[This Transcript is Unedited]
Hubert H. Humphrey Building
Room 425A
200 Independence Avenue, S.W.
Washington, D.C. 20201
DR. COHN: -- abbreviated meeting of the session of the Subcommittee on Standards and Security of the national committee, anyway, I think as you all know we are on the internet so we need to speak clearly and into the microphone, also to help those who are on the internet as well as aid those who are doing minutes from these meetings. I think we need to at least briefly do introductions around the room. I'm chair of the subcommittee, I'm Simon Cohn, the national director for health information policy for Kaiser Permanente. Maria?
MS. FRIEDMAN: Maria Friedman, CMS, staff to the subcommittee.
DR. ZUBELDIA: Kepa Zubeldia with Claredi Corporation, member of the subcommittee.
MR. HOUSTON: John Houston, University of Pittsburgh Medical Center, member of the subcommittee.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Healthcare Research and Quality, member of the subcommittee, staff to the subcommittee, excuse me.
DR. MCDONALD: Clem McDonald, Indiana University, Regenstrief Institute, member of the subcommittee.
MS. GREENBERG: Marjorie Greenberg, National Center for Health Statistics, CDC, and executive secretary to the committee.
DR. STEINDEL: Steve Steindel, Centers for Disease Control and Prevention, staff to the subcommittee and liaison to the full committee.
MS. AULD: Vivian Auld, National Library of Medicine, staff to the subcommittee.
DR. HUFF: Stan Huff with Intermountain Health Care and the University of Utah in Salt Lake City, member of the subcommittee.
MS. PICKETT: Donna Pickett, National Center for Health Statistics, staff to the subcommittee.
MS. LEON-CHISEN: Nellie Leon-Chisen, American Hospital Association.
MS. PROPHET-BOWMAN: Sue Prophet-Bowman, American Health Information Management Association.
MS. CLAUS(?): Linda Claus, AHIMA.
MS. ZIGMAN-LUKE(?): Marilyn Zigman-Luke, AAHP/HIAA.
DR. BICKFORD: Carol Bickford, American Nurses Association.
MS. ADAIR: Jared Adair, CSC.
MR. KILE(?): Frank Kile, American Dental Association.
DR. COHN: Okay, well now I think those of you who may be referencing our agenda will notice that our 2:30 to 3:45 sessions reviewing letters I think is sort of a non-issue, and I think we've just had our break so we don't need to take another break now. Similarly my understanding is that CHI is not coming to us today with presentations and indeed it looks like we may be having as many as 12 different domain areas coming forward to us in December for final presentation.
Yes, Kepa?
DR. ZUBELDIA: [Comment off microphone.]
DR. COHN: With the finals being done, the final three in January, it's hard to know.
Really what I wanted to spend I think a couple of minutes, once again I think we will get done, if we aren't done by 5:15 somebody has, we maybe need to look at ourselves, but I wanted to spend a couple minutes talking about the agenda for December and seeing what we want to do as well as talking just for a couple minutes about the January hearings and how that is moving forward.
Anyway, in December I think it's very clear that we're going to spend probably a full day on the whole, on the issues related to CHI and going through their recommendations. We may even have to spend a little more then that but given the speed at which, or the way these things are being presented and the way we're having the ability to comment on them, it sounds to me like it's around a full days worth of presentations, discussion and decision making.
Now that does lead us with some time on the second day and I know that I think Jeff, you're here Jeff, right, good, and I had been talking and let me just sort of bring this up and see how we want to organize it and what we want to do, is to try to have a session, and maybe as much as half a day, talking about claims attachments, talking about the issues of CDA and how all of that, both how that works together as well as CDA potentially independent as another piece of architecture related to PMRI. Now given the press of events we really have not had a chance to talk about this or think about how we might want to structure that period but I want to sort of bring it up, see what thoughts people have, and what might make sense in terms of that discussion.
Kepa, it looks like you wanted to comment?
DR. ZUBELDIA: Well I think CDA and claims attachment is very important given that there is proposed rule that will be coming out soon --
DR. COHN: Is it spring now?
DR. ZUBELDIA: Soon.
DR. COHN: Jeff?
MR. BLAIR: Do we have any update, I mean we did hear that they were hoping to have a claims attachment rule out January or February or March, in which case they're probably fairly well along on it and should we be hearing from Stan Knockensome(?) on that as well as probably from the CDA Technical Committee within HL7 because they, they've been working on that with ASC X-12-N? I mean I just, I guess what I'm trying to think of is that they're probably so far down the road now in what they're doing I'm not sure if we entertain something that is not consistent with where they already are.
DR. COHN: Maria, is this confidential or --
MS. FRIEDMAN: We're really, we're expecting the provider identifier final rule, it's actually on the regs publication date for December 26th of this year --
MR. BLAIR: Provider identifier.
MS. FRIEDMAN: Who knows? And claims attachment is spring.
MR. BLAIR: May?
MS. FRIEDMAN: Maybe.
