[This Transcript is Unedited]
Hubert H. Humphrey Building
Room 325A
200 Independence Avenue, SW
Washington, DC
Proceedings By:
CASET Associates, Ltd.
10201 Lee Highway, Suite 160
Fairfax, VA 22030
(703) 352-0091
MR. HUNGATE: I think we'll get started. I'll introduce myself. I'm Bob Hungate, chair of the Workgroup on Quality. Kathy, why don't you introduce yourself, and then we'll go on.
[Introductions were made.]
MR. HUNGATE: Well, yesterday I started with the full committee to preview our report. Some people were there. We didn't get very far, is what I would say. And yet, we got quite a ways in terms of my understanding of what the task is. So, I think we can be fairly productive today in working through we can and cannot get done.
And Kepa is going to join us from the Standards Committee in a few minutes. Karen is here representing that interest as well. And I think a lot of what we have to do is mesh what we are trying to say in the quality report, with what is said in other places in other ways, and make sure they are in synch.
I'm not afraid to tread on dangerous territory, which I'm told the personal identifier is one such territory. But I think that the interests of personal health dictate that you be an identifiable person. If you want to have a longitudinal record which improves your health care, you've got to be identified somehow. So, there is a tension there that I think we have to try to say what we think is going to be an appropriate way to move forward, because we've got personal identifiers in our list of recommendations.
DR. STEINDEL: But there is a difference between a personal identifier, and have a person uniquely identified.
MR. HUNGATE: I think it's a lot of semantic understanding. But I think we have an important challenge, if you will, in being the bridge to individuals in a communication sense.
DR. STEINDEL: Just to expand a little, most people who I've spoken to who are in the area of probablistic matching and matching of identities and everything said even if there was a person identifier, there would be a small percentage of uncertainty that is involved in the situation, and they would still require a second piece of identification for certainty.
So, once you start asking for a second piece of identification, then you start getting on a slippery slope. That's the only reason I made the comment.
MR. HUNGATE: Okay, well, it's a complex subject. But I think we shouldn't neglect those things that are complex.
The other thing that comes back to me in terms of the report itself is that we really need to narrow the number of things that we want to say in terms of recommendations. If we want to have recommendations that have any strength to them, we have to make them in fairly small numbers, it seems to me.
Now, others of you have more experience in what you do in reports and what you don't. But that is kind of what I came away from yesterday's discussion with that conclusion. I would like comments from others on what you have collected in other meetings, et cetera, there are germane on what we are going to do in studying the report itself. If we can collect those inputs first, it might speed our process.
DR. STEINWACHS: Bob, I would agree with you that it seems to me that we need to narrow down the recommendations. That may mean breaking this whole landscape up into sections, and taking one of those that we think is the first priority, and pursue that. Some of the longstanding issues are still issues that have to be pursued, so we shouldn't shy away from those.
But John has the answers.
DR. LUMPKIN: Well, I would suggest that we need to make the recommendations we need to make. And if that is a fair number of them, then we may want to highlight some of those. I think that the difficulty is that when we look at how long it took us to get to this point, if we are going to make recommendations, we don't really want to hold them up until the next report. So, I don't think we should be daunted by the number of recommendations, if we believe that's what we should do.
DR. EDINGER: The other thing is that we might consider prioritizing the recommendations, at least the ones we think may go first, like some of the stuff with the National Health Information Infrastructure. The electronic medical record may be a little further distant than some other things, so you might want to say things needed now, versus things that are maybe a little more distant, and separate them.
MR. HUNGATE: Other comments, observations?
MS. GREENBERG: I just would agree with John and Stan that this has been in the germination for a number of years. And if we have findings, and there is a recommendation that goes with them, I think you need to make them.
It depends. There are a number of different audiences. If you are trying to get the attention of even maybe the secretary or top policymakers in the department, then you might want to really kind of highlight a few things. But given that the recommendations will go to the Data Council -- that's usually the pattern -- and then go out to each of the agencies, you want to actually have something to say to different agencies.
So, if agencies are mostly responsible for surveys, then you want your survey recommendations, or AHRQ, which really has an in-depth responsibility for quality. So, in that sense, they will get kind of dispersed out to CMS, whatever, whoever is relevant. So, it's not that necessarily one agency has to kind of focus on the whole range of them. So, that's something to be said.
DR. LUMPKIN: Actually, in a perverse sense, the more recommendations there are, the more widely they are documented and circulated. Because when you think about the natural flow of an organization, if you have just one recommendation, it would probably only make it down to the top level leadership in the agency. But if you have got four or five, then it starts getting spread out. And you put perhaps the top couple in the executive summary, and that's how you get it to the secretary and the high level folks.
DR. STEINDEL: I think a good example is the initial PMRI report, which is a very lengthy document, and makes a lot of recommendations, and it is still very widely read. It was very widely read when it was released, because it was a topic of interest.
DR. LUMPKIN: Right. So, I think the key thing about this report is it should be a quality report.
MR. HUNGATE: Well, we have kind of two options. We can kind of go through the report page by page, and then get the recommendations. Or we can do the recommendations, work on them first, and then come back to the report. Do you have preferences?
MS. GREENBERG: Maybe we should ask Susan and Kathy too, since they are working on the report, what would be most helpful to them, since we have them both here. So, we should give them some feedback.
MS. COLTIN: I think what would be most helpful to me is to start with the recommendations, which I believe are Section 4, and then for each recommendation, I think each recommendation relates back to something in Section 3 that discusses a problem, and is intended to lay the foundation and provide the rationale for the recommendation. And one of the things I juggled a little bit was making that link explicit. And so, if there is any advice about how to do that better, that would be helpful.
Now, as somebody is reading through the report, when they read Section 3, they are going to hear about problems, they are going to hear something about what is needed, and then hopefully we're going to get to the recommendations, so, that's why they are saying that. Because it is not laid out in the recommendation section. They are kind of there above in that section. So, I would like your feedback about whether that feels right in the way to organize it.
DR. LUMPKIN: Well, one of the things that I see, many of the IOM reports have the recommendations in the body of the document, so you get that natural connection. And then they have a recommendation section where they are all pulled together. I think that might be a better way, because many people will just go to the things that they are interested in. And that way, they can find the discussion on the topic, and the recommendation on the topic in a much more efficient way.
MS. GREENBERG: I think the advantage to that in this report, it's always kind of a trade-off if you put everything up front, you build up to it. But as Bob said, some of these areas are controversial. They are issues that have been struggled with in the past, and we talked about this in yesterday's full committee meeting.
And so actually having the kind of justification, the finding, the case for it, and then the recommendation right there, I think given the nature of these recommendations, would kind of buttress them, because I think if you haven't been just embedded, imbued, or whatever, engrossed in some of the discussion, you might not make the connection.
MR. HUNGATE: I think I did not. I think I was unsuccessful in making some of the connections. So, I think that's a good suggestion. Is it easy to do that?
MS. COLTIN: Yes, I think that would help. I like they way they do it in the IOM reports. It's not the way we have done it very often, but as long as no one has a problem with it, I think that does make a lot of sense. We do lay the groundwork in Section 3 in each area, and we could make a recommendation immediately following that.
The one issue that we may get into is sometimes there is more than one problem which the same recommendation can solve. So, I'm either going to have to combine the discussions a little differently than they are now, so that the recommendation only appears once. Or the recommendation would have to be reiterated under the other discussion, the other point that that recommendation is intended to address.
