommendation from you whether we should continue going down the path that we are going.
Any delay in the path we are going makes the existence of an NPRM -- it is not generic. If I was a provider and you gave me an NPRM on attachments that is complicated and is only generic in context, I question the validity of a generic NPRM on attachments.
It is not security. This is a claims-related information and the claim 837 is this big and it is considered the mother of all transactions.
You don't make the data that falls out of that a generic transaction. If I am a provider, I want to know what is in this transaction and how it is utilized and what it is really meant to be.
MS. GILFOY: I would like to support what Bob said earlier, and I think in deference to the gentleman here who has been working diligently on the project.
I think what the providers were saying and what I am saying is, when we need to know the what, what we need to know is what kind of information is going to be needed by the payer.
We need to make sure that we are going to collect it. John, you said that if I have to go and find the chart later and I have to then review the chart and I have to do all those kinds of things, then I have lost all of this time.
If I know ahead of time what the payer is going to ask me, then I can make sure that I collect that information in a format that is electronically transmittable.
As I heard the discussion yesterday, you have already got that information. You have reviewed, what was it, 16 different attachments and you know primarily the questions and you have looked at them from some tremendous number of payers.
You know the questions, so you have a historical perspective on the what that is going to be required in a claim attachment.
I would like to support Bob and ask you to not specifically look at the technology that is going to be required to electronically required to transmit this information, but first and foremost, to look at the information that needs to be transmittable.
Then we can work on what the technology is. This technology is changing so dramatically, and the instruments that we need to effect this technology is changing hourly, virtually.
To tie ourselves at this point in time to a technology, to something that is so completely different, what I am afraid that we would wind up doing is automating a paper form, which is what we don't want to do.
If we can just take a look at what information historically the payers have asked for, then we can go back to our systems and see, do we have this information.
If we don't have it, then let's look at least so we can get it. Then that solves your problem of having to go back and do a chart review.
MR. BARR: If I may respond to that, one of the problems is you are talking about making a policy decision for every payer in the country for the attachment.
This group was not chartered to make a policy decision on what questions were asked of the entire health care payer community.
We were told to automate attachments. That is another issue, completely outside the realm of the attachment arena.
DR. COHN: That is why we have the reg process. What we are going to put in the NPRM is exactly what we are going to propose.
If that is incomplete or inadequate, we are going to hear back from those major payers and those major provider groups, that these things are missing. That is what I would expect in the comments.
DR. LUMPKIN: To take that further, though, to the extent that we set an electronically accessible set of questions, then the payer is going to have to make the determination, is that additional question worth it to get out of the electronic world and into the paper world. Hopefully they will make the conclusion that, no, it is not.
MR. BARR: That is what we hope to do. We hope to identify the 16 attachments, those data elements contained in the 16 attachments, how the process would work, identify those questions.
If the payer or provider has a question, they can come to us and say, point blank, we looked at your ambulance attachment, but you left out these pertinent questions, or this doesn't address our needs.
You know, we made a lot of assumptions based on a constrained set of data. We don't know if we have all the answers, but the only forum we have now to get input is the NPRM.
MS. GILFOY: I would suggest to you that the minute you publish something or you put it out on the web site, that you will have enough payers who would be beating down your door to say I need this information.
At that point, you can expand on the whats, but don't focus on the technology. That is all that I am suggesting.
MR. MAYES: Just briefly to follow up on that and also to address an issue that you brought up, Kathleen, one, I think that taking the approach that John just said in terms of here is a set of commonly-asked question, and the 80/20 rule or whatever, and then put it on the payer to decide whether it is worth the effort of going outside that envelope is a good idea.
Also, I think if we go back to looking at the ambulance report that Steve put up there, we don't even ask the questions when we commonly agree on the questions the same way.
Many of the elements, many of the issues -- distance, weight -- every one of those things could be much more clearly defined.
This isn't even an argument of is this all the questions I could ask. This is the argument, hey, everybody asks these questions. Yet, there is no way of knowing whether, when you ask for distance, whether you mean the same thing as when I ask for distance.
I think there is a lot of standardization that could take place without necessarily constraining the potential universe of questions that could possibly be asked.
I don't think you even have to go the route of saying these are the only 15 questions you can ever ask on an ambulance trip. But at least, here are the 15 most common questions asked, and here is, by common agreement, what we mean by each of these questions.
It would, again, get us a long way down the road of administrative simplification. Again, like you said, it is not a black or white or an either/or. I just think that, given the very short time frame, if we focus on things that actually have the most value added and put the least burden on existing systems, we will gain the kind of support we need to then move to the next step, which is really the integration with a full computer-based health record.
DR. COHN: I just want to make a comment. I am trying to think whether it is a follow up to what Bob just said or whether I may be saying the same thing but just in a slightly different way.
As I am listening to what is going on, I am hearing a couple of themes coming out that we need to be somehow dealing with over the next several months.
One is what I am hearing -- I am sorry Helene -- but I am really hearing a need for a proof of concept. There really does need to be a fundamental, despite the we shouldn't look at the technology, it needs to work.
We know that we need the wrapper and we need something in the wrapper and all of this stuff. Now, ambulance or whatever might be an appropriate thing to be inside that wrapper.
I also heard from you, Steve, yesterday -- and I think this maybe was a concern for me -- this whole issue of I guess ownership, development and maintenance of these attachments and who is responsible for it.
To me, this was yesterday the fundamental issue of all of this, in the sense that I am a little less clear in my own mind who is really responsible for development and maintenance of the electronic version of the emergency medical record, or you name it, Workers Comp attachment or whatever. I have to think about that.