MR. BLAIR: Well, then let me ask you this, so in other words if we brought in folks that gave testimony on a little bit broader basis it's not so close to your deadline that it would be disruptive if you got new information from our hearings.
MS. FRIEDMAN: No, I don't think so, and I think there's still plenty of time for input and I think the input would be appreciated. In fact I think this is a very good time to do it before things get too locked down in the process.
DR. ZUBELDIA: I think that we probably would benefit from a training session on CDA for the subcommittee members and I don't know if the training session would be during one of our meetings or perhaps at an HL7 meeting or some other venue, but it would benefit us to have a good training session on CDA and claims attachments before the rule comes out or the proposal comes out.
DR. COHN: And by training session do you mean a hands on boot camp or do you mean like an hours worth of background --
DR. ZUBELDIA: Maybe an hours worth of background and a good understanding and tutorial of what's coming. We had a presentation like that on the previous version of the attachment with the LOINC booklets and the X-12 structure and how everything fit together and a refresh of that presentation with CDA I think would be beneficial.
MR. BLAIR: Let me be candid about what I was thinking of when you heard the long pauses with my comment, I don't know whether the ASTM, HIMSS, CCR activities has anything that they would want to tell us that would relate to a claims attachment document or not, I don't know the answer to that. But if there's time I'd just like for us to check to see whether they feel they have something to say.
DR. COHN: Well, I don't think I have any objection to that, other thoughts on this? I mean it may not be exactly on point but I don't think we'd necessarily give them an hour, I presume it's 20 minutes or something like that?
MR. BLAIR: This is my thinking, okay? I think the answer is going to be no and that they're more interesting in other broader CDA issues that where they work with CDA where we're looking at clinical documents, so I think that's going to be how it's going to turn out, it's just that I didn't want to preclude if they were, if they already had some progress on the claim attachments that they wouldn't be heard.
DR. COHN: Clem?
DR. MCDONALD: I know we have a response exactly to that except that there's been work for about four years in HL7 with CMS and I mean all the sort of the players and I guess just some understanding of who the players would be because it could just end up with nothing, confuse everything if there are competing activities that don't have any connection. And who are the players working on the one you were just talking about, as well --
MR. BLAIR: That's kind of what I was trying to say, Clem, is that to my knowledge the CCR activity does not explicitly have work for claims attachments, I just didn't want to close the door in case they were doing something. If they were then I think we should give them a chance to be heard, but I think they're going to wait to want to be heard when they're, when we're looking at clinical documentation.
DR. COHN: Well, so Jeff, is the question for us to ask them, is A, what are you doing, and B, do you have anything that you're doing that's relating to claims attachments?
MR. BLAIR: Exactly.
DR. MCDONALD: Well, can we just ask that without, and then decide whether you need a hearing? You're talking about a hearing now.
DR. COHN: Well, I was talking about them potentially participating as part of the session, but certainly that sounds like probably the germane question. Carol Bickford.
DR. BICKFORD: Carol Bickford, American Nurses Association, what I'm hearing in this discussion is that we're moving forward with the way we've always done business and making sure that we have the tradition encompassed, and I'm asking if the committee is going to be thinking about new ways of doing business where we're looking at an information system that is integrated, that has standardized terminologies, that we're writing once, using many times, is the claim attachment sort of something that needs to go away. I'm just asking the committee to be thinking about new steps, new actions, and I don't know if this is the right place, but what's the future? I mean are we just doing it because we've always done it that way? Do we have any opportunity to begin thinking about doing business differently?
DR. COHN: Jeff do you want to comment?
MR. BLAIR: Carol, in this case I think that we, I don't think it's so much a matter of whether NCVHS can choose a new direction at this point in terms of whether or not we do claims attachment because one of the HIPAA directives to the NCVHS and for HIPAA was that there be a claim attachment standard, so my understanding is this is a responsibility that we've been designated to address. Correct me anybody else if we have more discretion or if my understanding is wrong --
DR. COHN: No, Jeff, I agree with you. Clem?
DR. MCDONALD: It's the 10th one specific in any of the law. But on the other side of it, and I'm not as up to date on it as I used to be on exactly how it's working and all, but the rough logical goal is that it does just pull stuff the way it would have come to the system and I think the major big change is if they happen to be scanning documents instead of entering them you can send a scanned one much more easily then one in the previous version, so that the structures, if you're asking for lab results, they'll look a lot like the lab results you got in an HL7 message. I think there is a reuse part to it that's pretty strong, but I think Kepa's suggestion to have sort of a presentation and catch up with it would be very important.
DR. COHN: Yeah, I think what I'm hearing at this point is doing in December is probably an hours worth, assuming somebody is available to give us an hours worth, but we need to ask and I don't know whether it's X-12 or HL7 or claims attachment, Kepa do you know the --
DR. ZUBELDIA: I think it could be either one but probably somebody like Wes Rischel(?) or Maria Ward that chair the groups would probably be the best presenters for that.
DR. COHN: Okay, so basically just an in depth review of what exactly this --
DR. ZUBELDIA: And I would ask them whether they can do it in one hour or two hours or what's the time they need to make a proper presentation.