MR. HUNGATE: What about having one bold faced recommendation, and the others italicized if they have been put someplace else as well? So, that you do have them there, so that they are coherent.
MS. COLTIN: Or maybe bold them the first time they appear, and then when they appear a second time, italicize them.
MR. HUNGATE: Something like that to differentiate whether it's a new piece.
DR. EDINGER: And make also a page reference where it appears the first time, so somebody can go back and see what the reference is and why.
MR. HUNGATE: Okay, Kathy, I only see positive head nods around this discussion, so you can take it that that's an accepted approach.
MS. COLTIN: Good. What that will also do is highlight orphan recommendations, because there are a couple of places where there were recommendations, and those were drawn from previous lists that the workgroup had pulled together, where we may not have yet laid all the groundwork we need to in Section 3. But I think that will be helpful.
MR. HUNGATE: All right, I think we will make the best progress if you lead the discussion, Kathy, taking us from recommendation back. And Susan has some suggestion here too, I think.
MS. KANAAN: I thought it would be useful to brief Kathy a little bit on what people thought were the key points of the discussion yesterday, because questions were raised about whether any of the recommendations are going to be overtaken by events, number one.
The things that are controversial, we don't need to bring to Kathy, because she knows which ones are controversial. But I think that some of the discussion yesterday may be relevant.
Rather than taking the recommendations as a given, I thought maybe the committee would want to give a little thought to whether the structure was right. We structured it in terms of data sources. And Kathy and I talked a lot, and I think this group talked some about different organizing principles for those issues.
Yesterday, it seemed as though people were leaning more toward -- there were some problems with the grouping of it that way. Because of the fact that the administrative data is sort of in flux, and some this might be overtaken by other kinds of sources. So, that is one of my particular concerns about the way the recommendations are structured.
But in general, I was thinking there were a couple of points that were made yesterday, that Kathy should know about before we move on.
MR. HUNGATE: Yes, and I think most of those come from the first set of recommendations, since we really already got beyond that. The race and ethnicity section, and the standards issues also got some discussion.
Who is in the best position to characterize those two subject matters? I don't feel I am.
MS. GREENBERG: We've been there, done that, Kathy. With the race/ethnicity the issue was whether it should be on the claim, or whether it should be in the enrollment. And we sort of walked through those issues again, and why, although ideally one would only capture it once, such as in enrollment, how that doesn't happen often.
And even if it were an enrollment, the state health data systems, et cetera, are not able to link with enrollment data. And then of course you get into the issue of personal identifier, and that fact that employers who are responsible for the enrollment are not bound by the HIPAA standards, aren't one of the covered entities.
And then the other thing that came out was that the Subcommittee on Populations of course has been doing a lot of hearings the last year and a half or so related to the need for better information on racial and ethnic populations. And that some of that, which is quite current, as recent as a month ago when they met out in LA, maybe should be fed into this set of recommendations.
There was talk about pulling this out, and then doing a separate recommendation with the Subcommittee on Populations. But then I think we ended up thinking that was not what should happen.
MS. KANAAN: But I think they did suggest, and I've heard this kind of suggestion before, to make everything about race/ethnicity sort of its own bullet, partly because of the complexity of it, the other kinds of questions that we are talking about that we might just want to go into a little bit. And I thought that made good sense.
We have got all the data gaps kind of grouped in a general category under this thing about revising the 837 and the NUCC, et cetera, which really does kind of put it in a sort of subordinate position.
MS. GREENBERG: Yes, I think everyone agrees that it should be treated in this report, but separately.
Now, Kepa of the belief that it should be an enrollment, but we talked through that issue -- not that we got agreement, but we did talk it through. The test results and the vital signs, he felt that there were currently sections in the 837 that could capture or did capture that information.
DR. EDINGER: It's for a limited number of test procedures. The actual ones that were on there was for a limited number of tests and procedures.
DR. STEINWACHS: We might want to expand that.
MS. GREENBERG: And then there was a concern about the upcoming claims attachment, hopefully. And I think Stan Huff made the point that there is experience and movement towards using HL7 messages for collecting clinical data. And that that should be supported as opposed to new kind of elements in the 837, although obviously, the claims attachment is supposed to kind of combine the HL7 an X12.
And we really didn't get past that. The indicator field, we know that's in the standard, although not in the current HIPAA guide. I think it's when you bring in the NUBC and NUCC data sets, and we talked about that a bit too, that those committees really felt the focus should be on the electronic transmission, the 837, rather than the paper form, which I guess these recommendation apply to the paper as well. So, those were some of the things I heard.
MS. COLTIN: Well, actually, I think the recommendations were intended really to apply to the electronic form. I think the reason that the NUBC and the NUCC were brought in is that my understanding is that they were the content committees. And if a field did not exist at all on 837, that that was a content issue.
MS. GREENBERG: No, you are right. And with the DSMOs, everybody kind of has a way in, so everybody would have to agree. But some of these are actually accommodated in the electronic, but not in the paper. So, I think you would have to make clear whether you were wanting the NUBC and the NUCC to also accommodate any of these recommendations in their paper content, or just leave the content for the 837.
MS. COLTIN: I think that is something that would warrant some discussion by the workgroup. Because there probably is a very small subset of those fields that we might want to see on the paper. Race and ethnicity may be one of those.
But my personal opinion is that most of them probably would be relegated to the electronic form only. And that over time, we are really transitioning to an environment where most claims will be submitted electronically, so you won't be losing that much information not having it on a paper form.
MR. HUNGATE: I think that's valid.
Don had a comment, and then Steve.
DR. STEINWACHS: It's sort of a question. Historically, in administrative data systems, something like race, ethnicity, age, gender, and so on, could get on a claim one of two ways. It was either put on the claim by the service provider, or it through processing it was taken off of the enrollment information. I assume that's still an option there, isn't it?
So, that this idea of does it sit on the enrollment, or does it sit on the claim becomes in part an option that deals with how those are handled. But ultimately, the claim would have it on it. But it would be through the process of either the provider, or if not by the provider, it would be by the payer.
DR. LUMPKIN: Well, sort of.
MS. COLTIN: What that does, Don, and I would agree with you is that it should be captured in both places. It should be on the enrollment, and on the claims. That you need to come at it from both sides, because not everybody who is enrolled, has a claim. And so, you wouldn't know if there were groups of people who weren't getting services at all if you only had it on the claim.
On the other hand, if you only have it on the enrollment, then you are dealing with some of the issues Marjorie mentioned about staging the systems that don't have access to enrollment data.
DR. LUMPKIN: Right. But I think that the reason why I answered sort of is that we have to recognize that even with the administrative systems that are in place now in many of the offices and providers locations, to sort of use a different term, there is an intake that occurs.
So, the first time that I go to Robert Wood Johnson Hospital in New Jersey, they do an intake, and all my information is gathered at that point. And when I come back again, no one takes that information again.
DR. STEINWACHS: Oh, you're lucky. That must be a good hospital.
DR. LUMPKIN: If they have an electronic system. Even if there is just a registration system, so much of this then in an information system that is operating at the provider location, at that one intake, the information will be collected. And then when they submit the bill, that populates those fields on the bill.
MS. COLTIN: Right.
DR. LUMPKIN: So, it's not that every time the 837 is created, that that data has to be queried of the patient. It's really an intake that is going to be provider-specific.
MS. GREENBERG: But that's a little different than like enrollment, which could be at the health plan or the employment.
