The Subcommittee on Health Data Needs, Standards and Security of the National Committee on Vital and Health Statistics was convened on Monday, September 8, in the Sheraton City Center Hotel in Washington, D.C. The meeting was open to the public. Present:
Barbara Starfield, M.D., Subcommittee Chair
John R. Lumpkin, M.D.,
M.P.H., Clinical and Administrative Standards Work Group Chair
Simon
P. Cohn, M.D., M.P.H., F.A.C.P.
Kathryn L. Coltin, M.P.H.
Kathleen
Frawley, J.D.
Vincent Mor, Ph.D.
Clement McDonald, M.D.
George
Van Amburg
Marjorie Greenberg, Executive Secretary, National Center for Health
Statistics (NCHS)
James Scanlon, Executive Staff Director, DHHS
William
Braithwaite, M.D., Ph.D., DHHS
Bob Moore, Health Care Financing
Administration liaison
Lynnette Araki, NCHS
Judy Ball, Ph.D.,
ASPE
Gail Janes, Ph.D., CDC
(Note: Documents pertaining to this meeting can be found on the NCVHS web page at HTTP://ASPE.OS.DHHS.GOV/NCVHS/)
The Subcommittee on Data Needs, Standards and Security met in the afternoon and evening of September 8 to cover a full agenda related to HIPAA standards and the Subcommittee's work plan.
Ms. Broseker reported on the status of the PayerID and the changes that were made in response to the Subcommittee's comments at its April meeting. Much of the discussion focused on the use of sub-IDs within legal entities, an area that they and the HHS representatives agreed requires further work. Another topic of discussion was the relative merits of numeric versus alpha-numeric IDs. Following the discussion, the Subcommittee agreed to recommend that the PayerID NPRN be published for public comment.
In response to the full Committee's comments on its draft letter on security, the Subcommittee discussed how to clarify terms, stress the importance of security, and strengthen the thrust of the recommendations. Ms. Frawley was asked to prepare another draft, and it was accepted later in the meeting with a few amendments.
The group was briefed by Ms. Mary Emerson on the recommendations of the HHS identifiers implementation team, and by Dr. Solomon Appavu on his report commissioned by the National Committee. The team, which felt strongly that it should recommend a unique universal identifier for individuals, decided to recommend the ASTM UHID for that purpose and the use of the Social Security Administration (SSA) as the trusted authority for administering it. Subcommittee members stressed the need for cost-benefit analysis of alternatives, including the alternative of having no identifier. They also discussed the need to get input from industry about the various options. Members had fairly different reactions to the report. Dr. Lumpkin, whowas the Work Group's liaison to the implementation team, stressed the deliberative nature of the process and its reasonable outcome. Dr. Cohn asked for convincing evidence that a unique identifier is needed to accomplish the complex linkages for which it is intended. He also expressed concern that the two reports fail to clarify a set of principles on the basis of which sound decisions can be made. Dr. McDonald and others asserted that if the policy issues around having an identifier can be resolved, it would be clinically useful to have one.
Members were in general agreement that privacy and confidentiality protections are a precondition for any kind of unique identifier, and that this stance is consistent with past NCVHS recommendations in this area. They also agreed that the Subcommittee needs more time to review the two reports and to talk with industry about its reactions to specific options. Out of the discussion emerged a sense that the best course of action was not to recommend any identifier at this time.
As they worked on a letter for submission to the Committee, the following issues received attention:
Once these issues were resolved, the group asked Dr. Braithwaite and Dr. Cohn to prepare a draft letter for presentation at the next day's NCVHS meeting.
The Subcommittee discussed the need to develop recommendations on a process for adopting new standards, testing new methodologies for standards, and revising existing standards. Because of the complexity of this area and the number of interests at stake, it was agreed that this discussion merely begins what is likely to be a lengthy process of investigation.
An SDO representative expressed concern about the implications of this discussion for the revision processes already underway in SDOs. In response, HHS representatives and Subcommittee members noted the need for industry suggestions on how to allow trading partners to test new systems without undermining the standards by creating a loophole. The group agreed to return to this topic in the context of the work plan discussions.