DR. COHN: Yeah, I think it would also be useful to have, I mean once again, we've got X-12 and HL7 working together on all of this stuff and whoever is, we need to have I think independent comments probably from both about their views of how things are going. And probably the question is is there anybody in the industry who either has issues, is ecstatic about it, or has any sort of opinions about how all this stuff might be or how it all might work, just so that we're aware if there's any sort of issues that are likely to be coming down the road once this things gets released. Clem?
DR. MCDONALD: From my past experience with it I think there's implicit issues, and I don't know they're there, and basically the issue is there's sort of, it's the defense and the offense in a battle and there's certainly clinicians think that the attachments are often used just as a way to delay payment, and the payers believe they want freedom to ask any possible attachment because we they have to do it for their fiduciary duty. So the challenge is what you'd like to get out of the standard would be a way where everyone knew both sides of the game. When we ask this is what we can ask for and this is what it means in a computable way, that would be sort of the end nirvana. But since both sides, this won't necessarily be a perfectly happy thing. But I think it will be better then what it is now.
DR. ZUBELDIA: There was a call last week to the industry by a payer in New York to start a claims attachment pilot and they were asking for vendors, clearinghouse, and providers to participate in a pilot with them, so some in the industry are already aware of this and they're starting to move even before there is even a proposed rule. I think that probably the biggest issue is that most of the payers and providers, except for institutional providers, are not only not ready they're just not even aware of what the implications would be. And all the payers that I've talked to about claims attachments they're saying well, we'll see what happens when the rule comes out. I know that from the technical perspective it's going to be a huge problem for translators and clearinghouses and all of that because of the size of the messages and I don't think they're prepared for this. So there will be issues to address, there's no question about that.
DR. COHN: Do you have a name that you can give Maria for about that pilot test?
DR. ZUBELDIA: It's Empire Group of Blue Shield, and Maria did participate in an Empire pilot back about seven or eight years ago on claims attachments, Maria Ward. Maria is not with Empire, I think it's Marilyn Bushman(?), I can look at the email and tell you what it is.
DR. COHN: Okay, because I think that would be an interesting thing to hear about in the context of all this.
DR. MCDONALD: One other tension between sort of the, I'm not trying to, don't overhear this, I mean over weight this, but sort of the, medical informatics types I guess including people like me would like to get the structure data so it would be just, it would be all part of the thing we're aiming for. But the practical reality is that the scanned documents are much more accessible and feasible and increasingly being viewed as, you know you scan your document for billing and I'll just keep it as a medical record for you, so there's some other kinds of opportunities, the scanning makes it a lot easier for a lot of environments and is very popular with some of the, some constituencies but you may have people pushing back because they don't want it scanned, because we want to get to that ideal. Personally now I think it'd be best to have what works best, so if you can scan, you scan, if you can't you do the other things.
DR. COHN: Jeff, do you have a comment?
MR. BLAIR: Every time somebody asks a question and you wind up pondering about it and thinking about it, and Carol's comment, can I ask Carol a question? Carol are you here? We probably don't have the latitude to wind up saying no, that we can even say we're not going to take a position on claims attachments as a HIPAA attachment. I think we're locked into that. However, you raise this issue and I think there may be thoughts or groups and I don't know what thoughts or groups or ideas are behind your comment, is it something where you or some group that you can think of, you think should be heard at the December session to kind of go on record in terms of your thoughts about alternatives?
DR. BICKFORD: No, my question was focusing on how quickly our technology is evolving and the significant changes we've seen just within the last six months to a year referencing, for example, the ICD-10 letter, the PMRI letter, thinking about the critical mass that we have with NHII and CHI, looking at doing business better, differently, talking about the integration of systems and reporting structures and standardization and messages. So I'm thinking about it from a standpoint of business redesign, reducing costs, increasing quality, having information available, the patient component pieces, so if there's any group that would be looking at this from the big picture it would seem to me that it would be this committee and NCVHS who have sort of the lead on helping us move forward with the NHII and the CHI. And it was not intended to make it not an option because if it's in the law it's in the law, but you can certainly explain in the law that it's old law and we need to replace things. I'm just raising it from the standpoint of helping us move from the way we've always done things, which may not be the best way now that we have resources available to help us move that.
DR. STEINDEL: Carol, when I heard her raising the points made some very, very good points and I agree they really don't apply with respect to the claims attachment because we do have a responsibility under HIPAA to produce the claim attachment and the NCVHS has a responsibility to review that process. But to get to the other side of what she is saying about changing the way we're looking at the system and what is occurring as we move the clinical terminology structure forward and the clinical messaging structure forward and the administrative terminology and the administrative messaging forward, the two of them are eventually going to have to merge in some way and as Carol said we should start thinking about how that is going to occur, it's going to occur within the confines of CHI within the federal government, it's part of what's coming out in the electronic health record recommendations that are being developed from HL7, and it's eventually going to wind up here.