DR. LUMPKIN: Right, and that's different than enrollment.
MS. GREENBERG: Going back to the same provider, they shouldn't have to ask you this every time.
MS. COLTIN: Right. Well, the other thing, when you put it on the claim, is usually often what the provider perceives is the race or ethnicity. They may or may not ask. Not every provider asks.
DR. STEINWACHS: Most don't.
MS. GREENBERG: Which is of course, a problem with the quality of the information.
MS. COLTIN: That's right. Where it's on the enrollment, it's generally self-reported. And to me, that's another argument of having it both places.
DR. YOUNG: I agree with that. I think that's a clear departing one, whether it's self-reported or reported someone one. I would recommend a clear distinction between those two.
DR. LUMPKIN: I think that we can argue this until the cows come home. More likely, provider generated race and ethnicity data is going to be observed, rather than declared.
MS. COLTIN: I would agree.
DR. LUMPKIN: Enrollment data is probably going to be more declared than observed. But I would argue that the experience of an individual in a health care system is more determined by their observed race and ethnicity, than socioeconomic status.
MS. COLTIN: I would agree with that as well.
DR. LUMPKIN: So, in a sense we sort of have data that doesn't jive. But we do create a somewhat natural experiment, at least in the near future, for us to answer some of the more important questions in large data sets.
DR. EDINGER: Also, we shouldn't separate the paper from the electronic. In other words, when we get into the personal medical history at that point, that would be captured in the claims data or enrollment usually. But it's probably more likely something like that would be further down the line with the electronic medical record, than the paper form. You probably do not want that submitted to your insurer, your whole personal medical history, if you were submitting your claim for a particular illness.
MS. COLTIN: But I think John's point is a good one. If we are studying disparities, they can occur at two levels. They can occur in terms of when someone actually accesses the health care system. And there, the observed race or ethnicity is probably the most important thing to look at in terms of what happens to that individual during the encounters they have with the system.
But the declared race and ethnicity can also be useful from a population-based perspective in enrollment data in identifying those who may not be able to access the system, or are not coming in for care, as well as for targeting interventions to particular populations.
DR. STEINWACHS: Just because I think it's always hard for the user of such data to sort of why someone has multiple races and ethnicities.
MS. COLTIN: I think it is. And I think it's helpful to know where it came from.
DR. STEINWACHS: Could there be a flag on that, whether it's patient reported yes/no, or something like that? You don't have to ask about the others.
MS. COLTIN: Because otherwise you are in the situation where someone is seeing more than one provider, and you are getting each provider's observation, which may not always match.
MR. HUNGATE: It sounds to me from this discussion, I address this specifically to Kathy and Susan, that we really do need to pull the race and ethnicity out, maybe as a separate section by the data on socioeconomic characteristics.
DR. STEINWACHS: Well, is race and ethnicity cross-cutting?
MR. HUNGATE: It's cross-cutting, so it seems to me that it needs to come back up into the body of the findings. And it needs to be described in the completeness of this discussion.
MS. KANAAN: With the added dimension -- I missed a little of what Vickie said yesterday, but wasn't she asking for also discussion for data on subpopulations? She wanted an even fuller yet treatment of this subject, so that there was something about getting data on the subpopulations.
MS. GREENBERG: And then you just have to really have self-identification. You can't look at a Native American and figure out what tribe he's from. It could be very relevant for cultural competence or certain types of language, certain types of genetic dispositions, but nonetheless, you are not going to be able to observe it.
MS. KANAAN: I have been debating about whether to even raise this, but if we pull out race and ethnicity, it has a stronger argument for scraping our entire structure, because Kathy, I think ultimately we're going to have to work this out in a smaller group. But maybe I'm just looking for your blessing, or at least some reaction.
The minute we pull out a major topic about the data area, and the various ways of getting it, then it's not just about administrative data, or survey data, or these other major categories that we have here. Then that suggests another structure altogether.
MR. HUNGATE: I think you are right. I think a content-driven structure, as opposed to a source-driven structure will make our recommendations have more strength.
MS. KANAAN: And then we can kind of hedge a little bit about where the developmental process is vis-a-vias that content. All we're going to say is affirm that these data are needed, but linkage is needed, et cetera, right?
MR. HUNGATE: But the actions that we ask for -- the recommendation would tend to stress actions. So, that we have to differentiate those which are recommended other places, and we're only reinforcing, or new recommendations for new efforts. I think we have to make that distinction.
MS. KANAAN: It's not all about content. As I looked at it, our major categories are the content areas, the standardization issues, and the linkage issues. And those seem like the big three. Does everybody agree? Kathy, how does that sound to you?
MS. COLTIN: Yes, that sounds right.
DR. HOLMES: I'm sorry, what were the three?
MS. KANAAN: There are content issues, particularly race and ethnicity, functional status, not particularly race and ethnicity, standardization issues.
MS. COLTIN: Well, there are a lot of content issues. The lab tests and everything were content issues.
MS. KANAAN: Secondary diagnosis, et cetera. And then the standardization issues, which pertain both to surveys and to EMR clinical terminologies. And then there are a number of linkage issues that we talked about. That would be another possible structure.
And that would mean that the findings would be -- we would embed the recommendations in the findings. That means that the findings have to structured that way, I think.
DR. HOLMES: Now, would completeness go under content then?
MS. KANAAN: We still get into some of those kind of political questions.
MR. HUNGATE: Let's come back to that after we have done some more discussion of the specifics. Let's kind of table that for the moment, and move to the next -- Karen, go ahead.
MS. TRUDEL: I need to ask a really naive question here. It sounds as though this discussion is based on a concept that every claim that is submitted to whomever is available for research in repository somewhere. And we know that is not the case. We know that claims submitted from a provider to a Blue Cross/Blue Shield plan are not likely to wind up in some kind of research protocol.
DR. STEINWACHS: We keep hoping so. We keep trying.
MS. TRUDEL: So, how do we distinguish between those? Because the providers that are sending the claims to Blue Cross/Blue Shield are going to say, well, if my claim is never going to be part of a research activity, then why are you making me report this information every time I submit it.
MS. COLTIN: I guess my response to that is we are not talking about research. We are talking about quality measurements, performance measurements, and quality improvement. And those are operational responsibilities of many of the payers that you named.
MS. TRUDEL: Well, then why aren't the payers asking for this data?
MS. COLTIN: They are asking for this data. Some of the people we took testimony from were people from the Blue Cross/Blue Shield Association, United Health Group. We are hearing from health plans, as well as from researchers.
DR. LUMPKIN: Let me give a concrete example. The Health Atlas at Dartmouth is looking at Medicare data right now. And what they can do, they believe that their instrument allows them to measure disparities within an individual institution. And so, the next step is if we now can identify how care linked to a single institution creates disparities in certain types of care, the next step is to reduce those disparities.
And how you determine whether or not you are making progress along that pathway is by beginning to look at what you can do with Medicare data, and doing it with other payers at the same institution. So, I think we are really beyond the point of research, into actual implementation.
MS. TRUDEL: Then I would suggest that the recommendation might want to contain the notion that rather than just having the department go and make additional requests asking for this to be added, that there be sort of a coalition of the people outside, as well as inside, who need this information to submit the request as a block.
MS. COLTIN: I think one of the things we run into that is a problem with that, and I alluded to it in one part of Section 3 is that all of the stakeholder groups are represented in many of forums where these kinds of recommendations are discussed, whether it's the content committees or X12N. All those payers are represented, and some of the large provider trade associations or whatever are represented on some of them.