Ms. Humphreys briefed the Subcommittee on the work of the HHS Implementation Team in this area. The group discussed some of the likely ramifications of the proposed changes in codes, about which they were generally positive, and the kind of issues that are likely to surface during the comment period.
They also discussed the data dictionary, with Mr. Mayes noting that it is becoming clear that the data dictionary effort has far-reaching implications and that it may be one of the most important things to come out of the legislation. He invited comments from the Subcommittee about how to make the dictionary more accessible.
Members expressed concerns about the clinical utility of the dictionary in its present state, citing the core data element recommendations as a reference point. They also commented that it is very useful to have the dictionary and to be able to see all the fields in a database. Mr. Mayes asked for the Committee's comments on what approach would be most fruitful and sustainable. In particular, the Department needs the Committee's thoughts about the broader implications of data dictionaries and registries and the approach that makes the most sense in terms of the big picture. It was noted that the effort needs to be compatible with and supportive of the work toward the computerized record.
Ms. Stahlecker briefed the Subcommittee on the work on claims attachments. The draft standard is scheduled for release in October 1998. Relating this to the timetable of the K2 Work Group, Dr. Lumpkin noted that the Work Group plans hearings on attachments in the winter, featuring payors and providers. The questions for the hearings will be developed at the Subcommittee's November meeting. The Subcommittee asked Dr. McDonald to work with Dr. Blair on preliminary questions for the hearing, and to serve as the K2 liaison to the attachments group.
Ms. Ball briefed the group on a draft outline for the annual report required by HIPAA on the implementation of standards. She suggested using the report to highlight the Committee's special concerns, notably the importance of privacy legislation. Other topics that were suggested for special highlighting were security and the Committee's sense that other initiatives such as birth certificates should be coordinated with HIPAA standardization activities.
Dr. Braithwaite asked for discussion of methods for monitoring implementation, and Ms. Coltin suggested hearings and website announcements as two ways to elicit comments. Ms Ball mentioned that the Faulkner and Gray survey is a source of information on the extent of EDI, and it was noted that they should be informed so they ask informed questions. Ms. Greenberg observed that some potential public sector users of standards, such as public health agencies and community health centers, either might be incorporated into the Faulkner and Gray or might be handled by a hearing or other means.
The Subcommittee agreed to develop its longer-term work plan after new members are added. They agreed not to hold any hearings in the fall and to decide on next steps after the CPRI terminology conference. They reaffirmed plans for a winter hearing on attachments. They agreed to ask for a briefing by John Eisenberg to the full Committee, as well as a discussion of issues of security, standardization, content and coding related to vital records.
Ms. Broseker reported that the latest draft of the PayerID responds to the four issues raised by the Subcommittee at its April 15 meeting. Members reviewed the relevant NPRM.
One of the questions in April related to high-level enumeration. Ms. Broseker said one ID will be assigned to each legal entity, defined as a health plan or health care entity. Separate legal entities within a health plan's business structure will get their own sequential PayerIDs. A registry will assign the numbers. A decision was made to give numbers in sequence, despite the problems that ensue from that, after the industry indicated its comfort with associating a number with a specific plan. It is understood that any inherent intelligence in the numbers will be temporary because of changes in ownership and other factors. The sequencing makes it possible to tie affiliated entities together under a health plan.
In response to a question, Dr. Cohn was told that a plan is defined as a separate corporation with its own employee identification number. Ms. Broseker also explained that the PayerID replaces both positions in the UB-92 and the NSF for payor/insurance identifiers.
The group spent some time talking about the use of sub-IDs within legal entities. Dr. Zubeldia said that private industry needs a way to identify specific units within legal entities, and clearinghouses need to know how to route claims. Dr. McDonald stressed that the number must serve industry. The group agreed that these are problems that need to be addressed in the developmental process.
Ms. Broseker added that if an entity is purchased or goes bankrupt, its number is retired and a date is hooked on the retirement time of the number. If the company is purchased, it gets the ID of the new company. Regarding another issue raised by the Subcommittee in April, Ms. Broseker said it will be possible to determine the relationship between ERISA plans and third party payors. The identity of dental, visions, drugs and long-term care plans are also now included in the system.
