Hubert H. Humphrey Building
Room 705-A
200 Independence Avenue, SW
Washington, DC
Mr. Chairman and members of the committee, I am Floyd Eisenberg, a Physician Consultant with SMS. My experience spans clinical practice, quality management activities within a managed care organization, and information technology. SMS, now in its thirtieth year, has focused exclusively on serving the information technology needs of participants in the health industry(1).
On behalf of SMS, I want to thank you for the opportunity to testify before you today on the very important subject of the data quality, accountability and integrity.
During my testimony, I will share with you
SMS is firmly committed to supporting industry standard message formats and vocabulary across its entire line of integrated solutions for the health care industry. We have actively participated in the development of these standards(2) for over a decade, assuming a number of leadership roles during this time.
Our customers have realized significant benefits as a result. By providing a common starting point for negotiating interface specifications among a health care provider’s software vendors, messaging standards reduce the amount of time that it takes to deploy interfaces. This is positive for providers and vendors alike. Standards also reduce the likelihood of misinterpretation of the meaning of the various elements of comparable PMRI messages used for data exchange, especially when implementation guides are provided so that all participants implement a standard message in the same way with the same data content.
But even though much progress has been made, there is much work to be done. Considerable inefficiencies and costs are still associated with non-standard interfaces. Financial standards are significantly more advanced than clinical vocabularies. The bulk of installation and support costs, in SMS’ experience are incurred developing interfaces that require mapping between non-standard vocabularies. The huge administrative costs within the health industry can be significantly reduced through standardization. We believe that HIPAA is fundamentally right and fundamentally important, we are committed to assimilating new standards as they are defined, and we are committed to continue our participation and leadership in this area.
Computer-based patient record (CPR) information is electronically maintained information about an individual's lifetime health status and health care(3). It replaces the paper medical record as the primary source of information for health care, meeting all clinical, legal and administrative requirements(4) It is not merely a recreation of the paper medical record. It enables health care providers to reengineer the health delivery process because it makes extensive health information readily available to the care provider when care decisions are being made and, as a by-product, provides a source to aggregate data for outcomes analysis. (The individually identifiable data can be excluded from aggregated data for health studies.) Clinical and financial decision-making are data and evidence driven rather than empirically formed.
The essential model is a “vocabulary” model. It is this vocabulary that enables the diverse and fragmented elements of the health delivery system to operate as a whole, coherently serving all stakeholders in facilitating effective and efficient health outcomes across the care continuum.(5)
Information that is meaningful, interoperable and shareable is the essential objective. This requires that the underlying vocabulary, and the format in which it is communicated(6), must be standard, and is key to achieving comparable PMRI.
The strategic goal of health information system providers such as SMS is the Computer-based Patient Record (CPR)(7). Whatever the technical implementation, it must be a truly portable record that follows the patient, and it must assimilate medical logic modules that are models of “best practice.”
The CPR is made possible by improvements in underlying technology, particularly the growing reach and throughput of electronic networks. The primary barrier now to achieving a viable CPR is the lack of universal standards that allow data and knowledge integration across diverse and fragmented health provider organizations and health networks. Progress is being made(8), but much work remains to be completed.
Inherent in the management of information for the PMRI are several elements – data capture, encoding, translation, auditability, decoding and presentation. Let’s examine the current state for several of these elements.
In addition to data requirements for individual clinical patient care, many efforts for standardization are driven by a desire to improve quality of care and financial outcomes. Standard vocabulary allows the workflow to be driven by patient-centered requirements within the construct of the most cost-effective treatment alternatives. Much of the requirement for structured data is also driven by accrediting bodies such as the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA). Each of these organizations has developed measures to address outcomes of care. ORYX" measures, incorporated by the JCAHO allow variation among healthcare organizations with respect to methodology; the selection of measures and the population(s) measured may vary with the facility. These measures often require significant data collection efforts with variable effect on clinical outcomes. HEDIS® (Health Plan Employer Data and Information Set) is NCQA’s standardized set of performance measures for commercial, Medicare, and Medicaid managed care organizations (MCOs). Many HEDIS® measures use administrative data for analysis, allowing for “hybrid” methodology which incorporates information collected from medical record reviews. Due to the current state of the health care industry, this hybrid process includes a laborious review of a random sample of paper records. In addition to the complexity of the chart review, physician offices have the administrative burden of making available those records requested by each health plan with which the office participates.
Information systems can simplify many of the current processes inherent in data collection for measurements such as HEDIS® and ORYX". However, the existence of multiple standards is problematic for the health care provider. Resources are not sufficient to support multiple methodologies and measurement sets based on the preferences of different accrediting organizations. The Performance Monitoring Coordinating Committee (PMCC), a joint effort NCQA, JCAHO and the American Medical Accreditation Program (AMAP), is one effort by national standard-setting organizations to establish measures that can be used across the healthcare marketplace. HEDIS® has been accepted by many healthcare organizations as a “gold standard” for outcome measurements. HEDIS®measures are carefully developed to evaluate the process and the outcomes of care delivery. However, the utility of these measures is limited to organizations for which the managed population is analogous to that of an MCO. To provide similar comparisons of outcomes among healthcare providers (i.e., integrated delivery networks and health enterprises), standard definitions must be established.