But the people, the individuals that represent those stakeholder groups on those committees tend to be the people who process claims, and are concerned with processing claims, and not the people in the organization who use the data that is collected on those claims.
And so, it's a group that you are not hearing from, and it is a group that isn't well organized, that doesn't have these forums to meet and discuss these issues. And actually, the first opportunity that I was involved with where people like that did get together to discuss these opportunities was when the AMA brought together the CPT work groups. There was a managed care work group, and a research work group. And then you've got those kinds of people discussing some of these kinds of issues.
But it's very difficult, and I think when we took testimony from those types of stakeholders, the people we heard from were the people using the data, as opposed to the people processing the data.
DR. EDINGER: Maybe we should look at this in terms of the kind of data we need to assure the quality of care for the nation, instead of using that as our reason from making most of these recommendations, instead of the research needs of various people, because most people in the department outside of the people that sit around here probably don't care about research needs.
MS. COLTIN: You know, honestly, if you read through the report, I don't even know if the word research appears anywhere in it. Most of the examples are operational examples.
DR. YOUNG: Just speaking from CMS, from somebody who is kind of big into the operational part of this, and not so much into the research, this is very important to us. I mean as we start talking about more paper performance, and that is now becoming a reality with the Premiere demonstration that just rolled out, those sorts of things. So, these issues become increasingly important to us.
The one thing that I want to get some clarity on, because the way we gain information in, and aggregate quality and performance data in is we look at it as kind of three streams, clinical streams, administrative streams, and systems streams. It has three very separate streams of data that flow in to make those adjudications on quite frankly, whether we value somebody performance at taking care of the beneficiaries.
Is there a move towards aggregating in this first recommendation, a move towards aggregating both the clinical and the administrative data together, and merging them? Is that conscious move?
MR. HUNGATE: I would say no.
DR. YOUNG: Because as we see the race and ethnicity, fine. But when we start seeing test results and vitals, and those sorts of things --
DR. LUMPKIN: I think probably the best way to describe this is that it is trying to -- as you look at pay for performance activities, the boundary between the clinical and administrative stream becomes blurred. Because now, whether or not they are doing hemoglobin A1Cs and giving beta blockers is going to determine their payment.
DR. YOUNG: In the first phase, in the process phase. The outcomes phase would be the second phase.
DR. LUMPKIN: Well, even then, because now you are going to want more of the outcome-related data, which is going to be somewhat related, not to the encounter, but to the span of care.
So, in the interim when we are not able to capture that data, if I am a provider, and there are four data fields I need in order to report on my quality of care, do you put them on an administrative form, or do you create a separate form to submit the data? And I think that's what is really reflected in that discussion.
It's saying can we, by adding two or three or four fields, enhance the administrative form, until we get to the point where electronic medical records makes the submission of this data much easier on the providers.
DR. YOUNG: That's our envisioned model, what we have in fairly quality where those spaces would be populated up to us. Medicare would be able to do the QIOs, where we can examine them and aggregate. But first the problem is that administrative data kind of comes to the carriers, and clinical data comes to the QIOs, and systems data comes to the QIOs. And we have to re-aggregate somewhere in the information system.
MS. GREENBERG: What is systems data? Is that like structured stuff?
DR. YOUNG: Patient satisfaction. Different kind of more soft indicators that we may use, wait times or availability, where clinical data is straight up clinical data. What's the blood pressure? Return to normal for a hypertensive, hemoglobin A1C, those sorts of things.
Clinical data are those very tangible things we know, and we see in many of the chronic care models. Administrative data of course are efficiency data. And then systems data tends to be everything else, because it changes with different sets, as you talk about different disease structures. But, if we move towards an aggregated data set, I think that that is a good thing.
MR. HUNGATE: I think we should be very clear about what is administrative data. Are administrative data and claims data the same thing? We use both terms.
MS. COLTIN: Well, administrative data includes both claims and enrollment data.
MR. HUNGATE: So, I think we need to be very definitive and very clear in what it is we are understanding, and where we see the limits, and how we see the transition occurring.
DR. YOUNG: It helps us structure our programming. And if we can tell you about our programming and how we look at things, and what our limitations are, because we have some fairly clear limitations --
MR. HUNGATE: Well, if I look at my job in Massachusetts as a payer for the state employees, our leverage is less than yours, but some of the problems are the same. We are not going to be able to use clinical data the way you will be able to . So, we are going to need some information in the claims side to help us bridge to asking the right questions.
So, that we need those things that let an episode be definable, the linkage, the who did what, the modifier diagnoses if there are such things. We need those things that let you look at the episode, because we are not going to get much beyond that.
DR. YOUNG: I think that we kind of have this separation between clinical data and administrative data now. And what I propose is that in the future, we see a merging of those two where we see one data collection, which I think is a good thing.
MR. HUNGATE: Which is the benefit of the electronic medical record. That's something that happens with the electronic medical record, and doesn't without it.
DR. YOUNG: Do we say that explicitly, I think is the question.
MR. HUNGATE: I think we should.
DR. LUMPKIN: Because the reason why I think we should say it is it makes it clearer to people who are working on the standards development committees why it is that we want to put this clinical stuff on what has been perceived as an administrative record.
DR. YOUNG: These are not going to go away. This is now a clear trend line in how we are going to start valuing health care services.
MS. GREENBERG: That was really the discussion that Arnie Millstein tried to engage the NUBC and NUCC on. And there was a reaction back that these are the data needed to pay a claim. And so, we don't want this information. This information is not appropriate. And then he came back with this pay for performance idea. This is what you are going to need to do to pay a claim.
So, I think this is the debate that is being engaged. But it's true, exactly what Kathy said, that people generally making decisions around the content of administrative data are representing that part of the organization that is really focused on paying the claims, and not on the quality assessment.
MR. HUNGATE: So, our report becomes a communicator of that information to a broader group.
DR. EDINGER: And it's also a good selling point when you are tying in quality with money and savings and outcomes, instead of just internal uses.
DR. JANES: And you've been hearing it throughout the committee, because this is what came up at that hearing in California in Populations.
MR. HUNGATE: So now, it seems to me that where we are is in the administrative data part that we have gotten where we started on recommendations. We've kind of got two content pieces that come out of that. One is the race and ethnicity discussion, which we had here, which I think almost has to be as complete in the report as it was in this discussion. So, the difference between observed and self-reported, et cetera, various views are captured.
And then it moves to the issues of test results, vital signs, those things that Arnie Millstein was pushing both in his early testimony before this group, and in his more recent testimony in other places. And that's the second content which relates to the pay for performance trend, which I think we should probably call out as an identified thing that is going on, and what it means in terms of the data sets, so that that's the way the recommendation is linked in the content.
Is that comfortable?
DR. EDINGER: Do we want to say in the case of the vital signs, that would be a very expensive data set, depending on what you want to put in there. Are we going to say that we should have it? Or do we want to recommend like in terms of the number of fields that should be available? Or some generalizable recommendation? How do we want to handle that?
MS. COLTIN: I think Arnie was talking about a very limited set of test results and vital signs that would be captured on the facility claim, and specifically the hospital facility claim. So, it wasn't this widespread, opening the door of saying in every office visit, you are going to submit all this test result information.