Dr. McDonald asked why they planned to use numbers only when the ID could be shorter by using some characters. He was told using exclusively numbers is easier on the keypads. The possibility of going to alpha at some point has not been ruled out. Dr. Cohn said WEDI has determined that it could tolerate some alpha-numeric if it were clear where it started and might spread from. He called the current approach a judicious one. Ms. Broseker said more comments from industry are welcome and will be considered.
The Subcommittee tabled this topic and returned to it later in the meeting. At that time, Dr. Starfield noted that if it feels its questions have been adequately answered, the Subcommittee could endorse publishing the NPRM for public comment.
Dr. McDonald observed that one remaining issue concerns the routing sub-ID; another question is why the structure of the ID was chosen. Dr. Zubeldia said the latter comes from the fact that an ID with all numbers can be included in a magnetic stripe.
It was moved and seconded that the Committee approve the National PayerID as a nine-digit number, recommending that the option be reserved to give consideration to making it alpha-numeric in the future, and in addition, that there be some available place for routing the information for subunits of an identified payor. It was clarified that the routing mechanism will not be part of the PayerID. Dr. Lumpkin observed that subunit routing could be accomplished through more granular use of the PayerID or other means; but the Subcommittee should not try to solve that problem. He added that this issue should be addressed following the comment period for the NPRM.
The group then discussed the potential impact of the PayerID-- for example, the impact of the number of positions. Mr. Moore commented that some organizations, including HCFA, will have to make changes in the way they route and process data. An audience member with Catholic Health Initiatives said the sooner providers and their vendors know what is expected of their database structures, the better.
The Subcommittee then passed the motion in support of the National PayerID.
Dr. Lumpkin noted that the full Committee had that morning discussed and suggested revisions to the Subcommittee's draft letter on security. He added that this recommendation is unlike others made by the Committee in that it addresses organizational practices as well as standards. The group discussed how to clarify terms, stress the importance of security, and explain the thrust of the recommendations. Dr. Starfield noted the recurring suggestion that the recommendations ask HCFA to include security as an aspect of its standards for participation in Medicare and Medicaid. Another suggestion was to specify the criteria against which the principles can be judged and to cite the problems and costs of having inadequate security.
Dr. Janes suggested calling not only for structural standards but also for process standards -- i.e., ways of measuring compliance with principles. Mr. Mays reminded the group that many industries in the country, notably defense and finance, have very well developed information security systems and standards. The question is how to apply existing technologies and practices that are not industry dependent.
Based on this and the morning's discussion, Ms. Frawley was asked to draft another version of the recommendation, for consideration at the evening Subcommittee meeting. At that time, the Subcommittee reviewed the revised letter on security and accepted it with a few amendments, for presentation to the Committee on the following day (September 9).
The discussion of this issue took place in stages throughout the long meeting. The Subcommittee was first briefed by Ms. Mary Emerson of the HHS identifiers implementation team. She explained that the team and Solomon Appavu (whose report was commissioned by the Committee) worked independently on their respective reports on the individual identifier. Dr. Appavu had been charged with not recommending a specific identifier, while the team had the opposite charge. Their approaches were also different, but complementary.
She described the process used by the implementation team, which started with the ANSI HISB inventory. That led them to the ASTM standards and six other candidate identifiers. The team was also made aware of several other proposals, and it evaluated all candidates using the 30 ASTM criteria. The proposals fell into three categories: proposals for unique universal identifiers, proposals for identifiers not designed to be unique or universal, and "proposals that were not really identifiers."
The team felt strongly that it should recommend a universal unique identifier, partly because it is mandated by HIPAA and partly because administrative simplification cannot be achieved in the area of patient identification without it. Two possibilities stood out above the others: the enhanced Social Security Number (SSN) and the ASTM UHID. The implementation team decided to recommend the use of the latter as the unique health identifier for individuals, and the use of the Social Security Administration (SSA) as the trusted authority for administering it.
