National Committee on Vital and Health Statistics
Subcommittee on Health Data Needs, Standards, and Security

Hearing to receive input from the health care industry on Standardizing Claims Attachments Issues: ASCII alternative to HL7 messages

Statement by Christine L. Stahlecker, Empire Medicare Services

June 15, 1998

Good afternoon Mr. Chairman, Members of the Subcommittee. Thank you for the opportunity to offer a statement on the issue of ASCII as an alternative to HL7 messages in the prospective Claims Attachment standard. It is privilege to be invited to address the NCVHS. I will first introduce myself and some of my background related to this issue and then address the topic.

My name is Christine Stahlecker. I am the EDI Coordinator for Empire Blue Cross Blue Shield’s Medicare Services Division. I have over 20 years experience in data processing with the last 17 at Empire. I am Empire’s representative to the Accredited Standards Committees of both X12 and Health Level 7 and I currently hold co-chair positions within each of those organizations. As part of the X12 Insurance Subcommittee and Health Care Task Group, I co-chair the Work Group on the 275 Patient Information transaction; within Health Level 7, I co-chair the Special Interest Group on Claims Attachments. I have been a member of the Proof of Concept projects on Request for Medical Records and Claims Attachments. Today, I am speaking as a representative of the X12 Insurance Subcommittee, Health Care Task Group, Patient Information Work Group.

Many members of the Claims Attachment POC team are included in this work group. The work currently being addressed is to complete the draft of the Claims Attachment standard so that the Department of Health and Human Services may consider it for recommendation to the Secretary for adoption under HIPAA. In my discussion, any reference to Claims Attachment refers to this draft and is not intended to imply predetermination of the standard. A final introductory comment is that I have included a brief list of definitions rather than to explain them in my discussion. Background information on ASCII is also attached.

The issue of whether or not ASCII text should be considered as an alternative to HL7 messages in the Claims Attachment has received a great deal of debate. When asked, "can it work?" the answer is yes. When asked, "should it be considered as an alternative to HL7?" the recommendation of the work groups is no.

Pursuing this alternative at this time increases the risk to success of the Claims Attachment standard recommendation.

Concerns with free format ASCII text are:

1. What's the benefit? There are many ways to move text electronically. Why burden this standard with multiple methods of expressing text? Why not use the HL7 standard message for expressing both text and codified data.
2. The standards developers have not addressed the implications of free format text as Claims Attachments. Initially this was not necessary since, at the August 1997 HL7 Plenary session, the method of expressing text in an HL7 message was first introduced and accepted by the POC team. Although, in December 1997 the scope of the POC test was expanded to include ASCII text in the X12 275, efforts since that time have been focused on the codified Claims Attachments. The test is not being conducted now due to the stop work order.
3. Identification of the version of ASCII being used may be required and has not been evaluated.
4. Free format text in other ANSI standards has not been considered. If free format ASCII is allowed, should other free formats, e.g. EBCDIC, also be allowed?
5. By canvassing some translator vendors prior to this meeting, it was learned that translation processing can be variable. Some packages will process the BIN content as data and subject it to translation. Others will bypass this process when the content is ASCII text format and rely on their file transfer software to perform any ASCII to EBCDIC translations. Standards for the process are not addressed by HIPAA and presumably would need to be defined in the Implementation Guide.
6. Industry experts in handling text, e.g. the publication industry, are moving toward more structure for data expression, not less structure. SGML and HTML are becoming de facto standards (among many) for document exchange and processing. XML is being evaluated to express HL7 and X12 standards. The point is where's the benefit of building a base of ASCII installations during the startup of the Claims Attachment standard when the industry is moving rapidly in another direction.

Advocates of ASCII text indicate:

1. The majority of providers do not have their medical records stored electronically. Those that do use transcription services may be able to forward text data electronically.
2. Small providers may not be able to create HL7 standard messages.
3. There will be an additional cost and learning curve for providers to implement another standard.
4. If Medicare contractors are required to distribute free PC software will it be required to handle attachments? If so, it will need to either include HL7 or ASCII text.

None of these points are disputed. However, ASCII text was not perceived as the solution among members of the work groups. The general opinions, respectively, were:

• Text data from transcription services can be included in the HL7 standard message.
• Small providers typically use software or service vendors who would offer HL7 capability.
• The cost and learning curve for any standard is to be expected. The benefit is having a standard - one and only one way of expressing the data. This recommendation is in alignment with the other HIPAA standards with a goal to be precise and unambiguous.
• Medicare will need to assess their position on standards in the free PC software.

Recent progress toward consensus has been made but commitment is still elusive. During the HL7 work session in May 1998 a vote was taken on this issue within the work group. The result was that only HL7 messages would be used in the X12 275 Claims Attachment recommendation. Since that meeting the draft Implementation Guide describing the X12 and HL7 components was completed. The HL7 component is now proceeding through that SDO's approval process.

An Open Forum was conducted at the June 1998 X12 working session where it was stated that only HL7 messages would be used in the X12 275 BIN. Only one question was raised for clarification, not dissent. Members representing NUBC, NUCC, and the ADA were present.

The X12 275 Additional Information to Support a Health Care Claim or Encounter is now published as a draft Implementation Guide for preliminary review. It can be found on the Washington Publishing website under Guides in Development. Comments will be accepted by the work group until August 2 and will be addressed in the final draft expected to be completed in October.

Thank you again for this opportunity. Do you have any questions?

Christine L. Stahlecker
Manager EDI Coordination
Empire Medicare Services
400 South Salina St.
Syracuse, NY 13202
(315) 442-4576 voice
(315) 442-4426 fax
cstahlecker@empirebcbs.com

DEFINITIONS

National Committee on Vital and Health Statistics

Subcommittee on Health Data Need, Standards and Security

Standardizing Claims Attachments: ASCII alternative to HL7 messages

Testimony for June 15, 1998

By

Christine L. Stahlecker
Manager EDI Coordination
Empire Medicare Services
400 South Salina St.
Syracuse, NY 13202

www.empiremedicare.com