You could go there, but that's not what we was asking for. In the recommendations that we are putting forward, we were going further than that, in saying that there ought to be a test results field on the professional claim. And that it would be a situational field, so that if in fact with a particular payer there was a pay for performance arrangement tied to having the results of a particular test, then that field had to be filled in.
MR. HUNGATE: That might be critical for hemoglobin A1C measurement.
MS. COLTIN: But it could be payer-specific. You could be focusing on diabetes, and it could be hemoglobin A1C. Payer B could be focusing on coronary artery disease, and focusing on LDL cholesterol results. So, all I'm saying is rather than having fields that pegged to a specific test, the idea was to have sort of a triad perhaps of data elements that might say this is the type of code that we're going to give you for the test.
It's a CPT code. It's a category 1 or category 2 or whatever. This is the code for the test. And then this is the result. So, these three generic fields could be used to accommodate hundreds of different tests. But all you need are those three fields.
DR. EDINGER: I'm just saying if you have like say coronary artery disease and diabetes, you probably need multiple places to enter that information.
MS. COLTIN: Well, it's a loop. The way they are doing in the electronic it's a loop, and you repeat it as many times as you need to. But it is three data elements, and they get repeated.
DR. YOUNG: I'm very comfortable with this type of recommendation, because if you actually talk with Arnie and start questioning him about details, it gets very, very fuzzy very quickly. And putting in a recommendation that is loose like this and letting it develop, I think would be more beneficial.
MS. GREENBERG: It's kind of creating the infrastructure to accommodate relevant clinical data for the case in question.
MR. HUNGATE: Susan, do you have enough to deal with that? Have we made that clear enough in our discussion?
DR. STEINDEL: I think the other thing is in the discussion we need to tread lightly about where to exactly put this information, 837, in NUCC, in NUBC, a claims attachment, because that is going to cause a lot of discussion. And what we want to try to avoid is getting the idea across, and letting it avoid, and not freeze because this SDO is claiming well it's administrative data, it's going to go in this field. And this SDO is claiming it's clinical data, it's going to go here. I think we want to move past that.
MR. HUNGATE: Sounds good to me.
DR. LUMPKIN: So, it's a situational recommendation, not situational fields.
DR. STEINDEL: The issue about the NUCC and NUBC is the NUCC right now is undergoing a large discussion about revision the "form." And I asked them why are you revising the form? Because it's electronic. Well, they actually gave a very good answer. They said that a lot of the input systems that are used in physician offices actually display the form, and the information is put in from the form. So, they want to revise the form so it more matches what goes into an 837, so that physician office systems can now be upgraded.
It was an interesting reason, and to me, it struck me as a valid reason. I'm not saying it was a good one on a bad one. I'm just saying it was a valid one.
MR. HUNGATE: I feel a lot more comfortable filling out my tax form if it looks right.
DR. STEINDEL: Yes, and that's the same experience.
MS. COLTIN: Well, and also, that's the difference between what you are doing when you are filling out tax forms online, and you reach a certain box, and you put a certain response, it can actually spontaneously create the new form, Schedule C now, or Schedule A, and put that information in.
And I think in a way these paper form discussions are simply ways of representing a lot of the fields that are on the 837, but in a way that in an office practice management system is sort of generating new forms electronically. Because it's not all going to print out on the same form if you were to try to generate a hard copy version.
MR. HUNGATE: Can we see if we can move on and see how many other pieces of the administrative data recommendations fit back in within the framework of these two sets that we have got so far, the race and ethnicity, and pay for performance content. Does that make sense?
MS. KANAAN: Yes. My assumption is there will be some other categories. Like functional status you wouldn't put --
MR. HUNGATE: Right, and that's down farther in the administrative data. Next to the last is the functional status. So, that's a place that we need to pull out.
I don't know about the other places in the administrative data here, whether they link to what we have already done, or whether they are moving to a different section.
DR. STEINDEL: Primary language might.
MS. KANAAN: Yes, that's right. And there is another one about secondary diagnosis. It was interesting to me that this other structure that I was kind of playing with last night, where there are content issues, standardization issues, and linkage issues, where we discuss some standardization issues and some linkage issues in this category of administrative data, which seems to me to suggest that this other structure may well work.
MR. HUNGATE: It seems to me that test results, vital signs, add indicator field, linked procedure code all are within the pay for performance discussion that we have just had. Now, I'm not sure about the next two.
MS. COLTIN: I think pay for performance is kind of a background discussion that belongs in the paper as sort of setting up a way of doing these recommendations. Sort of saying that we are not talking about a research environment here. We are talking about data that is used for operations to support functions that are carried out both within payer organizations, and within provider organizations. And that in fact, are now migrating into payment systems, and forms of compensation based on quality performance. And I think that's more the set-up for a lot of these things.
MS. KANAAN: In fact, this section hasn't been completely developed. But we actually had a short section on trends on page 7 in the background section, and that may be the place to introduce it. I don't think we mentioned that. But we could add to this list of trends, which may get discussed a little bit further, this pay for performance trend.
MR. HUNGATE: I would like to try to get through all the recommendations in the time that we have got, which means I'm going to push us a little bit in moving forward.
MS. COLTIN: I think it would be very helpful for me if rather than going through and discussing every recommendation first, if we could simply start by going through and saying which buckets do we want to put this recommend into in a reorganized format. We have already done that for some of them. We've said, okay these tests and test results, race/ethnicity belong in the content section, because we are talking about new data elements.
Which of them belong in the standards section, which of them belong in the linkage section? And then let's go through the content section and go by these one by one.
MS. GREENBERG: Part of that is content, bringing in information about function status. But if there are systems that collect functional status now, they collect it differently. So, it's a standardization issue.
DR. YOUNG: Instead of saying research here, the importance of using and collecting the data. And then indicator more research is needed to determine --
MS. GREENBERG: That's true, how to standardize it, and what needs to be collected, and how to agree on standard ways of collecting it.
DR. YOUNG: We should take out the word research.
MS. GREENBERG: I agree.
DR. YOUNG: It's needed, it's used for performance measures, but it needs to be standardized. Discuss that in a separate place.
MS. GREENBERG: Well, there is a case where if you build the case, attach it to the recommendation, then the case really comes out of the functional status report. But what that report said was that it wasn't really -- like the use of ICF -- it wasn't really ready for prime time.
Now, there has been a major report, which almost broke down my printer the other day trying to print it out, that has been done by the people at the Mayo Clinic for ASPE on some aspects of functional status data collection in long-term care. I printed it out. I haven't read it yet, but I think it's relevant to this particular topic. So, there is some of this research already being done.
I think again, it is important to put it in that context of you actually need this for outcomes or risk adjustment or various purposes.
MS. TRUDEL: The term research for DISMOS(?) is like a hot button. The more this can be related to operations and reimbursement, the more people will find that it is relevant.
MR. HUNGATE: We are dealing with assessing and improving quality.
DR. YOUNG: We actually had a discussion about this just yesterday, kind of that gray area between research and operations. And just to use another industry term, this is research and development work. This is really what this is. This is what Medicare demonstrations are. This is really that merging between those two areas.
Operations is those people in the here and now, who are just doing this everyday. Research is kind of developing these databases, and research and development is that area in between. So, pay for performance right now, I would say is still research and development, going more towards operations every day, but still research and development.
MS. COLTIN: Well, that may be true within CMS, but it's an every day reality in my health plan.
DR. YOUNG: Pay for performance?
MS. COLTIN: We've been paying for it since 2000.