Ms. Emerson explained that the SSA has improved its ability to verify individual identity accurately and efficiently, and the improvements are expected to continue. It also has an existing infrastructure for assigning unique IDs, verifying identity, and dealing with the public. It is the most cost effective choice. The ASTM UHID, rather than the enhanced SSN, was chosen as the identifier because of its several significant advantages. A separate ID for health care would require no procedures to distinguish it from other applications of a broader identifier like the SSN; it already includes plans for the check digit and encryption method; and it has been designed to last for the foreseeable future. It was felt that even an enhanced SSN would not have the advantages of an identifier used only for health care.
Dr. Starfield asked about the team's definition of health care, noting that it does not normally include health surveys, yet a mechanism is needed to link them. She asked if the SSN or the other number would be used for that, and Ms. Emerson said they did not deal with that question.
Dr. Cohn observed that although the implementation team and Dr. Appavu used similar frameworks for their evaluations, they reached different conclusions.
Dr. Braithwaite asked what attention was given to the cost of the options, and Ms. Emerson said they discussed it but had no hard figures to go on. Dr. McDonald noted that the report mentions four billion dollars. (Ms. Emerson later explained that this figure was cited as the cost of any unique number, either the enhanced SSN or a new number.) Dr. McDonald said certain things about the ASTM proposal would have to be changed to make it workable -- notably the length of the number, which would preclude its practical use; the check digit, the selection of which is "completely capricious"; and the unnecessary duplication of having both encryption and the check digit. He strongly suggested "staying with what works," as HHS is doing with the PayerID. Ms. Emerson said the implementation team agrees that the six check digits is "overkill" and recommends further study. The Subcommittee then read a letter in which Dr. McDonald outlines his critique of the implementation team's recommendations.
Dr. Lumpkin said that as the NCVHS liaison to the implementation team, he participated in and observed the process and found it to be deliberative and good. He noted that the problems with the SSN as a unique identifier would be costly to fix, and he speculated that systems that use several elements to identify a person would still need to use a number.
Dr. Cohn said he found the two reports more confusing than clarifying and came away "very deeply troubled." He noted the reports' failure to identify fundamental principles with which to build a conclusion, and questioned whether the implementation team's proposal is consistent with administrative simplification and the responsibility to save the country money. It is not clear to him that any gains from having a unique personal identifier would justify the billions it would cost. Noting that the kind of linkage the Committee has talked about would require a robust network, he asked for convincing evidence that a number is needed in addition to this infrastructure.
Dr. McDonald suggested that if the primary policy questions surrounding selection of a unique number can be resolved, the selection of a number can and should be decided on the basis of economic and political criteria. He asserted that it is folly to suggest that a new number will be perfect, because no system is error free; moreover, there are no "immutable characteristics" by which to accomplish linkages, as suggested. Nevertheless, a unique number can be useful in identifying patients, and he expressed hope that one can be established.
Dr. Cohn said he would like to hear from the industry about the relative costs of changing to a single number versus using their old number -- i.e., the costs of conversion and mapping.
Asked about next steps, Dr. Braithwaite said the Department hopes to publish the unique identifier draft by the end of October, but has been holding back awaiting the Committee's recommendations, after which it plans to vet its decisions in various political environments.
Asked to comment on lessons from the European experience, Dr. Detmer said other countries' experiences offer no clear answers on this issue. He observed that it is difficult to pursue this discussion in the U.S. in the absence of the important foundation that good privacy legislation would provide. Dr. Cohn suggested that the Committee call for adequate privacy and confidentiality protections as a precondition for any kind of unique identifier. In answer to a question, he said that in that event, he would favor a unique identifier provided it had been shown to save the country money.
Mr. Mayes pointed out that the Department is putting the proposed rules out for public comment, and intends to rework them in that basis.
Ms. Frawley asserted that before recommending anything in this area, the Committee needs more time to review the two reports and to talk with industry about its reactions to specific options. Dr. Cohn agreed, noting that the Committee's job is to advise the Department and that it is within its mandate to state that it would be foolish to proceed until confidentiality and privacy issues are addressed.
