My name is Dr. Tracy Gordy. I am the Interim Chair of the American Medical Association’s (AMA) CPT Editorial Panel. It is my pleasure to appear today on behalf of the AMA before the Workgroup on Computer-based Patient Records of the National Committee on Vital and Health Statistics (NCVHS). I would like to thank you for the opportunity to testify.
My statement summarizes the views and concerns of the AMA on issues related to uniform data standards for, and electronic transmission of, patient medical record information, as well as the appropriate role for the federal government in addressing these issues. By way of background, AMA policy, H-480.971, with regard to computer-based patient records includes the following statement:
The following steps will allow the AMA to act as a source of physician input to the revolutionary developments in computer-based medical information applications, as a coordinator, and as an educational resource for physicians. The AMA will:
(1) Provide leadership on these absolutely critical and rapidly accelerating issues and activities.
(2) Work, in cooperation with state and specialty associations, to bring computer education and information to physicians.
(3) Work to define the characteristics of an optimal medical record system; the goal being to define the content, format and functionality of medical record systems, and aid physicians in evaluating systems for office practice computerization.
(4) Focus on the CPR aspect of human-computer interaction (the physician data input step) and work with software venders on the design of facile interfaces.
(5) Provide guidance on the use of computer diagnosis and therapeutic support systems.
(6) Continue to be involved in national forums on issues of electronic medical data control, access, security, and confidentiality.
(7) Continue to work to ensure that issues of patient confidentiality and security of data are continually addressed with implementation resolved prior to the implementation and use of a computer-based patient record.
The following comments will address the questions we have been asked to discuss before the Committee as well as other issues of concern to the AMA.
1. Definitions and requirements for Patient Medical Record
Information (PMRI):
How would you define or describe PMRI?
A· Why is comparable PMRI required, what functions does it serve?
B. How comparable does the PMRI need to be for these purposes, i.e., how precise, how accurate? What are the consequences if the PMRI is not accurate?
The AMA believes that a patient’s medical record should include sufficient information for physicians and other appropriate health care professionals to assess previous treatment, to ensure continuity of care, to decide upon further treatments and clinical activities, and to avoid unnecessary or inappropriate tests or therapy. It is the primary source of information for a patient’s overall health care, meeting all clinical, legal and administrative requirements. In essence, PMRI is medical and health care data about an individual, including facts, observations, interpretations, plans, actions and outcomes. This description should apply to either paper or electronic formats of patient medical record information. Moreover, the strictest protections of patient privacy must attach to such information.
Comparable and accurate PMRI will assist in realizing the clinical utility of such information. It can also enhance the value of such information for clinical research and epidemiological purposes. At the same time, efforts to enhance comparability must not detract from the fundamental clinical purpose of such information as outlined above, which will focus first and foremost on the needs of patients, their physicians and other health care professionals, and the institutions and facilities in which they receive their care.
The AMA realizes that one of the biggest barriers in health care information technology relates to the current status of standards, particularly in the electronic area. Standards for electronic patient medical record systems need further work in a number of areas, including, but not limited to, medical vocabulary, common identifiers, data exchange, and privacy and confidentiality. In addition, standards are lacking in the categories of authentication, system interfaces and interoperability. This latter deficiency is especially troublesome because the underlying technology and infrastructure of an electronic patient medical record system must incorporate the ability to communicate between one system and another.
Although, many organizations are addressing standards and issues related to electronic patient medical record information and systems, no organization is focusing on the necessity for vendors to incorporate the specific needs of the practicing physician in the ambulatory care setting. Since there are no agreed upon standards for electronic patient medical record systems, the vendor community is creating a variety of electronic patient medical record systems that are often incompatible and therefore, the data not comparable. This situation leaves little guidance for physicians in selecting systems.
2. The role your medical terminology plays in representing PMRI:
A. What is the intended purpose of your medical terminology? What is it currently used for?
B. What is the clinical domain, scope, or healthcare setting addressed by your medical terminology?
C. What evidence do you have of market acceptance of your terminology?
D. In what areas are you now planning to expand your terminologies?
The AMA’s medical terminology, Current Procedural Terminology (CPTÔ), is used primarily as a working clinical nomenclature. CPT codes describe medical procedures and services. The CPT code set is an organized listing of terms and identifying codes for reporting the services of health professionals. The purpose of the terminology is to provide a uniform language that will accurately describe medical, surgical, and diagnostic services. Accordingly, CPT terminology provides an effective means of communication among physicians, patients, and third parties. The current version is CPT 1999.
CPT addresses the full scope of medical services (MD/DO), as well as physical therapy, occupational therapy, speech, language and hearing, optometric services, chiropractic services, podiatric services, psychology services, and other allied health professional services.
CPT is unique in that it describes clinical practice in a manageable number of codes with pre-coordination of terms to meet the needs of physicians, other health care professionals and payers. It has been extensively adopted as the basis for most payment and administrative systems, has wide acceptance by practitioners, and is updated annually. Updates are published annually and made available through an extensive distribution network, including electronic formats (tape, disk) and though licenses to many third party vendors.
There are many indicators of market acceptance for CPT including the following:
The AMA is currently working to develop the next generation of CPT (i.e., CPT-5), which is being explicitly designed to meet the HIPAA criteria for a longer-term clinical procedure code set for administrative and financial transactions and a promising and integral element of the coding sets needed for electronic patient medical records.
