Minutes of the April 6, 2005 NCVHS Subcommittee on Standards and Security Hearing

Department of Health and Human Services

NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS

Subcommittee on Standards and Security

April 6, 2005

Hubert H. Humphrey Building, Room 705A
Washington, D.C.

Meeting Minutes

The National Committee on Vital and Health Statistics Subcommittee on Standards and Security was convened on April 6, 2005 at the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Present:

Committee members

Jeffrey S. Blair, M.B.A., Co-Chairman
Harry Reynolds, Co-Chairman (via conference call)
Simon P. Cohn, M.D.
Stan M. Huff, M.D.
Judith Warren, Ph.D., R.N.

Absent

Staff and Liaisons

Maria Friedman, D.B.A., CMS, Lead Staff
Vivian Auld, NLM
Jeannine Christiani, Magna Systems
Jorge Ferrer, MD, VA
J. Michael Fitzmaurice, Ph.D., AHRQ
Marjorie Greenberg, NCHS/CDC, Executive Secretary
Donna Pickett, NCHS/CDC
Marietta Squire, NCHS/CDC
Karen Trudel, CMS

Others

Bill Alfano, BlueCross BlueShield
George Argus, AHA
Carol J. Bickford, ANA
Sue Bowman, AHIMA
Richard K. Brook, ProxyMed
Susan Christenson, AHRQ
Arthur A. Ciarkowski, FDA
Michael J. DeCarlo, BlueCross BlueShield
Sheila Lynn Frank, Delta Dental Plans Assn.
Matthew B. Johnson, ACA International
Stuart Kersky, Walgreens
Frank A. Kyle, Jr., ADA
Mary Zigmund Luke, AHIP
Mark McLaughlin, McKesson Provider Technologies
Jean Narcissi, AMA
Michael R. Pollard, Medco Health Solutions
Jim Shuping, WEDI
Michael J. Simko, Walgreens
Joseph S. Smith, BlueCross BlueShield
Paul Speidell, AMA
Robert M. Tennant, MGMA
Tony Trenkle, HHS, Office of HIPAA Standards
James D. Whicker, WEDI
Kepa Zubeldia, Claredi

EXECUTIVE SUMMARY

ACTIONS No formal actions.

Suggested Action Steps

Establish effective date code sets.
Invite practice management system vendors to present their views about barriers or lack of return on investment (ROI).
Invite clearinghouse representatives to provide testimony that helps the Subcommittee understand the impact of the significant increase in their workload.
Learn more about cost shifting within practice management systems and physician offices.

PLANNING FOR FUTURE MEETINGS

A conference call to firm up an agenda for the July 26-27, 2005 hearing will occur after the next Executive Subcommittee conference call on May 19, 2005. A decision about whether to include education efforts in a hearing with the full committee will be decided in collaboration with the Executive Subcommittee.

Next steps

Presentations to the Subcommittee (1/2 to a full day) will include a “primer” and an opportunity to learn more about what others are doing (i.e., AHIMA; NLM; FDA, ONCHIT; CMS, NCHS, Chris Shute, and Jim Campbell). The relevance to the all NCVHS Subcommittees (especially the Quality Workgroup and Population Subcommittee) and NHII was noted.
A three-phased approach was suggested 1) education exploration; 2) what people are working on; and 3) establishment of three to four priority areas (which might result in more focused hearings).

Themes of today’s hearings 1) get feedback from the industry on their experience with implementing HIPAA standards (especially with regard to ROI); 2) explore how clinical data can be captured once at the point-of-care with derivatives of clinically specific data available for clinical research, reimbursement, and public health; 3) explore ramifications of a national patient identifier (NPI); and 4) introduce Mr. Tony Trenkle, the new director of the Office of HIPAA standards.

All official NCVHS documents are posted on the NCVHS Website.

CMS UPDATE Tony Trenkle

Mr. Trenkle introduced himself and discussed the HIPAA claims attachment proposed rule; modifications to the transactions code sets; the enforcement proposed rule; compliance complaints received; overlapping security and privacy issues; and the e-prescribing rule (note website: www.cms.hhs.gov/hipaa). The Subcommittee will receive a substantive report when the claims attachment regulation is out that allows for further recommendations. No current information is available on the contingency plan for Medicare operations but the Subcommittee will be informed about CMS’s decision to terminate the contingency. CMS has led the industry in how to work into HIPAA standards for claims transactions with almost full compliance.

Mr. Blair provided background history about the adoption of standards for the patient medical record information (PMRI) portion of HIPAA. Questions arose about the interaction of Mr. Tremble’s role with clinical, terminology and other standards versus federal health architecture and what ONCHIT and others (including the private sector) do. Part of his job is to determine when CMS should assume a lead role and what the points of coordination are. The Subcommittee can help by continuing to bring reality tests to CMS. Ms. Friedman stated that CMS has followed up on the Subcommittee’s recommendation to continue discussions with HHS and the DEA.

PANEL I HIPAA Return on Investments (ROI)

Joseph S. Smith BlueCross BlueShield Association (BCBSA)

Four key points

HIPAA administrative simplification has not produced positive ROI.
Plans are helping providers comply with HIPAA transaction and code set standards.
HIPAA administrative simplification may produce positive ROI if providers use the full suite of transactions.
BCBS Plans will continue to work with providers, state local, and industry groups to improve HIPAA.

Factors influencing the lack of ROI were discussed as were BCBS efforts to make HIPAA work. There is much greater ROI potential for non-claims HIPAA transactions for standards remittance advice, eligibility, and claims status (see detailed summary or transcript for specifics).

Robert M. Tennant Medical Group Management Association (MGMA)

Expectations and HIPAA ROI in medical practices were described, as were the HIPAA challenges (see transcript for specifics).

Recommendations

Medicare and private health plans should be permitted to continue accepting proprietary claim formats (significant notice should be sent to the industry before Medicare ends this enforcement flexibility).
Medicare, Medicaid, and commercial health plans must report back missing data to submitting providers.
CMS should expand provider educational activities.
CMS should expand vendor educational activities.
Prior to implementation, an independent and comprehensive analysis of costs and benefits of all electronic health initiatives should be completed.
Recognition of the need for staggered compliance dates and sufficient time to ensure successful implementation.
Identification of financial resources to assist physician practices in migration to existing and future standards.
Continued identification of roadblocks and difficulties faced by providers and other covered entities as they work toward compliance. Learn from past mistakes.

Jean Narcissi American Medial Association (AMA)

AMA’s HIPAA ROI results, business impacts, adoption percentages, and challenges (including standardization; transaction fees, submission of attachments for claims) were delineated (see detailed summary or transcript for specifics). The AMA encourages NCVHS to recommend inclusion of CPT guidelines and instructions for applying the codes as a national standard.

