[This Transcript is Unedited]

National Committee on Vital and Health Statistics

Subcommittee on Standards

February 27, 2013

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

Proceedings by:
CASET Associates, Ltd.
Fairfax, Virginia 22030

P R O C E E D I N G S (2:00 p.m.)

Agenda Item: Subcommittee Discussion

DR. SUAREZ: I think we will reconvene. To get us started in this discussion I thought we could mention a few logistic things first before we launch into the discussion. As in our tradition we after the hearings such as this one, we prepare a letter with observations on recommendations to the Secretary. We are certainly planning to do that in this case. We will be taking the next couple of months probably to engage this subcommittee in several conference calls – conference call discussions – given the topic and significance of it and the wealth of information that we received and the many important issues and opportunities and also challenges that we see with this particular transaction. I think we will need to convene more than just one call a month between now and June, which is when the next full committee comes together.

We are hoping that clearly we would have something available to the committee by then. I know there is some pressing time as well on the rulemaking process from CMS perspective in terms of being able to receive this input and begin to prepare the regulatory action.

I think generally speaking what we hope is that w would have a series of calls of the subcommittee to discuss the many topics. I will highlight during this discussion several of them and then bring back to the full committee, hopefully in advance, to the June meeting a letter with a lot of explanation probably and descriptions and analysis and understanding of the various observations and recommendations.

That is what I think I see would be our process over the next several months. It is really very difficult to summarize in a few sentences all that we heard. I wanted to take a chance to highlight a few items, if not all of them, I am sure that I am going to miss many of them, but I think the first thing I wanted to say is this truly is one of the most critical transactions – and more than a transaction, it is truly an opportunity to look at one of the themes that came out today, I think, which was this concept of this convergence of clinical and administrative data.

Probably not with other transactions that we have dealt with under HIPAA, we have really have looked at the level of integration that is needed on both the clinical side in terms of the EHR and the data that comes from there and the administrative side. But it is a side, not just a single transaction.

We heard today that this touches on so many aspects of the process of not just administrative health care but the process of care itself. This is truly a very challenging and very critical transaction.

I think I heard several things and I am going to list them here very much in terms of general themes and some ideas, without getting down into the detail recommendations, although that is certainly part of what we will be discussing. One of the most important themes we heard besides this concept of convergence was this theme of a roadmap of a picture that truly puts this into the perspective of other processes. When I say “this” I mean the attachment – the world of attachments and submission of medical documentation in support of different functions, administrative and others.

It is important to continue to pursue that concept of a roadmap. We also heard the concept of incrementalism and phasing this. There are so many parts and elements here that putting them all together and then expecting that everything will be met by certain dates, all the aspects that this implies would be very challenging.

So taking a look at what are the building blocks, what are the components that form all these elements around attachments is going to be important. Then giving some levels of priorities of what are the things that we need to focus on as part of the initial sequencing. And then how the other elements come to play is also going to be very critical. So incrementalism, and sort of phasing and transitioning this over the next several years.

We also heard a consistent message of one size does not fit all for many of the applications and the users of this. That the reality is we need to be flexible and adaptable in terms of the elements that we see would be recommended for adoption standards.

We heard also an important message of considering the different components of the attachment transactions as a whole, from the purpose and business and purpose of those transactions to the elements of the content and coding of the standard and the structure. And then separating those but still making sure that they are able to not in consistent with each other, separating those from the transport and the mechanisms by which these transactions are delivered. I think we heard that as an important element.

We also heard about the concept of conceptually thinking about attachments as whole, in the broadest definition, but then certainly there are going to be applications of that concept for different business purposes. I am going to try and stay away from the concept of transaction purposes, but more importantly business purposes. Clearly we can see – at least the definition of attachments – at least I can see a definition of attachments is generic, and applies to multiple business purposes. But building sort of a priority sequencing of the implementation of standard for those purposes, and again, not trying to put all in one single pot of requirements and have them all be applied at the same time.

Then we also heard the importance of making sure that the standards that we recommend are able to be consistent with and aligned with the standards that are being used in the clinical world, basically, and are being required and used today as part of meaningful use. Since a lot of this data is really coming from electronic health records systems.

At the end of the day and I think we heard a nice summary from Kari from OESS, CMS has some expectations if you will, or interest in making sure that NCVHS provides certain recommendations. They highlighted recommendations about the transaction per se, the definition of it, the content standard, the transport, and then some of the uses and applications around that. In other words, the business purposes and business rules, sort of related to the operating rules for attachments.

But in addition to that we heard a lot of other important messages from the industry perspective. Actually in the Standards panel I think we heard a lot of consistency across the message about what is the definition recommended, the kind of standard being recommended, the codes being recommended. I think we heard more consistency than differences in terms of the recommendations.

In the second panel I think we heard some differences in perspective in terms of the expectation from the industry. This was the panel we called the Industry Panel, about the use and the applicability of this. In some ways the expectation was that since that we are maturing in terms of the claims transactions and the other administrative transaction, with more refined and defined code sets like ICD 10, that the expectation would be a tendency I guess, in terms of the trend, would be to reduce the need of the use for attachments and the submission of attachments.

But at the same time we also heard the issue around as we begin to expand and look at other ways of delivering services and other ways of organizing the industry and all the things that are coming down the pike from the health reform initiatives, there are going to be different data expectations in terms of needs from payors from health care, managed care organizations and provider organizations, ACOs and others, about the documentation and exchange of medical information.

I think we heard sort of those different perspectives around the use and the expectations around the standard.

A couple of other things I wanted to mention, I think one we heard that was important in terms of the process was that CMS should consider writing a notice of proposed rule rather than what is expected under the provisions of the Affordable Care Act to publish a final rule by January 1st of 2014. That is an important concept I think to consider.

The other one was the sequencing – this is not sequencing in terms of the requirement – but sequencing in terms of standard versus operating rules. I think there were some important considerations about without having the standard defined, being able to establish and write and define operating rules would be difficult. We heard from CAQH CORE how the time line for them recommending to this committee operating rules on attachments will be probably first quarter of 2014. Which would probably mean that the first round, if they were to come out of proposed rules, might have two separate components, one could be the actual standard if that was the case, and separately and afterwards, the standards operating rules. Those are some important considerations in terms of the sequencing, I guess.

I think probably the last point I want to highlight here, just in my quick summary, was the importance of defining when this – the definitional aspect – when is an attachment really going to be expected, needed, and required? We need those parameters, which are part of what probably the operating rules will be defining, then create a structure of what will be required in terms of the standard.

I think I am going to stop there and certainly open it up for others to comment. Before I do, I just want to highlight that we have about 10 or 12 different important elements that we need to cover, not necessarily today, but through the discussions. I am going to just mention it very quickly, we need to define the scope of what we are going to be talking about in terms attachments versus claim attachments, all those concepts. We need to come up with a definition of the transaction or transactions, as it might be recommended, as part of what the regulations would have to say, this is a transaction and this is the definition of it.

We need to identify certainly the priority areas for applicability and the use of the standard. Identify the implementation specifications. So besides the standard, we know there are those three elements with standards, implementation, specifications and operating rules. We need to define those three as we move along.

