The Health Insurance Portability and Accountability Act (HIPAA) of 1996 charges the Secretary of Health and Human Services with adopting standards for specified administrative transactions, data elements for such transactions, and supporting standards to enable health information to be exchanged electronically. The purpose is to improve the “efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of standards and requirements for the electronic transmissions of certain health information.”
HIPAA also directs the National Committee on Vital and Health Statistics (NCVHS) to assist and advise the Secretary and to “study the issues related to the adoption of uniform data standards for patient medical record information and the electronic exchange of such information” and to “report to the Secretary not later than 4 years after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996 recommendations and legislative proposals for such standards and electronic exchange.”
A Work Group of the NCVHS’s Subcommittee on Standards and Security has the responsibility for studying the issues and preparing the committee’s report by August 2000, four years after the date of enactment.
a. Generally lack of top management buy in to funding the creation of an electronic medical record. Question asked is “What is the benefit to the provider?” We can see the benefit of electronic claims in that payment is faster and more accurate. We are just beginning to show that the new realtime clinical decision support systems really can reduce costs (Route to less expensive but just as effective drugs) and cut risks. Until these systems are more deployed and there is more evidence of savings there will be lack of complete support by top management. Most healthcare organizations don’t believe health care is an information business. This results in less staffing for IT and less spent as a percent of revenue compared to other industries and businesses.
b. Lack of buy in to automate from Nursing, Physicians and other care givers. Difficult to get physicians to enter clinical data (progress notes) unless they are residents (employed by facility) and are required to do it. Our physicians tell us they won’t embrace automation unless it makes them more efficient and saves them time.
c. Lack of current automation. Millions of dollars have been invested in information technology in health care over the last 20 years with not a lot to show for it. History of failed or delayed implementation of systems.
d. Costs/Lack of funding. Balanced Budget Act is taking its toll on healthcare’s bottom line. Inpatient Revenue, most hospital based organization’s cash cow, is projected to continue a decline until around 2002/2003 and then, because of aging population, is expected to begin to increase.
e. Lack of integration - Islands of information within a typical health delivery system. There may be many places or systems where clinical data is maintained. Healthcare industry consolidation is creating larger entities but is also creating disparate IS environments within these organizations that are going to take years to consolidate. Integration is more difficult than most vendors would have you believe. It takes time, time and more time.
f. Complexity of health care. Average large hospital will have several hundred different types of software resident. (Y2K inventory).
g. Archival/Historical storage of clinical data. Most Healthcare facilities maintain some automated clinical data today - but most of the data is purged sometime after the patient stay. How far back in time is information important or pertinent? How much of the record do you make available to another provider?
h. Accuracy or integrity of clinical data? Who is responsible in each organization for accuracy? Can physicians trust the information from other health care delivery points? Minimal standards for achieving accuracy.
i. Common patient identifier. Must insure everyone has one and that they are used.
j. Issue of an on line real time clinical system, containing lots of text, that care givers use in minute by minute, concurrent care of patient vs a data base with standard definable fields of data that can be queried and analyzed retrospectively. The real time system is rich in clinical data but lacking in standard data sets.
k. Standardization of clinical data. - For example, Potassium normals may be different depending on which manufacturer’s test equipment is used.
l. Technology - There is not a system today that a healthcare organization could go out and buy that would achieve total automation of the patient record.
m. Many special interest groups for standards.
n. Whole issue of clinical automation in the small clinics - individual physician clinic. Handwritten patient records.
o. Security/Confidentiality.
p. Remediation of Y2K problems has set IS projects back 6-12-18 months. There has not been a lot of focus on new clinical technology as a result.
a. The private sector can develop and implement the electronic record over some reasonable period of time.
b. What I’m not sure of is the private sector deciding on standards in a timely fashion and the subsequent setting of some realistic target dates for the implementation.
a. Coordinate development of standards. Solicit input from the healthcare community to insure understanding of the complex challenge.
b. Coordinate with healthcare industry the setting of reasonable time frames for implementing. Must be segmented into manageable and achievable components.
c. Establish incentives to get providers to implement as soon as possible.
d. Fund and publicize demonstration projects.
Common Patient Identifier comes first.
There is some minimal data that would be very important in the care of a patient: Base Line Lab Results, Baseline Chest X-ray,
Baseline EKG, History/Physical, Allergies, Current Medications and any significant medical event.
There is some merit to initially utilizing coded data from the electronic billing process already in place. That coded information includes a patient’s diagnosis codes, surgical procedure codes, other procedure codes, chargeable procedure codes, drug codes, primary physician codes and referring physician codes. Standard coding used in this billing process includes ICD-9-CM, CPT-4 and HICPIC codes.
Any standard that allows NMHS to eliminate redundant tests and procedures as well as reduce risk. Being able to access the minimal data listed above would be a big help. This should also help to create greater patient satisfaction.
We have patients today who go to different doctors for the same problem and end up with getting duplicate, expensive test procedures. On the other side, we also have patients who go from ESD to ESD seeking drugs.
Also, data standards that allow us to set up data bases to determine best of breed clinical practices and to become more efficient would be a major benefit. We have found a lot of use toward that end with coded data already:
ICD-9-CMcodes Attending physician codes
Diagnosis codes DRG codes
Surgical codes Chargeable procedure codes
Procedure codes Drug codes
Ordering doctor codesCPT-4-codes
HICPIC codes Referring physician codes
Yes. This emphasis recognizes that uniform data standards and the subsequent electronic medical record allowing for exchange of this data is a key to better health care delivery and support.