DR. YOUNG: I mean like Bridges to Excellence that's coming out, pay for performance, I would call that a significant research and development event at GE and Verizon.
MS. COLTIN: I'm telling you in Massachusetts, at least three of the health plans that I'm aware of have active pay for performance programs, and have been paying providers based on these kinds of data for at least two years.
DR. YOUNG: This is fine. I can only speak for our small little purchaser.
MS. GREENBERG: How are you gathering the data?
MS. COLTIN: With difficulty, because that is a problem. I think what has happened is it has limited us in what types of performance we can pay for, because we are not able to pay on the basis of outcomes, because we don't have the data. So, we are paying on the basis of process measures, but we are choosing those where there is a tight link to outcomes. But we would prefer to pay based on outcome, but we don't get the test results data, so we can't.
MS. KANAAN: I did some of this exercise that Kathy wants to do. I did it tentatively last night to see if works. So, the content issues I have are race/ethnicity, test results, vital signs -- I'm just putting this up here to see if this expedites it -- secondary diagnosis, functional status. Local and state level data -- is that a content issue? That's one of those gray areas.
MS. COLTIN: Where is that?
MS. KANAAN: Well, it's the one where we had a lot of text. Sample at the most appropriate level necessary.
MS. COLTIN: That's surveys.
MS. KANAAN: See, we're saying we're not organizing this in terms of data.
MR. HUNGATE: Let's try to organize this filling of the slots by going sequentially through the bullets page-by-page. Susan is ahead of us, but I think we are going to need a discussion of the categorizations as we go in order for it to settle.
MS. COLTIN: I agree. And some of them may appear in more than one. For example, the discussion we just had about functional status, I can actually see there is a research and development component that belongs under standardization. How should it be coded? But there is a content of well, once you've got it, where do you put it?
MS. GREENBERG: And there is even collecting it where it isn't currently collected.
MR. HUNGATE: Let me be a little rigid in my moving us here, and move us to line 856, because I think the ones of that, we have dealt with. I'm on the one that was in the packet today, page 27, line 865. Promote standardization of coding for common data elements that span care setting administrative data sets.
MS. KANAAN: I put that here, coding.
DR. YOUNG: That would probably go across both electronic and administrative data.
MS. KANAAN: Susan, I don't think you sent me the version that you sent Debbie, because my numbers are all different.
MR. HUNGATE: Are the sequences the same?
MS. KANAAN: The line numbers may be different.
MS. COLTIN: I have a recommendation beginning on line 894.
MS. GREENBERG: In our version it starts on 841.
MS. COLTIN: Okay, so something was taken out.
MR. HUNGATE: Let's just get ourselves calibrated to the same point.
MS. COLTIN: I'm there. So, it's the subheading called "Core Administrative Data."
MR. HUNGATE: Right. Promote standardization of coding, we just categorized under standardization. And the next one there is accelerate creation of CPT category 2 codes, performance measurement codes where appropriate.
MS. KANAAN: Wouldn't that go under content?
MR. HUNGATE: It seems like it's content.
MS. COLTIN: You know, I think that's a standardization issue, because of standard codes. We already have CPT codes. We are not talking about adding new data fields, unique content and new data fields.
DR. YOUNG: With CPT codes you should use that kind of an argument.
MS. COLTIN: Yes, but when you are talking about the coding set itself, that's a standards and code sets issue to me.
DR. YOUNG: You are not saying use it, you are basically saying create it.
MR. HUNGATE: Why are we saying we should do this? Why should we accelerate the creation of CPT codes, category 2 codes?
MS. COLTIN: The CPT category 2 codes are a set of CPT codes that were created specifically to support performance measurement, as well as tracking new technologies. So, they are codes that would allow a provider to tell you for example, that I didn't immunize this patient today, so I'm not submitting this code to be paid. But in fact, this patient had this immunization three weeks ago at the public health clinic.
So, it helps you to capture relevant history that is needed for a performance measure. And it allows you to identify someone who perhaps should not be included in a performance measure because of some past event like status post double mastectomy is someone who wouldn't be in a mammography denominator, for example.
So, those are what those codes are intended for. They actually thought about creating codes that could represent some of the vital signs and lab tests. So, the represent an alternative approach to creating data fields for lab tests and vital signs. Because you could have a CPT code that says the value for the code itself is blood pressure above 140/90, blood pressure below 120/80, or blood pressure between those two values.
DR. JANES: Are any of these in use yet? Kathy, you say accelerate.
MS. COLTIN: Well, there are some that have been submitted. There were requests that were submitted. I think some of them were approved. And I also think this is the route that CMS is promoting with the AMA physician consortium as a means to collect a lot of quality measures in the Doctor Office Quality Project.
MS. GREENBERG: Now, on the use for the like vital signs and test results, I know what someone like Clem McDonald's reaction would be, and probably correctly so, that the best thing to do is really get the value. And then you are not having to have one version that is over 140.
DR. YOUNG: It gets to validation as well. The merging of those two is much easier.
MS. GREENBERG: What you are saying is there is this capacity actually to create standard codes. So, I see that relates to standardization, but it's really a content issue, because it allows you to capture more content that you are not able to capture currently. So, I would put it in both.
MS. COLTIN: And then it gets you into the discussion that you just started to have as which is the more appropriate way to collect that content. If the content is a lab result or a vital sign, is the CPT category 2 code the better way to collect that content, or is creating a new field for a lab result the way to do it?
MS. GREENBERG: And again, I don't think this committee should get into those weeds. I think it should identify what is needed, and why it's needed, and what some of the options might be, and then throw it back to the experts, and Kepa has entered the room now, so I look at him, who have experience in what would be the best way to really do it.
MR. HUNGATE: I want to argue a little bit for making the standardization being driven by the content. In other words, that our emphasis is on the content that is needed, and where it requires a standardization effort, we call that out.
MS. GREENBERG: You know what that reminds me of, Kathy? It reminds me of your camera with Liza, that vision. That you don't just start standardizing things, you figure what do we need to know. And you come down to finally, well, what is the standard for knowing it.
MS. COLTIN: Right. And I absolutely agree with your suggestion. I think the way I tried to do this in Section 3 is lay out the problem. And now what you are saying is in the recommendations, when we see that there is more than one approach to solving that problem, we should just lay out some of the options we see.
And our recommendation is that those options be explored, and that the problem be solved, not necessarily that one or the other of those options is our recommendation.
MR. HUNGATE: Well, stated. I think that is very apropos of the problem.
MS. GREENBERG: And I also think maybe if we push for some either documenting pilots that are currently going on, or doing more pilots, and probably both, we'll probably get a better reception than just saying get all this onto everybody's records. That's what we were trying to argue with Arnie, and I know he wants this yesterday, rather than tomorrow. But I think you need demonstrations, both on the feasibility of collecting the information accurately, and then the fact that people will really use it.
DR. YOUNG: Just a recent example. As we negotiated on the Premiere Demonstration --
MS. GREENBERG: Is there information on that somewhere?
DR. YOUNG: The Wall Street Journal.
MR. HUNGATE: Okay, I want to move on.
DR. YOUNG: Validation was the issue with that. And it was trying to merge those two between that CPT 2 codes and the actual data. That was a real operational hurdle, how do we do this? Who does this? Where does that reside? And it actually goes to the discussion we had earlier about merging those data sets. At some point having that vision.