We need to discuss and define and decide what we will be recommending with respect to solicited versus unsolicited. I was mentioning earlier with some people, in many respects, and we heard some recommendations about the unsolicited to be still supported but try to be pre-defined as possible. Many respects, the word “unsolicited” is not probably the right term to use there because ultimately if providers know that they have – it should be called “pre-solicited” or “advanced solicited”. It is a known solicited transaction it is just that it is submitted concurrently with the attachment. Those are the kinds of considerations we have to talk about.

The elements of structure versus unstructured formats, is another component. The concept of transport and envelope is another component. The last two elements, one is the question about acknowledgements, we heard a couple of comments around that. The last one, and certainly not the least one, is the privacy and security considerations – the privacy aspects that are going to be so critical the exchange of attachments.

I just wanted to highlight those, sort of 10 or so important elements that we will have to include in our observations as part of our discussions here. There are probably more. As I said, my notes and my comments are certainly not completed.

I am going to open it for others to jump in and we can begin the discussion.

DR. SCANLON: I have to say from my perspective I think this is the best Standards Subcommittee Hearing that I have been to. This may be an illusion, I think I understood a larger percentage of what was said than I have ever before. Though it was probably still small – a small percentage – and it is probably not because I have really gone up the learning curve by coming to other meetings. It is really I think that the altitude of the discussions sort of was raised. I am used to dealing with little oxygen and so at these higher altitudes I can understand things.

Having sort of said that, that that has been sort of in my mind, sort of the issue of our ultimate objective. Today the fundamental thing in my mind was not necessarily attachments, but sort of the integration of clinical and administrative data. Sort of ending hopefully once and for all, the absolute distinction in saying they really are sort of two parts of sort of the same thing, which is information, and sort of how do we get the information that we need for a variety of purposes and how do we do that in the most efficient manner possible.

The question in my mind is sort how do we best pursue that. The idea of a roadmap is I think is very important because we live in a world where there are transition costs and we can obviously move instantly to new endeavors without incurring those costs and we need to take them into account. But designing the roadmap is really a challenge because you want to be efficient about the roadmap. You want to do things in a way that you are not sort of iterating back and forth. You are kind of in some respects, moving sort of moving on a continuous path forward.

That is one of the things that sort of disturbed me after listening to the testimony today, is that we identified the majority of the applications. But it is a challenge to think about taking all of them into account, at least in the way that we give them some relevance in terms of not building future obstacles to their achievement. The idea of use cases is helpful but you have got to have enough of a range there.

It is not necessarily that you try to achieve everyone of those use cases instantly, but you will at least be aware that there will be the need to think about that in the future.

I was just starting to jot down a list. Claims adjudication is a part of this, rates setting is a part of this, risk adjustment is a part of it, quality assurance, population health, all those kinds of things. We need to think about all those dimensions when we are sort of moving forward on this.

I was also heartened by the fact that I had been thinking before this hearing that attachments was not necessarily the right focus, but I am not sure I agree with myself anymore on that because maybe if we have the right definition for attachments, or we just use it as a label and we don’t have to open up other doors, then we can have a roadmap that is going to achieve what we want.

My prior thinking had been that the issue was – and this goes to the solicited versus unsolicited – there are things that we have not gotten in the past on a routine basis that we will want in the future and we can get in the future very efficiently. We would want to expand the information that flows with a claim, essentially. It doesn’t have to be that we reopen the claim content question, but we say the attachment is the vehicle that we are going to get that information.

Because it is conditional information, we don’t want the same information for every service, every sort of patient, because that would be grossly inefficient. Just as when you are online and you are filling out some form, they don’t always ask you for the same information but they remind you what you did not send them and they don’t let you go any further. We now have the capacity to do that here too, to make it sort of easier for people that are submitting the information to know what needs to be submitted and to do it efficiently.

I think the attachments is maybe the right sort of label we can use, it is the question of sort of defining them well.

I am also would say I understand the need for flexibility but I also am worried about the trade-off between flexibility and true administrative simplification true of cost savings. When electric sockets were standardized there were probably a lot of pain when people had to rewire to have the standard socket, but everybody now is a beneficiary and has been a beneficiary of that for a long time.

I think we are going to have to consider whether it is worthwhile incurring some short term pain that some might object to in order to get standardization gains for the longer term. I would not hesitate, it is not that I am being dogmatic on this, but I would not hesitate to look very carefully when we say this is an area where we want to have flexibility, is it really true.

I think we have to think about it from a different perspectives. This whole issue of the transport – if you are an insurance company and you are saying this is how we want things to come in and all insurance companies don’t agree on that and they all have their different ways, that may be fine from their perspective. But if I am a provider dealing with six insurance companies and there are six methods, that is a different situation.

So I think we have to look at this from both sides of the transaction to understand what are the costs and then factor in what would be an optimal situation in terms of administrative simplification.

I liked Walter, that you highlighted through what CMS is going to be making decisions about because I think in part is an important guidance that we need in terms of what we say. Because frankly, again, I was feeling this morning that we had covered a tremendous amount of ground. Then sort of when you stop and say, alright, what am I going to say about all of this, you have to have something to hook onto. The CMS decisions are obviously the critical next step.

Thinking about what those are going to relate to and what the broader context for them is, is a helpful focus of the committee. So thank you for organizing this hearing. It was very helpful from my perspective.

DR. GREEN: I want to ask Bill to just go a little further with the next to your last sentence. Clearly the CMS decisions are critical next steps. What are the implications of that?

DR. SCANLON: My sense of the implications is that they in some respects cast the die or the form for the next four or five years. The issue is – I know that we had a sidebar conversation about thinking about expanded uses. If the CMS decision really precludes some of those expanded uses, and potentially even inadvertently, then we are in a worse off situation.

I can’t give you much more specifics but I am thinking it is principles. It is the fact how they decide the attachment rule is going to be, is going to be critical in thinking about sort of this roadmap for the future. It is going to start you down the path and you would like to not have to reverse course for the next steps.

MS. GOSS: Am I also hearing maybe between Bill and Larry, that there is a dynamic where we know we have something we need to deliver to CMS for them to write a reg, but that may not be in alignment with what we are really hearing we need to do to help truly blend the two worlds of clinical and administrative financial together? So it all comes back to that EHR data set.

I am wondering our marching orders towards what we need to give to CMS versus what needs to be complied with in 2016, versus where we think we need to go to kind of make the bigger long term bang for the buck.

DR. SCANLON: I think our marching orders are relatively broad. We really do have the discretion. In some ways, we heard from various parties today, and we heard from them over the years. My sense is that we also bring a sort of societal perspective. I don’t know whether it is the taxpayer or the consumer or what, and it is our obligation to take that perspective and speak out regardless if we had been asked the question explicitly.

MR. SOONTHORNSIMA: To add onto that I think the comment about CMS I drew a different conclusion and said, if you look at a lot of changes in our industry, even payment reform and things like that, payment innovation, starts with CMS.

In a way that is what commercial plans try to do. After a while they just kind of get on board and follow what the CMS model is. Bill, that is how I read from your comment so there is kind of a commonsensical approach, what is CMS looking at this morning, if I can remember, is pretty often then post review, that type of thing. Those are pretty easy first steps, if you will, because that seems to have some common pay points, not only for government business but also commercial business.