I would certainly like to hear from some of the affected parties about what they think about all of this. Somehow this feels a little more intrusive into some areas that aren't traditionally X12 areas, for example.
I would like to sort of be hearing about some of those data issues and ownership.
DR. LUMPKIN: Let me just clarify what you just said. If you define the attachment for the emergency department, you define the emergency department record.
DR. COHN: That is my belief.
DR. LUMPKIN: Which now has clinical implications for people who are treating folks, much more than anything else we have done.
DR. COHN: Exactly, and that sort of begins to reference back to an earlier discussion we had about like who owns all the data. We began to talk about that some this morning in some of the hearings, that was sort of an aside.
We began to talk about talking about that a couple of months ago. Somehow that has gotten sort of off the agenda and we need to begin to roll in on this.
Claim attachments are an issue. Similarly, the 837, the institution, non-institutional claim and on and on and on about how all that data gets managed and all of this, that somehow feels that it is part and parcel of some of this discussion that needs to begin to occur.
What I was hearing from you, John, is a comment about really administrative simplification, which is to my mind, yes, agreement on asking the right questions.
Also, rather than having to get the questions asked three weeks after you have sent the report out, you have to go back to the file room and find the stuff and package it up and send it out or whatever.
Maybe you can get some agreements, opportunistically, from vendors and others, however that may happen, on how you might package some opportunistic attachment pieces with 837 pieces and get it out in a way that really does support streamlining of some of these processes, and maybe that is another area that we should look at.
Those are the things I was hearing. Maybe there is something else that I am missing, but it seems like there are opportunities in each of those to try to get some work done.
Some of it is definitely yours, Steve. I think some of the stuff around ownership is really something that we need to wade into.
We certainly need to start asking vendors and others about some of these opportunistic pieces, that if they had this at the time, maybe everything would work better; just a thought.
DR. LUMPKIN: I hear, from what Simon just said, that you listed three things that we have. One is for proof of concept and we have a proof of concept team, so I am not sure that we need to go any further in that way, other than to perhaps, as a committee, say go forth.
I think it is a worthy venture if we think that is the way to go and let's see where it runs.
The second issue, which is -- I am saying that, and stop me if someone disagrees, that that is probably not something that we need to do a hearing on.
DR. STARFIELD: You need to do it soon, though.
DR. COHN: The hearing, once they have something, to sort of expose it and ask others.
DR. LUMPKIN: Right, which would be in a different time frame. I think that that may be something that understanding that the proof of concept and hearing about the results of that are not going to jive with our charge of making a recommendation to HHS within the time frame of coming out with an NPRM.
We are talking about the results of that coming out in August.
MR. BARR: Yes.
DR. LUMPKIN: The NPRM is in August. What about the proof of concept?
MR. BARR: We start testing in March or April. We were going to run it through October, but we are going to take the data that we have before August and use that as the determination of whether that works or does not work.
DR. STARFIELD: But that is a process that you are testing. What we are doing is endorsing the process as a way of getting at simplification.
DR. LUMPKIN: It might be of value for us, sometime in the fall, to look at the lessons learned during the proof of concept, given our longer range perspective of that.
I don't see that there is a way for us to be involved, except for Clem, who is our liaison, to the -- what is the title of that working group -- the claim attachments team, work group, the special interest group, proof of concept team, depending on which work group it is? The claim attachments implementation team.
So, Clem will be our liaison to that, so we will have some input to those discussion and some review of those internal discussion.
As a committee, I don't see any other organized way to be involved with evaluating the proof of concept in relationship to the NPRM.
DR. COHN: Maybe I am confused. I actually thought -- I don't think our responsibility is to evaluate their work. I do think we need to provide an important role to get input on what others think of the process that is going on, once they have an attachment to begin to show.
DR. LUMPKIN: Or a recommendation that the way we are going is the way -- that is the only feasible way to go at the present time, considering the pace and the time frames we have to go.
Right or wrong, I think as it was mentioned by Bob, when we publish it in the NPRM, we will get the entire industry input, payer, provider, vendor, who will tell us right or wrong, what we have done is acceptable or not.
MR. BARR: I suspect that if we make recommendations in June they probably will not be specific. They will be more general.
MS. GREENBERG: Although if there are some results by June from the proof of concept, we can certainly make time during the June meeting for the subcommittee to hear those and react to them and determine if something else needs to be done.
BARR: If you would like, we could give you a status or an update or whatever you would like at the June meeting, to tell you what we have done from this date until your June meeting, to give you additional data that may be helpful for you to make your decision.
MR. BLAIR: Maybe I don't understand. I thought in the notice of proposed rule making, that the recommendations that Bob Mayes and Helene Gilfoy were giving us, that what we should come forth with is the set of questions that happened to be in the proof of concept.
It is the set of questions that we are going to come forward with. The proof of concept is just a vehicle to wind up determining whether those questions are specific enough, and whether or not it could be implemented in a system. It is the questions per se; is that not correct?
DR. LUMPKIN: What I am suggesting, because I can tell you for sure that I know I will not be ready to vote on a set of questions in June, but I think it is important for this committee to make recommendations.
Our recommendations may be that there be a set of questions and that those questions be tested and the proof of concept be evaluated.
MR. BARR: That is one of the plans that we have done. There is a concurrent process that I recommended yesterday and showed you where there are these 27 individuals who have volunteered to start standardizing the questions.
They will take the ambulance attachment. Those questions that are on the ambulance attachment, they will redo, determine which is a better language, which is a better question to be asked, and they will standardize that.
If they are available for the proof of concept, we have already decided that we will bring that in and begin testing them during the test process.