Recommendations

Physician practices must embrace all HIPAA transactions for a ROI.
The Convergence Project should identify differences and similarities of payer companion documents to provide information that organizes HIPAA payer transaction requirements.
Physician practices directly connected to payers would save on physician transaction fees.

Discussion There was agreement about ROI potential for non-claims transactions and direct connections at the point of origin; and about the need for more outreach from CMS to providers and vendors. Discussion ensued about different formats that go through clearinghouses; differences in companion guides; and the usefulness of staggering versus fixed dates for payers and providers. The BCBSA noted their initiatives to quantify benefits and the AMA described their approach to phasing in individual transactions. A suggestion was made for CMS to have X12 meetings and focus groups in places where clinicians congregate. Contingency plans and windows (making claims transactions available to the 835 format) were raised as were the challenges of maintaining two systems simultaneously. Involving vendors and practice management systems can help the whole process and generate savings.

A summary of today’s panel discussions The benefits of standardization have not been realized because it hasn’t yet occurred. Even with diminished volume, there is “static overhead” for continuing to support the old system as companion guides proliferate. How can benefits be recognized without standardization? How can this be done with no revenue loss and strong incentives to standardize? Until physicians can access what they need in the new formats, they must revert to using the old. It is very expensive and disruptive to change practice management systems, especially for small practices but even for vendors.

Other topics of interest included The Convergence Project (see this afternoon’s presentation for further information); use of technologies such as XML; whether there are plans to make more changes to claims submissions that are not HIPAA compliant; whether conformity or compliance testing is needed for practice management systems; how to approach the implementation of compliance claims; who is investing in compliance and who is not; a vision of the future for practice management systems; and who should be responsible for data content of message standards.

PANEL II HIPAA Return on Investments (ROI)

Jim Whicker Workgroup for Electronic Data Interchange (WEDI)

HIPAA successes and challenges were described at length, as was implementation and ROI for Intermountain Health Care (IHC) in Salt Lake City, Utah. Areas of functional improvement as a result of HIPAA were presented.

Recommendations to improve ROI

Reduce variability between payers and providers as much as possible.
Develop an industry-wide standard for positive or negative acknowledgement of a claim.
Create cross-industry support for using standard development organizations to resolve content and usage issues and to improve communication.
Finish the roll-out of current HIPAA transactions before adding complexity.
Take new transactions through a proof of concept process prior to adoption.
Any national information technology standard should use the same road map.
Resolve lingering payment issues of payment eligibility and claims status transaction.
Adopt a national payer identification.
Simplify set up, communication, speed of response to transactions, quality data and mapping codes.
Clarify what constitutes an institutional versus professional claim.

Mark McLaughlin McKessen Provider Technology

The ROI for McKessen Provider Technologies were delineated as were positive impacts and challenges of HIPAA. Adoption percentage rates for HIPAA transactions and code sets were outlined.

McKessen Recommendations

NCVHS support for WEDI recommendations and a recommendation to HHS that the Centers for Medicare and Medicaid Services implement the recommendations completely.
NCVHS request that HHS issue guidance on appropriate rejection methodology to help the industry move forward with a single efficient solution.
Creation of a single effective date for all code sets.
Investigation of the local code issue and elimination of continued usage.
Convergence of requirements of the claim transaction to reduce HIPAA programming maintenance. McKessen urges HHS and CMS to participate in the WEDI Convergence Task Group.

Dr. Kepa Zubeldia Claredi

“From HIPAA to Interoperability”

Dr. Zubeldia presented background history about NPRM for transaction and code sets and final rule specifications. There are many additional requirements imposed by payers and clearinghouses, most of which are reasonable (see transcript for examples), which can be found in the HIPAA companion guides, the NCPDP equivalent (called payer sheets), provider bulletins and newsletters, legacy computer systems, someone’s head, or instructions for filing different claims types. While there is one standard format today, there are at least 1,082 companion guides for the X12 HIPAA transactions and at least 200 for the NCPDP payer sheets (see transcript for guideline specifics and inventories). Claredi has created a website with updated links to all identified companion guides (noting that only 60% of the guides are available on the internet). The website address is:www.claredi.com/convergence. The next task is to put the NCPDP payer sheets on the website. Claredi will also work on attachment templates. Eventually, there will be a CCR template website.

The HIPAA Convergence Project aims to help the health care industry converge on a manageable set of requirements for HIPAA transactions; to identify divergent requirements; to automate the identification of the requirements in a machine-processed format; and to provide a convergence model that is useful for other transactions (see detailed summary or transcript for further information).

Discussion The large amount of convergence variability can be reduced but the process is likely to take 10-15 years. Payers and clearinghouses must change their systems.

The number one issue is increased use of non-claims transactions. It is also important to encourage practice management systems to fully implement all of the transactions. Implementation problems and the need to reduce variability were recapped. A suggestion was made to review non-regulated HIPAA transactions to help providers understand what transactions have been accepted or rejected. Flexibility of interpretation will help in some cases and hurt in others. There are several processes rather than one good process to resolve these issues at present (see transcript for description of processes). The Office of HIPAA Standards is distinct from the payment aspects of CMS. CMS’s responsibility is to work with industry to enhance HIPAA implementation.

The Convergence Project is a strictly voluntary effort that has developed a valuable and secure user-friendly tool within a website that also maintains a directory and repository. The need to define reasons for different interpretations and methods among plans was stated. When the Convergence Project has questioned payers about the usefulness of specific requirements, 99 -100% have examined the issues and made changes.

SUBCOMMITTEE DISCUSSION ON SECONDARY USE OF CLINICAL CARE DATA

Facilitated by Stan M. Huff, M.D.

Dr. Huff presented the idea of gathering clinical care data encoded in using standards, shared data models, and standard coded terminology using standardized algorithms for classification or derivation. A list of what could be done was put forth. Questions about payback and incentives were raised. Since many models are interchangeable, the idea is to recognize synonymy in order to automatically transform the models. These systems could become the basis for rules that would be stated against some assumptions about the data model rather than against assumptions of the standard codes used in the data.

The development of a research agenda was discussed, which some thought useful and others thought to be outside the purview of the Subcommittee. A series of presentations to the Subcommittee by vendors was recommended in lieu of a work plan. Questions were raised about using automation to assign mortality or morbidity codes. A request was made to establish priorities about practical needs of the public and private sectors and vocabulary translations. Attention should be paid to different ways to model the data (e.g., through algorithms or data models, etc.) in addition to mapping between terminologies. Dr. Huff agreed to add the amalgam of reimbursement and measures for quality (i.e., pay-for-performance) to his list.