The group discussed the fact that the Committee has already recommended a unique identifier, in the context of its UHDDS and core data elements recommendations. Ms. Greenberg pointed out, however, that the recommendations have included the proviso that there be appropriate privacy protection; given that "it is documentably obvious" that none exists, it would be consistent with earlier NCVHS recommendations to decline to recommend a unique identifier at this time. Dr. Lumpkin added that if the Committee cannot specify what the number(s) should be, it should not make a recommendation, pending further exploration.
Dr. Solomon Appavu then briefed the Subcommittee on the report he prepared as an NCVHS contractor. The first part reviews the components, purpose and functions of the unique identifier, and the second evaluates every available option. There were 14 in all, including seven unique individual identifiers and seven other identification methods. Some of these are existing identifiers with proposed enhancements, and others are new proposals. The latter are still at the conceptual level and, as such, lack infrastructure.
Dr. Appavu identified six necessary attributes of an identifier and used those and the 30 ASTM criteria to evaluate the alternatives. His investigation found that the key issues are privacy/confidentiality, the check digit, and encryption. There are three basic approaches to selecting an identifier: enhancing an existing option; starting with a new identifier or identification method; or using software-based solution. He briefly discussed the options, and said none of the proposals he studied met all the criteria.
In conclusion, Dr. Appavu identified three courses of action available to the Committee: to select the existing identifier that comes closest to meeting the criteria; to choose a brand new option (of which there are many) and develop it; or to wait for the industry to develop the options and assess the situation at a later stage.
The Subcommittee then discussed how to communicate their concerns about the privacy/confidentiality issues, whether to cite the Committee's historic support for an identifier, and what else is needed to enable them to make an informed recommendation to the Secretary. Two possibilities suggested were hearings and posting a notice on the Website and asking for responses. Members agreed that if and when Dr. Appavu's report is approved, it can be circulated as well, with a request for comments. They agreed to get any comments on the report to Dr. Braithwaite by September 15. If no objections are raised, it is to be considered accepted after that date. It was noted that the Subcommittee has three documents to study: the Appavu report, and the report and matrix prepared by the HHS identifier team.
An audience member called the Subcommittee's attention to the fact that the contracts many providers have with vendors stipulate that only federally mandated changes will be made free of charge. Therefore, the Subcommittee's recommendations are much more likely to be implemented if they are federally mandated.
Dr. Cohn offered some language on the health identifier for individuals that could be incorporated into a letter from the Subcommittee. The following issues were pivotal as they considered the text of a letter:
On the first, Ms. Greenberg pointed out that the letter is an opportunity to draw Congressional attention to an issue about which the Committee feels strongly. No strong opinions were expressed either for or against the ASTM criteria. Members agreed that the other factors would be public comment (industry feedback) and cost-benefit evaluation. Members leaned toward citing the top candidates. On the basis of this discussion, they asked Dr. Braithwaite and Dr. Cohn to prepare a draft letter for presentation to the Committee on the following day.
Ms. Ball reminded the group that the Subcommittee talked at its last meeting about the need for recommendations on a process for adopting new standards, testing new methodologies for standards, and revising existing standards. Dr. Braithwaite added that the problem is that the SDOs develop standards that meet their business needs and "then they go off and do what they want." It takes a long time for a new business need to be recognized through a published private sector standard, and now a government process has been added to that already long and difficult process. What is needed is for the Committee to look at the process from a global perspective and see if it can recommend a way to smooth and speed up that process.
Dr. Cohn observed that this is a very complex area, and the present discussion should be seen as only the first step of a process. The questions need to be identified on the basis of which public comment is elicited. The Committee needs to talk with the many interested parties, including SDOs.
In response to a question, Mr. Mayes said the forthcoming NPRNs will not address this question to a great extent. The intention is to keep the initial standards dynamic enough that they can facilitate rather than impede the changes occurring throughout the industry. Mr. Moore described two different processes of change in which the addition of new elements can change the structure of the transaction, while the addition of new codes does not. Dr. McDonald noted that the more the variability in the tables can be shifted out of the structure of the standard, the easier it will be to live. He added that some things must be cleaned out.