That time frame is not up to us. That time frame is really up to this other group and how fast they can react.
DR. LUMPKIN: I think when we look at what we do as a committee, it was easy when we dealt with the 837 and the other transaction standards. They were already approved by an SDO.
We ran into the same problem with the security standards, where the industry told us, well, we are not ready for one standard, but we are willing to accept some general principles.
We aren't even that far with this. We can at least have some conceptual things that we would like to see reflected in the administration's policy on transactions and on attachments.
What I am proposing to the committee is that our recommendation that we would pass at the June board meeting not be as specific as a list of questions, but would be more general as to the outlines of the policy that we would like to see reflected in the NPRM.
DR. COHN: Policy meaning what?
DR. LUMPKIN: That there be questions, that that be the first start, that it be a phased-in process. I think those are the kinds of things that we need to get to the point where we can list five or six or seven, eight principles, of what we want to see in the policy-related attachment. I am just tossing that out.
Looking at the time frames and how we can work as a committee, I just know that the other members of the committee, sight unseen, would be unwilling to vote on a list of questions that have not been field tested, fully field tested.
MR. COHN: I guess I had never actually thought that as a committee we would be voting on what questions were asked for an ambulance report.
I had thought that we would be getting input and basically overseeing the process, or assuring that the process was appropriate, to make sure that all the right input is occurring on each of these attachments, so that actually these things happen right, that the data occurs right and all this, and that that would be a piece of recommendation we would want to make, having received advice from some of the stakeholders in all of this stuff.
I think that is a piece of recommendation. I think that we may want to have some recommendations on things like LOINC and HL7 and some of the more basic pieces of the whole thing, like are we going to be driving this on a two-lane road or flying a spaceship, and how exactly is this going to be -- the recommendations around the syntax for all of this, how it is all going.
You are right, I don't think that we were agreeing that we needed to have the final sign-off on what the ambulance language was.
DR. LUMPKIN: Right.
DR. COHN: On the other hand, having said that, I would warn the proof of concept committee that they need to be careful, and they came up with a very aggressive plan yesterday.
One needs to make sure that one doesn't inflame public sentiment in the process of developing all of these things where it comes out, HHS defines emergency department record or whatever the headline happens to be.
MR. BARR: That is one of the reasons we said we did not want to be the leader of that group and we hoped that the NUCC would take that leadership responsibility over.
They expressed an interest to take the leadership responsibility over for that. We would just be a working member of that group.
They are going to discuss that in their March meeting, whether they are going to accept the responsibility of being the chairperson for this committee.
DR. COHN: So, explain to me again, the NUCC is going to be responsible for defining the emergency room record.
MS. GREENBERG: Where does the NUBC fit in?
MR. BARR: What we had talked about is that there would be some kind of protocol. The NUBC sits on the NUCC committee. They are jointly working together.
Anything that was decided upon, there is the NUBC, there is Weedy on the committee, there are all these other groups that are on the committee. It wouldn't just be one person agreeing to this.
DR. LUMPKIN: That gets to your second question, which is who owns this process, which we need to get to.
MS. FYFFE: I would like to make a comment about this. I think it has been obvious during the hearings and up until now that there seems to be a lot of turf issues when it comes to who owns this.
I think we should carefully consider that all players need to be involved and that we need to be very careful about any recommendations we make about who should own this.
I have some real concerns about giving it to one part of the industry to the exclusion of other parts of the industry.
We have got volunteers who want it, but I don't know that we should give it to them.
DR. LUMPKIN: So, we either need to be silent or come to some closure on that. Part of what we are talking about today is how we do that by June, because we don't need to come to closure today.
MS. FYFFE: Another issue that we really haven't addressed lately, and has always been nagging me in the back of my mind, is that when you look at the overall time frame for the standards for claims attachments, and then you look at the recommendations for a computerized patient record, it sort of seemed out of synch.
You are making recommendations about attachments which are part of the medical record, and the medical record isn't computerized yet.
So, perhaps if we agreed to have principles as our recommendation, that there has to be some sort of link to the future recommendation about the computerized patient record.
DR. LUMPKIN: One of these days I am going to track down the person in Congress who wrote that bill and give him a piece of my mind.
MS. FYFFE: I think it was an innocent oversight.
MR. BARR: Kathleen, may I make a statement?
MS. FYFFE: Yes.
MR. BARR: Maybe I have confused you. The fact is that the committee that I was referring to for the NUCC, they are going to be the ones who are going to have the overhead of the volunteers who try to standardize the questions.
The data content for all the attachments, I did not recommend that this goes to one committee. That would go to the appropriate committees that do the claim, NUCC, Weedy, whoever they are. They would have that full, entire gamut.
This is just a special group that would just be responsible for standardizing the questions. It was not the data content. I just wanted to clarify that.
DR. COHN: I guess of all the issues that I need to bring up, I think this is probably the most important now, and the fact that we are sitting here trying to answer it in a half an hour or an hour at the end of two days worth of hearing is a statement to me that it is obviously an important issue.
It is one that I don't have the answer to, by the way. I am just aware that it is an issue. I think we need to figure out some way to get additional information and input on how to deal with this whole thing, and deal with it not in just a particular attachment issue, but are there principles that come through that we can recommend, is there a process that we can recommend, where does HHS fit in, and on and on.
DR. LUMPKIN: I am going to bring us full circle to how this conversation started, which is now that I think we have delineated our challenge and the time frame, which is that we need to come up with a recommendation, which I think we are all tending to agree is going to be more along the line of principles, we could very well just come up and say there needs to be one very clearly identified home, and that it needs to be negotiated with the SDOs where that is, whether that be a new consortium or one of the existing ones.
