All official NCVHS documents including meeting transcripts are posted on the NCVHS Website (http://www.ncvhs.hhs.gov/).

Department of Health and Human Services

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

Subcommittee on Standards

Roundtable Discussion on the Future of Information Exchanges for Healthcare Transformation
consolidated version

November 15, 2012

National Center for Health Statistics
3311 Toledo Road
Hyattsville, MD 20782

The National Committee on Vital and Health Statistics Subcommittee on Standards convened a roundtable discussion on November 15, 2012. The meeting was open to the public and was broadcast live on the internet. A link to the live broadcast is available on the NCVHS homepage.For the attendance record of this meeting, go to the last page of the report.

EXECUTIVE SUMMARY

Thursday, November 15, 2012

ACTIONS

  • In the next few months, the Subcommittee will summarize priorities and recommendations taken from the roundtable discussion. A presentation will be given to the full Committee at the February 2013 meeting.
  • Future meetings, virtual and in-person, may be held to discuss NCVHS priorities.

COMMON THEMES

  • Provider engagement:This involves an understanding of the value of the changes. What actionable information can be provided at the point of care; and how can information be captured more effectively from diagnoses? Capturing data upfront in the provider setting allows for proper decision support.
  • Provider-payer engagement:Information exchange is no longer about claims but rather about shared outcomes and clinical data. The usefulness of patient identification was stressed.
  • Patient and consumer engagement:Consumers are demanding more information in order to make decisions about care, access and quality. When consumers are brought to the table as partners, they can help reframe the value of the changes.
  • Business case for change:What is the roadmap for industry changes and mandates? Have the right value definitions been explained? How will they be implemented? Will the benefits be achieved?
  • Vendor engagement:Can vendors be engaged more effectively? How so? What are the incentives? What are the enforcement opportunities and authorities?
  • Standards, terminology, common definitions: Exchanges will be focused on value, properly vetted and tested, appropriately developed and maintained, meaningful and driving improvements on cost and quality
  • Coordination and collaboration across industry: Alignment of policies, mandates and initiatives across the industry is critical, with appropriate sequencing and timing.

CALL TO ORDER, WELCOME, INTRODUCTIONS, AGENDA REVIEW

Walter G. Suarez, M.D., M.P.H. and W. Ob Soonthornsima, Co-Chairs

The discussion will explore the future in terms of data needs, exchanges and standards.

Facilitation and Ground Rules Kathy O’Connor, M.P.H.

Framing the Issues – Introductory Remarks Roundtable Discussion

Participants responded to the following question: ideally, what will information exchange between providers and payers look like in five to ten years?

Information exchange is driven by business purpose. Ideas must come from how clinical and non-clinical data, knowledge and analysis interpret and measure effectiveness of care while considering economic investments and ability to make cost-based decisions about healthcare delivery. The role of payers was raised as more organizations move into ownership of total medical expense and quality of care (“covered” vs. “siloed” care). The focus should be on efficient information flow. Software is not keeping up with the development of standards. Methods of saving money were suggested.

Characteristics and challenges of information exchange were described as were the value and changing nature of HIEs and the evolving role of payers. Semantic interoperability techniques help care teams share an understanding of patient issues. Such a data model can be used and leveraged in real time and on a population basis to optimize care and achieve the Triple Aim. It is useful to identify expected outcomes; how to get there (including roles and coordination); cost drivers; and how standards fit into the equation. Interoperable data available in real time improves consumer health and safety while engaging consumers more effectively. Consumer data sets such as biometric and social media goals are often not discussed. The Committee must look beyond payer needs; and a “roadmap” for the entire community should be consolidated. Despite the meaningful use program, much is not covered by these standards.

Communication tools are needed for efficiency in electronic communications, and systems must catch up with increasingly technically savvy patients and providers and more evaluation is needed. Will data be seen as a common good or as a competitive weapon?

Additional challenges were cited to include how to encourage the market; how to allocate responsibility for infrastructure support; and funding mechanisms. Much can be done by consolidating, cutting down silos and breaking down fragmentation.

The NCVHS serves as the statutory public advisory body to the Secretary of Health and Human Services in the area of health data and statistics. In that capacity, the Committee provides advice and assistance to the Department and serves as a forum for interaction with interested private sector groups on a variety of key health data issues. The Subcommittee has dealt with issues specific to regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and most recently, the Affordable Care Act (ACA)– both addressing administrative simplification and its impact on the electronic communication between payers and providers. It was suggested that the Subcommittee and full Committee should consider addressing data issues beyond administrative functions under HIPAA and ACA as the same data is used for clinical exchange. In response, Ms. Greenberg clarified the Committee’s responsibilities in the administrative simplification area and noted that it also has addressed electronic exchange of clinical and population health data. She asked for feedback from non-government roundtable participants about how the Committee could be most helpful; and where ONC and CMS fit in. The need for harmonization (to some, a “roadmap”) has been widely acknowledged.