DR. SCANLON: If you take those processes and start to put them into the context of a new world where you have got bundles where you are thinking about holding people accountable for quality and things like that. The dimensions for information requirements change dramatically. Some of that you can anticipate today in terms of the specific requirements that you want to impose and others you are going to just sort of leave the door open to be able to refine over time.

DR. SUAREZ: I think it is important to distinguish and I will go to Linda in a second, but distinguish CMS as the regulator and their expectation from NCVHS recommending certain directions on this topic. Versus CMS as the Medicare administrator that is operating a project that is dealing with the same concepts called ESMD.

Certainly we heard a lot of very important information from ESMDs project. But we also heard, and where I thought Bill was going too, is we also heard the expectation that OESS, the division within HHS, that is going to write these rules, what are their expectations outside of what Medicare doing – not outside in the sense of independent of – but certainly taking into context the recommendation from NCVHS that are broad enough.

That is what I really appreciated from the perspective CMS, the regulators who are going to write the rules, saying we want to hear the broad perspective. We don’t want to focus exclusively on a particular transaction. At the end we will hope to have the ability to define the standards for and we will have to – I suppose that CMS will have to define the standard for the particular transaction called “claim attachment”. But what I heard that was very important was that they want to hear the broader perspective of attachments and the broader perspective of how this fits into the rest of the structure.

That is very different – that is a different group within HHS, from Medicare. Linda, I think you had some comments.

MS. KLOSS: A couple of summary comments that I would add to your good list, Walter, that I think we need to preserve. Three additions. One was the recommendation that we have some kind of further dialog with stakeholders about the business cases. This is a little more of a dialog with the industry about what is going to work. I think that is something that could affect our timeline and how we proceed with our work.

The second item that came up from several testifiers was the need for education. I think often we have that kind of come at the end, but it might be very good to move that up and even just start using the concepts and the terms and what are we trying to accomplish.

A third thing that I would like to kind of get on the list so we don’t use it is the concept of minimum necessary. George incorporated that in his comments and certainly that was a very big guiding principle in the original HIPAA. This was an area where we kind of do no harm. Enough information to support that business case, but not too much. How do we reconcile that with being in the age of big data? I think we have to grapple with that and it may be that we need to have some dialog with in the Privacy Confidentiality Subcommittee about that in this context.

SO I would add those three to our list. I don’t think it is just privacy. I think it is data for purpose, not just lots of data for the sake of lots of data.

Then I go right to how do you eat this elephant? We know what we are trying to get at and we have a tough time lime. Maybe we should just take the about what would be that incremental scope? Where would it start? Where might it expand to? And is there any way we could lay out a first cut of that based on some of the recommendations that we heard today?

DR. SUAREZ: I think we could jump into it.

MS. KLOSS: I will just throw something out just to start us. The first round that would be effective in standards in 2016 would be to get rid of paper. Move everything to some kind of electronic. Not to preclude those who are ready to go further faster, but as a baseline. Then look at what other applications get supported as we step that up, moving out.

I don’t think this is a one-time, implemented in 2016, and we are done with this problem.

SPEAKER: When you say get rid of paper by 2016, you mean very specific cuts.

MS. KLOSS: Correct

DR. SUAREZ: Basically instead of moving paper – mail, fax – move paper electronically.

MS. KLOSS: As a minimum standard.

DR. SUAREZ: Interestingly, from CAQH testimony we heard of three sort of phases. Phase one paper – today faxes and FedEx and UPS and all of that. The second phase was moving a lot of that paper electronically, which is in great respect what phase one of the SMD is – really sending the same type of papers but in PDF or JPEG or some basically picture form, but it is still paper except it is just moved faster and more efficiently. Then the third phase that was referred to was the structure data.

Now what is interesting, and what I wanted to point out, is really phase two and three can happen at the same time because if you heard the testimony from the standard side, HL7 and X12, the content and the payload, as they refer to it, can be payload that has structure or unstructured data.

MS. KLOSS: But the pilot that was done was 2004. Some of the standards we heard are still new.

DR. SUAREZ: No, that is sort of basically the new standard, which incidentally is the same standard as meaningful use – using CCDA, except that CCDA can carry structure data elements inside, structure data content inside, as well as unstructured. You can imbed inside CCDA a JPEG or a PDF or a medical note or a clinical note. So you can do both at the same time to achieve the same goal of moving paper electronically, as well as now pushing the envelope to move it in a structured way for certain elements of the message.

So yes, but clearly there are different aspects of the roadmap, if you will. One is this sequence that we just talked about, the there steps, if you will. Another way of looking at is also what are the priority business application? We heard there are at least ten or more application areas, business areas where attachments are currently needed. Not just claims, but we also heard about medical audit like ESMV. Or we heard about from eligibility to prior authorization to referrals. We heard several different business needs, I call it — we normally call it transactions – where there is a growing expectation that attachments are being used.

So the question was, part of the transition and roadmap, was how do we begin to sequence those? We cannot say the standard for attachments should be X, and then say that applies to all attachments from attachments to prior authorizations to attachments for claims. We could say that but we cannot expect that it will move everything January first, 2016, for all attachments to that standard.

So the idea was sequencing also that, starting with maybe claims, which is one area that is certainly expected under the Affordable Care Act. But looking out into the future, what is the right sequence and what is the right timing over the next whatever, with years, ten years, whatever we want to build?

That is another way of looking at the roadmap, is relay sequencing business meetings.

MS. KLOSS: And leveraging other changes that are also going on in the industry that is supported.

DR. SUAREZ: Other observation?

MR. SONTHORNSIMA: I have — I am not going to repeat all of the things that we have said. One more thing that I noted this morning was that there is much greater collaboration among the SBOs, it seems like. Of course I think this is where we have to also have the offering entity to be working very closely and define those use cases. I think that is probably alluding to the 2016 to go electronic, for what particular use case, for what particular attachment?

I heard this morning that is one of the things that the folks were talking about, our testifiers, that some of these use cases have to be vetted by the folks form the industry, the various stakeholders, to find where the biggest pain point is you can get, you go after.

Another thing I hear and I am not sure this is true, is that adoption is still going to be very critical, very difficult, even with good use cases. So I think that is another thing that we need to figure out, even if we have the standard, even if we have the operating rule in place – how big that hurdle would be for the providers. I heard about the small providers having a very difficult time unless they go through the third party to do the submission.

DR. SUAREZ: Great point. What I was thinking was even if I am a small provider, if I am participating in a meaningful use program, I am expected to be using an electronic health record that is certified to be capable of generating a standard. And if we were to recommend the standard we heard today from HL7, that is the same standard that EHRs are being certified. So even if I am a small provider I should be able to do that, right? I have this EHR product and it is certified to push out CCD8. But what we are seeing and what we heard, basically shown in testimony like from MEA NEA, that in reality providers are not yet using a lot of that for this. In fact, very little.

So one thing is providers their EHRs to generate the transaction to meet meaningful use, which is sending to another provider, by the way, so it is provider to provider – that is what meaningful use is all about, provider-to-provider, not provider-to-payer. So provider-to-provider they are sending out referrals and CDAs to meet whatever threshold they need to. But when it comes to payment, now they are being hit hard, because now if the rule were to say a hundred percent of your electronic claim attachments should follow this standard, then one of two things could happen.