That may be our recommendation. Obviously the committee, while we are charged to make recommendations, we are not charged to implement them. We may pass that on to our enabling body, which is the Secretary in the Department. But clearly, we need to say something about that.
Given our discussion, is it the feeling of the committee that we need to have another hearing, or do we need to have more time with the committee, perhaps, asking for specific information that could be provided in writing for us to read, from involved parties, which would be different from a hearing.
It could be something along the lines that it could be a meeting. We could tack it onto another meeting. We could have a separate one day meeting.
DR. STARFIELD: I am not hearing any specific questions. I think the hearings yesterday and today were tremendous informative. I think we know the issues. It is my view that we probably have enough to do it with.
DR. COHN: Actually that is interesting. On this issue I don't feel that we have any information at all.
DR. LUMPKIN: About which issue?
DR. COHN: About the data ownership issue and the process issue. I thought we heard a lot about claim attachments.
DR. LUMPKIN: So, your impression is that the issue that we need information is on the ownership and who is going to develop it.
DR. COHN: Ownership process, maintenance, going back to some of the key data issues that I know Dr. Starfield feels as strongly about as I do.
DR. LUMPKIN: The question is whether or not we think that a hearing is the best process to try to get answers, versus interrogatories to various bodies, return of written comments, then review of those and then follow up, say for instance, at the March meeting, in an extended meeting from our breakout session.
MS. FYFFE: The March meeting is three weeks away. Do you have to go through a formal process of putting questions in the Federal Register?
DR. LUMPKIN: We have an X12 standard for getting answers back from the various involved parties. We could transmit it electronically and get the answers back.
DR. COHN: It is called an attachment.
MS. FYFFE: An attachment, okay.
DR. LUMPKIN: Do we want to schedule it, then, and try to see if we can find some time in late March or early April?
DR. STARFIELD: Why?
DR. LUMPKIN: For a one or two day meeting, a one day meeting?
DR. STARFIELD: To do what?
DR. LUMPKIN: To send out the interrogatories and to hammer out a recommendation for the June meeting? I am just getting a feeling that there is a need for some additional information. I think there is a need to sit down and kind of work through a recommendation.
Perhaps we could put together a subcommittee of the work group.
DR. COHN: Certainly I think I speak for myself on this one, but I would like to hear a little more from both the standards organizations and other interested parties around the data content piece, to try to understand where their positions are, where they converge and diverge.
Obviously there have been a whole lot of other parties that we have identified today that it would be nice to hear about where they are interested and how they see themselves participating in the whole process.
I think that maybe a hearing with follow up written information or some combination of what would be very appropriate.
MR. LUMPKIN: Might I suggest -- I love to bring up this registry issue, but I am going to do it again. We are always going to have this issue of data ownership. It is not going to be resolved.
The ER people are not going to let NUCC, I don't care how persuasive you are, to define what an ER record is.
I think that rather than just have a bunch of people say, no -- I mean, ADA isn't going to let up. We heard that today. NCPDP has said it to us a number of times.
MS. FYFFE: It is turf wars.
DR. MAYES: It is always going to be that way. However, that doesn't mean that there can't be a fruitful discussion.
I think that what we need to do is try to bring it up a level of extraction and say that, assuming that we can come up with a mechanism -- and I think we are going to propose one for the broader HIPAA standards -- that would allow you to, in a standard fashion discuss this, is there an overall strategy that we can use that doesn't require that you give up your data chunks, or your data set, or that you -- this organization -- give up your data set.
Rather, we would be able to focus discussions at the truly critical elements. In other words, there are going to be some instances where the data in an ER report is meaningless to the data in, I don't know, one of these other attachments.
Why would they worry about them, what they say or they say. However, there are going to be specific data elements that span across all these attachments, particularly demographic and that sort of data.
That is really where the discussions need to be focused on, not who owns all of it, but how do you coordinate the activity on the meaningful intersections between all of these, while still allowing the appropriate group who has a professional interest in maintaining and developing these data sets to continue to do that as they would like.
DR. COHN: I hear your concern about this issue and I share your concern. I am just not sure that we are going to hear anything different from what we heard today.
If we have a hearing and we add -- let's say we bring in your friends and ours at ASEP. We know what their position is going to be -- American College of Emergency Physicians.
They are going to be that, as emergency physicians, they believe that they have a vested interest in the design of the record as well as the form and they don't believe that can be delegated to any committee.
We are going to get back into a process -- so, my concern is if that is the major focus, I am not sure that a hearing is necessarily the vehicle to get us new information, other than what we certainly have heard and know what are the issues.
MR. MAYES: This is fundamentally the same question around the procedure code issues, in fact, and the recommendation was to think about coming up with a unified framework.
It is going to be the exact same issue, really, in that in the procedure world there were so many different groups that had their procedure codes, and they don't feel the other groups represent them.
If you come up with that framework, I think it will be applicable to this situation.
DR. BRAITHWAITE: Let me just ask a question to Bob. Are you going to be presenting work on the data dictionary at the next NCVHS meeting?
MR. MAYES: I would be happy to. We are not on the agenda.
DR. COHN: I guess to me is that this discussion needs to occur at some venue. We keep sort of missing the discussion on this whole data issue, how we are going to move forward on it.
I am happy to do it at the main NCVHS meeting. Obviously, it is not on the agenda. I am happy to do it at hearing or a subcommittee, but I don't think it is a discussion that can wait another six months.
