The HIT Transition Weblog

New HIPAA Standards Clear Regulatory Hurdle, Approach Flaming Commentary Hoops

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way.  Or at least it's coming into view.

The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days [OOPS! Meant to verify this before posting. In truth the rule of thumb is 90 days for the review; insiders say it is on a fast track, though. -Ed.] to approve it (with or without revisions negotiated with HHS) or reject it.

I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds.   We won't be able to say goodbye to those nasty Companion Guides, but at least they will be thinner.

Besides reducing ambiguity in hundreds of passages -- saying when NOT to send data as well as when to send it, for example -- the updates incorporate a number of issues currently vexing implementers:

• Unambiguous instructions for consistent implementation of National Provider Identifier submissions across all transactions and all payers.
• Intrinsic support for the Present on Admission data, rather than the K3 stopgap introduced last year.
• Support for the ICD-10 codeset, not available in the current 4010A1 standards.
• Better, clearer remittance advice instructions and standards, including mandatory utilization of the Remark Codes segment.

The standards were developed over a period of months and published back in 2004 and 2005. First the draft guides were released for public comment, then the workgroups responded to each of comments and finalized the implementation guides (now referred to as "Technical Report 3's" or TR3's) and submitted them for approval via X12's consensus process.

It has taken three years for HHS to put together the regulatory language to adopt them.

And once that draft regulation is released will come another comment period.

Um, what was that?

X12 is anxious about this. Tagging a regulatory comment period on to the standards development comment period brings a lot of new participants out of the woodwork. While techically this may improve the end result, it also stands to send the standards folks back to their own review/comment/edit process, further delaying implementation.

Last time this happened, it was under the deadline for adoption of the original HIPAA standards -- the finished 4010 guides got hurriedly updated with the A1 Addendas, and the industry has had to work out of two sets of books ever since. (I recommend purchasing the Combined Guides for those who have difficulty reading out of two volumes at once. They're not "official" but they will keep you from making a lot of errors or at least getting a lot of headaches. Go to www.wpc-edi.com and check out the HIPAA link.)

I haven't been able to participate in X12 for awhile, but I know they are all over this. I hope that some of their collaboration with the regulators produces both better standards and better adoption processes.  We soon shall see.

More Uses for English Majors

I feel like I hit the lottery! NAHIT has published its list of healthcare IT jargon definitions. And I win!

We were more or less assuming the RHIO and HIE definitions three years ago. But it seemed like anybody who wanted a for-profit model wanted HIE, while the NPO [Ed. note: That's "Non-Profit Organization," for those of you stuck in the money-making paradigm.], crowd was unafraid of RHIO and its hoary socialist allusions: Regional and Organization. Now maybe everybody won't think they know what I'm talking about when I say RHIO (pinko commie big brother freebie hippie healthcare) versus HIE (fat cat capitalist libertarian survival of the fittest healthcare).

Instead, now HIE -- health information exchange -- is a process of exchanging records, while HIO -- health information organization -- is the thingy that exchanges them, and a RHIO is a "type" of HIO -- presumably a HIO for a R(egion), but NAHIT's still a little cagey on that point.

Glad we got that straight.

Quick! Everybody grab the new keyword!

Medicare's Wrong... No Willy Nilly NPIs

We wanted to know whether Medicare's demand that an NPI be placed in secondary provider slot, even if it's the wrong one, was really the right thing to do. Our question to the official standards body was dead simple:

In Medicare's guidance to its billers, it states:

"If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields."  (MLN Matters Number MM5890)

Using an ID/name other than that of the actual referring/ordering/etc. provider in the data element so designated seems a clear violation of the standard.  Please advise.

Also, if a secondary provider does not have an NPI (and is not required by law or contract to obtain one), what should the biller use instead?

X12's Response:

The 837 Implementation Guides contain usage and content requirements for the listed provider roles in conjunction with the services reported on a given claim; for example, Attending Physician. Name and Identification Code data elements are for the reporting of information pertaining to the person or entity performing the provider role designated by the Entity Identifier (NM101) qualifier in that loop.

The Trading Partner Agreements section of the Implementation Guide’s Purpose and Overview (Frontmatter section 1) states that trading partner requirements may not modify the requirements in the Implementation Guides. It further states that trading partner requirements may not modify the definition, meaning, or intent of the Implementation Guide.

Regarding the usage of NPI, when the Implementation Guide requires a provider ID, the use of NPI is required when mandated by the NPI rule. Other identifiers are available in the guide when NPI is not required by the rule.