DR. BICKFORD: It's sort of like the saying that if you want to predict in future invent it, and we're doing some very important things at this point in time inventing the future, so a think about for this group is one thing we don't have in our country is a common vision and that's sort of, I mean we have the NHII now, which is sort of like, and the CHI, so how can we leverage that most effectively in the work for this subgroup as well as then bringing it to the NCVHS full committee perspective.
DR. COHN: Sure, good point. Stan, do you have a comment? You've been quiet. Of course I haven't been looking over there, so you could have been raising your hand vociferously.
DR. HUFF: No, I wasn't raising my hand, I agree, when I'm quiet it's because I'm agreeing with what's being said, I agree that it'd be great to have a tutorial on CDA and the plans for the claims attachment. I think it's clearly mandated in the law, I think to try and address some of Carol's questions, I mean one thing that we could ask when we get into hearings is say can you imagine other scenarios that would work better then what we're planning, in other words, I mean I was trying to think what are the alternatives, the alternative would be I've got my electronic medical record and you have permissions to see certain parts of it to justify and so what you're doing is allowing web access into your system to justify, I mean I'm just thinking, I'm thinking what the alternatives, I'm thinking outlandish things outside the box kind of to think about how this, but I mean you could ask those questions, you could ask the people do you see alternatives to claims attachments that would be more cost effective, more --
DR. COHN: Well I think there's probably two questions, I mean one is the one that you just asked, the other is probably the more mundane one, which is what sort of redesign, what is your vision of how the business would work even if you had electronic claims attachments, which is I know a much more mundane vision but one that we have not been able yet to have, much less any of these other pieces, so maybe there's some ways to ask, for example Maria or someone like that to talk about that a little bit. Linda.
MS. CLAUS: If I may, Linda Claus, AHIMA, this is a topic that our membership has begun to buzz about, I think you can well imagine that if we have a claims attachment standard that calls for imaging portions of the record and conveying it that way that in some ways what we've done is substitute the portable Xerox machines for imaging and we haven't really done anything to restrain or support the minimal necessary concept, so I really do think from a real major operations standpoint we need to explore where this going. And if it's the best alternative for today then as Carol and others have said just make allowance or find a way to move from that technology forward as quickly as we can because it will be an enormous impact on the industry.
DR. COHN: It sounds like your organizations is volunteering to testify in December, am I --
MS. CLAUS: We'd be happy to quantify what the impact will be from a personnel standpoint.
DR. COHN: Thank you.
DR. MCDONALD: Just a comment, that is exactly the tension because the original one didn't allow, the very first draft did not allow any imaged documents, or almost none, and the forces kind of came to another equilibrium that encouraged the structured one but allowed more imaging and I'm not sure how much --
MS. CLAUSE: I'm not either, but I'm just saying I think that it would be a very worthy topic for some exploration in December.
DR. COHN: Thank you. Jeff?
MR. BLAIR: I have a quick question.
DR. COHN: For us or for --
MR. BLAIR: And part of what I'm thinking of is related to the work of the Continuity of Care Record Group, that's the HIMSS ASTM Mass General piece, and so the claims attachment kind of blurs over on that because the clinical document architecture is such an important piece of that so my thought is if we're going to wind up basically moving on something which is making a decision on clinical document architecture then I do feel that we need to hear from CCR from the standpoint that, and I'm going to use my words here, not everybody might agree perfectly with this, but the clinical document architecture is consistent with HL7 and it's kind of structured in many ways from the standpoint of the headers and the sub-headers and then the text within it, so it's kind of focused from the top down where CCR also using XML and work within that context and complement it and tends to be working from the bottom up but since it's working from the bottom up not only would it be compatible and complementary to the HL7 work efforts within CDA but it also could be independent of them as well. So if our hearings extend beyond claims attachments to looking at clinical document architecture from the standpoint of clinical documents then I do think that it would be appropriate for us to get a tutorial on both CDA and CCR.
DR. COHN: I worry about your term tutorial --
MR. BLAIR: Maybe tutorial isn't the right one.
DR. COHN: An update or short presentation --
MR. BLAIR: I was picking up on Stan's comment.
DR. COHN: When I think of tutorial I think of an hour, I'm thinking more like if we listen to CCR it's more like 20 minutes, but I think an update and a better understanding I'm fine with. Stan?
DR. HUFF: Could you clarify, Jeff, the relationship between CCR and your employment? Because I don't hear, I mean CDA is a standard open consensus process and I hear a lot in the industry about that and adoption and CCR I really only hear it from you and Peter and other people, so I'm nervous about elevating it to the same stature as an open independent standard.
MR. BLAIR: Well, Steve, actually I have attended one meeting, actually wasn't even a meeting, it was a presentation of it, and I think Steve and Mary Jo Deering maybe could answer your question better because I haven't been closely involved in it.
DR. FITZMAURICE: Well, let me just jump in and say that my understanding is that it's an ASTM standard under development.