If it can be done -- if we can start it in March and then at the end of the meeting see if we have made progress. If we feel comfortable with the solution -- there are other things we can do than having to fly out whenever.
DR. LUMPKIN: I think there are two parts to it. One is to define the problem, which I think is always the trickiest component of this. I think we have defined this problem. I think we need to come up with some solutions.
I just don't see that there are solutions that are forthcoming, which means that we need to put up a straw person and throw it out and see what happens.
That may be one of the things that we would suggest or ask for solutions. But having a hearing, I don't think, would work. Maybe we could perhaps ask you and Clem to come up with a straw person on this particular issue.
DR. COHN: I think that Bob Mayes may actually have a straw person, a straw registry or something to throw in.
As I said, I think it needs to be exposed, discussed, see if it seems to be a solution to more than just myself or potentially Clem and see if it makes sense, so that we can then begin to go down that path also.
DR. LUMPKIN: I think that would be a more fruitful discussion in March, to talk about a potential solution, than to spend more time defining the problem.
DR. BRAITHWAITE: I just wanted to get the sense of the committee, if anyone heard anything negative or something which would change the direction of the current work of the proof of concept team.
If we said to them, go forth, is there any advice to them to change their direction in going forth and coming up with this proof of concept that we might apply to the claim attachments standards.
PARTICIPANT: I know the questions are over here and that is a definite problem. The vehicle in which we are going to be sending and receiving the information is more what I want clarification, as to whether we are going down the right road.
I mean, there is an issue with the questions and we are addressing that. Is the 275 and the HL7 or the bin or the ASCI text and the bin the route that we should be going to receive the information back.
DR. LUMPKIN: I did not hear anyone who argued against that approach.
DR. COHN: There is nothing else on the table.
DR. BRAITHWAITE: I think the messages go forward.
DR. LUMPKIN: The only suggestion I would have -- and Steve and I have already talked about the emergency component of that, I think that one of the areas where there is a large issue is the reports issue, particularly with the operative and the procedures.
You may want to have some involvement by the anesthesiologists, the surgeons, the ob/gyn, the clinical side of that, the nurse, the anesthetist, just to broaden that little piece out a little bit, if you haven't already touched those bases.
I think that is the only area I think of in listening to it and in looking at the composition of the committee, where there is the potential for a clinical group that, if they are not at the table, will complain but, if they are involved, I think will buy into it.
DR. STARFIELD: That is just your perspective. I am sure that every clinical group will want to buy into the table once they see what is on the table. We have to leave open that possibility.
DR. LUMPKIN: To the extent that we are talking about individual reports that affect a well circumscribed clinical area, you have to have a certain sensitivity.
DR. STARFIELD: It is a general sensitivity.
MR. BLAIR: I don't think there is going to be another message format, folks. I think those two organizations, SDOs, have stepped forward there. I think the issue is whether there are going to be other data set or code set developers who are going to say, you overlooked me in terms of how you respond to the information.
DR. LUMPKIN: That is going to sort itself out anyway, because as we start to look for how you are going to answer the information, you are going to look out there to see what is out there that you can use.
MS. ROBINSON: I would just encourage the proof of concept team to -- I know that technically it can be done, what they are planning on doing.
I would like to see some sort of a study on the feasibility of the economic models on both sides. I think that is the only way that we are going to know if it really works, if both the providers and the payers can economically make sure that what they are planning on doing is going to work or not.
MR. MOORE: I don't think we are going to be doing an economic model. One of the things we said when we started this was that the economic model was put in the first piece with the NPRM on the provider model.
I think that a lot of people agree that there was a payoff, and that there would be some costs.
The costs that we have estimated on that is in the billions. We said that over five years it would cost us a couple of billion dollars to get this done, the whole job.
There would be savings of billions over that same time. So, when you are saying cost out this particular activity of attachments, I don't think we are going to be doing that, where we go through and look at the attachment and look at the cost and every provider, who has got a computer and who doesn't.
We did some grandiose estimations on doing that with the actuaries, looking at the whole effort.
MR. BLAIR: I think she is getting at something slightly different there. I am not sure that I understand, but at least I reacted to it a little differently.
I think part of what she is getting at is, if we are going to wind up issuing regulations that the responses to the 16 different questions have to go through using ASCX12 and the HL7 responses in a 275 format, where a lot of the questions are why questions, and it is less expensive for somebody to simply scan in the operative reports or scan in the progress notes, and that is 30 percent or 40 percent of the responses that are involved, and we are forcing them to wind up using information systems that require X12 and HL7, then we may be adding an unnecessary cost burden where both the payer and the provider can get it done less expensively and more efficiently. Was that the essence of your question?
MS. ROBINSON: That is exactly what I was trying to get across.
MS. FYFFE: The law already addresses that. There is language in the law that says cost must be considered. Maybe you could quote it verbatim.
DR. STARFIELD: There is always the issue if you are going to do cost, you have to do the cost of the current system, the added costs to that system.
MR. BLAIR: I don't think that in this case it necessarily means an economic model. Is it possible that the marketplace could just sort this out itself? We could wind up saying this is available, but not restrict them.
MR. MOORE: Jeff, we did that exact same thing with the claim. We have every payer in the country saying, I want to use my claim. I have got one that has been modified.
HCFA was right in there pitching for the UB92 and the NSF, as the biggest payer saying, we don't want to change a damned thing. It was not to our advantage.
I know at the July meeting questions came up about -- well, we were talking about transaction standards, not what is going to be processed in the provider shop or what is going to be processed in the payer shop, that processing. We are not talking about that.
We are talking about moving information from point A to point B, and standardizing that method. Yes, people will have to change, and some people it will cost and some people it will save.