One is they will say I won’t do electronic attachments; I will just send everything by paper. Theoretically some people could read the concept that I am only required to do it if I choose to do the transaction electronically. That is what HIPAA says, providers are only required if they choose to dot he transaction electronically. So people are going to say I am afraid of sending out an attachment using CDA so I am going to go back to paper.

Or they are going to have to invest a lot more because now there are transactions that generate payment, not transactions that are used to meet meaningful use or to fulfill referrals, which might not happen as often as sending claims.

So anyway there is that reality that when we are applying this to the provider-payer relationship we are really inserting a major bar, compared to what meaningful use bars are being applied to. This is relay potentially moving the bar so high for some small providers that they will drop to paper and they will keep sending paper.

So that is where flexibility – and we heard it also today – comes into play. Being able to submit transactions using an unstructured mechanism n=that allows them to push the same content that is not yet structured, but electronically would be a possibility.

DR. SCANLON: I guess even though HIPAA allows the paper claims and things to be exempted, is that really an option any more? We have other requirements for electronic submission. There are contractual arrangements between plans and providers. I think there are other ways this can become all electronic.

We are now finally going to direct deposit on Medicare payments. This is the 21st Century and we are getting there. I think there is the question that we should assume that these things are going to happen. I am not sure the reversion can be tolerated.

DR. SUAREZ: That is why the bar would go very quickly to pretty high levels. If you think of bars the people in meaningful use kind of think what is the threshold I have to meet for meaningful use? And to submit electronic reports to another provider I need to meet ten and then fifty percent. But here potential could go from zero claim attachments electronically to a hundred very quickly, and that jump is the one that potentially, in some instances – again, a provider could say if I choose not to do it under HIPAA I can not do it, but then, yes, there are program requirements, there are business relationship requirements that will push them to do it.

So we are potentially raising the bar to a high level. I think that is part of the concern of relay the impact that this could have in the provider-payer relationship. It is quite different from the impact that this type of standard has on meaningful use. There is a bar that is different in terms of the speed at which the bar could go up.

DR. FITZMAURICE: A lot of good things have already been said. Some of the things I heard – the other was good cooperation among the SDOs and the payers and some interest by physicians, spenders or handlers. Handlers was kind of a new term for me. I assume that is somebody who comes in and helps a physician with maybe meaningful use, with doing attachments, not a billing service where they do it for you but they get the physician ready to give this stuff to the billing service. That is anew feeder in the chain of how information flows.

DR. SUAREZ: I know the experts are here, too, but health information handler, HIH, is a term within the ESMD project. But in summary, and I know it is not a fair comparison, but I would generally relate it to the concept of a clearinghouse. It is a mechanism to take a document from a provider and get it to the payer. In this case, you know, clearinghouses, their function as defined by HIPAA, is to take a non-standard transaction, convert it into a standard, and move it to the other end.

Health information handlers do kind of the same, but they don’t relay convert a standard. They use it to interface and then transport the data to the payer.

DR. FITZMAURICE: It is kind of the same as a billing service. Here’s my stuff, put it in the right form to send it to the clearinghouse. Okay, so maybe it is not an extra feeder, because we are trying to reduce costs.

I heard that claims attachments should not ask for information that is already on the claim and should not mandate the use of claims attachments for non-administrative purposes. This is mostly George Arges. But he also said it is a matter for negotiation between the user and the data requester and the provider. When he boiled it down it seemed a fairly reasonable statement, even though it raised fireworks among a lot of us – you mean not for research, not for this? He wants claims attachment for business and then anything beyond that is subject to negotiation. Don’t mandate the use for that.

I heard that health plans have prior authorization rules, but often they are given out piecemeal in response to requests from providers. He likened it to the game of Battleship. It seems to me from that and from further discussion that there is a need for a standard for expressing prior authorization rules. That may be the hardest step. How do you express the medical knowledge in prior authorization rules?

Then you need a set of definitions, a taxonomy of rules, because you are going to have all these rules from different health plans. How do you make sense of them, but once you do then you need to have a directory for each health plan’s provider attachment or prior authorization rules. The once you get to the health plan you need to give as contract number of the persons Social Security number of get what the benefits are and what is the co-insurance and what is the deductible.

So it seems to me if we look into the future, this could create an extra way to economize, to make the administrative process more speedy and take fewer resources.

DR. SUAREZ: Great point. Just a comment on that, two comments on that I guess, from my perspective, I really like the way Melanie characterized the concept of the attachments in terms of claims related. She pointed to the prior authorization process and the pre-adjudication type of attachments, and then the post-payment attachments. Those three elements are really part of the whole concept. Outside of certain other expectations, I guess, in terms of attachments that could be used for other things like coordinating benefits or some other things.

But I think the prior authorization discussion, in my mind, had two different elements – one related to attachments and the other one related to the business process of the prior authorization itself.

So all the discussion you have raised and the point that you raised in great respects were relay about the business elements, aspects of the prior authorization, and the issue – I need to check first if I am authorized for this service. But that is already a transaction fact. That is a HIPAA transaction that already exists and is supposed to be used, the 278. But in addition to that there is some instances, some times where the prior authorization, when you use a 278, if you were to use it, requires that you send attachments.

So that is separate. Those are two different elements. It was relay interesting to hear the discussion of the prior authorization, and at some point we would have to go back and discuss, as a subcommittee, the transaction called prior authorization, because there are a lot of questions about what is going on there. But outside of that there are some instances where the prior authorization requires attachments. Maybe in most cases or maybe in fifty percent of the cases they require attachments.

So those two, I think, are relay two components of the discussion around prior authorization, which was really fascinating.

MS. WILLIAMSON: Most of what I had in my notes everybody has covered. But I have two that I don’t think have been discussed. One is Dan’s comment about what vocabulary for what purpose. That sort of homed in on making sure that we make the association with the vocabulary, especially when we look at the minimum necessary that you talked about. What’s the appropriate vocabulary to support that?

And the comments from MEA/NEA, also supported by Linda’s comment on ROI. So what is the return on investment? They specifically noted for the seven dollars savings potential per transaction, so we want to put something there.

DR. SUAREZ: Mari provided an attachment, one page that actually builds on that and it is very complete. It says basically, and this is from the testimony from MGMA and AMA – average cost for a provider for a paper-based attachment per request is $21.34. Assuming the number of attachments to be 400 to 500 million, based on the MPRM back in 2005, the total cost today of attachments is between $10 and $12 billion. That is the total cost today. And that does not include an estimated 100 million attachments sent by hospitals and other attachments sent by other providers.

Then the average cost of paper-based attachment, and this is Medicare, and this is the report I think we heard from ESMB, a million claims subject to complex review cost to send an additional development request or ADR – that is the request they send and it is about seventy-one cents put in the mail basically – that is $923,000. Then the cost to review and process attachments and prepare medical review is about $32 million.

So maybe this doesn’t answer exactly how much will we save of the $21.34 if we go to an electronic claim paper-based attachment, but the size of the attachment-based transactions of the 12 million on the outbound is a pretty high size, I guess, in terms of the total amount.

DR. SORACE: Listening to that, it is hard for me to know where to attribute the cost, and whether there is a savings simply because it is electronic. You have a situation – I hate to say it but $900,000 for mailing stuff in the United States for a $2.6 trillion industry or whatnot is not a great savings. We can make things electronic but we can still divert as much secretary and provider time to filing them out. We may even make it worse. So it is hard for me to understand exactly how we can assure that we are sort of fulfilling our mission, which is administrative simplification, and to provide a cheaper, frankly, billing system.