Dr. Lumpkin suggested learning what criteria the SDOs use to come out with a new version, and he noted that the Department's criteria may be different because of its attention to impact assessment. He observed that there is advantage to bureaucratic delay, in that money can be saved by not insisting on being at the cutting edge of technology.
Dr. Zubeldia (who co-chairs the X12N digit 2 work group 12 on the interactive claim) expressed concern about the thrust of the foregoing discussion, given that X12 already has a change process in place. Noting that new transactions are coming out with the same or similar names to the ones defined in the legislation, he asked whether SDOs will be expected to stop the development of innovations (e.g., the interactive claim) because a similar transaction already is in place. He urged that NCVHS recommend a process whereby SDOs are allowed to implement transactions during the test phase to demonstrate that they work, without being penalized. Otherwise, in a few years industry will be locked out of any further development of existing transactions.
Dr. Lumpkin agreed with this point and suggested that there be a mechanism for field testing new versions or new standards. Mr. Mayes said the implementation teams are concerned with this question, as well, and they welcome the industry's suggestions about how to allow trading partners to test new systems without "just opening it up as a giant loophole."
Ms. Chris Stahlecker, of Empire Blue Cross/Blue Shield, suggested that as it considers the process for addressing new transactions, the Committee also consider extended use of already mandated or legislated transactions, given the multiple business purposes of those transactions.
Dr. Starfield suggested that the Subcommittee revisit these issues when it develops its work plan for next year and subsequent ones. The group agreed to return to the topic in the context of the work plan discussions later in the meeting.
Ms. Humphreys briefed the Subcommittee on the work of the HHS Implementation Team in this area. She said medical coding recommendations will be part of the proposed rule for transactions rather than a separate NPRM. The team has identified three areas in which improvements can be made: dental codes, where there is an attempt to eliminate duplicative codes from HCPCS; the elimination of J-codes in favor of the use of NDC codes; and local codes. The NPRM will propose the development of a national process so that when the standards are implemented there is no use of local codes that duplicate the standard national codes -- currently a common practice. The proposals were developed in response to comments from the industry about what should be changed, and the NPRM will invite further comments and suggestions.
The group discussed some of the likely ramifications of these changes and the kind of issues that are likely to surface during the comment period. They were generally positive about the proposed changes.
The Subcommittee then turned to the subject of the data dictionary. Mr. Mayes said that it is becoming clear that the data dictionary effort has far-reaching implications and that it may be one of the most important things to come out of the legislation. He invited comments from the Subcommittee about how to make the dictionary more accessible. (Currently it is available through Washington Publishing Company (WPC), and the Department is "working on" offering it free of charge.) The dictionary will contain all the code sets that go with the data elements.
Members offered various suggestions and comments in response to the HHS report. Dr. Cohn noted the importance of knowing not only the definition but the code values of a field in order to determine comparability of values, a matter of great concern to the Committee. Dr. McDonald asked to see a list of code fields. He noted that this effort is not simply a matter of database normalization, but of conceptual normalization around such things as the level of specificity. Dr. Starfield echoed his concerns about the clinical utility of the dictionary in its present state, citing the core data element recommendations as a reference point.
However, she and other members commented that it is very useful to have the dictionary and be able to see all the fields in a database.
Mr. Mayes said there has been discussion of how formal a data registry to create, and he asked for comments from the Committee on what approach would be most fruitful and sustainable. He added that the dictionary already contains the Committee's core data elements and the NCPDP data set. Dr. Cohn observed that the data model would be strengthened by having consistency in its level of abstraction.
Ms. Greenberg raised the question of code sets in respect to race and ethnicity and pointed out the need to know the code set specified. Mr. Moore said it is impossible to include the code sets in the regulation; they will be stored in the WPC publication. Dr. McDonald said the code sets should come from "some kind of an organized world where you don't have to worry about adding on." He urged the implementation team to talk with Stan Hof about the development of ways of working across the standards for the planning fields, using a list of code sets that are legal for those fields. He pointed out that the goal should be "atoms that don't change," and he urged that the "broken stuff" be put in separate tables. Mr. Mayes agreed that at present, there is a mixture of "elements that are treated as if they are atomic" and others that are truly at the atomic level. Asked about plans for a hypertext structure, Mr. Mayes said this effort is receiving a lot of attention internationally as well as in the U.S.