MR. BLAIR: Which HIMSS is collaborating with and the Mass General Society has been working with also, but I think Steve has attended some of the meetings --
DR. STEINDEL: No, I've actually just attended the one meeting that you attended, Jeff, but I do think a clarification is a little bit in order because I think we're throwing around some terms that need to be a little bit better defined. There is CDA and there is claims attachment, and there is the use of CDA in the claims attachment. And CDA itself is a very complex evolving subject within the standards community and CCR actually fits into that evolving structure of CDA in the sense that a CCR document as it develops as a standard within ASTM can be transmitted as a CDA document. So from that point of view there's a compatibility, but a lot of the basic clinical documents can be transmitted as CDA as its evolving. But CDA as part of the claims attachment is more limited, and I think what we're really asking for is not education on CDA but education on CDA as it's being proposed for use within the claims attachment, and that defines the scope down. And where it would fit in with something like CCR in this point of view would probably be that you can create a CCR document on paper and you can scan it and you can send it as a claims attachment if it's appropriate.
DR. ZUBELDIA: Steve, are those claims attachments that have been defined under HIPAA the initial six attachments or is that just as a conceptual future claims attachment?
DR. STEINDEL: That's one thing I would like to hear because I haven't heard the details of the claims attachment, the proposed change. What I'm hearing is that there will be, basically what we're looking at is a level one CDA document, which is a header and then a body section, and the body section you can put a scanned document in, or you can put in the type of HL7 structures that were proposed for the claims attachment in the previous manifestation --
DR. MCDONALD: Just a clarification --
DR. STEINDEL: And Clem is probably going to be better --
DR. MCDONALD: Well, again I'm not up to the last minute but it's all XML, but there would be the same, it would be like an HL7, analogous to an HL7 RU(?) message and the hierarchies and the connections and the tables, the independent tables that defined what was an attachment for, and those attachments, those are not changed, they're independent tables on one they're independent tables on the other and that really controls the questionnaire or what's in the claims attachments.
DR. ZUBELDIA: And they're based on the same RIM?
DR. MCDONALD: I'm not even sure RIM is an important dimension of claims attachments, these weren't RIM, these are actually specific, this question number one, question number two, these are the answers exactly as decided by the committee, those same questions and answers so you got how far was the ambulance from, this has nothing to do with the syntax, this is sort of the contact, how long and far did you drive, why'd you pass the nearest hospital, for the claims attachments for ambulance, there's 14, 15 questions with the answers all specified, questions all specified, the optionality specified, it's really more like a questionnaire in these fixed kinds of attachments. And that hasn't changed, at least not in relationship, there might be a slight evolution of what's required and not required because of some change in CMS but that hasn't changed because of this conversion to version two type styles, to an XML style, which lives within the CDMA strata style. And CMA is RIM based but I don't know RIM very well.
DR. COHN: Steve?
DR. STEINDEL: Kepa, the way I'm envisioning the new manifestation of the claims attachment working is the CDA itself we would learn consists of a header that tells you what type of document you're transmitting and that's where the ambulance claim LOINC codes and stuff would appear. And then there's demographic information that's defined by the CDA and also defined by the HL7 message structure, but there's demographic information. And then there is a body part of the CDA document and what you can put in that body part is a scanned document so if you were sending an ambulance attachment and you had a standard ambulance form you used in your institution that answered the questions that are appropriate you could scan that and put it in the body text and send it as a CDA document and that would be your response to their request for electronic information for claims. But as Clem points out there's also been developed question and answer styles using LOINC, so you say what you're answering and say how far the ambulance traveled, etc., and what I'm not sure about is how that goes into the new version of the claims attachment because under the rules of CDA you can add it either as ASCII text or in the form of an XML message.
DR. COHN: I usually feel pretty versed in CDA but this conversation I'm trying to go along hmmm, causing me to rethink this a little but. I suspect that next year we will be getting in a deeper level into this whole CDA issues. In December I think we obviously need to keep it pretty well circumscribed to the claims attachment piece because otherwise it's going to be a day and a half hearing on CDA along. Now I do understand, I think though Jeff's feeling some tension trying to figure out geez, how does this all relate to that other activity, which I think is a very valid question, and I don't have to the answer to and I think that for example what we might ask if we wanted for example to invite or have somebody testify from the HIMSS CCR activity it really should be around this issue of the claims attachment standard and the CDA and is there anything there that is conflicting with the work that they're going to do or issues that they have about it. Because that's really what the more immediate issue is, is like geez, is there anything that they're doing here that down the road or whatever somehow interferes with what they want to do or do they have an opinion about and so it becomes sort of a responder/testifier relationship to that --
MR. BLAIR: Could I just add one --
DR. COHN: Sure, Jeff.
MR. BLAIR: I don't think it's, at least in my mind it's not whether it conflicts, it's whether it complements because that's my understanding, that it would complement.
DR. COHN: Okay, well, I think that would be the question for them. I think also that there probably needs to be a wider discussion of CDA and clinical utility, I think somehow maybe in March, I'm just looking at January as getting pretty full certainly with CHI and everything, we've got a bunch of things listed here. But somehow it's sort of the same and it's sort of like an introduction in December, but sort of like begin to get a deeper look about how all this plays out.