NPI IMPLEMENTATION

Mr. George Argus American Hospital Association (AHA)

AHA concerns about NPI implementation were presented (see detailed summary or transcript for specifics

Recommendations AHA is co-developing recommendations for a deployment or staged implementation approach to the NPI. AHA recommends that the period from May 23, 2005 – May 22, 2006 allow for NPIs to be acquired but not used. The enumerator or organization issuing NPIs should run periodic progress reports by each type of provider category. Collaborative outreach programs will increase provider awareness, and web-based boards can respond to questions. The fast-track bulk enumeration readiness by the NPI contractor must be moved up significantly from an unacceptable fourth quarter of 2005. May 23, 2006 – December 2006 should be a testing period between trading partners that allows providers and health plans to examine whether appropriate identification and processing of claims can be derived from the NPI information supplied, and to modify accordingly (these first two stages will require constant monitoring). From January 2007 – May 23, 2007, the third stage should allow for routine sending of NPI and legacy IDs, which enable health plans to utilize the information as a crosswalk that validates the NPI against previous legacy IDs. From May 23, 2007 on, all eligible providers should report only the NPI, using one start date for all. AHA is offering to use its numerous communication vehicles to ensure that all critical information reaches the hospital community.

Discussion CMS has recently announced Fox Systems as enumerator (see website press release). The merits of a testing period of the NPI were raised. The AHA hopes for a formal timeline with specific milestones. The complexities of varying provider numbers and of the consolidation process were noted. Dissemination of NPIs to the user community has not been discussed or added to the timeline. Many unanswered questions remain.

The pros and cons of bulk enumeration were discussed. Dr. Zubeldia believes that bulk enumeration may be the source rather than the resolution of problems. He suggested bulk invitation rather than bulk enumeration but he would prefer to eliminate bulk enumeration altogether.

Ms. Karen Trudel CMS

As a group of covered entities and the NPI implementer, CMS is actively involved in outreach. A program management office, which will provide a matrix of all CMS organizations and players, is developing an initial message that encourages early involvement despite a compliance date that is two years out (2007). CMS is aware of the need for outreach and especially, for information about sub-parts. Regarding bulk enumeration, the general idea is that CMS will do a one-time load with the database rather than asking each provider to enter separately. There should be no duplication because of duplicate criteria

SUBCOMMITTEE DISCUSSION

There was further discussion about outreach; the function and cost factors related to clearinghouses; the fact that providers lag behind vendors in knowing the marketplace and recognizing costs and benefits. Currently, providers do better by working with existing practice management systems and clearinghouses or billing services that make transactions HIPAA-compliant.

DETAILED SUMMARY

CALL TO ORDER, WELCOME, INTRODUCTIONS, AGENDA REVIEW

Themes of today’s hearings 1) get feedback from the industry on their experience with implementing HIPAA standards (especially with regard to return on investment [ROI]); 2) explore how clinical data can be captured once at the point-of-care with derivatives of clinically specific data available for clinical research, reimbursement, and public health; 3) explore ramifications of a national patient identifier (NPI); and 4) introduce Mr. Tony Trenkle, the new director of the Office of HIPAA standards.

CMS UPDATE Tony Trenkle

HIPAA’s claims attachment proposed rule (adoption of an electronic standard for claims attachments) will complete its clearance process in the summer of 2005. The progress of the standard unique health plan identifier proposed rule (adoption of a national plan ID as a standard identifier for health plans) will be updated in this afternoon’s discussion by Ms. Karen Trudel. Additionally, the second round of modifications to the transactions code sets under development is expected to be published by December 2005. In the last week of March 2005, a notice was published in the Federal Register about procedures to review and investigate complaints in HIPAA enforcement. All information is available at:www.cms.hhs.gov/hipaa. The enforcement proposed rule (to be published in the late spring of 2005) details violation policies and actions to be taken against violators. As of March 28, 2005, 325 complaints were received, with 78% against private sector entities; 16% against Medicaid; and six percent against Medicare. Complaints primarily had to do with compliant claims rejected, code set violations, and trading partner disputes. Of the Medicare statistics through March 25, 2005, 99.32% of national HIPAA claims were compliant. Most claims were settled fairly quickly and cooperatively by industry and the federal government. The deadline for the security area is April 20, 2005 and the deadline for the small plans area is 2006. Because overlap between security and privacy is of concern, CMS is addressing overlapping issues with the Office of Civil Rights. These issues are being examined from an intergovernmental, agency, and customer service point of view. The process will essentially be complaint-driven and self-reporting. Standard methods of addressing recurring issues will be developed.

The comment period for the proposed e-prescribing rule was closed on April 5, 2005. The final rule is scheduled for publication no later than September 1, 2005. Discussions continue with the OMB and the DEA. An RFP for e-prescribing pilots is being drafted. Dr. Fitzmaurice asked about additional priorities for the next set of claims attachments. The Subcommittee will receive a substantive report when the claims attachment regulation is out that will allow for further recommendations. No current information is available on the contingency plan for Medicare operations but the Subcommittee will be informed about CMS’s decision to terminate the contingency (see transcript for current contingency plan). CMS has led the industry in how to work into HIPAA standards for claims transactions with almost full compliance.

Mr. Blair provided background history about the adoption of standards for the patient medical record information (PMRI) portion of HIPAA, about which NCVHS was asked to make recommendations. NCVHS has developed a strategy for how to proceed in this area and has identified major standards organizations, issues, and criteria for selecting and recommending standards that have been approved by CMS and HHS. In February 2000, NCVHS used the criteria of full operability to recommend its first set of PMRI standards (a set of message format standards that includes HL7, IEEE-1073, DICOM, and NCPDP Script). These recommendations became the Consolidated Health Informatics Initiative standards, which the federal government adopted early on. Incentives were developed because the standards were not mandated. NCVHS’s next recommendations addressed reference terminology (September 2003). The Consolidated Health Informatics now interfaces with other entities such as ONCHIT and the federal health architecture.

Questions arose about how Mr. Tremble’s role would interact with clinical, terminology, and other standards versus federal health architecture and what ONCHIT and others (including the private sector) do. Part of his charge is to determine where it makes most sense for CMS to assume a lead role as well as the points of coordination. It is critical to be clear about priorities and to work cooperatively. When government and industry join forces, the supply and demand sides can develop a plan that makes the most business sense. The approach to e-signatures was given as an example of the problems that arise when the focus is on solutions rather than on what the problems are. The Subcommittee can help by bringing reality tests to CMS and continuing to dialogue. Ms. Friedman stated that CMS has followed up on the Subcommittee’s recommendation to continue discussions with HHS and the DEA.

PANEL I HIPAA Return on Investments (ROI)

Joseph S. Smith BlueCross BlueShield Association (BCBSA)

Background The BlueCross BlueShield Association is comprised of 40 independent, locally owned plans serving over 91 million Americans. All BlueCross plans are fully enabled to support HIPAA transactions but providers are not using all the transaction sets.