I told my wife, when I started working for this committee, that what I really learned that the United States health care system has never paid a claim the same way twice. So we need to sort of keep that in mind.

The other thing is I think there is a bifurcation here that is coming up really quickly, and that is we are sort of in a low information claims world. Most of our information claims and most of the things we are doing between payers and providers now actually have probably relatively little informatics time factor, perhaps a few ICD-9 codes some dates and providers and who did what.

We are hoping we can scale this thing to relay complex events, that might be bundled services, and might involve things like diagnosis and staging and therapy for the cancer patient, which are challenging things to work on medically and informatically if you are just trying to care for the patient.

So I think what we relay need to figure out is where the best savings and the simplicities lie, and at what point do we scale from structured documents to hybrid documents, and documents that are going to require review. And the more we ask for, the less saving you might actually get on the savings side.

DR. SCANLON: This is kind of a GAO perspective on some of this. The one million complex claims, the number is one million in part because that is the money CMS has to pay to look into those kinds of claims. It is not that they would necessarily be all the complex claims that one would want t0 look at. Because when studies are done of inappropriate payment we discover that there is somewhere – I don’t know the current numbers – but between four and seven percent of Medicare dollars re paid inappropriately, which turns out to be somewhere in the range of $30 to $50 billion a year. One of the things we would always say at GAO was that if you invested more in claims review there would be a very significant rate of return for that.

So I think there is that aspect of this. That actually is not something the providers necessarily want to happen, is to have more careful scrutiny, but from a social perspective it is something that really is important to do.

I think where the administrative simplification comes in is again this notion of turning the unsolicited attachment into sort of an automatic feature. It is in the record, and I know this is sort of very futuristic, because we are not there yet, but it is information, it is in the record, and in the context of the other parameters of a particular claim, it is recognized that that information needs to flow with that claim. So if you have a certain service, a certain diagnosis, a certain other set of conditions, you know that this information has to go. It doesn’t require a human intervention, because the rule is firm.

SPEAKER: Sort of claim decision support.

DR. SCANLON: It is. And it is to eliminate all of this thinking on the part of individuals to decide this is something we need to look at, and they asked me to look at it and now I have to go gather that information. We want it to just flow.

MS. GOSS: I am hearing this conversation about the unsolicited and I am hearing that a balance quality with cost and I am really struggling with understanding the need to have unsolicited claims attachments data just automatically just coming in when we are trying when you look at meaningful use and the HITECH programs, trying to create a ubiquitous sense of federated information exchange – right information at the right time to do the right job.

So it seems to me that if we are looking at that perspective from a clinical world, we have got to find a way to blend that in the payer world because I get what you said about lets have it unsolicited, just send it in and it is a part of the record. From a payer’s perspective, having working in Medicare and having supported a variety of payers as a private consultant, they are not going to like that.

The data is already out there folks. It is in that EHR. That provider is not getting rid of that. The problem is we don’t have a one size fits all in the provider’s readiness in meeting sort of these futuristic, just in time data needs.

DR. SCANLON: Again, I am thinking from a Medicare perspective in term of how we currently pay for things. In terms of a hospital payment we ask for the diagnostic information and we have become more sophisticated in using that over time. We used to just use the principle diagnosis, we now use co-morbid conditions.

In terms of nursing home payment or home health payment, we have got other information that flows in that also determines payment.

Medicare will have to adapt, too. That is going to be a part of this. And the issue would be as you expand this clinical information that becomes part of administrative data, what are your opportunities in some ways, to refine payment?

In terms of hospital payment, we had a real issue when we were using only principle diagnosis in terms of how inappropriate the payments had become and there was a need to revise. The same thing, if we had more information and we start to look below what we currently have we may discover that there is a lot to be gained from trying to calibrate and refine payment policies that we have not been able to do in the past because we haven’t had the information.

This is that issue of transition costs and it is from everybody’s side. It is not just going to be on one side or the other. It is going to be all sides of this.

DR. GREEN: Walter, I am turning to thinking about tomorrow. I am wondering what you guys are going to say to the Full Committee.

DR. SUAREZ: We still have about eight hours to prepare for that.

DR. GREEN: Let me offer some premium comments here about this and get your reactions to them. One is I am struck today at how so much as already changed and is changing except the way we think about claims. The fact that we are stuck thinking about it as a claims attachment is sort of an indictment on where we are. Forgive me for – some of you have heard me say this before – I feel like I am just cursed with the mind of a physician – but biology is really smart. Without most of us knowing it, a large extent today we have had a conversation about something else that actually replicates one of the most sophisticated biological systems that we know about. Forgive the digression here.

One way to think about what we are going to talk about tomorrow and what the role is for NCVHS in some particular space, is we have got to find our level. Where do we fit? We have had a year and a half of discussions about that. One of the things that I think the Full Committee agrees with is that a couple of things at NCVHS is good for is being a neutral convener, and that has come up in comments here today.

The other is trying to envision where the end game is. Where do we get to? Along those lines, the way that biology would think about this could go like this. What we are looking for is infinite variety in a medical health care economic landscape where information just flows, the way Bill says, it just flows, accommodating infinite variety while being absolutely standardized.

On the face of it that is impossible, but look around the room and every person here represents infinite variety in the human species and it all comes down to a double helix and four basis.

One level for us to shoot for is could we just agree what the two strands of the double helix are and what the four basis are? To stay with the biology for a minute, the rest of this is just about proteins. And we don’t have to decide what every protein is going to do. Some of it will turn into muscle, some of it won’t. I beg forgiveness for that.

But thinking about managing the committee, we are going to have a Privacy, Confidentiality and Security Committee sitting at the table tomorrow and they are going to have serious issues with a lot of the stuff that was discussed today, and Linda calling out the fact, minimally necessary. So there is going to be some action there for sure.

I don’t know what I would say if tonight some of the committee members start emailing and saying, what did you guys do? What would I tell them an attachment is? I am kind of wondering about that. It seems to me that what we have learned today is that there is a serious set of issues about attachments as they used to be and what they used to be used for, and there is unfinished business there and there risk there and there is cost there and there is work that has to go on 24/7. That airplane has to fly while it is being rebuilt. That is going to be really hard and that sort of stuff.

On the other hand, I hear great enthusiasm for us recognizing that an attachment is sort of like one of those four base payers connecting up something else and that if we can just get that out on the table and established, the roadmap gets easier toward that end game. It can do a lot of stuff if we could just come to some sort of –

I want to abuse one of our testifiers, the MEA/NEA folks, this is verbatim, said in the millions of transactions we process we see nearly as much volume of the longitudinal medical record information requested by health and dental plans from providers as we do claims attachments.

I think that is a jaw dropper. We are talking about something that has the potential to help adjudicate the money, operate the system, but we are also talking about actually being able to be a learning healthcare system where we have the audacity to think you might improve someone’s health measurably so. And that we are messing with the DNA components of this. That is what I believe is going on here.