The CPT-5 project is developing actionable recommendations to:
CPT-5 is also being designed to meet the diverse needs of its various users, including clinicians, payers, managed care plans, and researchers. The CPT-5 project is structured to capture input from a variety of sources within both the public and private sectors. CPT-5 currently has six topic-specific workgroups: Managed Care, Research, Nonphysician Practitioners, Maintenance and Education, Sites of Service, and Structure and Hierarchy. Participating on these project workgroups are coding, payment and health systems experts from a variety of backgrounds, including clinical, data management, and research. In addition, representatives from the Health Care Financing Administration (HCFA), the National Center for Health Statistics (NCHS) and the Agency for Health Care Policy Research (AHCPR), as well as a liaison from the National Library of Medicine (NLM), participate in the workgroups.
The core purpose of CPT-5 has been expressed by the Executive Project Advisory Group as:
We anticipate that CPT-5 will be released in 2002, although some outcomes from this project may be implemented prior to that time and others after its formal release, taking into account the needs of CPT users for stability and predictability.
3. How does your medical terminology relate to other medical terminologies?
The AMA has taken initial steps, with the National Library of Medicine (NLM) and the College of American Pathologists, to map CPT to SNOMED. In addition, CPT contains many concepts that are similar to those in ICD-9-CM volume 3. Formal relationships with other terminologies have been modeled in the NLM’s metathesaurus.
4. How does your medical terminology relate to healthcare message format standards?
A. Which message format standards reference or include your medical terminology?
B. Is the use of your medical terminology within these message format standards required, preferred, or optional?
CPT is explicitly used in ANSI ASC X12 and HL7 standards as required data elements for identifying professional medical services.
5. Are there issues related to medical terminologies that deserve government attention or action?
A. What are they?
B. frame?, a five- to ten-year time frame?
The responsibilities of the NCVHS to evaluate and recommend patient medical record standards, which includes clinical information standards, are addressed within Section 263 of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L.104-191). Section 263 states that the NCVHS “shall study the issues related to the adoption of uniform data standards for patient medical record information and the electronic exchange of such information; and shall report to the Secretary (DHHS) not later than 4 years (August 2000) 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.”
It is important to note that NCVHS’ responsibilities on this issue are fundamentally different than those for HIPAA administrative transactions. There is no federal legislation requiring implementation of patient medical record information standards or the code sets that would apply to such standards. Moreover, it is not at all clear if the HIPAA model for administrative transaction standards, which is intended to address inter-enterprise communication, is fully applicable to patient medical record information standards that involve a large intra-enterprise focus.
Therefore, the AMA believes that the government should limit its focus to broad recommendations for medical terminology frameworks, with the specific code sets maintained by the private sector. In addition, the AMA believes that the NCVHS should also continue to study and identify privacy, security, and access measures to protect individually identifiable health information in an environment of electronic networking and multiple uses of data. These measures must be in place to assure a secure and ethically principled electronic environment for patient data.
6. Are there issues related to the comparability of PMRI?
A. If so, what should be the role of the government?
B. Is there a need for increased coordination among terminology developers? If so what type.
C. Is there a need to coordinate between terminology developers and message standard developers? What type or form should it take?
D. In the short run (1-4 years)/long run (5-10 years)?
The AMA believes that standards are deficient for electronic patient medical record information and systems in a number of areas, including, but not limited to, medical vocabulary, common identifiers, data exchange and privacy and confidentiality. In addition, we believe there is no single solution to the vocabulary needs for electronic patient medical record information. One model has identified the need for clinical interface terminologies, clinical reference terminologies, and clinical administrative terminologies. Each of these types of code sets, which will overlap somewhat in their functionality, has an important role to play in this area.
Clearly, SNOMED and the soon-to-be-released SNOMED RT have a major and promising role to play as a clinical reference terminology for computerized patient records and other purposes. In addition, CPT-4 and CPT-5, clinically-based working terminologies that reflect the preferred terms and communication needs of physicians and other health care professions, and which have carefully designed pre-coordination of terms, will be an important part of the overall terminology solution.
The AMA believes that a true private sector approach to standards development for electronic patient medical record information is needed, with the role of the federal government much more sharply limited than has been the case with the development of administrative transactions standards. The federal government could play a useful role, however, in helping to identify any gaps in standards. At the same time, we state emphatically that the AMA does not believe that federally mandated standards for PMRI are likely to be an appropriate or productive course.
Coordination among code set developers and message standard developers should follow a largely bilateral and limited multilateral model, driven by the actual needs of each codes set and its developer. We believe that this model is exemplified with the previously mentioned coordination between the NLM, the AMA, and the CAP, as well as the work of CAP and LOINC on coordination of LOINC and SNOMED. Similarly, both X12N and HL7 have readily incorporated such major external code sets as SNOMED, CDT, and CPT based on user needs.
As stated previously, in addition to studying the issues relating to the adoption of uniform data standards for patient medical record information and the electronic interchange of such information, the AMA believes that the NCVHS should also continue to study and identify privacy, security, and access measures to protect individually identifiable health information in an environment of electronic networking and multiple uses of data.
Thank you for this opportunity to present the views of the American Medical Association on these extremely important matters.