Subcommittee on Standards

Hearing on Electronic Attachments Standards and Operating Rules

Hubert H. Humphrey Building
200 Independence Ave, SW, Room 705A
Washington, DC 20201

Wednesday, February 27, 2013

Printable Acrobat Agenda and Hearing Background 

Wednesday, February 27


9:05 – 9:15am Call to order, Welcome, Introductions Dr. Walter Suarez and Mr. Ob Soonthornsima, Co-Chairs
9:15- 11:15am Panel 1 – Attachments Standards and Operating Rules

  • Current State of Attachment Standards
    • HL7 Standard 
    • Attachment Coding
    • X12 Standard
    • Pharmacy
  • Current State of Attachment Operating Rules
  • Medicare – esMDInitiative
  • Regulation development
  • Questions from Subcommittee 
Jim McKinley & John Quinn, HL7 

Dan Vreeman, Regenstrief Institute 

Margaret Weiker, X12

Lynn Gilbertson, NCPDP

Gwen Lohse, CORE 

Melanie Combs, CMS

Bob Dieterle, Signature Consulting

Kari Gaare, OESS 

12:00 – 12:15pm BREAK
12:15 – 12:25pm Big Picture Perspective of Technology Doug Fridsma, ONC
12:25 – 2:10pm Panel 2 – Industry Perspectives

  • Plan Perspective
  • Provider Perspective
  • Multi-stakeholder Perspective
  • Vendor
  • Questions from Subcommittee
Gail Kocher, BCBSAGeorge Arges, AHA

Mari Savickis, MGMA/AMA
Durwin Day, WEDI

Lindy Benton and Don Gerdts, Healthcare Information Services

2:10 pm Adjournment
2:10 – 3:00pm LUNCH BREAK

Afternoon Session of the NCVHS Standards Subcommittee


3:00 – 3:05pm Welcome and Introductions
3:05 – 3:45pm Subcommittee Discussion

  • Debriefing from Hearing
  • Identification of Observations and Areas of Recommendations
3:45 – 4:00pm BREAK
4:00 – 4:45pm Subcommittee Discussion

  • Continue debriefing from Hearing
  • Subcommittee Plans for March – June 2013
4:45 – 5:00pm Public Input
5:00 pm Adjournment

Hearing Background


Under ACA provision, HHS must adopt standards and operating rules for electronic attachments by January 2014, with a compliance date of January 2016.  The goals of this hearing are to:

  • Explore the entire spectrum of the need to exchange clinical, medical and/or additional administrative data between providers and payers to support administrative processes, including claim, eligibility, prior authorization, etc. (currently referred to as “attachments”)
  • Discuss the policy, business, and technical approaches to “attachments” and their various elements, including solicited/unsolicited, structured/unstructured, human readable/computer processable, etc., with special emphasis on claim “attachments”
  • Discuss the status of development of “attachments” standards and operating rules, and the degree to which they are ready for adoption and use
  • Review and discuss current work associated with “attachments” being done by the industry (including esMD)
  • Identify the implementation issues and milestones needed for a successful implementation of attachments within the timeframe defined in law
  • Review and discuss industry perspectives on the adoption and implementation of “attachment” standards and operating rules



Testifiers are asked to address the following questions and topics,as appropriate,in their prepared remarks. In other words, every speaker need notaddress every item – just those that are relevant to his or her topic.Testifiers are encouraged to submit written comments addressing any of the questions from the list below that they did not cover during their remarks.

  • Attachment Standards and Operating Rules
  • Are there multiple definitions of attachments under discussion, and what is the recommended definition of “attachments” to be adopted under regulations?
  • What are the priority business (health related) areas for which “attachments’ are necessary? How is this expected to change in the next five or 10 years?
  • What are the recommended approaches to the submission of ‘attachments’?
  • What is the status of development of ‘attachment’ standards?
  • Are there other standards for clinical information exchange rather than or in addition to HL7 C-CDA that should be considered?
  • What metadata or pieces of information would be necessary to include in the envelope that is not available today in the HL7 C-CDA?
  • With respect to the ‘envelope’ of the message, should more than one enveloping standard be permitted to wrap the standard clinical information? What are examples of these standards that build on existing or future infrastructures?
  • With respect to transport, how would you envision the routing/transport(sending or receiving) of clinical/medical information occurring?  How does it relate to HealtheWay and/or ONC Direct and/or ONC Connect?
  • Should we consider optional or situational enveloping (and/or transport) standards?
  • What is the set of attachment standards being recommended for adoption?
  • Are there any known limitations or gaps in the recommended standards? How will they be addressed?
  • Are there any Operating Rules to be recommended for adoption at this time? Which would they be?  Are the ‘infrastructure’ related operating rules in place applicable to attachments?  What are the plans for developing further ‘attachment’ operating rules?What processes/steps have been taken to identify/develop such operating rules? What might be some of the lessons learned thus far from the development of previous operating rules that may be applicable to the development of attachments operating rules?
  • Are the recommended standards (and operating rules, if any) applicable only to claim attachments, or will they be applicable also to other types of attachments?
  • What are some of the most important business and technical issues surrounding attachments for providers, health plans, and vendors, and how would you recommend addressing them?
  • Industry Perspectives
  • What is the current state of industry with respect to the exchange of standard clinical information to support administrative or financial transactions?
  • What problems or repercussions occur because of the current state? How would these be addressed if this process was standardized?
  • For this transaction, can we predict the technological state of the industry so that we adopt standard(s) that provide consistency, yet are flexible enough to take advantage of emerging systems and technologies?
  • With regard to claims attachment or attachments in general, what is the role of operating rules in relation to the transactions; i.e. what problems could they solve?  What problems do they create?  How can the process of development be improved?
  • Overall, what would you say are the most significant benefits we should expect to see (i.e., efficiency, quality, safety, economic, other) that we can rely upon to monitor progress and measure success?  Where do you think would benefit realization be most challenging?
  • What are your current costs (estimate) associated with the exchange of clinical information to support financial and administrative transactions?
  • If clinical information in support of administrative transactions was exchanged electronically, what are the estimated costs and savings? In what areas, would you realize these costs and savings?
  • How would use of existing infrastructure or infrastructure that will be in place by 2016 impact costs and savings?  Providers, health plans and vendors are asked to speak about this from their individual perspectives.
  • With respect to operating rules, what areas related to attachment transactions do you see are most important to address through the creation of operating rules?
  • Are the current standards (and operating rules) you have heard about applicable only to claim attachments, or will they be applicable also to other types of attachments?
  • What are some of the most important business and technical issues surrounding attachments for providers, health plans, and vendors, and how would you recommend addressing them?

Should you require reasonable accommodation, please contact the CDC Office of Equal Employment Opportunity on (301) 458-4EEO (4336) as soon as possible.

Times, topics, and speakers are subject to change.  For final agenda, please call 301-458-4200 at NCHS or visit the NCVHS Home Page at

April 2, 2013