Four key points

HIPAA administrative simplification has not produced positive ROI.
Plans are helping providers comply with HIPAA transaction and code set standards.
HIPAA administrative simplification may produce positive ROI if providers use the full suite of transactions.
BCBS Plans will continue to work with providers, state local, and industry groups to improve HIPAA.

Factors Influencing the lack of ROI (see transcript for elaboration of factors)

Higher implementation cost than originally projected.
Fewer benefits than originally projected.
Continuing need for contingency operations.
Gaps in readiness of vendor-supplied Provider Management Systems (PMS).

BCBS efforts to make HIPAA work

Readiness of Plans to implement the full suite of transactions since the 10-13-03 compliance date.
Plans work with trading partners to enable them to implement those transactions.
Plans help providers by: establishing testing facilities for trading partners; providing EDI web pages and call numbers; publishing and making available a free-of-charge widely-used HIPAA Toolkit to aid implementation efforts; and publishing companion guides that cover critical components (such as acknowledgements) associated with EDI that are not specified in the standards.

Future potential of HIPAA ROI There is much greater ROI potential for non-claims HIPAA transactions for standards remittance advice, eligibility, and claims status (see transcript for specifics).

Robert M. Tennant Medical Group Management Association (MGMA)

Background MGMA is the nation’s principal voice for medical group practice. Its 19,500 members manage and lead more than 11,500 organizations in which more than 240,000 physicians practice.

HIPAA ROI in medical practices The expectation was that several HIPAA TCS standards would provide advantages to medical practices that conduct business electronically (e.g., the 837 Claim and COB transaction [increased efficiency]); the 278 Pre-Certification and Referral Authorization Transaction (especially for practices treating managed care patients); 276/277 Claim Status Inquiry [increased transparency]; 270/271 Eligibility Inquiry and Response Transactions [increased efficiency]. There is also ROI with National Provider Identifier (NPI) and from implementation of electronic claims attachments.

HIPAA challenges Focus on privacy (yielding focus on compliance rather than ROI); lack of educational outreach on TCS from CMS; reliance on a non-covered entity for compliance [frustrating and expensive]; marginal compliance (of 837 and 270/271) by some health plans [lack of standard format causes providers to go through clearinghouses, which is viewed as a “wasted transaction”]; difficulty in securing provider “buy-in”; few reliable cost/benefit analyses of HIPAA; problem with delayed timing of regulations (see transcript for specifics).

Recommendations (see transcript for specifics)

Medicare and private health plans should be permitted to continue accepting proprietary claim formats (significant notice should be sent to the industry before Medicare ends this enforcement flexibility).
Medicare, Medicaid, and commercial health plans must report back missing data to submitting providers.
CMS should expand provider educational activities.
CMS should expand vendor educational activities.
Prior to implementation, an independent and comprehensive analysis of costs and benefits of all electronic health initiatives should be completed.
Recognition of the need for staggered compliance dates and sufficient time to ensure successful implementation.
Identification of financial resources to assist physician practices in migration to existing and future standards.
Continued identification of roadblocks and difficulties faced by providers and other covered entities as they work toward compliance. Learn from past mistakes.

Jean Narcissi American Medial Association (AMA)

HIPAA ROI results achieved AMA does not have specific information about ROI and believes that it may be difficult to gather this information via surveys. There is lack of clarity about use of transactions other than for claims. Transition costs are significant and practices in the process of converting will not have realized a ROI. Only when physician practices fully embrace certain transactions (270/271 Eligibility; 276/277 Claims Status Inquiry; 278 Authorization and Referrals; and 835 Remittance) will a ROI be realized (see transcript for specifics).

Business impacts of HIPAA An unjustifiably high percentage of every health care dollar is spent on administrative overhead (see transcript for specifics). The health care industry has developed standards to accomplish these transactions electronically that have been difficult to implement. Physician practices must embrace all the transactions to realize positive impacts.

Business challenges related to HIPAA

Standardization: almost 1,000 payer companion guides have been identified for the X12 HIPAA transactions. The goal of the HIPAA Convergence Project was noted: to provide a means for the industry to converge on a common set of transaction requirements that will minimize the need for unique data requirements and articulate differences and similarities of companion documents (Note: project presentation will be given later in today’s hearing).
Transaction fees: when payers no longer subsidize physician fees and clearinghouses are forced to raise their fees due to lost revenue. AMA President John Nelson, MD believes that the needs of patients are best served by free market competition and free choice regarding electronic transactions by physicians or vendors.
Submission of attachments for claims in order to get paid: Seventy-six percent of physicians report that payers require medical practice to submit additional documentation for, on average, 20% of their claims. Standardization of formats should reduce costs but until this is achieved, use of attachment standards should remain optional and based on trading partner agreements between physicians and payers. Standards implementation guidelines for code sets, which would eliminate many attachments, are essential for uniform national application of code sets.

The AMA encourages NCVHS to recommend inclusion of CPT guidelines and instructions for applying the codes as a national standard.

Recommendations

Physician practices must embrace all HIPAA transactions for a ROI.
The Convergence Project should identify differences and similarities of payer companion documents to provide information that organizes HIPAA payer transaction requirements.
Physician practices directly connected to payers would save on physician transaction fees.

Adoption percentage for HIPAA transactions and code sets The AMA and Forester survey results indicated that 88% of their medical practice claims are submitted electronically. There is no breakdown of implementation percentages for individual HIPAA transactions.

Discussion Mr. Reynolds wondered what consensus exists between presenters about what needs to happen to close gaps. There was agreement about ROI potential for non-claims transactions and direct connections at the point of origin; and about more outreach from CMS to providers and vendors. Asked about electronic claims transmissions, Ms. Narcissi noted the use of different formats that go through clearinghouses. Several initiatives of the BlueCross BlueShield Association quantify benefits from more comparable data for purposes of benefits coordination, quality assurance, and pay-for-performance. Differences in companion guides have been addressed and additional data has been added to BCBS eligibility requirements to ensure responsiveness and to improve the process on the 835s. Mr. Tennant is encouraging CMS to think more strategically about how to get their message out to the industry in a timely manner, how to build momentum, and how to stagger in order to allow testing time. BCBSA does not support staggered dates for payers and providers because it believes that advanced work must be done in a coordinated manner by a fixed date to avoid running redundant systems during transition phases. Several years ago, the AMA recommended phasing in individual transactions and other HIPAA transactions in the following order: electronic claims, privacy and security, NPI, HIPAA transactions, and individual transactions.

Companion guides The 400 claim formats were used prior to HIPAA. Of the 1,000 or more companion guides covering all transactions, 250 or more are related to 837. There may be different requirements for different benefit plans but this should be carefully examined because there are too many similarities that could be reported in the same way. Mr. Tennant stated that there is not enough provider participation at the X12 level. He suggested that CMS have X12 meetings and focus groups at the American Academy of Family Physicians and other places where clinicians congregate. Mr. Smith noted that many of the content data of companion guides are related to optional data elements. Gaps exist in standards or individual ways to communicate, test technical difficulties, and address self-employed benefits.