That is why some of the third party payers like the self insurance industry, they are saying, I am going to wait until I see all of this filter out and then I am going to put my investment in.
I am not going to make any investment until I see where all this comes down and all the regs are published.
As far as us trying to estimate whether somebody can fax it, if we are going to say that if you are going to send information and it is going to be this set for ambulance or physical therapy or others, and you are going to do it electronically and you are going to do it this way.
MR. BARR: Like Bob Mayes said earlier today, if you don't want to do it electronically, there is a paper out that you can send the claim by paper or you can send the attachment by paper. That has never been taken away and will not be taken away.
DR. COHN: The payers are going to have to develop it.
MR. BARR: I think what you have heard in two days of testimony, just to end up, you have heard that this process -- and I repeat -- is the most complicated process, just by the questions you have asked in the last day.
We have addressed every one of these questions as a group of 10 individuals with very little background except systems backgrounds. We have had to make a lot of hard core decisions.
Right or wrong, we have made them, and we have gotten as far as we have. I really appreciate, for myself and for the proof of concept team, the interest you have expressed and the allowance for us to go forward continuing with this.
So, as I understand where we are at, at our March meeting, Simon and Clem, with help from Bob and the rest, are going to come in with some recommendation on dealing with the issue of ownership and how this process is --
DR. LUMPKIN: No.
MS. GREENBERG: Not ownership; registry.
DR. COHN: What we are going to do is, we are going to look at the registry as a model, as an approach for how we might deal with the ownership issues.
MR. BARR: That is exactly what I said.
DR. COHN: Is that right, Bob?
MS. GREENBERG: At the subcommittee level.
DR. LUMPKIN: And identify other issues that need to be further dealt with.
We will begin to put some format to how we want to make our recommendations at that meeting, and then evaluate, then, depending upon how much progress we make, whether or not we need to have some mechanism for the committee to flesh that out for the June meeting, whether that be a conference call, whether that be a single day face to face meeting.
MS. GREENBERG: The subcommittee is meeting May 4 and 5 with others for the unique identifier hearing.
DR. LUMPKIN: That is correct. So, that could be a vehicle.
MS. GREENBERG: It could provide some opportunities.
DR. LUMPKIN: So, we have some options to try to deal with what we need to deal with.
MS. GREENBERG: Provided we are not talking about a whole hearing.
DR. LUMPKIN: I haven't heard anyone, in the last 10 minutes, mention the word hearing. Okay, I think we have gotten as far as we can get on attachments. Okay, thank you.
Computerized patient records. We are going to have a session at our March meeting, which is going to be the opening salvo of, this is how good it could get part of the discussion, with some examples.
Are there some -- it will then begin to set the framework for our more extensive hearings that will start off the process in the fall.
Are there issues that we feel we need to deal with prior to that, that will position us to begin to address the issue of computerized patient records?
MR. BLAIR: I had a few. I have a feeling like the time is going to go awful quickly between now and when we have to make our recommendations. So, I have a sense of urgency on this subject.
DR. LUMPKIN: Even though we have more time for this than we had for anything else in HIPAA.
MR. BLAIR: I think that this is going to be something which is a very serious issue that a lot of folks are going to react to and we are going to need time to be able to set forth our ideas, get people's reactions and challenges to them and defend them, before we can really set them -- we are going to have to build a little bit of a consensus, I think, not just wind up coming up with recommendations and taking them to Congress. That is going to take some time.
The thoughts that I had were, this is right off the top of my head. It is the original things. It is for us to try to get a little focused on how we start to approach this whole issue.
What I would like to see us do is to try to identify issues related to the computer based patient record which the private sector, the vendors, are making reasonable progress on, and which we should just leave them alone.
Those areas where either the standards community or some of the associations that are working on data sets and code sets are making some progress, but if we could provide them some aid -- we meaning the government or Congress -- could provide something to facilitate and expedite the work they are doing, either for convergence purposes or things that could be enablers, for example, we focus on what areas those are.
Then the third area is where a government initiative or program or action or agency really needs to specifically play a role to fill in the missing pieces.
I was almost wondering if we could begin to organize the way we pull together our hearings and the folks that testify to us, in a manner that could help us get those questions answered.
DR. LUMPKIN: Could I perhaps suggest -- it is clear that you have given this a fair bit of thought, even though these are from the top of your mind. I was wondering if you could perhaps put some thoughts on paper.
We could use that because our meeting is just three weeks away. We could use that after we have heard the presentations, as part of the work group meeting, to kind of structure our process, you know.
People can get a chance to look at it, add in their additional ideas. That will give a little more substance to our discussion in March.
DR. STARFIELD: Not only that, at the subcommittee meeting in March we will have to identify the questions we are going to ask, even at the earliest hearings.
MS. FYFFE: Can we think about possibly seeing some demonstrations of existing computerized patient record systems?
I am under the impression that there are systems out there that are being used. They might not be comprehensive systems that would meet everyone's standards, but I think that the industry has certainly made progress over the past few years.
I can tell you that three-and-a-half, four years ago I saw a demo of what I thought was a computerized patient record system. Certainly since then there has been further progress.
I want to get beyond the theory and actually look at some tangible stuff. Hopefully we can have some people come here and show us some stuff on a PC or we might be able to look at something out in the field.
DR. LUMPKIN: I don't know. My druthers would be to go someplace. Systems always look much better when you bring them into a room like this and show them.
MS. FYFFE: Yes, there are physical limitations because you can't go to a lot of places, but we might do both, maybe see one or two and then ask people to come in.