MR. HUNGATE: Okay, we have taken about an hour roughly on the first half of the recommendations. And we have 20 minutes to do the rest of them, because I refuse to not have a cup of coffee before I go to the full committee.
Moving right along, primary language I think goes to the race and ethnicity discussion.
MS. GREENBERG: But again, I see that recommendation as for enrollment. And wouldn't you have the same problem that you have with race/ethnic, that if you can't link it to the enrollment file?
MS. KANAAN: The linkage issues I think are going to cross-cut, and we'll say that. The linkage issues pertain to many of the --
MS. GREENBERG: But why are you saying race/ethnicity in the claims transaction, and primary language and enrollment?
MS. KANAAN: Are we saying that?
MS. COLTIN: Yes, we are saying that. I think that when you start getting down to what is the argument for it, and why is it you need it, the issue is more identifying a population in advance of a service context, as opposed to within the service context.
I mean when somebody is there coming in for a service, you know what language they are speaking. And I'm not sure what value it is having it on the claim, and using it retrospectively. No one in any of the testimony talked about using primary language retrospectively.
MS. GREENBERG: Okay, it's more of a service delivery.
MS. COLTIN: It's prospectively. What language should I send this survey out to the person in?
MS. GREENBERG: Or do I have a provider who speaks his/her language?
MS. COLTIN: What kind of educational literature should I send to this patient?
DR. EDINGER: I think you make the same argument for the electronic medical record. You would like to know ahead of time to use a translator or something.
MS. COLTIN: So, if it's in the registration system or the enrollment system, then it's there for prospective use. And that is mostly what we heard about with prospective use.
DR. LUMPKIN: We may want to flip this issue back to the Population Subcommittee. One of my concerns is to what extent do providers have access to enrollment data when the patient is coming? So, if they don't, then it doesn't help with service planning.
MS. COLTIN: I can only speak for Massachusetts environment, but I think almost every provider in Massachusetts that has a computer, has access to online enrollment information for any patient that comes through their door who has insurance.
DR. JANES: Coming from where, Kathy? From the payer?
MS. COLTIN: Yes.
DR. JANES: We are just winding up a big study in Michigan, a fairly sophisticated state, working with the three big automakers and their health plans. And the automakers send the enrollment files to the health plans. And the health plans take off what they want, and that does not include race/ethnicity.
MS. COLTIN: We're not talking about employers now. We are talking about providers. And if I'm a doctor in the office, and a patient comes in, I need to determine their eligibility. In other words, is this even covered. And most of them have online eligibility determination. And the information in that eligibility record is the enrollment information.
DR. JANES: Yes, but that's what I'm saying is that that information comes from the payer, and the payers aren't picking it up.
DR. LUMPKIN: So, the question is, are we talking about the right form? In other words, it should be on the enrollment form, but maybe it also is -- and Kepa will probably tell me -- there is a transaction for determination of eligibility, isn't there?
DR. ZUBELDIA: Yes, and there is a transaction for enrollment, and there is another for determination of eligibility. The Michigan problem is very common, that the payer will receive the enrollment information, and they only keep in their files, part of the enrollment information. For instance, the segment that contains the race and ethnicity, also contains citizenship status. Most payers don't care about that. They don't keep it in the records. They don't keep race and ethnicity in their systems. Some do, some don't if there is not a requirement to keep.
Also, the HIPAA information, because it's designed between employer and payers, and it's not really designed as a health care information transaction, but it's an enrollment into the health plan, has the old X12 race and ethnicity element. And it is one element that happens once. For race and ethnicity, that doesn't work.
MS. GREENBERG: Aren't they trying to change that in the X12?
DR. ZUBELDIA: It's going to be changed in the future versions with the new composite segment that has race and ethnicity, and you can repeat it. But currently under HIPAA, this doesn't work. It's the old concept of race and ethnicity all combined into one.
MS. GREENBERG: And duplicative also in overlapping categories, redundant categories.
DR. ZUBELDIA: And with very few columns. There are like 20 columns.
DR. LUMPKIN: So, if we are going to have any impact, then it needs not only to be in the enrollment, but it also needs to be in the verification.
DR. ZUBELDIA: The eligibility verification, and the requirement of the two. If it is going to be required, it needs to be required in both, so it is maintained.
DR. LUMPKIN: Right, exactly.
MR. HUNGATE: The mechanics of how we proceed with us and the Population Subcommittee are how?
DR. LUMPKIN: I think we probably have enough discussion here that we could include that in our recommendations. But it's a little bit more refined.
MS. COLTIN: Are we now saying enrollment and eligibility transactions? Is that what we are saying?
MR. HUNGATE: Yes.
MS. KANAAN: For both race/ethnicity and primary language?
MS. GREENBERG: I think we are talking about primary language.
DR. ZUBELDIA: I would say they both roll together. The things that don't change from encounter to encounter, and the things that can be collected just once.
MR. HUNGATE: So both. Now, can I go to the next page?
DR. ZUBELDIA: I'm sorry, I missed half the meeting. But on this first page, I see some things like giving procedure code to providers. That is already in all the HIPAA transactions. Every single procedure code is linkable to a provider.
MS. COLTIN: That's true in the 837 institutional?
DR. ZUBELDIA: If they send the information, it's true. The way the provider information works, the instructions in the implementation guides say that if the rendering provider is different from the billing provider, then it needs to be reported as rendering provider for the clinic.
And then on the service lines, it says on each service line, on each procedure code, if the rendering provider is different from the one reported at the claim level, then the rendering provider on that line must be reported.
MS. GREENBERG: So, it actually allows you to --
DR. ZUBELDIA: It not only allows, it requires you to report the rendering provider for all services, either as global rendering provider for all services, or as individual providers for each one of the services.
MS. COLTIN: What I think we are struggling with is that what we were trying to address with this is the ability to link a procedure to an individual clinician. And what we are seeing is that the codes that are being used, because we don't have a national provider identifier, are often a tax ID, or a clinic, or a billing entity for a provider organization.
And when you get to the individual procedure level, it's that same code. So, you can't figure out if it was Dr. Jones that did this out of the 20 different doctors in that clinical.
DR. ZUBELDIA: No, that's not how the system works. If you look at the implementation guide, and look at the strictly required data elements, you could derive that conclusion. But, the reality --
MS. TRUDEL: Effective this coming October.
DR. ZUBELDIA: Yes. The reality is that the rendering providers are identified by UPIN today, until we have a national provider ID. And the UPIN is assigned to the individual practitioner.
MS. COLTIN: Okay, so you are saying the rendering provider field contains the UPIN value?
DR. ZUBELDIA: There are two elements. There is one called the primary provider ID that contains some sort of general tax ID for the practice. And then the individual UPIN would be sent as a secondary provider ID. But practically speaking, if you don't send the UPIN, the payer will refuse to pay. So, the providers are always sending the UPIN in every time.
MS. GREENBERG: I wonder if the problem is that on the paper form, the UB-92, you can't make this linkage.
DR. ZUBELDIA: On the paper form, you can send the UPIN without having to send the tax ID.
MS. GREENBERG: But can you associate a UPIN with each service?
DR. ZUBELDIA: I believe you can, on the service line on paper.
MS. COLTIN: That is something we need to confirm, because that is the problem that was identified to us, an inability to identify a single individual who delivered the service.
MS. GREENBERG: Actually, Todd Ogmanson(?), I think is still here. We can ask him.
DR. ZUBELDIA: He will be here this morning.