Contingency plans and windows Mr. Smith described the process of making claims transactions available to the 835 format (two separate processing modules). Through the contingency window, payers must now run modules that generate the 835 transaction as well as modules to generate the old format since many physicians cannot yet work with 835s. Maintaining two systems to accommodate that contingency also holds true for other transactions, although contingency is no longer needed for claims transaction. Involving vendors and practice management systems would help the whole process and generate savings.

Summary of Panel Discussions The benefits of standardization have not been realized because it hasn’t yet occurred. Even with diminished volume, there is “static overhead” for continuing to support the old system as companion guides proliferate. How can the benefits be recognized without standardization? How can this be done with no revenue loss and strong incentives to standardize? Until physicians can access what they need in the new formats, they must revert to using the old. It is very expensive and disruptive to change practice management systems, especially for small practices but even for vendors.

Convergence Project If X12 could learn from the Convergence Project, perhaps there could be a claim format the payers agree upon and no need for a contingency plan. It was suggested that effort be put into the Convergence Project to bring key stakeholders together to examine transactions and companion guides, which cannot be done within a standards development organization like X12.

Other topics of interest Use of technologies such as XML; percentage of BCBS claims that are compliant with HIPAA standards; whether there are plans to make more changes to claims submissions that are not HIPAA compliant; whether conformity or compliance testing is needed for practice management systems. Does the market work? Health plans are investing a lot to be HIPAA compliant but providers and vendors are not (although providers pay for clearinghouse services and billing services). Is there any provider organization willing to provide ROI for providers for HIPAA transactions by working with health plans, vendors, and SDOs? The vision of the future is a practice management system that sends materials to a directory that routes the claim to the health plan in a standard format, making prior authorization much easier. Business rules can be worked through. Who should be responsible for the data content of message standards? Ms. Narcissi suggested the formation of a consortium to discuss the future and how to measure ROI. In the past, CMS has turned the positive into a negative by using a “stick approach” that stipulated a payment delay if a compliant claim was not submitted. Mr. Tennant suggested providing a carrot instead: if a compliant claim is submitted, payment will occur in seven rather than 14 days. Why not add a pay-for-performance component that pays providers for utilizing other HIPAA transactions that will save health plans money?

PANEL II HIPAA Return on Investments (ROI)

Jim Whicker Workgroup for Electronic Data Interchange (WEDI)

Background Located is Reston, Virginia, WEDI is an association of over 200 corporate, government, and individual members. Mr. Whicker is director of EDI for Intermountain Health Care (IHC) in Salt Lake City, Utah, which has an advanced technology system and integrated network of 21 hospitals, over 100 clinics, and more than 550 physicians.

HIPAA successes include increasing the volume of claims, eligibility, and claim payment transactions. Cost and payment waits have been reduced as more claims move through automated adjudication processes. Providers report reductions in claim denials and increased efficiency using automated posting and data validation.

HIPAA challenges include variability of data mapping, code usage, and transaction implementation by providers and payers relative to the number of industry companion guides. Trading partners must still customize data processing to and from payers, providers, and clearinghouses in order to move transactions. Adoption of standard acknowledgements for claims is a pressing need. Internet access gives payers and low volume providers the ability to automate transactions, increase the speed of responses, and eliminate manual intervention. However, this may not work for high volume providers. To bring EDI transactions on a par with web application might encourage more provider adoption but to accomplish this, practice management systems must, at a minimum, integrate the 270/271, 837, 276/277, and 835 transactions.

Implementation and ROI At IHC, 80-85% of claims go out in the 837 format and 65–70% are received using 835 transactions. Fifty percent of payers have been implemented with eligibility transactions, 40% with claims status. Sixty percent of payers use an unsolicited 277 transaction that Utah payers and providers have implemented (noting that the percentage for non-claim transactions is significantly lower). Some providers report that claim totals are at 100% due to clearinghouse or vendor assistance. Most entities report increased volume of 835s and eligibility, although the numbers are still quite low. Generally, providers and payers have not yet realized a significant ROI although covered entities that have transformed business processes are starting to experience benefits. In UHIN, there is a 30% increase in claims volume, mostly due to non-traditional providers who can now send claims in standards formats. At IHC, seven FTEs have been reassigned from the EDI submission process and accounts receivable (AR) days are at the lowest in history but other providers have not had this experience. The transactions and systems are complicated. Those entities that report positive impact have made changes to the way their systems operate. To eliminate problems with claim implementation, payment status, and eligibility, transactions must be implemented in concert with standard acknowledgements for claims.

Additional areas of functional improvement for IHC and others as a result of HIPAA include: centralization and automation of cash posting function for electronic payment; COB claims transactions that can now be sent to secondary payers with little manual intervention; payment data that can be used for research and statistical purposes; an eligibility request that takes two key strokes; and received data content that allows for comparisons between payer and provider data, which enables systems updates. A large regional provider organization reports an average 45% decrease in claim denials due to eligibility and a 43% decrease in the dollar amount in aging categories between 90–120 days. Automation of 835 has reduced two FTEs. Providers who have implemented all core transactions have reduced claim denials. They are better able to collect patient co-pays at the time of service; track revenues of payers or contracts; and reflect payment data. Those who use the EFT capability of 835 streamline data and reduce costs. Active provider outreach, education, and communication help to increase volume.

Recommendations to improve ROI

Reduce variability between payers and providers as much as possible (noting quality of content disparities).
Develop an industry-wide standard for positive or negative acknowledgement of a claim.
Create cross-industry support for using standard development organizations to resolve content and usage issues and to improve communication.
Finish the roll-out of current HIPAA transactions before adding complexity.
Take new transactions through a proof of concept process to resolve issues prior to adoption.
Any national information technology standard should use the same road map to simplify implementation.
Resolve lingering payment issues of payment eligibility and claims status transaction.
Adopt a national payer identification.
Simplify set up, communication, speed of response to transactions, quality data and mapping codes.
Clarify what constitutes an institutional versus professional claim.

While it is too early to determine the ROI for NPI, WEDI is working with New York Empire, BCBS, X12N, HL7, and two New York providers on a claims attachment demonstration project. Work is being done to evaluate issues related to NPI.

Mark McLaughlin McKessen Provider Technologies

Background McKesson Provider Technologies is a wholly owned subsidiary of McKessen Corporation, a Fortune 15 Corporation and the world’s largest supply management and health care information technology company. McKessen provides supply and information solutions that include market-leading businesses in pharmaceutical and medical surgical distribution; automation; information technology; and outsourcing services for health care providers and payers. McKessen software applications include enterprise-wide patient care, clinical, financial, and strategic software management as well as internet-based and networking technologies, electronic commerce, outsourcing, and other services.