MR. BLAIR: We are going to be in Chicago and we are going to be in Denver. We might try to take advantage of the places that we will be.
MR. MAYES: CPRI has these Davies awards -- just to follow up on this. They have had the Davies award for several years as part of that process. They actually do look at quite a number of systems.
They will be testifying and they would certainly be able to supply you with some potential sites in a variety of settings, not just inpatient. They have looked at ambulatory care systems and others. You might think about visiting them when you are having a meeting there or whatever.
DR. LUMPKIN: If I could follow up, perhaps what we could do is, since we all live in different parts of the country -- I am not sure that this needs to be a group activity.
We may come up with a list of installation sites all over and then we could, at our leisure, see three or four sites in our home cities in between times of meetings, instead of trying to do it at a hearing.
MS. GREENBERG: I was actually wanting to make a few responses to Jeff. Also, taking this most recent statement first, one place that we could go or talk we, we actually tried to have some kind of demo of the VA system here in the Humphrey Building. That didn't work too well.
So, I would definitely recommend not trying to do it here. I would suggest going to the site. Rob Callodner works with us at VA. That is something that could be arranged. Your other suggestion about going places where you already are is good as well.
On the issue of getting some focus, it was my understanding that this panel -- and Bill, you are probably working with Jim in setting this up -- that was part of the idea, was to get a sense -- this one in March which will be for the whole committee, not just the subcommittee -- was to get some sense of what the state of the art is when it comes to standards, kind of as Jeff was letting out, without a great deal of detail, where there is a lot of progress being made and the real challenge toward more convergence, and where there really is a void and we are not moving at all toward convergence, and where initiatives are needed.
I think that some of that, I think, is what we are going to try to do bringing in types of very macro questions that we are going to be asking when we bring people in for the March meeting.
If you have thoughts now on what some of those questions should be or even people to bring in, please share that with us, because this is obviously a work in progress.
The other thing, of course, is that the ANSI HSB is developing this clinical inventory that Jeff is in charge of.
That is tentatively, I think, supposed to be presented to the committee at the June NCVHS meeting, which again, there are always limitations with the inventories because it is hard to get the analytical piece, because each organization is putting in their piece.
It certainly will fill in, to some degree, where are those standards at least being developed and where are they not and where are there too many. So, I think that inventory, I mean, is being compiled now and it should be helpful to the committee.
DR. STARFIELD: I think when we look at the various models that are out there, we should be very careful to have a spectrum, not only to the hospital ones, but also to the ambulatory ones, not only to special populations but also to general populations, and perhaps even pay some attention to the long-term post-acute setting.
DR. LUMPKIN: I think my concern -- and I can't remember because my wife was looking at it and, wow, computerized patient records, and there was a firm that didn't present here today that sent a video.
On the video they were talking about their computerized patient record product. The person who was talking about it was sitting in the midst of a bunch of charts.
The kinds of questions that we need to see are actually, do these systems help eliminate the paper in the system. You don't see that from the presentation. You really have to go in and actually see how it is being used, what kind of acceptance there is to get at some of the fundamental questions that we want to address on how important certain standards are, because we are looking at relative importance as part of our deliberations.
MR. MAYES: Just along those lines, as part of this data -- and Simon has been involved in this -- the submission packet that they require from different agencies has a whole list of issues and questions that would be, I think, very useful.
They are exactly of that sort. They say, for your system, how many people are using it.
As part of the requirement, fundamentally, it has to be used as the primary system in that facility.
DR. STARFIELD: CPRI activities; is that what you are talking about?
MR. MAYES: Yes. I am sure they would be happy to supply the template that they use.
DR. LUMPKIN: I think that would be useful. Not only would it be useful to understand the systems that we are seeing and what it means that they got the award, but it also gives us some framework, at least, of the criteria that they used to determine what is a good system and what isn't.
DR. COHN: I was going to say, there is actually a committee in CPRI that has to do with CPRI evaluations, that has been part of the group that have done the Davies.
It might be appropriate at some point that you, or the chair, get some sense of how their evaluation methodology has evolved.
Actually, the Davies symposium this year, on my calendar, is on July 10. If indeed we are working toward standards in this area, it might be a useful meeting for members, since obviously these are discussions of the best CPRIs of the last year.
I think it is in Washington. That is what I have written down here, is Washington. I could be off. It could be the 9th instead of the 10th, but it is one of those two days.
I was just going to comment. I think the key to the first session, or this coming session, has to do with the questions we are asking.
I don't have a copy of them. I don't know what you are asking, but I would certainly make sure to include the very basic and important first question on all of this, which is what is your definition of a CPR.
You would just be amazed. What standards you have, what you do, how you set it up and what you need has a lot to do with sort of your definition of what this is.
I can certainly speak for the CPRI that over the years we have really had to do some stretching and modifying of what we consider to be CPRs.
I mean, one that has received an award in the last couple of years would be one that in previous definitions from prior times would not even have been eligible for an award.
So, it is once again a statement of how the definitions have evolved and how they vary.
DR. LUMPKIN: So, we have got a plan for March.
DR. COHN: The other thing is that, obviously within my own organization, which we have a couple of different CPRs that, as we have occasion over the next while, we can make available side trips if it should prove to be of value.
MS. GREENBERG: Is there one in Cleveland, I know?
DR. COHN: We have got them all over.
DR. LUMPKIN: Okay. NPRM discussions. What role should the national committee play in the process? My assumption will be that the implementation teams will be charged with reviewing the comments.
So, each of us who are liaisons to the implementation teams will obviously be monitoring and tracking.