Transformational changes in the healthcare market at the federal level were noted as were increased burdens on providers and the shift of payment for individual services to payment in bundles. Cost and lack of adequate compensation are big concerns of practicing physicians. For the first time, increased demands are contributing to physician resistance to participating in the new hospital care survey. Data stream harmonization, flexibility and consideration of end users are needed.

Pharmacy’s 20-year involvement with claims transmission and information exchange was discussed, including payment challenges. The cost of making such changes is so prohibitive that more physicians, especially those with small practices, might “fade away” rather than change. More training and attention should be paid to the “garbage in, garbage out” question, noting high intra- and inter-observer coding variability. The various uses of clinical code sets were described. The ideal HIT system is a smooth end-to-end process that goes from eligibility to claims payment that is uniform across the industry (which could be a driving force in standardization of all administrative issues).

Policy Questions and Considerations Roundtable Discussion

Participants were asked to discuss structural, business and policy considerations; and to address questions about major information exchange changes between providers, payers and the major policy, business and structural drivers of the next five to ten years.

What must happen for the industry to see HIPAA requirements and meaningful use as part of an integrated whole? A new care paradigm is needed, especially with shifts from acute to home care or other post-acute care settings. Are health plans doing follow-up along with providers? Billing data, abstracted from clinical data, must be understood. Redefined roles must align with a more collective, coordinated approach with patient well-being at its core. Automated processes drive out costs. Providers are moving quickly toward patient-centered medical homes, ACO-related services and a new model for providing input and measuring quality. Payers and providers must come to terms with risk adjustment by 2014, which will drive a need for more information exchange.

The Health IT Policy Committee has addressed meaningful use and how to link with HIPAA standards. Meaningful use as a separate program will end. When this happens, an opportunity to integrate the spirit of meaningful use with robust parts of HIPAA will open up. HIPAA and HITECH rules address coordination. The 1996 rule was delineated. Anoverarchingroad map or strategic planwithin HHS that coordinates the needs of CMS, NCVHS, ONC and health statistics is strongly recommended.

From a provider point of view, interoperable data standardization should occur at the national level. It has been helpful to use the EHR to coordinate care. Systems that talk to each other save money and lives and prevent errors. The Committee should identify their most important goals; create a roadmap around those goals; build in ways that track and measure ROI; and determine next steps. The functions of the Administrative Simplification Group within the Office of Enterprise Management and Office of eHealth Standards and Services of CMS were delineated as were new components of ACA. The industry would be better served by collaborative efforts that line up with statutorily-dictated deadlines. While industry efforts are underway to link code values, a method of championing them is needed.

A concern was raised about moving forward with claims attachments when utilizing the same clinical information for Meaningful Use, Stage Two. Many providers and hospitals agree that collecting data (especially clinical) once is preferable. Gross assumptions are made about what the needs and data uses are. The Committee could do an inventory of what kind of work is happening around meaningful use; and what is working to bring stakeholders together. If the Committee does such an inventory, leveraging that information could provide greater insight into what payers need from care delivery data.

Concerns about quality of care were raised. It was suggested that NCVHS consider a universal patient matching routine or resurrect the idea of a national patient identifier. The governance and harmonization of terminologies and classifications, raised as an issue with ONC and NCVHS since 2006, should be worked out jointly.

Resolving patient identification is critical to exchange business among different health plans as well as for patient attribution and ACO- or patient-centered medical home settings. Without a standard, payers will invent one, which will increase costs.

HIEs will bring wide scale change, especially as employers use them more. How these systems might work within private industry was described. What patients and providers want was outlined. NCHS hopes to send analyzed data back to hospitals as an incentive. HIEs have subscription fees and are complicated. As partners in their care, consumers need access to their data in Meaningful Use, Stage Two. Consumer mediated exchange was raised as were the function of operating rules. If links were provided to a patient electronic data storage site and privacy issues addressed, a centralized national clinical database might not be necessary. Providers need “actionable information” from data. Access to full sharing within clinical relationships is necessary as well as an ability to transport information between systems.

Suggested Policy Priorities

Data quality and the need to eliminate errors are big concerns. From a Medicare perspective, standardizing the interface between reporting quality metrics and information supporting the calculation of those metrics in values-based purchasing initiatives is needed. Because true administrative simplification starts with software, vendors must be engaged with certification. Patient identifiers are critical because without them, data is not accessible to different stakeholders. Another key need is to harmonize the definition of data elements. The policy should standardize every element entered into the EHR. A suggestion was made to adopt a healthcare smart card. Standardization and a federal regulatory environment that allows for clinical information sharing is needed as are portability and transportability.