DR. MCDONALD: Sorry, getting back to Steve's point, if you ask people to give you a tutorial on CDA you'll get it. If you ask people to give you a tutorial, explain attachments, you should get what you need to do to understand all the pieces of it and there's an X-12 piece and there's, I mean there's a couple important pieces to this thing.
DR. COHN: And there are certainly business issues that I think we need to explore.
DR. MCDONALD: Question and response and I think the focus on the attachment direction and we could all of us, none of us know the elephant well enough to --
DR. ZUBELDIA: I think there's three different topics, one is the CCR that I'm trying to understand where it fits, the other is the CDA, independent of attachments, and then the topic of attachments, and in the topic of attachments the last time I heard about it they had defined six attachments and they were going to be part of the first round of HIPAA and I think there's like nine more that they have in the pipeline and if there are subsequent attachments they need to be brought up to a DSMO and the DSMO would have to say this is an attachment that becomes part of HIPAA or not. But I think that has nothing to do with the CDA or the CCR, it's a completely different track, so if the CCR has something that they're going to automate and that could potentially become an attachment I think the venue for them would be to go to the DSMOs, and have the DSMOs recommend that whatever they have done becomes a HIPAA attachment. I think there's two different, very different things.
DR. COHN: I don't know that CCR is, I think we need to figure out a little more about that, I don't know that CCR is a claims attachment, or if it it would cause me to think very differently about what I think CCR is doing --
MR. BLAIR: The presentation that I got, their focus appeared to be referrals and consults and discharge summaries, that's what they seemed to be focusing on first, I'm kind of just mentioning it just to make sure that, they had claims attachment on the list but I don't think it's something that, well, I don't want to, I just don't want to preclude somebody if they --
DR. COHN: Sure, I'm fine with that. Steve?
DR. STEINDEL: Basically the way I understand CCR and one way you can just view it is it's another clinical document, like a history and physical could be looked at as a clinical document, the CCR is a clinical document, for a specific type of medical information that needs to be transferred. In this particular case the first model of the CCR is the medical information that the Massachusetts Medical Society has agreed to provide to other providers when a patient moves from one provider to another, it's just a clinical document in that sense. They're working on expanding, one of the things that they found out was when people became aware of this Massachusetts document other people became aware that it could be extended to be used for the same purpose.
DR. COHN: And I guess my point here is is that I feel uncomfortable hearing from second and third parties what this thing is without somebody who really knows what it is here to tell us. My question for December is does it have anything to do with claims attachment and if they think it does we should hear from them about how it relates otherwise we ought to be talking about it in the context more of clinical utility of CDA type documents and all of that into March. And so that was really the only, from my view that's really the pregnant question, and I can't answer it and I don't think you should answer it, Steve, but you'll raise your hand anyway.
DR. STEINDEL: I'm responding to your statement and I'm asking you a question back, do you think we'll be here, we'll hold other discussions in the future with regard to claims attachments, and this is just our preliminary one, or is this going to be it?
DR. COHN: I don't know.
DR. STEINDEL: I would suspect that we would probably be holding some more in the future.
DR. COHN: Well, we might, I mean I think certainly we'll be hearing more on CDA including the utility, I'm pretty certain into next year. Whether or not we have more on claims attachments depends on what issues we discover when we hold the hearing in December on claims attachments.
DR. STEINDEL: That's why I think we should probably just focus the hearing in December on the claims attachment and the CDA with its role in claims attachment and find out from that hearing if we need to include other parties in subsequent hearings. Because I think if you ask people do you want to be part of this hearing they're going to say yes.
DR. MCDONALD: How busy is that day? Is it a light day?
DR. COHN: Well, I think that CHI we know is day one, day two right now is --
DR. MCDONALD: This is the 9th of December?
DR. COHN: Something like that, CHI might go off into day two, too --
DR. STEINDEL: We're looking at 12 domains in CHI in December, on final reports.
DR. ZUBELDIA: On final reports I think we need to allocate easily 45 minutes to an hour per domain on final reports.
DR. STEINDEL: I mean some of them are going to be quick and some of them are going to be lengthy, but our experience has been is Kepa's right, we should allocate between 45 minutes and an hour.
DR. COHN: I think we have somewhere between a two hour block to a four hour block for this thing.
DR. STEINDEL: For CDA.
DR. COHN: Yeah.
DR. STEINDEL: Yeah, that's what I'm thinking.
DR. COHN: For claims attachments.
DR. STEINDEL: A day and a half on CHI.
DR. COHN: Yeah, or a day and a couple of hours basically is what potentially, and then the question is is do we, is a single session or is it a double, two session.
DR. ZUBELDIA: At this point I would not bring the CCR to the plate at all, I think that if there is a need to look at CCR we can look at it later as part of attachments or whatever we need to look at, but at this point I don't --
DR. COHN: Jeff, I'm sorry.