Dr. Starfield asked how the Committee could help with the dictionary project. She questioned the emphasis on billing purposes, given the diminishing use of this form of payment. She noted that the Committee's objective has been to expand the uses of data beyond those related to billing, and the importance of making sure that current efforts are compatible with the development of the computerized patient record. Dr. Cohn pointed out that "money is still a very important thing" even in the managed care environment, so cleaning up those transactions is important in its own right. In his view, the teams' process for the near term makes sense and provides a good foundation.
Mr. Mayes said the teams are currently working with X12 on cleaning up the dictionary, a detailed effort that the Subcommittee engaged in at a recent meeting. Further contributions of this detailed nature are welcome, but what is most needed from the Committee are its thoughts about the broader implications of data dictionaries and registries, and the approach that makes the most sense in terms of the big picture. This involves determining the ultimate goal of the exercise. He agreed with Dr. Starfield that the team needs input from people who are thinking about the computerized record.
Dr. McDonald observed that the claims have a lot of clinical data, and these must be gotten straight at the outset if the medical record is to make sense. Mr. Moore said the Claims Attachment team is starting to address the fact that the claim currently contains a lot of clinical data. Mr. Mayes added that the team starts from the position that a claim should be stripped to its essence, and the attachments should be standardized. (Reiterating an earlier point, Dr. McDonald commented that if the atoms are standard, they can be grouped however is needed.) Ms. Stahlecker affirmed that HCFA's Proof of Concept project on the claim attachment, on which she serves, will probably recommend "lightening the load" of the claim.
Regarding the time frame, Mr. Mayes said all the elements are now in the basic database, and over the next four to six weeks the teams will look for gross duplications and representation problems. They hope to have the element lists for each transaction spelled out by the time of the NPRM, with the name and definition. Work on the data elements will be a continuing focus as the implementation guides are developed.
Dr. Starfield then opened the discussion to other topics on the maintenance of data content. Ms. Greenberg noted that the conversation about content at the August 5-7 meeting had ended with an agreement to provide background on the criteria for deciding whether an element should be included in a transaction data set. In response, she has pulled together a summary of NUCC, NUBC and UHDDS criteria. Another question was what organization should be responsible, and since then NUBC and NUCC have recommended that they be responsible for the institutional and noninstitutional claims, respectively. Mr. Mayes said the NPRM will discuss the process by which the content will be maintained. Ms. Greenberg noted that discussions are underway about representation of public health and health services research on NUBC and NUCC, a subject on which the Committee may wish to weigh in. Mr. Mayes added that a process is needed for reviewing NUCC and NUBC standards recommendations to the Secretary. Dr. Cohn noted the resonance of these issues with the earlier discussion of the process for changing standards, and asserted that a lot more investigation is needed before any decisions are made. Mr. Mayes said one question is whether to combine or separate responsibility for content and technical messaging standards, and Dr. Cohn noted that both the SDOs and the public at large have a stake in how this plays out.
Ms. Stahlecker briefed the Subcommittee on the work on claims attachments. The group has used a 1994 HCFA survey and has written private and commercial payers and Medicaid directors seeking to assess the data content needed for the transaction sets. In August it completed a review of the technical structure and began the project's developmental phase, which will continue through March 1998. This will be followed by the testing phase, which is to end in August 1998. The draft standard is scheduled for release in October 1998.