Progress is being made. But progress could be much greater if “funding,” in whatever form, allowed a more intensive effort. Government should support these efforts by established independent measurement and accrediting organizations to develop measurement standards.
The federal government can have a significant impact in the standardization of vocabulary by taking several actions.
(a) Provide leadership by adopting domain-specific vocabulary standards that incorporate the many existing terminologies. This step will eliminate confusion in the provider and vendor communities and facilitate patient-centric clinical information transfer from one practitioner to another.
(b) Place the adopted standard in the public domain. This step is required to achieve data sharing among disparate providers in a climate of cost-sensitivity. Continuous maintenance will be required for the adopted clinical vocabulary standard to keep pace with evolving medical technology and advancement. The “owner” of any particular standard could be in the public or private sectors, but the standards themselves should remain in the public sector.
(c) Encourage nationally recognized sources of evidenced-based clinical care recommendations to publish accepted guidelines and protocols in standard format such that they can be placed in operation as true plug-ins.
(d) Provide incentives for accrediting and regulatory organizations to develop vocabulary and problem based clinical quality measures. Such measures should standardize performance measurements for multiple healthcare delivery models. They should also eliminate the requirement for duplicate and costly data collection by incorporating existing data entered electronically at the point of care.
We believe that the HIPAA legislation is a valuable initiative that will eventually help the Industry reduce the overall cost of administering Health Care. However, the investment spike to achieve the projected savings is significant and daunting to many. The challenge is not in the logic or value of standardization; the challenge is in how we can collectively afford to get there from here.
One mechanism that has worked in the past in American industry is the concept of targeted investment tax credit. If the Government would like us to achieve the benefits associated with using standards and efficient electronic communications, then helping guide the Industry’s investments would stimulate progress in a meaningful direction. We strongly believe that targeted tax incentives applied to meaningful investments on the part of the all parties of health care (providers, payers, suppliers, information systems and technology companies) will accelerate our collective ability to realize the benefits described throughout my testimony.
SMS and our customers understand the monumental benefits of the computer-based patient record, and the critical role that terminology standards play in fully realizing these benefits. Towards that end, we have committed significant resources toward the development of common vocabulary and message format standards. While progress has been satisfactory, we believe that more complete, extensive, and stronger standards for the health industry are essential. We believe that the federal government can best help by providing much-needed financial incentives to increase participation by the private sector in the development and implementation of appropriate standards, and by endorsing medical terminology standards once they are proven and are integrated into a consistent and systemic terminology model.
Mr. Chairman and members of the committee, it has been an honor and a pleasure to deliver this testimony to you. Thank you very much for this opportunity.
(1) SMS has made it its business to develop, deliver, and support the information solutions that help our customers meet their varied and changing business needs. SMS provides these health information solutions to customers in 20 countries and territories across North America, Europe, Africa, the Middle East, and the Asia-Pacific. Our customers include integrated health networks, multi-entity health corporations, hospitals, physician groups, government health facilities, managed care organizations, health benefit plan administrators, and payers. Based on customer need, our solutions can include any combination of clinical, financial, and administrative applications, enabling technologies, and integration and support services.
(2) SMS specifies:
(3) A mobile population, cost concerns, chronic disease, and emphasis on wellness and prevention, and fewer, larger health systems all combine to continue the shift from managing discrete episodes of care to coordinating care for an individual across all episodes, in any setting, for a lifetime. The multitude of care settings remains, but the clear intent is to share information across modalities and across time and to enable informed and effective health maintenance and disease and case management.
(4) The PMRI necessarily encompasses all data related to the person's health care, including demographic, clinical and financial information. The data include text, numbers, sounds, images, signal tracings and full motion video, which are integrated so that any given view of health data may incorporate one or more of these structural elements.
(5) The elements of this vocabulary model are the standard:
(6) Each information system and each care modality can essentially operate as a “black box”, each with its own policies, procedures, organizational structure, and systems. And this is certainly the case today. However, information generated as a by-product of each health care encounter within this “black box” must be available to others to support future encounters, as information about past encounters and active treatments must be available to those handling the current encounter. Basically, the issue is how we all communicate with one another, not how we internally store and process the information.
(7) Ideally, this record is truly a lifetime record for an individual, which spans the period from birth to death, and which includes all relevant personal information and encounters with the health system. It may indeed have to be a logical record that spans multiple information systems, but that still requires a central integration point to identify the location of all information and to pull it together when needed.
(8) Standards organizations continue to improve medical code sets and message formats. Work on HL7 version 3.0 and X12 administrative and financial transactions are good examples of this, and HIPAA starts to put some teeth into their uniform and across-the-board adoption.