What does X12 recommend? Read on...

Marty's HIT List 2008

Here's my official list of prognostications for 2008.  In 2006 and 2007, I didn't call them predictions, so I probably don't deserve any credit if anything I said came true.  If you agree -- or not -- you can give me your own scorecard by clicking here.  Give your feedback by January 23 and I'll post the results (and any interesting comments) in a blog at the end of the month. As far as we know, we're the only industry analysts that give you, our valued reader, this critical "You're Full of..." HIT response tool.

Is 5010 a Year?! Why HIT Standards Take So Long...

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling."

Oh, no.  I had inside information.  And that information became public this week.  The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards.  The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014 -- that's seven years from now to implement a standard I helped smarter people finalize almost three years ago. 

According to Holt Anderson, Executive Director of NCHICA,

“Our estimate is based on the key assumption that a proposed rule on 5010 will be published in June 2008, and if only minor revisions are made, a final rule will be published in 2010. It is projected that it will take three years to move to limited production of new standards and one year to move to full compliance, bringing us to 2014.”

Don't believe it?  Check out the details on the WEDI/NCHICA site devoted to the study.  And if you still don't believe it, download the MSP file and plug in your own assumptions. Heck, join in the conversation on their listserv!  The link says "membersonly" but it's supposed to be open to everybody.  If you have any difficulty subscribing, shoot me a note and I will inform the powers-that-be.

Adding 2.0 to HIT Alphabet?

I've been tracking the Health 2.0 buzz generated by Matthew Holt's blog-boosted thought machine.  The idea that HIT can help remake healthcare, instead of just automate its dysfunctions, has a significant appeal. Marty Tenenbaum's post suggests the creation of a new convening entity, akin to the CommerceNet alliance that bootstrapped web-based commercial exchanges. 

Early CommerceNet members included startups like Netscape, Yahoo, and Amazon as well as established organizations like Visa/Mastercard, FedEx and IBM. The members of CommerceNet collaborated on initiatives like search, catalogs, security, payment, and shipping/fulfillment, leading to complete end-end transactions where one could actually locate a product, buy it, pay for it and get it delivered. Not only was overall market growth accelerated; many business deals resulted, generating a lot of wealth.

Um, yeah.  I guess from an insider's view, though, the deal of creating yet another HIT collaborative after the explosion of alphabet soup bowls we've seen thrown at the walls of US healthcare for the past 10 or 15 years leaves me a little, well, lukewarm.  And sloppy.

PHR-as-a-Verb and Kibbe's Sparse Information Model

I caught the end of yesterday's NPR report [partial transcript, with audio link] on Personal Health Record technology, and fell into a pit of despair with the realization that HealthFault's ad-sales-driven, bigger-better-silo model was taking hold of the media's imagination.  On the same show, the Medical Data Bank concept got a plug, too, which is a slightly different model: A data-sales-driven, smaller-lousier-network model.

The conventional HIT approach seems to be building PHR as a personalized version of the oh-so-successful standards-based EHR that's in use in 98% of all healthcare facilities today, and allows for the seamless interoperable communication of key health data between any two providers, even those who work in different buildings. A big, fat chart the patient can hide in their own personal virtual drawer.  Call that the software-sales-driven, personal-fantasy-record model.

A much more hopeful scenario is offered by David Kibbe on the Health 2.0 blog.  Kibbe's thought processes seems to point to the "PHR as a verb" concept that I alluded to a couple weeks back.

HL7 Ballots PHR Model

Standards Development Organization HL7 is getting some press for releasing its Personal Health Record functional model for ballot.  Skip all the press release reprints you may be seeing, the definitive article is in Digital HealthCare and Productivity.com, a mouthful of an online journal if I ever swallowed one.  The author is blogger Neil Versel, who may have actually landed a paying editorial gig.  Neil connects the dots on HL7's pact with America's Health Insurance Plans, to migrate their formative PHR standards effort into HL7's process.

PHRing Like a Kitten
I'm encouraged by the development.  I've tried to stay away from the PHR theme park, but have been drawn in by the bone-headed way some major players were starting to push their free-standing "solutions."  PHRs were mentioned in every other presentation at last week's CCS conference, and I came away with a rant beginning to bubble its way into my forebrain. 

The first line of that rant would begin: "PHR is a verb, you knuckleheads!"

Social Contracts Signed with Disappearing Ink
The next part of the rant says something about the average length of enrollment in a private health plan and the average time an employee spends on a particular payroll.  Let's just say those two numbers do not bode well for the plan-based and employer-sponsored PHR silos we see propagating across the marketplace. 