ROI McKessen has enhanced applications and services (including their clearinghouse) to enable their covered entity customers to be compliant with HIPAA, at a cost of $11 million (not including support services for customers who must resolve implementation issues). There has been little or no ROI but McKessen sees this initiative as the cost of doing business in the current market. It is hoped that the new infrastructure will generate positive benefits in the future. Because electronic real time prescription claim billing has been happening since before HIPAA, there have been no discernable positive impacts from the software development perspective. NCPDP 5.1 has added complexity without improving payer responsiveness, claim processing accuracy, or speed of payment. This is due to migration to a variable claims standard form from a standard that combined fixed and variable components; inconsistent implementation of standard concepts by different business partners; increased operational costs for necessary upgrades; and new data elements.

Positive impacts of HIPAA Implementation of additional process improvements that make system maintenance more efficient; reduction in sales cycle time; common language between trading partners and more efficient communication; and reduction in documentation. A shared benefit of using eligibility data between pharmacies and prescription drug plans is anticipated as a result of standardization provided under HIPAA’s administrative simplification.

Challenges Insufficient two-way communication between business partners; transactions that vary in content due to variations in the inbound claim batching scheme; a batching scheme that, defined by the health plan, does not include a detailed assessment of the validity of the data element and contents within a file (see transcript for example, which notes that additional standard electronic acknowledgements may provide added benefit); and some business partners who still enforce a file-level reject based on a claim-level error (problematic because one errant claim in the clearinghouse can cause all provider claims to be rejected). The latter problem creates more processing overhead and additional cost. Also, valid claims can be rejected because a business partner does not want to use the data being sent (see transcript for example). Code sets are ubiquitous. Managed by various entities, there is no single point of truth for what codes are valid or when they go into effect, which causes unnecessary and constant updating that hinders provider productivity. While preferable, it may not be possible to have a single maintainer/distributor of all code sets due to copyright and royalty issues. Local codes are still required by some business partners despite the fact that they should have been eliminated with HIPAA.

McKessen Recommendations

NCVHS support of WEDI recommendations and a recommendation to HHS that the Centers for Medicare and Medicaid Services implement the recommendations completely.
NCVHS request that HHS issue guidance on appropriate rejection methodology to help the industry move forward with a single efficient solution.
Creation of a single effective date for all code sets.
Investigation of the local code issue and elimination of continued usage.
Convergence of requirements of the claim transaction to reduce HIPAA programming maintenance (see transcript for McKessen illustration of the need). McKessen urges HHS and CMS to participate in the WEDI Convergence Task Group.

McKessen Clearinghouse adoption percentage rates for HIPAA transactions and code sets were presented. Lessons learned were elaborated (see transcript for specifics).

Dr. Kepa Zubeldia Claredi

“From HIPAA to Interoperability”

Dr. Zubeldia presented background history about NPRM for transaction and code sets. The final rule specifies requirements for trading partner agreements and stipulates that the definition, data condition, or use of any data element in the standards or standard implementation specification cannot be changed or added. The expectation for HIPAA is acceptability to all covered entities, payers, providers, and clearinghouses. The reality is that there are many additional requirements imposed by payers and clearinghouses, most of which are reasonable (see transcript for examples). These requirements can be found in the HIPAA companion guides, the NCPDP equivalent (called payer sheets), provider bulletins and newsletters, legacy computer systems, someone’s head, or instructions for filing different claims types. While there is one standard format today, there are at least 1,082 companion guides for the X12 HIPAA transactions and at least 200 for the NCPDP payer sheets (see transcript for guideline specifics and inventories). Dr. Zubeldia does not know of a payer that accepts transactions electronically without a companion guide. Claredi has created a website with updated links to all identified companion guides that serves as a free companion guide portal (noting that only 60% of the guides are available on the internet). The website address is: www.claredi.com/convergence. The next task is to put the NCPDP payer sheets on the website. Claredi will also work on attachment templates. Eventually, there will be a CCR template website.

HIPAA Convergence Project Begun in 2004, the project aims to help the health care industry converge on a manageable set of requirements for HIPAA transactions; to identify divergent requirements; to automate the identification of the requirements in a machine-processable format; and to provide a convergence model that is useful for other transactions (e.g., those in the NHII). Data content profiles and how the website resources can be used were described in detail (see transcript and Claredi website). The project supplements rather than supplants companion guides. Private profiles should not exist within HIPAA but the reality is that they will probably not go away. The website helps to define what elements are used more or less than others. To date, 250 837 profiles and 837 professional, institutional, and dental sets have been entered. Dr. Zubeldia would like to see payers enter their own profiles in the future. Information will be published by NUBC, NUCC, ADA, ADCC, CAQH, NDEDIC, and NCPDP. HIPAA covered entities should publish their own profiles. Each publisher maintains profiles and the project is entering an initial set of payer-specific profiles (250 to date) as part of the implementation in order to seed the directory. Practice management vendors will be able to download profiles and build them into practice management systems, which will help them to understand what their payers need. Until there is convergence, there is a web portal that references companion guides.

Discussion The tool that Dr. Zubeldia described is currently divided into three claims (professional, institutional, and dental), with two subsets in the institutional (inpatient and outpatient). He suggested that the large amount of variability be reduced. Every participant in the HIPAA Convergence Project believes that it will guide the industry toward convergence. The process is likely to take 10-15 years and probably several more iterations. Payers and clearinghouses must change their systems.

Dr. Cohn summarized the relation between ROI and key issues of the panel presentations (see transcript for specifics). The number one issue is increased use of non-claims transactions. It is also important to encourage practice management systems to fully implement all of the transactions. Implementation problems and the need to reduce variability were recapped. Mr. McLaughlin recommended looking at the non-regulated HIPAA transactions as a way to help providers understand what transactions have been accepted or rejected. Mr. Whicker noted that the more specific the requirements from trading partners, the more likely that they’d be dropped to the bottom of the implementation list. Flexibility of interpretation will help in some cases and hurt in others. There are several processes rather than one good process to resolve these issues at present (see transcript for description of processes). Standardization of the industry is a delicate balance between business processes versus transmission of standards. Relative to the government’s role as payer and interpreter of the law, there is an Office of HIPAA Standards that is distinct from the payment aspects of CMS that separates the HIPAA regulatory and enforcement functions. Despite no specific legislative mandate, CMS’s responsibility is to work with industry to enhance HIPAA implementation. Dr. Fitzmaurice mentioned that the Subcommittee has not heard from the Medicare program as a health plan.