And there may be a problem with terminology, because sometimes it is called rendering provider, sometimes it's called performing provider. And there is a slight terminology difference, and if you ask the question too narrowly, maybe you get a wrong answer.
MR. HUNGATE: Okay, so that is a verifiable thing. We may also be seeing something about records from earlier studies where the problem has been discovered, and records that would now be different.
MS. GREENBERG: You are saying what the 837 allows, a lot of people weren't using it. So, this is something that needs to be verified.
DR. ZUBELDIA: Another bullet, if you don't mind, just for my education. An indicator field -- to flag certain diagnoses that were present on admission.
MS. GREENBERG: That is already in the standard.
DR. ZUBELDIA: The standard now has a primary diagnosis, a secondary diagnosis, and an other diagnosis. And there is also principal diagnosis, and there is an admitting diagnosis. Those are different qualifiers that you can use for a diagnosis code. And you can say this code is the admitting diagnosis. These are secondary diagnoses, this is the principal diagnosis.
Now, you can say this is the admitting diagnosis, this is the principal diagnosis, and this is the secondary diagnosis. I don't know what it means to say these are the secondary diagnoses that were present on admission, and these are the secondary diagnoses that were not present on admission.
MS. GREENBERG: It's trying to differentiate between complications and co-morbidities. And actually, it is in the standard. It's not in the current HIPAA implementation guide, but it is in our Public Health Data Standards Consortium reporting guide, because at least two states already collect it in their hospital discharge systems, California and New York.
So, the problem is if you can't differentiate between something that was present on admission -- and there is an option I think, don't know -- and something that occurred during the admission, then you can't differential co-morbidities and complications.
DR. ZUBELDIA: So, I don't know what the solution to that is. It would be a simple change to the implementation guide, when you say this is the admitting diagnosis, to be able to give more than one. But today you have the ability to give the admitting diagnosis, and the principal diagnosis, and as many secondary diagnoses as you want.
MS. GREENBERG: But that flag for secondary diagnoses is already in the standard, the 837 standard.
MS. COLTIN: It's assigned to the discharge diagnoses. A lot of claims systems, a lot of payers don't keep the admission diagnosis, or don't even take it. Because it's the discharge diagnosis that is used for the DRG payment systems and all. So, it is really looking at these discharge diagnoses, and saying which of these were present on admission.
MR. HUNGATE: Qualitatively, it's important.
DR. ZUBELDIA: So, the problem is not with the transaction, as much as it is with capturing the data in the first place. Capturing the data, and keeping the data in the hospital in the first place. The transaction, I think today only accommodates one admitting diagnosis, but could be easily tweaked or changed or accommodate as many as you want admitting diagnoses.
MS. COLTIN: I'm not sure you want to deal with the admitting at all. This is a flag for the discharge diagnosis.
MS. GREENBERG: This flag already exists for secondary diagnoses in the transaction.
DR. ZUBELDIA: Well, if you want to identify iatrogenic events, you need --
DR. LUMPKIN: Yes, but they are not just iatrogenic events. If you have a person who comes in with an acute myocardial infarction, and you want to know whether or not this hospital does a good job in treating people with acute myocardial infarctions, then you need to do some risk adjustment.
And it makes a different on whether or not they are admitted to the hospital with pulmonary edema, or they develop pulmonary edema while they are in the hospital, on how you judge their performance.
DR. ZUBELDIA: So, the biggest issue I think is having the hospitals keep that data.
MR. GREENBERG: Well, the record has to be clear about it. Obviously, if it isn't there, they you can't record it.
DR. ZUBELDIA: The infrastructure to do this is already in place. It would have to be in the implementation guide for this chapter in reporting that would reflect this. It's a ten second change. It's very easy to make that change in the implementation guide. You have two sets of primary and secondary diagnoses, one set for admitting, one set for discharge. That would be technically very easy.
The problem that I see is capturing the data in the hospital. So, I don't think you need to add fields, not to the 837.
MS. GREENBERG: No, the infrastructure is there.
DR. ZUBELDIA: And the indicators are there. So, the language that says here add indicator field to the NUBC 837, I don't think that's a problem.
MS. GREENBERG: Well, again, the question is whether you are talking about the paper, because the NUBC paper does not accommodate it. Again, I don't think we should be pushing for paper, certainly not in the institutional environment. It cannot be accommodated by the paper. It can be accommodated by the institutional.
MR. HUNGATE: Which means that the machine that does that has to have some way of allowing that, some form on the screen.
MS. GREENBERG: The problem always with paper is real estate. There isn't room.
DR. ZUBELDIA: These CPT category 2 codes, probably you could have a separate qualifier. Right they are qualified as CPT codes, and there is also another qualifier for HCPCS codes. And there is a new qualifier for ADC codes. And you run into conditions where you have a code, and you don't know what code it is unless it's qualified. So, my recommendation there would be to create a CPT category 2 code qualifier for the standard.
MS. COLTIN: And that's because it looks different?
MR. HUNGATE: Kathy, repeat your question.
MS. COLTIN: I'm wondering, if I were told that what's coming in is a CPT code, what is the added value of knowing it's a category 2, rather than a category 1 or a category 3 code? Has anybody else asked for that?
DR. ZUBELDIA: There is no category 3. There is either category 2, or the old style CPT codes. And the problem you run into in the HIPAA transactions is that there is no distinction between and HCPCS qualifiers.
MS. COLTIN: Oh, I see.
DR. ZUBELDIA: So, you need to know it's a CPT, and it's not a HCPCS.
MS. COLTIN: Okay. So, this becomes a two part recommendation. So, it allows you to add an additional relative value on the code indicator fields, as well as proliferate more of the particular category 2 codes?
MS. GREENBERG: You want to do both.
MS. COLTIN: Okay, thank you. That's helpful.
MR. HUNGATE: Well, we have run out of time, and we'll have to figure out how to deal with that. There are a couple of things I wanted to bring up rather quickly.
The NHII Workgroup is going to have a panel discussion around the personal health records on August 7, as part of their next meeting. That's the afternoon of August 7. Given our interest, I would encourage all who can, to attend that. And if we end up with a lot of attendees there, then I think we ought to try to use the morning of the 8th to work further on this content.
How many calendars would permit that? Just a quick show of hands? I think mine could do. August 7 afternoon is the hearing on the personal health record.
Let's just see, and we'll look at who can do that. Gracie will play field general on this one, and straighten it out. And then if it's practical to do something on the morning of the 8th, we'll do it. If it isn't, we won't.
You know the other dates of the meetings, September 23-24, November 5-6. It's likely we're going to need a conference call I think to look at language in between the 7th and the September date. I don't think we ought to try to do anything other than do a conference call.
In other words, if we are trying to do another pass on the report for the 23-24, we need more face time on the 7 or 8 if we can do it. If we don't have that, then we are going to have to figure out some other way. But at least we need some reviewing of language and opportunity to talk.
MS. GREENBERG: I will say if I can't be there on the 8, -- I can't be there on the 8, but if there is a new version of a document to review and everything, I certainly will get my comments to you for that.
DR. HOLMES: Any consideration of a call in July in preparation for August, or no?
MS. KANAAN: I don't think Kathy is very available in July.
MS. COLTIN: No, I'm really not.
MR. HUNGATE: I think this is going to be enough work for them to do. There is enough that has gone forward here.
Okay, thank you all.
[Whereupon, the meeting was adjourned at 10:00 am.]