availity logo

National Committee on Vital and Health Statistics

Subcommittee on Privacy and Confidentiality

June 7-9, 2005

Washington D.C.

First, I would like to thank the Committee for allowing Availity the opportunity to share our experience, thoughts, and needs regarding privacy and health information technology, specifically with respect to the creation and deployment of a national health information infrastructure.  My name is Jon McBride.  I am a computer scientist and serve as the Chief Technology Officer for Availity.  I have worked across a broad spectrum in healthcare IT, from clinical IT developing electronic medical records for emergency department information systems, to global Provider collaboration portals, to my current position with Provider-Payer connectivity and collaborative applications.

Briefly, I would like to give some background on Availity for context.  Availity is an independent joint-venture created in Florida in 2001 between two large Health Plans, Humana and Blue Cross Blue Shield of Florida.  One of the purposes for the creation of Availity was to provide a utilitarian Internet solution to the looming HIPAA compliance deadline in the State of Florida. The idea was that by collaborating on and consolidating Provider portals, Provider workflow could be improved and healthcare costs could be reduced.

Eligibility and benefits, authorizations, claim statuses, and of course claim submissions and remit advice was available securely online; and all of this was provided at no cost to Providers, which was another appreciated efficiency.  In addition to our Payer-owners, today Availity has connectivity to over 1000 Payers nationwide including real-time connectivity to a total of 10 Payers that represent approximately 58% of the private Payer market in Florida.  By offering functionality via these Payer connections to Providers across the state of Florida, Availity services over 90,000 portal users and 400 vendor partners.  This has resulted in 13,500 out of 15,000 Provider sites using Availity in Florida in some way, shape or form – over 90% of Provider sites in the state representing approximately 40,000 Providers. On behalf of our users, Availity submits over 8 million HIPAA compliant transactions to Payers each month, and is on a run rate to exceed 100 million HIPAA compliant transactions in 2005.

The formation of an NHIN could be based upon this and other proven methodologies.  The NHIN will likely evolve from existing networks and technologies and will not be revolutionary or installed in some massive system implementation.  As such, the evolution of the NHIN should be incremental in a phased and structured approach.  The NHIN must be open, not only in standards but in participation by all industry constituents.  NHIN governance must consider and allow every size and configuration of those who access the NHIN to participate in a collaborative manner per guidelines.

Based on evidence from Availity’s administrative experience in Florida, we believe that with enough Payer market share in other regions, providers and vendors will modify behavior towards more efficient workflows.  Market share drives adoption and utilization since there is an efficiency to be gained in the provider workflow; more patients being seen will be covered.  Then utilization will drive down costs, and the repeating cycle of improving the workflow can continue.  However, the administrative transactions are only the beginning of what can be interconnected.  Administrative communication provided the connectivity and network; now many follow on applications can now take advantage of that investment in infrastructure and utilization. The electronic health record can be created by appropriately combining the Provider-based electronic medical records, the Payer-based health records, and aspects of the consumer-based personal health record.  This does not necessarily mean that the records are stored in a centralized location, but rather that centralized record pointers could provide locating and accessing services.

Given privacy and other concerns, some may question the need for a National Health Information Infrastructure.  To those people I’d like to introduce Amy as a real world example of how sharing health care information could have made a difference.  Amy was 27 and pregnant with her first child when she developed an aneurysm near her spleen.  Unfortunately, Amy’s care providers did not or were not able to collaborate and share information to create a complete picture of her medical history.  Later it was determined that even though Amy’s lab and other diagnostic information was available, it was not shared.  She visited the same ER on two separate occasions before her obstetrician ordered an emergency delivery.  Sadly, baby Madeleine did not survive her mother’s aneurysm.  Surgical intervention was not immediate because Amy’s doctors did not collaborate and share information.  It is possible that with more medical information shared at each point of care, Madeleine would have survived.

In the National Health Information Infrastructure, Patients should control their data, and their personal data should remain private except in certain well-known and appropriate circumstances, perhaps such as the one Amy endured.  In Amy’s case, the ER physicians may have reviewed her history via the NHIN and perhaps would have had a better chance of quickly making the correct diagnosis.

Finally then I have six key recommendations and requests on the creation of the NHIN for the committee as follows:

Uniformity of laws and leadership established

Uniform application of laws and government leadership should be applied to the NHIN as well as other national healthcare initiatives.  There are too many federal, state, and local laws and departments that conflict. Without one clear governing body any initiatives at the national level will be extremely complex if not impossible to support.  In addition, HIPAA needs to be completed so that it can be used as a building block for the NHIN.  As the primary foundation and standards backbone, it is clear that until and unless the industry can do the easy part (ubiquitous delivery of administrative transactions) it will never be able to meet the challenge of the more complex clinical delivery, especially as a voluntary effort.

A Privacy model should be created

A user model and associated use-cases must be created to clearly define who administrates, controls, authors, accesses and edits health records.  The NHIN governing body should consider the creation or selection of one or more “trusted” entities which is only responsible for servicing the requests for data, but does not necessarily store the data.

Patient participation in the NHIN should be voluntary for patients, but opting in requires patients to follow the standards established for the NHIN.  Consumers should therefore be represented on NHIN governance boards.

Unique identifiers should be utilized

While implementation of the HIPAA National Provider Identifier is proceeding, the remaining HIPAA identifiers such as health plan and individual identifiers are critical to helping evolve healthcare interoperability. Registries that securely manage the digital identities of patients, providers, payers, and medical staff are a core requirement to the secure operation and adoption of a NHIN.  Without unique IDs, locating records and communication will remain inefficient and prone to error.

Controlled medical vocabulary utilized

The usage of standardized data elements and concept/context management should be mandated by the NHIN governing body. This will allow the data to remain meaningful across network boundaries.

Interoperability standards created

Interoperability standards including privacy and security requirements must be created at the national level.  Wherever possible and appropriate, existing standards should be leveraged.  For instance, the Internet must be uniformly embraced by all public-facing government healthcare entities as well as the remaining public entities.

Availity believes that in order to achieve the goals as stated for the NHIN in the timeframe allotted, a line must be drawn in the sand for the planned obsolescence of technology.  This should happen with the creation of the NHIN but also be an ongoing strategy of the governing body or bodies of the NHIN.  Sunset and maintenance rules must be created and adhered to, perhaps tying funding with established timeframes.  A continuous rolling 10 year plan should be published with achievable milestones.

Federated model of networks

DHHS should create a federated model of regional networks, RHIOs and otherwise, which when connected make up the NHIN.  The regional networks could apply for connectivity with the NHIN based on meeting minimum interoperability requirements.  This would allow many networks to evolve in parallel, but driving towards to same requirements.

Thank you very much for your time.