The Convergence Project is a strictly voluntary effort that has developed an extremely valuable and secure user-friendly tool for the field within a website that also maintains a directory and repository. Practice management systems can download information automatically and build requirements into their system. Future costs will be negligible. Recognizing that there is more to companion guides than meets the eye, Ms. Trudel indicated the need to define reasons for different interpretations and methods among plans. In reviewing companion guides, Dr. Zubeldia said that when they have questioned the usefulness of specific requirements, 99 -100% of payers questioned examine the issues and make changes. Dr. Cohn suggested that the Subcommittee dialogue with some practice management system vendors. He emphasized the need to think through HIPAA compliant attachments versus “everything else.”

SUBCOMMITTEE DISCUSSION ON SECONDARY USE OF CLINICAL CARE DATA

Facilitated by Stan M. Huff, M.D.

Dr. Huff presented the idea of gathering clinical care data encoded in using standards, shared data models, and standard coded terminology. Data would include orders and results; text documents and clinical assessments from respiratory and physical therapists as well as nurses, that would record what is needed for patient care. The data would be the basis for algorithmically assigning and doing tasks. A program could be applied that would algorithmically assign appropriate morbidity and mortality codes for a stay or visit or it would assign appropriate billing codes or it would automatically create HEDIS reports for quality. This would automate what is now happening manually. Algorithms would be standardized and would constitute rules for standard classification or derivation. They would become executable instructions. A list of what could be done would include: automated assignment of morbidity and mortality codes; automated assignment of billing codes; automated creation of HEDIS reports; evaluation of adherence to best clinical practice; QOI to assess quality directly from the primary care data; automated response for clinical data to support claims; assignment of nursing acuity codes; and derivation of some population statistics (see transcript for example).

Who is working on the above issues and what has been done to date? What is the potential pay back or incentive? What can be done to encourage activity; and what activities or standards are common to the process? One example is that standard coded vocabularies speak to the need for standard shared data models to be coupled with these vocabularies(see transcript for other examples). Dr. Huff also talked about rules that cause classifications to occur within software which become the criteria for translating (see transcript forexamples). Dr. Huff suggested that the Subcommittee make specific recommendations. Since many models are interchangeable, the idea is to recognize synonymy in order to automatically transform the models. These systems would become the basis for rules that would be stated against some assumptions about the data model rather than against assumptions of the standard codes used in the data.

It was suggested a research agenda be called for that involves the Office of the National Coordinator, the National Library of Medicine, etc. Ms. Greenberg wondered about the idea of using automation to assign mortality or morbidity codes. She could not see how to skip the death certificate and, practically, how to have someone certify a death by making judgments based on algorithms in the records. With morbidity, the path is mapping from SNOMED codes to correct ICD codes. What Dr. Huff is suggesting goes beyond this by applying algorithms that look at tests and lab work, etc. (coders do not currently diagnose patients from record information). Dr. Huff responded by saying that mortality coding could be done although that data is never encoded in the medical record. Morbidity is quite different in that one looks at algorithms rather than code mapping (see transcript for examples). To go appropriately from SNOMED to certain ICD-9 codes, algorithms are already used, in that the patient’s record is examined for information that is associated with codes in order to make appropriate mapping.

Ms. Friedman thinks that mining large clinical data sets and helping them to communicate with each other is very important. Another research agenda could address variation within and across databases and defining a set of standards or algorithms that could be applied retrospectively. Mr. Blair suggested gathering information about multiple objectives separately and together to encourage synergy between mapping patient care data (to support the reimbursement process) with the ability of quality indicators (to support pay-for-performance). Such information gathering could yield recommendations on, for example, a core set of PMRI terminology. A workplan could include information gathering and an inventory of what is currently out there. Locating special interests to provide funding to fill in gaps would be another consideration. Dr. Cohn interjected that the Subcommittee’s role may not be to develop research agendas (although bullets can be added to an NCVHS research agenda). He thought that presentations would be more useful than a workplan at this time. He suggested that Chris Shute, the NLM, and AHIMA share their ideas with the Subcommittee. AHIMA currently has an industry-wide workgroup that is examining computer assisted coding, the process of going from clinical data at the point of care to secondary data uses (a brief on this topic will be given to the Subcommittee). AHIMA, which is producing a white paper on the role of SNOMED and ICD -10 in the EHR and how they tie into an interoperable NHIN, is also doing mapping work.

Dr. Fitzmaurice would like to set priorities about practical needs of the public and private sectors and vocabulary translations. Attention should be paid to different ways to model the data (e.g., through algorithms or data models, etc.) in addition to mapping between terminologies. Dr. Huff agreed to add the amalgam of reimbursement and measures for quality (i.e., pay-for-performance) to his list.

Next steps

Presentations to the Subcommittee (1/2 to a full day) will include a “primer” and an opportunity to learn more about what others are doing (i.e., AHIMA; NLM; FDA (working on classification of devices on terminologies and on beefing up RxNorm with the NLM) ONCHIT: CMS – Dr. Ferrer suggested getting CMS’s Office of Clinical Standards and Quality [OCSQ’s NORDI] involved). The relevance to the all NCVHS Subcommittees (especially the Quality Workgroup and Population Subcommittee) and NHII was noted.
It was suggested that the Executive Committee be brought into the loop, and that either the whole Committee attend the tutorial or overview presentations or that representatives of other Subcommittees and Workgroups attend. The interest of parties outside of the Subcommittee must be determined.

Dr. Huff suggested a three-phased approach: 1) education exploration; 2) what people are working on; and 3) establishment of three to four priority areas (which might result in more focused hearings). Dr. Bickford noticed the lack of focus on health, wellness, and health promotion. She suggested that linkages between diagnoses, interventions, and outcomes might fit into the decision support arena, though it has a “much bigger perspective” in looking at outcomes. Also missing is the context of care delivery – who is doing what, and where; and what are the relationships as hand-offs occur?

NPI IMPLEMENTATION

Mr. George Argus American Hospital Association (AHA)

Background The AHA has 4,700 member hospitals and health care systems and 31,000 individual members.

Concerns about NPI implementation Hospitals are confused about how and when the NPI will be implemented and especially about the sub-part identifier. Without guidance, NPI implementation will likely result in significant additional costs that could be avoided. A central authority must effectively respond to questions and concerns about the NPI (see transcript for specifics). It is essential to coordinate additional collaborative outreach initiatives to ensure development of materials that are consistent with NPI regulations and instructions. There is insufficient guidance about what criteria to consider as providers determine whether to apply for a sub-part identifier. There is wide variation on how providers are approaching sub-part identifiers and hospitals are afraid to make the wrong decision – which will defeat the purpose of administrative simplification and probably increase costs for providers and health plans. Providers fear that they will be coerced into filing for a sub-part identifier in order to accommodate to a health plan’s need. Factoring into this decision are operational elements such as location, governance, senior management team, strategic budgeting, and operational oversight; and organizational elements such as specialized units that require or meet unique certification and/or special licensure requirements.