More discussion about priorities ensued, including how to support less sophisticated organizations on the administrative side. The Committee should determine a process that establishes governance and harmonization of clinical terminology, classification and metadata that address data integrity and exchange questions. The Committee was encouraged to think more broadly about how the pieces of the whole healthcare system fit together. Economic forces are leading to consolidation and more mergers.

A range of questions about data, national architecture, national reference vocabularies, patient outcome measures and process measures were asked. Out of these questions, the priority issue was to make healthcare data more uniform, accurate, valid, computerized and protected; and then to use it to improve efficiency and effectiveness of the whole system.

The challenge of access to affordable information that community health centers face was raised. The complexity of the current process was reiterated. Patient identification was mentioned as a priority for pharmacies because patients must be tracked. A physician participant thought that a patient ID on a smart card with an attached and continually updated face sheet (of accurate medication lists, allergies, family history, and diagnostic codes) would prevent errors.

Technical Questions and Considerations Roundtable Discussion

From a technical point of view, questions to consider include: How will information flow from healthcare reform on the care delivery and payment sides with the formation of new structures, ACOs and health information exchanges? What transactions should support the flow of information? How must enrollment and eligibility processes and standards change to align with a forward direction? In general, what transformative changes are needed in transactions and standards in health IT? How is EHR adoption changing information exchange opportunities between providers and payers?

WEDI has created an ACL bundled payment workgroup because the manual process of handling bundled payments must change. Aspects of Meaningful Use, Stage One, Two and Three were compared. Terminologies like SNOMED must be adopted to provide the necessary granularity (European countries are further along). A gap must be bridged in user interface (e.g., vendors and caregivers). Not everyone has the ability to use the full array of data components on claims. As operating rules (which improve how standards are use) get developed for other transactions such as claims, the hope is that organizations will build “edit logic” needed from codes contained on the UB. Functionality must be part of the process.

NCVHS must identify a manageable chunk of work. NCVHS should ask other committees for help (e.g., HIT Policy or Standards Committees).

The Subcommittee on Standards’ mandate (administrative simplification) was delineated as was a failure to recognize other uses of generated information (e.g., use of UB for more than quality measurement). According to the IOM, the technology is there but people have not necessarily been trained to use it. To achieve administrative simplification, stakeholders must understand how to effectively use technology, standards and processes at the primary site.

Pharmacy compliance problems with prescription drug monitoring programs that use products that are not real time were described. The recommendation is for a “real-time world” for pharmacists and providers. Another suggestion was to look outside of health care for industry standards that support similar or related processes.

A successful 2005 pilot of the claim attachment standard between a New York practice and a Medicaid contractor was described. At present, the standard is due to be changed by 2016.

Suggested Priorities

The group identified the following topics/areas as suggested priorities for further work by the Subcommittee:

  • Data quality
  • Standardizing the interface between quality metrics – seamless exchange
  • Engagement with vendors and certification
  • Patient Identifier
  • Harmonization of data elements (EHR); codify
  • Smart card
  • Educating constituents on the value of what “they have to implement”
  • Governance and stakeholders to standardize
  • Minimal data set about the patient
  • Incentives
  • Voluntary vs. mandatory steps to drive the right lever

Transformative changes to standards and to technology are not interchangeable. No single model that includes financial and clinical quality metrics can calculate true ROI. A standardized methodology that measures real ROI (including financial, business and clinical metrics) would be useful. Qualitative improvements include patient safety, proactive consumer health and better outcomes. It is important for companies to remain open to innovations (e.g., Cloud services; APIs) and aware of what others are doing to create information ecosystems.

National economics and politics must align with improving efficiency and effectiveness of the health care system to maintain quality and achieve other national goals. Health care should adopt a remote distributive processing model, which is quite common in other fields. This will only happen if the architecture is defined to do that. A big consideration is how to interoperate with content or payload to produce information in real time (Wal-Mart is an example of where this is done). It is important to know the customer. Physician practices want to know how they compare with their peers. The Committee could showcase organizations that are ahead of the curve in using data innovatively. The most innovative technology for administrative simplification will come from the marketplace. Perhaps NCVHS can expand its role of making standard adoption recommendations to the government to non-governmental organizations. Could the Committee accelerate voluntary adoption in addition to examining the regulatory process? It is difficult to push voluntary efforts in the industry. The importance of real time was reiterated. Government enforcement is critical to bringing together convergent elements within the industry. A question was posed about what it will take to make the technology simpler for the end user.

Next Steps Walter G. Suarez, M.D., M.P.H. and W. Ob Soonthornsima, Co-Chairs

In addition to the core themes discussed above, other areas of consideration included: a need for more effective certification to accelerate alignment of data needs with system usability. The need for standard terminologies and common definitions was stressed to include harmonizing and improving terminologies; and coding data from correct definitions and standards. Since a more granular dataset or standards may not necessarily translate into effective data capturing, it is important to ensure that workflow changes occur effectively as standards are being rolled out.