This sounds very exciting to me. For me to try and figure out how to chair this committee, the whole committee, this supports the notion that we are going to work as a committee as a whole. I think this is going to take the Populations folks, it is going to take the Privacy folks, it is going to take the Standards folks. I am thinking that one of the things we are going to have to convey tomorrow is that we are going to need the whole committee to wrestle with what looked like a standards issue called a claim attachment.

I will hush now. Help me out here because what I want to do tomorrow is help you get to where you guys in this subcommittee want to get.

DR. SUAREZ: All you said is very true. I think the most interesting element is the fact that this is going on today and will continue to go for several more years – this reality of exchanging of data between providers and payers. It is going to change the type of data, the way of exchanging it, the purpose for which it is exchanged, and the uses that the data is giving.

It is going to change also in terms of the bi-directional type of information. I was surprised I guess, as you were, listening to that testimony that providers are asking payers for electronic medical record data. It is sort of like making medical decisions based on those. Anyway, it is an interesting statement because it means they are not finding the medical record from other places that should have it. They are going back to the payer to obtain medical record information, presumably to make medical decisions.

So it is an interesting statement, but the reality is maybe that is not necessarily the way it should work because ultimately the information should flow across the system the way it is envisioned through the option of electronic health records and the expectation of open interoperability and exchange of information between providers so that I know where the data of this patient is all the time, and I can access it all the time from the source of that data, which is the provider that wrote it in the first place, and not from third part sources. At the point of care – the emergency room, where I must make decisions right there. Right now, because we don’t have that, we go to other sources and we depend on that data.

The true sense of this is there are sort of two tracks going on. One is the realities of today that we have to try to address, which are the standards that we are trying to deal with today and that are being implemented in the next 12 months, 14 months, 18 months, two years. Then the vision that we have for 10 years from now. To try to align the two it depends on what your vision is because if your vision is that everything should flow the way it should, ideally, then we would be dealing with transaction-based type mechanisms or document-based mechanisms. We could have web-based interactions that we heard today that are already happening through efforts like FIRE from HL7 that are building on a new way of looking at exchange or access to information.

So it all depends on what you see as your vision for ten years from now. It all depends on how you see the effect of things like health reform. The vision I had two years ago is totally different from the one I have today based on what I see might happen with health reform. Then I am sure as soon – health reform started with insurance exchanges and ACOs and medical homes and all that. Things are going to even change more. We have been hearing that health plans are called wellness health organizations and they might even begin to change the way they do business in terms of being a health plan to being a provider of wellness services. Now they become a provider.

So there is a whole host of different view. But at the end of the day, to address your comment, I guess I would probably be reporting back, or at least I think we could report back tomorrow to the group, that this truly is one instance where we are really going to have an opportunity to build on one of the three core themes that we have now as a committee, which is convergence.

I really like Bill’s perspective of we should take the opportunity to completely break from the traditional separation of administrative and clinical data. We should take advantage of saying that and say this is the time, this is opportunity that we have.

We do need to deal with what we are going to be looking at in terms of what gets adopted as an industry because the worst fear I have is that whatever we decide in the next three or four months about what should be recommended could take the industry in the direction of something that might not be the best thing over the next two years. We are two or there years away from when this needs to happen.

So that, to me, creates the very higher level of cautionary note of saying if we recommend something we have to be very careful what we recommend and it has to be very flexible and adaptable to changes as we move forward into the future, and not be necessarily as prescriptive and predefined as in other cases we might have been with other transaction. This truly could take us in a direction that we might not want to go.

The essence of it is early this is a unique opportunity. Probably this conversation we could not have had seven years ago when we were talking about attachments of the previous rules, the initial proposed rules. I think the opportunity that EHRs and the maturing evolution of the standards associated with the EHR messages are going to take us to a place where the convergence could happen, and really we could just forget any more about talking of different transactions and different worlds in this industry.

I think we are going to want to tell a little more to the committee in terms of what we heard from the industry, the general consensus about certain areas, areas where the industry felt there were some differences in terms of how to proceed and sort of what will be our next steps in terms of what we would do over the next four or five months before the unity.

That was my plan as I have been thinking about what we could say tomorrow. It clearly fits within at least one of the new pillars of our national committee. It truly ties to population health, and I was so pleased to se Bruce here. It ties back to quality and it ties back to privacy, so it really serves as an opportunity.

In fact, there is a document Michelle was showing me. An entity called IHE, Integrated Healthcare Enterprise, which is an international organization that puts together profiles to implement electronic transactions for healthcare exchanges. They wrote a document that talks about how to integrate the administrative and the clinical information coming from an EHR to produce data for multiple purposes, including quality, public health and other reasons.

So I think this opportunity is just coming to us basically.

MR. SOONTHORNSIMA: Today has been quite challenging and a great learning experience at the same time. There is a lot to absorb. One thing I think we try to stay true to, and that is the point you are trying to make, the vision – we have to think forward and not get down into the granular level. And the way I am thinking about that is, one, there are some traditional ways of doing things that we were talking about today. But at the same time, what I heard today is everybody around the table is thinking ahead as well, which is very positive.

Even some of the use cases they are talking about, and this is where we need to focus tomorrow, where we can actually influence. You are not going to influence – we aren’t going to go back and make changes in, I don’t know, I personally don’t feel that we need to go back and change how pre-auth records should be submitted. Pre-auth is always going to happen in the meantime, but some things that are still evolving, particularly around risk adjustment. That is still evolving, I think. That is where you have the convergence between administrative data as well as the clinical data, more so on the clinical side.

I think we can influence not only the folks working on the standards and operating rules, but I think we can influence the policy makers as well as to how they write these rules. Don’t write these rules that are so counter to the progress we are trying to make.

For example, even in the healthcare, health insurance exchange, how the risk adjustment is being written. I don’t know all the details but you can’t actually use – my understanding is you can’t actually use some of the attachment that I was hoping that we would be able to use. It might be too late, but we have to influence any future policy that might come down the like where we can leverage what we are working on today, but really think about future applications.

And this is where the combination of clinical and administrative use of information can really come into play. Does it make sense? We still have time. I am not sure how far along some of these health care reform rules are – it might be too late for us to change the risk adjustment.

SPEAKER: They are all going to evolve.

MR. SOONTHORNSIMA: So we need to look at that. This is how we can make more of a forward play as opposed to getting back to the same old attachments, if you will. So we have to be very selective as to what use cases we can focus on. And I heard today also we are no longer talking about claims attachment. Everybody is saying that. Make it broader. The application can be much broader, but over the next few years let’s be very specific – that’s what I heard – let’s be very specific. So I am chiming in, whatever we are going to be specific around let’s influence those future changes. And I don’t know if risk adjustment is the right one or not. I am just throwing that one out as an example.

DR. FITZMAURICE: I would just add to that that we are bound by the Secretary’s authority under HIPAA as to what the Secretary can adopt. So we should probably get a refresher on just how much latitude the Secretary has to adopt it. But I don’t think it hurts to promote the use of attachments, even if they are not official HIPAA attachments. I mean we are looking to the future.

MS. KLOSS: I think I kind of going where Mike has gone a little bit with a question I feel compelled to kind of throw out. In November, when we had the hearing and kind of came to consensus that what would really be valuable is kind of the thinker picture of how all the pieces of administrative simplification fit together.