Recommendations AHA is co-developing recommendations for a deployment or staged implementation approach to the NPI. AHA recommends that the period from May 23, 2005 – May 22, 2006 allow for NPIs to be acquired but not used. The enumerator or organization issuing NPIs should run periodic progress reports by each type of provider category. Collaborative outreach programs will increase provider awareness, and web-based boards can respond to questions. The fast track bulk enumeration readiness by the NPI contractor must be moved up significantly from an unacceptable fourth quarter of 2005. May 23, 2006 – December 2006 should be a testing period between trading partners that allows providers and health plans to examine whether appropriate identification and processing of claims can be derived from the NPI information supplied, and to modify accordingly (these first two stages will require constant monitoring). From January 2007 – May 23, 2007, the third stage should allow for routine sending of NPI and legacy IDs, which enable health plans to utilize the information as a crosswalk that validates the NPI against previous legacy IDs. From May 23, 2007 on, all eligible providers should report only the NPI, using one start date for all. AHA is offering to use its numerous communication vehicles to ensure that all critical information reaches the hospital community.

Discussion Noting Ms. Trudel’s absence, Ms. Friedman said that CMS, which is very involved in NPI implementation, has recently announced Fox Systems as enumerator (see website press release). Mr. Reynolds suggested that individual providers would also need outreach. Dr. Fitzmaurice thought that electronic prescribing pilots would benefit from a testing of the National Provider Identifier. Mr. Argus clarified that the testing period would help organizations work out methods of operating with their trading partners. The AHA hopes for a formal timeline with specific milestones achieved within each of the timelines. Mr. Reynolds discussed the complexities of varying provider numbers and of the consolidation process. Ms. Frank noted that dissemination of NPIs to the user community has not been discussed or added to the timeline and that many unanswered questions remain.

Bulk enumeration Dr. Cohn thought that “bulk enumeration” was an attractive concept (which will be ready in the fourth quarter of 2005). Mr. Argus hopes that bulk enumeration can be fast tracked to alleviate provider and group practice burden. Dr. Zubeldia discussed his concerns about the bulk enumeration timeline. He worries that it may perpetuate an incomplete and incorrect ID numbering system and that no one will be able to request a number until bulk enumeration is occurring within a given state. He believes that bulk enumeration may be the source rather than the resolution of problems. He suggested bulk invitation rather than bulk enumeration (whereby the bulk enumerator source would propose that a provider be assigned a number; if they have not heard back within a month, a number will be requested for that provider). Dr. Zubeldia would prefer to eliminate bulk enumeration altogether.

Ms. Karen Trudel CMS

As a group of covered entities and the NPI implementer, CMS is actively involved in outreach. A program management office, which will provide a matrix of all CMS organizations and players, is developing an initial message that encourages early involvement despite a compliance date that is two years out (2007). CMS is aware of the need for outreach and especially, for information about sub-parts. While CMS expects to enumerate in May 2005, Ms. Trudel does not know the details about batch enumeration. The general idea is that CMS will do a one-time load with the database rather than asking each provider to enter separately. There should be no duplication because of duplicate criteria. If a provider is first enumerated individually, a second upload should get caught by the criteria (UPIN database will not be used).

Discussion There was concern about additional work for individual applications for people who don’t know if they will be picked up in bulk enumeration at a later date. To avoid duplication, people might apply at the last minute. Ms. Trudel thought that outreach could alleviate some of these concerns. While the final rule does not specify bulk enumeration, the door is left open. Dr. Fitzmaurice expressed numerous concerns about NPIs. Ms. Trudel said that every plan that implements an NPI must figure out how to do so, working around constraints of the rule and their business rules. She described how CMS is implementing this process. CMS and HHS are responsible for providing guidance about the NPI, particularly with regard to the sub-part issue and multiple identifiers. Providing best practices information has not yet been done but can be done. There is no clear answer to how new providers will know that they must get an NPI. Ms. Trudel is interesting in brainstorming with people with linkages to educational institutions about how to get this content into curriculums. A data use strategy is currently being developed to help users understand how to access the NPI database for information about providers they have contracts with.

SUBCOMMITTEE DISCUSSION

Ms. Trudel volunteered to summarize the ROI discussion. Key points include: increased use of non-claims transactions; reduction of unnecessary variability (e.g., varying timings of code set implementations); voluntary implementation of non-mandated transactions (like the 997 and 999). The earlier discussion about companion guides was reiterated, emphasizing their usefulness and Dr. Zubeldia’s strategy to help payers eliminate inappropriate requirements. Mr. Blair wondered about creating incentives for convergence of companion guides. Great appreciation was expressed for the work of the Convergence Project, particularly the standardization of reporting differences among companion guides. At this time, there are no recommendations to bring forward that address the divergence in companion guides. Making all code set changes at the same time is recommended.

Action items

Establish effective date code sets.
Invite practice management system vendors to present their views about barriers or lack of ROI.
Invite clearinghouse representatives to provide testimony that helps the Subcommittee understand the impact of the significant increase in their workload.
Learn more about cost shifting within practice management systems and physician offices.

Dr. Warren suggested outreach to vendors to figure out how to stimulate them to produce some of the standards. Dr. Bickford thought it useful to find out what is going on in clearinghouses and understand why they have a market share. Dr. Warren noted Joseph Smith’s testimony that prior to HIPAA, people were doing direct billing and after HIPAA, there was a shift to clearinghouses. As such, a market was created as a result of HIPAA that adds to processing costs. Dr. Fitzmaurice noted that health plans and providers gain with more electronic interchange, though clearinghouses may suffer. The tools developed by the Convergence Project can help providers achieve some ROI that health plans either are or will be getting. Further, he believes that vendors are “smart” about knowing their markets but that providers are “behind the eight ball.” He’d like to think that the transition is toward a smoothly-run system within a marketplace that recognizes costs and benefits. Currently, providers do better by working with existing practice management systems and clearinghouses or billing services that make transactions HIPAA-compliant. Economies of scale are built into the clearinghouse rather than into the software at the site of care.

Summary on derivatives of clinical information Dr. Huff suggested that an educational session be scheduled around theory and potential opportunities as well as activities. It would be useful to hear from AHIMA, NLM, FDA, NCHS, Chris Shute, Jim Campbell, and ONCHIT. Once information is gathered, the Subcommittee should prioritize the “low hanging fruit” and make recommendations.

PLANNING FOR FUTURE MEETINGS

A conference call to firm up a schedule for the July 26-27, 2005 hearing will occur after the next Executive Subcommittee conference call on May 19, 2005. A decision about whether to include education efforts in a hearing with the full committee will be decided in collaboration with the Executive Subcommittee.

Mr. Blair then adjourned the meeting at 4:03 p.m.

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

/s/ 9/22/2005

Co-Chairman Date

/s/ 9/22/2005

Co-Chairman Date