MR. BLAIR: The only thing that I was asking for is if they feel that they're part of the claims attachment solution, whether it was ASTM or Peter Wagerman(?) or whether it was DIECOM or IEEE or anybody else, I just would not feel comfortable saying that we don't want to hear what they have to say on this issue. I suspect that they're going to say that they're not part of this issue, I just didn't want to preclude giving them the opportunity if they say they are part of this issue.
DR. COHN: And clearly what you're saying is that this is the issue, claims attachment, CCR is not the issue.
MR. BLAIR: I don't think so, I just didn't want to preclude it so I wanted to give them the opportunity for us to check and it doesn't have to be me, Simon, if you want to check or Steve or Kepa, just verify, whatever, or Maria, whatever, check with ASTM and HIMSS --
DR. COHN: And let's sort of move beyond this discussion for just a second, are there other groups that we ought to be hearing from? I mean we've heard CMS, CMS, I think we have one of those to my left --
DR. MCDONALD: Social Security had been exploring the same mechanism, I don't know where that stands.
DR. COHN: How they use claims attachments? There going to use CDA maybe.
DR. MCDONALD: No, they were going to use, it's the syntax is kind or irrelevant, it's just a way to define questionnaires, they're a lot like templates, but that's what defines what has to be sent and so they were, I don't know where it stands but for getting the disability reports. I don't know if they're doing it or how far they are but --
DR. COHN: Is there anybody around claims attachments that we ought to be --
DR. MCDONALD: They wouldn't call it a claims attachment.
DR. COHN: Yeah, I know, that was sort of my point.
DR. FITZMAURICE: What about Blue Cross/Blue Shield? They've had a lot to say before, they might have something to say about this. I would give them an opportunity --
DR. COHN: I'm reminded, the gentlemen from Southern, no not Jim Daley Reynolds --
DR. MCDONALD: Weren't you going to talk, invite Empire? Involved in the pilot?
DR. COHN: That's true, so that might be a --
DR. ZUBELDIA: And from that email, it's from Marilyn Bushman with Empire Medicare Services. And I sent you both a copy of her email.
DR. COHN: I know you are nodding your head, was that American Hospital Association or was that --
PARTICIPANT: I'm sure they would want to have something to say since we do have to provide a lot of --
DR. COHN: Well, I think we're getting pretty filled up here pretty quickly. I guess the other question will be is trying to figure out how all the times slot fit in all of this and how much time CHI, I mean I'm feeling a little gun shy with CHI at this point only because it's, they've not been real good at meeting all of their deadlines and having things ready for sessions.
PARTICIPANT: I think we'll have at least one day of CHI, it's the question of spillover into the second day.
DR. COHN: And we can figure that out, yeah, and that's really what I'm saying is whether everything will be ready and I expect we'll be seeing something late January. Carol?
DR. BICKFORD: Carol Bickford, American Nurses Association. We've been talking about some of the players in this initiative for the claims attachments, are you going to be talking about the decision makers who use that information and what constitutes the minimum data set of information that has to be transmitted?
DR. COHN: No.
DR. BICKFORD: So I'm, okay, is that something that this committee is going to be talking about in the future sometime?
DR. COHN: I think it's all part of what's in the documents.
DR. MCDONALD: It's all defined. I can't quote by verse but that's what the standard is, the draft that they're working on.
DR. COHN: That's how I think getting to what you're talking about, I mean it's not an explicit conversation about the decision making but it's more a review of, see where the agreements have come in terms of what --
DR. MCDONALD: Well, I mean again, I can just talk about these content parts, there's two kinds of attachments, one of them are the ones where it's a specified form more or less, you got to answer these questions, and they get all the parties together, they've done this through the five standards groups, and say one of the things that was a neat thing that came out of this ambulance one they used to ask did the patient get hospitalized, they asked the ambulance driver, well, they don't know, and so they took that question off and I thought that was pretty good, that was progress when they had all this dialogue. It's really the payer and the provider issues, so the ambulance companies are the ones that are submitting --
DR. COHN: Okay, well I think with this sort of information I will ask Maria, can you, I know we're done with ICD-10 now for the moment, so we've got, is that something you could --
MS. FRIEDMAN: You mean there's life after ICD-10?
DR. COHN: I hope. Is this something we can ask your help in terms of contacting some of these people? Okay, and we'll obviously work to try to put something together, which will be obviously somewhat constrained by what CHI is going to do and I guess we'll get a better take on that. Also I want to, after having had three day hearings for the last 12 years, at least it seems that way, I really do want to get people out at a reasonable hour for a December meeting --
DR. ZUBELDIA: Oh, I thought you meant today.
DR. COHN: Well, we will get people out very quickly here today, too. That will be the next step after this.
DR. MCDONALD: I just want to clarify, it is December 9th? Because that's not on my calendar, it's on this piece of paper so I'm assuming that's what it is. December 9th and 10th.
DR. COHN: Okay, let me give you, let me pull out my magic book, this one is all day December 9th and half day plus or minus on December 10th.