Relating this to the timetable of the K2 Work Group, Dr. Lumpkin noted that the Work Group plans hearings in the winter featuring payers and providers. The questions for the hearings will be developed at the Subcommittee's November meeting. Ms. Stahlecker added that HCFA wants to sponsor a provider/payor work session in November as well, involving NUCC, NUBC, the ADA, WEDI and others, to get their input in to the attachment proof of concept project. It was noted that the Subcommittee and Work Group have no liaison to the claims attachments group, and also that Mr. Blair is working on this for the HISB. The Subcommittee asked Dr. McDonald to work with Mr. Blair on preliminary questions for the hearing, and to serve as the K2 liaison to the attachments group. Mr. Moore said HHS would share the questions and issues they encounter as they work on this. Dr. McDonald cautioned that the process must be carried out in coordination with the standards group, to avoid confusion.
Ms. Ball briefed the group on a draft outline for the annual report required by HIPAA on the implementation of standards. She suggested using the report to highlight the Committee's special concerns, notably the importance of privacy legislation. She asked if other concerns should also be highlighted. Dr. Braithwaite proposed that the group focus its discussion on methods for monitoring implementation, to give the staff input so it can draft the report.
Dr. Lumpkin noted that this is "phase zero" of the reports to Congress in that there is no implementation to report yet. The Subcommittee may want to have hearings prior to future reports, to learn what problems people are encountering. He suggested adding security to the issues to be highlighted in the initial report, drawing on the "eye-opening" August hearing. Ms. Ball suggested reporting on the process used by the Department and the Committee to get input from and collaborate with industry.
Responding to Dr. Braithwaite's question, Ms. Coltin suggested hearings and website announcements as two ways to elicit comments on implementation. Dr. Lumpkin suggested calling attention to the Subcommittee's recommendation to encourage the certifying bodies to look at security.
Ms. Ball said the annual Faulkner and Gray survey is a major source of information on the extent of EDI adoption by the industry. It is expected that this will continue, along with other sources. Dr. Starfield commented that in that case, Faulkner and Gray should be informed so they ask informed questions on their survey. Ms. Greenberg observed that some potential public sector users of standards, such as public health agencies and community health centers, either might be incorporated into the Faulkner and Gray or might be handled by a hearing or other means. Ms. Ball asked the group to supply her with other thoughts on measurement and assessment. Mr. Scanlon suggested that the report periods correspond to calendar years.
Ms. Coltin noted that the Committee has traditionally issued an annual report to the Secretary covering all its activities. She also observed that the report to Congress might convey the Committee's sense that other initiatives might benefit from coordination with HIPAA standardization, such as birth certificates. Ms. Greenberg explained that the requirement for an annual report to the Secretary was dropped in the new NCVHS charter, but the Planning and Implementation group may revisit this practice.
The Subcommittee agreed to go ahead with its report to Congress, with the possibility of incorporating it later into a larger report to the Secretary covering all NCVHS activities.
Dr. Starfield reviewed the items on the Subcommittee's work plan that it has already accomplished. She suggested that the year ahead cannot be planned until new Committee members are on board. Dr. Cohn noted that the Committee is helping to plan the mid-November CPRI conference on health care terminology, in which several Committee members are participating. The group agreed not to hold any hearings in the fall and to decide on next steps after the terminology conference. They reaffirmed plans for a winter hearing on attachments.
Dr. Starfield noted that the Executive Subcommittee agreed that the data Subcommittee should move forward with discussions on general data needs in regard to health needs and accountability. The Subcommittee agreed that a proposed presentation by John Eisenberg on that topic should be added to the agenda of the full Committee.
Dr. Lumpkin raised a concern for the Subcommittee about weaknesses in the birth certificate issuance process and other issues related to vital statistics, and Ms. Greenberg said this was also discussed by the Executive Subcommittee. The group agreed to ask the full Committee to hold a discussion on issues of security, standardization, content and coding related to vital records.
Dr. Starfield and Ms. Greenberg noted that a joint meeting with the Subcommittee on Population Specific Issues is being proposed on functional status classification and the mental health encounter data set being developed by SAMHSA. This will probably take place in winter or spring.
Dr. Cohn expressed concern about delaying the meeting on version control until the spring, feeling this may be too late to address such questions as responsibility.
The meeting was then adjourned.
I hereby certify that, to the best of my knowledge, the foregoing summary of minutes is accurate and complete.
/s/ Barbara Starfield June 10, 1998
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Chair Date