I think one of the things that we are struggling with is we don’t have that backdrop. So now we are talking about one thread and trying to look at how that might have its own evolution. And I wonder if we were stepping back to look at the bigger picture of an integrated process for advancing administrative simplification if this would be a topic that has priority. Or if we would conclude that there are other levers that would be more important to advance more quickly. As it relates to this, let some of the evolution that is going on with regard to the clinical documentation standards and all of the other changes that have happened, if two or three years from now would it be yet again a different picture.

So we are talking about this with great urgency because that is what the law says. But is that correct? Should we be advising at a higher level?

DR. SCANLON: Actually before I came here today I really thought this was the most important thing, because I think that this is the issue of information. And most of the discussions about the future and the mechanisms or the structures that we are going to use in the future have been at a level that is highly conceptual, and implementation of it requires information. It is information we don’t have today. We have experience with similar kinds of constructs in the past and we have operated them with limited information and we have seen the consequences of that. I think we have to move beyond that for the future.

Part in response to what Larry asked earlier, whether attachment was the right focus, for me attachments is the train that is leaving. It is what we put on it. We can’t put everything on it, but I think we have to be strategic about making it the most useful short-term change that we can accomplish. I think all of these ideas we have for the future, which we heard in the November hearing, heard a lot about how the system was going to be transformed, they are not going to be possible unless we have a much stronger understanding of what the consequences of change are, and we can build in the safeguards so that those consequences are positive, not net but distributionally as well. We just don’t have the information to do that today. So we have to think about starting on the road to getting that information.

DR. SORACE: We heard a lot about the about claim attachments in dialogs between practice management systems and electronic health care creators. Since I am a pathologist by training, don’t forget lab systems and pac systems because ultimately they are going to end up carrying a lot more of the basic diagnostic information that actually supports the diagnostic codes of the patients.

I just wanted to put a quick place holder in there. It is easy to blow by.

DR. SUAREZ: There is a whole host of other domains, I think. Pathology labs is one. We received testimony, and I want to acknowledge it again, we received written testimony from the dental industry. We did not receive testimony, but I am sure we could get input, from the long-term care industry.

There are several other sectors of our healthcare industry that are certainly very much affected by or relate to this whole concept of attachment. As Bill was saying, and Bill always brings up some very unique points about the future really, I was thinking imagine in the future we would not be calling what we do claims or attachments. We would just call it medical documentation, for lack of a better term. I am sure there are many other better terms. But at the end of the day it is truly exchanges of information. Right now the process – and I was going to mention one thing – back in the early nineties when EDI was the big thing, still is, I hope, and HIPAA was not even written, the industry was talking about something called the EDI cycle in health care. I taught about it and had seminars about the EDI cycle on health care. And in health care the EDI – for electronic data interchange cycle – starts with the enrollment process of individuals and when the patient is going to go to a clinic, before the patient shows up there is an eligibility inquiry. And then the patient shows up and there is potentially the question of do I need to refer the patient or do I need to verify eligibility for certain services, so prior authorizations. And then there are referrals or others, and then there is treatment, and then there is the claim submission. And then there are potentially additional attachments for supporting the claim. Then there is the claim payment and the coordination of benefits.

The entire cycle of the EDI world in health care is engaged around all those business processes that back in the nineties was, and still is what we are doing today. So ultimately really the question becomes we call each of those elements a particular transaction — enrollment transaction, eligibility transaction, and claims and referrals and others. In the clinical world we also have transaction-based exchanges – lab reports and lab orders and transition of care messages and things like that.

But at the end all of that is about moving information that should exist in a system that combines the electronic medical record with some other demographic and administrative data and all that. It is just moving it for multiple business purposes, the same information, ideally the same information going back and forth.

DR. SORACE: I just want to add the College of American Pathologists’ electronic cancer check list effort to move cancer reporting to structured documentation. The Radiological Society of North American has their structured template reporting for various radiological efforts.

So it is a timely moment for this because again large chunks of very valuable diagnostic information are being supported by the societies that are essentially the specialties that produce it. So it is a unique opportunity.

DR. GREEN: I want to use a metaphor of moving data or moving information. That has come up over and over all day and in the last hour and a half the verb that is used most often in our conversation has to do with motion. This is another crazy metaphor. I will ask for forgiveness now. But how many of you have a wheelbarrow? Wheelbarrows come in different sizes and shapes, but the critical thing about a wheelbarrow is whether the handles are strong enough to handle the leverage of the weight of what you are putting in the wheelbarrow, like concrete or a tree. The other thing is the size of the wheel. The small diameter wheelbarrows just aren’t worth very much if you have serious work to do. But a larger diameter wheelbarrow, it is amazing what one person can move.

It seems to me that a metaphorical definition of attachment that fits your comments about it being a propitious moment to actually do something – if we just had the equivalent of a wheelbarrow that we could just drop anything into and it just had enough standard specification that if it needed a tree it could carry a tree, but if all it needs to do if take a cup of water you can also move a cup of water with it.

Linda’s point about flexibility, and you have to be very careful of what we do, that would be a great service for the next decade or so if we could just get – Bill said this is the train pulling out of the station, what can we put on it? Maybe that is all we should settle for right now in the immediate future. Could be just do that.

DR. SCANLON: I think we have to hope when we get the flow going that there is a wheelbarrow there that we can use. And the two aspects of the wheelbarrow that I would sort of worry about – let’s talk about the wheel as the analytic power, just to keep up with your metaphor.

Efficiency demands, as well as maximizing the effectiveness of information, that we have new methods for dealing with it. I was talking about the risk adjustment. I can understand why you would say we are not going to use attachments in the risk adjuster, because it is partial information. You have it for some people; you don’t have it for others.

Historically we have been doing risk adjusters for I don’t know how long, but we have never early confronted the case of what do you do with partial information? You are really looking at sort of a rectangular data set saying we can now risk adjust because we know this about all these people. We have got to think about a future where that is not the mode, where we have possibilities of taking partial information and making correct inferences. So that is the wheel part.

I am going to go back to the privacy part because I think that is very important – we will use that as the handles. This whole thing is going to fall over if the privacy issue is not addressed completely. And it doesn’t mean there is no information. It means that it is protected completely adequately. It is the security side of the privacy discussion, and that has to be absolute, and we have to make sure that we have the mechanisms in place that does make it absolute.

I think you are right. It is not just flow. It is what we are going to do with the flow once we manage to start it.

DR. CHANDERRAJ: I have a big question about the convergence. It is nice to seek the clinical and administrative components, but I thought I heard several testimonials today from several people that the clinical element requires a lot of work, including the HL7 and the LOINC people said that, and we heard comments that the clinical content is not there yet.

So in order to meet the timelines why don’t they just move the administrative part, move the attachments, categorize them in several forms, give it alphabet A for clinical, B for pharmacy – and put a second block where we can come address it later to the convergence part or the clinical part when this part is working and we can have all the HL7 and the LOINC people to work on the clinical documentation and do a structured document which can be then transported easily

DR. SUAREZ: That is part of what we could look into as a building block. What we heard was in the presentation from the standards side that the HL7 and LOINC support both the structure, as well as the unstructured elements. So potentially one could argue that by adopting something like that we would be supporting both the unstructured and the structured capability.