Now I have sort of a comment that we're, January seems to be that one hearing date, does seem to be filling up doesn't it, if we're adding a third day, not our fault. But I think as we've talked before for January and you'll have a chance to talk about this in December also, obviously we have security, which will be a half day on the first day, whatever is left from CHI, assuming there's something left from CHI to discuss, the DSMOs want to come and give us a yearly update, and I think we ought to try to have a conversation with them about improving the process. And I think we'll at least pull out a little time potentially for dentistry, dental content discussion, just to sort of see where the various players in dental content area are. I think that will certainly fill up the day and a half and certainly if we go the third day we'll have the second day be a full day also at that point. So that's what we've got.
Now, comments, other things we're missing, other things that people want to talk about? Should we adjourn early? Your choice. Adjourn early, I think Kepa, no Kepa doesn't want to adjourn --
DR. ZUBELDIA: No, I do want to adjourn early but there is, at some point the contingency planning will start to fade away under the HIPAA transactions and I think we need to get some reports probably from payers and clearinghouses as to how things are going, I don't know how much time I would devote to that, probably an hour or so, and CMS, there's a rumor out there on the street that CMS will start the contingency planning on January 1st, and CMS has clearly said that they're going to monitor how things are going before making that decision. But there is that rumor, so I think at some point we need to kind of have an opportunity to hear from the payers and clearinghouses and perhaps providers how things are going.
DR. COHN: Do you think January is a reasonable time for that or too soon?
DR. ZUBELDIA: It's probably too soon.
DR. COHN: Well, we'll be hearing something from the DSMOs is why I was referencing January, I guess it depends on whose ending their contingency plans when. You know we heard Texas was at the end of December.
MS. FRIEDMAN: Right, but they're the only ones we've really heard from, it's very unclear who's going to be turning off the switch when and what lead time they're going to be giving to do that. I mean it's one thing to say we're going to turn it off and then we're going to turn it off three months, six months, whatever from now. So at this point I don't know if we have enough information to even make that call.
DR. COHN: January is a long time from now. No, I mean I think it's really a question of whether, I think Kepa's right that checking in January to sort of see how things are going with all that, and I think that will flow into the conversation.
DR. ZUBELDIA: And we probably ought to periodically have an opportunity to talk to even the same payers and clearinghouses to get a status report as to how they are doing and kind of monitor through that sort of sample.
DR. COHN: Carol.
DR. BICKFORD: Carol Bickford, American Nurses Association, there was a comment when we had the full committee talking about the public health component of our recognized terminologies or code sets or whatever, is there going to be any further work at the subcommittee level talking about what are the gaps, what needs to be refined, how they're fitting together, how terminologies can be expanded or included be it ICD-10 or through SNOMED or whatever, is that going to be part of the discussion?
DR. COHN: Well, Steve, it looked like you were going to have some conversation with Population Subcommittee weren't you? On this? I think from my view I would first of all say that I'm a, I don't mean to, well, I'm not even skeptical or cynical but it's just trying to figure out what exactly public health terminology really means or what the terminology needs of public health are as opposed to every other sector of health care. I'm curious to see what you and that group will determine.
DR. STEINDEL: The issue that's coming up from a CHI point of view of the Population Health Reporting Workgroup, which I'm chairing, the conclusion that we've come to is that it's going to be very difficult to recommend a terminology or terminologies to use in that area because this is an extremely diverse and complex field. And so what we are probably going to do is recommend that we study the issue further and since this issue crosses over into population health statistics, which is one of the areas that the workgroup from the CHI point of view has identified as an area that needs to be addressed, is how can the migration from clinical terminologies to the presently used classification systems to the longitudinal history on health care statistics be preserved. I wanted to discuss that in particular with Vickie to see what her reaction was and then eventually after we make the CHI recommendation, which will be rather quickly as you can see from the timetable, I would like to get that into CHI before the first of December. It obviously will not be a very well fleshed out thorough recommendation but it's probably part of the conversation will be at the NCVHS level, where should this be further pursued and we will probably suggest that it be brought up in the executive committee at NCVHS to find a home for it.
DR. COHN: Well, what goes around comes around. Okay, I mean I think certainly a definition of the area would be probably very useful and I'm sure you'll be working on that.
DR. MCDONALD: I think it's all of medicine and clinical care and nursing plus, I mean there's just, it's completely overlapped, and so if you're reporting on a communicable disease it's lab tests, if you're reporting on mental health it's DSM, who knows, DMSA or it's surveys or it's depression scores, or it's initial assessments, so I think it very much overlaps it's just how you add it up and report it.
DR. COHN: Good point.
DR. STEINDEL: Yeah, that's where the issue comes in, and how you add it up is not just a simple statement.
DR. COHN: Okay, other comments? I see Kepa is getting ready to, Kepa is getting read to adjourn, anybody else have any other issues coming before the subcommittee today?
Well, I want to thank you all for extraordinary work, three days in Washington last week I think has created some deliverables that we can be proud of. In honor of that I think we will adjourn early today and see you tomorrow morning.
[Whereupon at 4:00 p.m. the meeting was adjourned.]