MR. MAYES: There have been one or more individuals for each team. It won't be the whole team. There have been a specific individual or two for each team that have been designated.
As the comments come in electronically, they will automatically be forwarded. Each NPRM has its own mailbox. So, those will be coming in.
They will be brought up for discussion, I assume, by each team, but there is a contact for each team.
DR. LUMPKIN: I guess the question is, will those be sent out to the list serve for the implementation teams when they come in?
MR. MAYES: I don't think so. I would assume it would depend on the volume. If we have wound up -- I can't imagine -- only getting a few, then that might be an option. We are gearing up toward receiving several thousands of them. The traffic would simply be too much.
MS. FYFFE: For the information that is coming in via e mail we are actually having the members of the implementation team set up separate user IDs, mostly in HCFA, to receive the comments, so they don't bring their own systems down.
We are working on ways to sort them out and to get them ready to go on the web after the comment period closes.
MR. MOORE: One of the things the committee might want to think about, normally we would take all of these comments and categorize them into the different categories -- you know, I don't like this at all or I love it. That is the extremes.
Then you have got all the other things about how we ought to change it. We will have to take all those comments and put them together and then summarize them.
You know, we have got 1,000 people who said they liked it, but we need to see these changes. Then we will need to list those changes, and all that, because we will have to respond to it.
Then we will narrow that down and have a summary. Maybe that is what should come back to the committee, is the summary of the analysis of all those comments.
Then, if you see any summary that really leaps out at you, that maybe you then need to go back and look at some of the specific comments to see how we put that together, that gives you an opportunity to look at it on a larger scale, that the staff will be doing.
Then if you want to see all the detail that they had to go through in certain areas, you may need to go look at that.
DR. LUMPKIN: So, those summaries will then come to us as special government employees?
MR. MOORE: Right, like the NPR did.
DR. LUMPKIN: Prior to that. So, those would be shared with the work group or those who are interested in it?
MR. MOORE: They will be shared with all the members of the committee, really, because we are asking for a vote of the whole committee, not just this particular work group.
MS. GREENBERG: This will be pretty much at the end of the process; right?
MR. MOORE: It will take us some time to pull all that together, yes. It is the same kind of issue that we would have to provide back to the data council and the administration. The administrator doesn't look at all that.
We have to provide back, here are the major comments on this reg. Here is how many people commented. Here are the things that they said. Here is how we are addressing those comments. Here is how we have changed in order to make that happen.
MR. MAYES: It would be prior to the publication of the rule.
MS. GREENBERG: Right. My point is that I think that is very good.
MR. MAYES: You would be able to input.
MS. GREENBERG: It was, I think, an agreement -- but again, you could reraise this, I think, at the March meeting, but there was an agreement, I think, at the November executive subcommittee meeting that was confirmed at the January meeting, that the committee should comment on the NPRMs during the comment period, if only to anywhere from just being supportive to raising issues or what have you.
If that is going to be done, that would have to be done prior to this. This is a different piece of it, which I think is very important, what Bob just described.
I think you could reopen whether you feel commenting during the comment period would be of value. As I heard it, there was a sense that, you know, we have invested a lot in this process. We have been working with the department a lot and it is appropriate to comment. So, we have to decide, if that is the case, what you want to do about it.
MR. BLAIR: Is there any possibility during the next six months to a year, that we could have a list server set up to expedite our ability to communicate and share information?
As we go through a lot of these processes, in addition to e mail, if a list server was available with the whole committee being able to communicate, that might speed up our ability to deal with issues.
DR. STARFIELD: The whole committee, you mean, and not the subcommittee?
MR. BLAIR: Well, the subcommittee is probably more appropriate.
DR. BRAITHWAITE: The subcommittee has a list server.
MR. BLAIR: We do?
DR. BRAITHWAITE: We will tell you about it.
MS. GREENBERG: You mean the K-2 group? Doesn't that involve a lot of other people, too? That is just the work group?
DR. LUMPKIN: What do you need to do to get on the list server? The answer is probably yes. We think we already have it. We just need to review who is on it and update it.
Okay, so as a committee, the full committee will respond to the NPRMs when they come out, I assume based upon some assessment.
When the NPRs come out, I guess we will need to take a look at those to see how they deviate from our recommendations as a committee. Then, based upon that we will come up with a comment which probably, by and large, judging on what I have seen so far, will be we are so glad you followed our recommendations.
In addition, when the summaries of the comments, after the end of the comment period, we will get those summaries.
I think what I would like to suggest is that we would, utilizing our list serve, perhaps share comments that we may have, to determine if there is a more organized response that we might want to make.
For instance, if we see recommendations for changes that we resonate with very strongly, it would be appropriate for us as a committee to encourage our sponsoring agency to make the changes that may have been suggested in the commentary.
MS. GREENBERG: A lot of this is going to have to be done by conference call, e mail, et cetera.
DR. LUMPKIN: Correct.
MS. GREENBERG: Depending upon when they are published, the comment period, the actual 60-day comment period, would be over by the June meeting, obviously.
DR. LUMPKIN: That is correct. It depends on when the summaries are. The summaries may come out contingent with one of the hearings we may be doing, in which case we will have a discussion there. If not, we will do a conference call or e mail or whatever.
The intent would be for our committee to be involved and to give feedback to HHS about the comments and the directions and give them some feedback so they at least would have our input as they are trying to decide how to respond to the comments.
Okay, we have about a half an hour for a contemplative meditation in silence, for those who feel obligated to stay until the end. Otherwise, I think we have exhausted our agenda.
(Whereupon, at 3:10 p.m., the meeting was adjourned.)