Standards development should be harmonized across the industry to focus on values and to be timely. Coordination and collaboration is needed across the industry, to include an alignment of policies, mandates and initiatives in order to drive cost and quality improvements. Other issues raised had to do with data quality; standardizing the interface between quality metrics; a seamless exchange between all entities; certification; how to codify data standards definitions at the point of care in the EHR system; use of a smart card to make access easier for consumers; educating constituents on the value of what they must implement; minimal datasets; incentives; and voluntary versus mandatory steps to drive change.

Next Steps: In the next few months, the Subcommittee will summarize priorities and recommendations taken from the roundtable discussion. A presentation will be given to the full Committee at the February 2013 meeting. Future meetings, virtual and in-person, may be held to discuss NCVHS priorities. Communication will be via email. A “roadmap” that aligns processes is of special interest to the Subcommittee, the full Committee and many agencies such as ONC, CMS and others, as is an understanding of where current standards and the work of HIPAA and the Affordable Care Act fit in.

A letter report with recommendations is not on the agenda as the roundtable discussion is a starting point for the Subcommittee’s work over the next year.

Adjournment: 1:00 p.m.

To the best of my knowledge, the foregoing summary of minutes is accurate and complete.

Walter G. Suarez, M.D., M.P.H.
Co-Chairman

W. Ob Soonthornsima
Co-Chairman

DATE: November 15, 2012

Attendance Roster for November 15, 2012

Sub-Committee Members Present:

Walter G. Suarez, M.D., M.P.H., Co-Chair
W. Ob Soonthornsima, Co-Chair
Justine M. Carr, M.D.
Raj Chanderraj, M.D., F.A.C.C.
William J. Scanlon, Ph.D

Full Committee Members Present:

Bruce B. Cohen, Ph.D.
Llewellyn J. Cornelius. Ph.D.
Larry A. Green, M.D., Full Committee Chair
Linda L. Kloss, M.A., RHIA, CAE, FAHIMA
Vickie M. Mays, Ph.D., M.S.P.H. (phone)
Sallie Milam, J.D., CIPP, CIPP/G

Staff and Liaisons

Suzie Burke-Bebee, ASPE
J. Michael Fitzmaurice, Ph.D., AHRQ Liaison
Marjorie Greenberg, NCHS/CDC, Exec Sec
Katherine Jones, CDC/NCVHS staff
James Scanlon, ASPE, Exec Staff Dir.
Jim Sorace, M.D., ASPE
Michelle Williamson, R.N., MSIS, CPHIT, NCHS

Absent:

Lorraine T. Doo, M.P.H., Lead Staff

Roundtable Participants

Roxanne Andrews, Ph.D., AHRQ
Georges Arges, M.D., AHA
Clarice Brown, NCHS
Alan Conrad, M.D., Cadillac Family Physicians
Diane Conrad, D.N.P., R.N., Cadillac Family Physicians
Frank Coyne, BCBSA
John Daniels, HIMSS
Laurie Darst, WEDI
Anne Elixhauser, AHRQ
Doug Fridsma, M.D., Office of the National Coordinator for HIT
Nick Gettas, M.D., CIGNA/Total Health & Network Organization
Karen Hudgins, VA
Chuck Jaffe, M.D., HL7
Charles Kennedy, M.D., Aetna/Accountable Care Solutions
Rosemary Kennedy, R.N., Ph.D., NQF
John Klimek, R.Ph., NCPDP
Alice Leiter, CDT
Deborah Meisner, Emdeon
Judy Murphy, R.N., FACMI, ONC
John Quinn, M.D., HL7
Dan Rode, AHIMA
Iyad Sabbagh, M.D., Beacon Eastern Maine Health System
Cathy Sheppard, X12
Jim St. Clair, HIMSS
Christine Stahlecker, CMS
Robert Tennant, M.A., MGMA
Robin Thomashauer, CAQH
Margaret Weiker, X12
Kitt Winter, SSA

Others

Margret Amatayakul, MBA, RHIA, MargretA Consulting, LLC
Matthew Albright, CMS
Peter Barto, PWC
Larry Casalino, M.D., Ph.D., Weill Cornell Medical College
Lauren Fleeyer, VA
Stephanie Jamison, HIMSS
Devin Jopp, Ed.D., WEDI
Terri Postma, M.D., CMS
Mari Savickis, AMA
Nancy Spector, R.N., M.S.C., AMA
Maria Cora Tracy, CMS/DEM
Kelley Turek, AHIP
Leah Vaughan, Ph.D., The Health Policy Group