Granted tha6t there are questions and concerns about the complexity – and this is not just because of this discussion. This has been the discussion of meaningful use, the complexities of implementing standards. Why are we interoperable? There are questions already on the web and all sorts of places – what happened with interoperability? We have EHRs, we have EHRs that are certified to do standards. Why are we in trouble? There are many reasons. There are business reasons and there are technical reasons and all that.

I think complexity is one of them, and it is maybe an unrealistic expectation that over 16-18 months people are going to implement an EHR and start pushing out messages. It is going to take several years. First of all, because EHR implementation itself is going to be a multi-year project for most health care organizations.

So in reality I think there is the business aspect of this. There is the standard part of it and the technical complexities and all that. Then there is the transaction element of it. I think, as has been said a number of times, we tend to focus a lot on transactions and a lot of the standards. I think we have the opportunity to really go up and discuss more of the4 business aspects of it.

Then we will have to come back with what are the expectations in terms of standards. Even in the future operating rules, as we heard, it is going to take some time to determine what are the right operating rules for this whole concept. I think we are going to see sort of a roadmap evolving out of all these discussions that will help us identify the right sequencing and the right timing of things. That is my expectation really. I think that is the challenge that we have and I know we have about 20 more minutes or a little less than that.

One thought I had. Usually what ends up happening after this, of course, hearings, is we have to come back and extract the key observations and the key concepts and begin to frame any recommendations we want to do. That is usually what we do. Normally Lorraine and Michelle and Ob and I would take the first step. We are probably going to do a little bit of that this time, but not a lot, because this is a very complex area and we really want to engage not just the subcommittee, but as Larry said, probably expand it to the entire committee in terms of framing.

We could identify and summarize some of the key messages and all that, but we early want to engage everyone to help us frame what would become the recommendations coming out. I think in terms of timing we do expect – and I am just thinking here procedurally basically. Ob and I and Lorraine and Michelle will probably put our summaries together and start to identify some of the key observations.

We again very much acknowledge and thank everybody for their detailed recommendations. We didn’t cover them all in these discussions, but there were very specifics recommendations, a lot of them very consistent across the testimony, and that is very good. We will take all of those, of course, into account in our deliberations.

After we come up with our first round of observations, we will be disseminating those to the subcommittee for input, and then convening a series of conference calls. As I said, this is going to take more than just one call a month. We only have three calls before June, so I don’t think we will have enough. So we will probably have to do every other week conference calls with very specific topics and all that.

One of the other things we will try to create, and I have begun to picture already based on all the discussion, is sort of a roadmap, as had been said, a roadmap with some higher level pictures of sequencing. The first roadmap will probably be too rough, but it is precisely for that to try to get us all into providing input and trying to identify things. But that is one of the things I hope we will be able to do along with the documentation of the observations we heard today.

So with that I don’t know if there are any other comments before we go to public. Any other comments from the subcommittee members? Larry?

DR. GREEN: A request. The paper that Michelle was talking about – can we all get that? Could that be sent to us?

MS. WILLIAMS: I can send it to the subcommittee. It is a draft, but I think there are some good content in it that people will enjoy.

DR. SUAREZ: Yes, all right. We are going to go to public comment. Why don’t we start?

DR. RODE: Good afternoon, I am Dan Rode. I am with the American Health Information Management Association. As a way of background I also worked in the original X12 work on transactions that became HIPAA. We did start talking about attachments in about 1993. I was also a member of the Uniform Billing Committee and I voted against e-codes for exactly the reason that George was talking about this morning. We were going beyond that. But we had no other way in those times to exchange data.

I want to both compliment you and maybe provide additional challenge. I will compliment you because between this hearing and the one in November I think we really began to push the issue of convergence and why we can, or maybe why we can’t, converge. And that is where the challenge comes in.

As I listened to the testimony this afternoon I think this committee is shackled by HIPAA. We talked today about attachments. We didn’t talk about just claims attachments; we talked about other attachments associated with other transactions. I think there is a fantastic opportunity for this committee. Several of the testifiers suggested that we need a new NPRM. I absolutely agree. The one out there is seven years old. It was an entirely different environment.

But I would like to suggest in addition, as I watch some of the other work that the Secretary has done with regulation, that you consider some of the other transactions that, in their present form, are creating the problems you have been talking today about attachments.

So are we getting the right information in the eligibility transactions? Are we getting the right information when we are looking for prior authorization? Is it time to take a look at where we are today with electronic transactions and begin to say that maybe we need to change some of those others? And you guys have been coming up and down today. I almost thought you were going to break through the water. You didn’t quite get there. To take a look – should the claims transaction be changed?

One of the problems we had with HIPAA was while we were building from eligibility to claim – Walter, you went through the cycle. We thought that would be the way we implemented HIPAA. No, we started with the claim. Then we went to the payment. AS some of you alluded to we haven’t even gotten to eligibility in some places.

So taking a look at that cycle, which I don’t think has necessarily changed, are we at appoint where perhaps among the recommendations you make, is that we make some tweaking of these other transactions so the system works the way it was supposed to, and we look at it from the standpoint of where we are with the electronic transactions itself.

To answer a question that came up, our members have a significant problem today because there are state governments who believe you can present all of the attachment information for fifty cents – the cost of the disk that somebody wants for it. They forget what it takes today to put that together, the numbers that you got from the American Medical Association.

So I would urge this committee to sit back for a second and take a look at claims attachments, not as claims attachments, but what do we need to do within the entire array of HIPAA transactions that can make this system work better? Rather than narrowly saying we have a claims transaction, we have to get it done by 2016, and find that it doesn’t do anything. Is it time to say let’s tweak our requirements with claims? Is it time to say let’s tweak our eligibility?

I know the SDOs can make those changes if we have to make them. But I think this committee is the only forum right now that we have that can really now address where are we with HIPAA in toto, because I think that is the problem we are looking at with this claims transaction. We are trying to work with the whole array of HIPAA standards that, in essence, haven’t been changed since 1996 to 1996.

I think that is a real challenge. I don’t envy you at all. I will submit some written testimony because I am sure what I have just told you isn’t AHIMA, it’s Dan Rode. But I do think after sitting here this afternoon, having sat through documentation integrity two weeks ago, and meaningful use last week, it is time for this committee, who has purview to make recommendations on HIPAA, to make HIPAA fit in the 21st Century. Thank you.

DR. SUAREZ: Thank you very much. Any other public comments? Do we have anyone on the phone?

MS. KLOSS: Can I follow up on Dan’s comments? Just to share something that I have been jotting here and thinking about. We have seen the power of using continuity of care beginning to move care transitions. Are we thinking – you know, the information enabled clinical care process – are we thinking of something parallel, which is kind of the information enabled reimbursement or payment process? Is that a way to kind of bring it up a notch? I think Dan’s comments were where I was kind of thinking that it is essentially the same information. It is just being used for an intelligent payment process instead of an intelligent payer process, but then they all come back together again into the learning health system.

DR. SUAREZ: Absolutely. Well, thank you everyone for participating, on behalf of the subcommittee and the committee. I want to also thank Michelle for your support.

MS. WILLIAMSON: Thanks to Lorraine, even though she is not here. She had to spend time with her grandchildren, but she assured that everything would be in line, so she made it easy sailing for me today.

DR. SUAREZ: Thank you everybody. We stand adjourned

(Whereupon, the subcommittee adjourned at 4:52 p.m.)