What kinds of "critical information" would you store in a file cabinet that would self-destruct in three years?

HIT Forums Point the Way for 2008 (Part 2 of 2)

Crystal Blue Persuasion
The mid-week shift to the Blue Health IT Symposium was a bit of a culture shock.  The venue was the elegant-but-somewhat-shopworn Biltmore hotel in LA.  The ornate downtown showpiece was the glitzy scene of a number of the early Oscar ceremonies, with oversized black and white photos of grinning film stars adorning the Historical Hallway.

The symposium is held by the Blue Cross Blue Shield Association for the benefit of its member organizations, whose IT and management staff make up the lion's share of attendees. There were also a number of vendor/sponsors in attendance.  I was among a much smaller handful of speakers who hadn't bought booth space or carried boxes of enlogoed pens, notepads or bouncy balls to distribute.

It was nice to be back among my doers and persuaders, of course, but for the rest of the week, no one insisted upon buying me a single-malt scotch or told me about the night club they built to avoid boredom on their horse ranch in Cucamonga.

I wasn't wearing my journalistic hat at the Blue conference, so I better keep quiet about that breakout session called Mandating Serial Colonoscopies for Documentary Producers: Medical Necessity vs. Karmic Comeuppance.  I can report on a couple of the things I did and said, though.

Standards Development Organizations in Development
One panel session addressed standards development and implementation, and featured a number of speakers I hold in high regard, along with others whom I hadn't met, but had earned high positions in industry-leading private and public organizations.  One of the former was Alix Goss, chair of X12N, the group responsible for developing administrative transaction standards for the insurance industry, including the familiar 837 claim formats.  Earlier in the day, Alix told me that X12 had rolled out a more interactive web presence, and had added a forum for the (unofficial) Provider Caucus, of which I had once been a member.  She knew I would be pleased, because a few years back, I made a case for expanding provider participation in standards development work [NOTE: MS-Word doc file] through the engagement of collaborative technology.

She should have known not to encourage me.  Because when I realized that before me sat the people responsible for developing and implementing healthcare standards at X12, HL7, BCBSA and CCHIT [mynorca limit exceeded for this article-- look them up yourself -ed.], I made the case for SDO 2.0.

[continued]

HIT Forums Point the Way for 2008 (Part 1 of 2)

I was fortunate enough to attend two healthcare IT conferences last week; one as a journalist (really!) and the other as an invited speaker and guest.  Officially, I was gathering information at the first conference and sharing information at the second conference.  Unofficially, I was flogging our products and services -- upcoming webinars on Real Time Adjudication, HIT ROI for provider organizations and the Black Swans of Healthcare IT; and our just-released 5-volume set of healthcare IT funding sources.  Nobody seems to have discovered these ulterior motives so please keep my secret to yourself.  Whatever you do, don't forward this email to everyone you know that might care about saving money or avoiding disaster next year!

How the Other Half of One Percent Lives
The Collaborative Communications Summit is a boutique conference for C-suiters.  The concept is to put the event in a tony venue that pampers the executive appetite and bring in a raft of brilliant speakers and those who move and shake the industry. Last week’s CCS topic, “Transforming Healthcare through Health Information Technology,” was enough to pique my interest when I read about it a few months back. When the conference organizers offered us a media sponsorship that included a free press pass, we jumped on it.  I was already going to be in LA to speak at the Blue Cross Blue Shield Association's Blue Health IT Symposium, so I could make the CCS event for the price of a couple nights at the hotel.  How much could that be?

Historically, my conference experience has been more focused on getting in the thick of things with the doers and persuaders than rubbing elbows with the financers and deciders. I’m pretty familiar with the Metro system in DC, the shuttles at O’Hare and the rental car agencies at DFW, but finding my way to CCS’s ivy-cloaked venue, the Peninsula in Beverly Hills, was a different sort of commute. In my more skeptical moments, I fully prepared myself for one of those fly-and-bye junkets we hear about – the execs make an appearance at the keynote, then head for the golf course, spa or shopping district.

It’s good to be wrong sometimes.

The President is a Lot Smarter Than You Think!
No, not that president.  I’m talking about the president of the company – maybe even your company. The CCS sessions were substantive and dealt with the underlying causes of the challenges and dysfunctions facing the healthcare industry, and the ways that healthcare IT can – and cannot – hope to address them.  The event was intimate – all the sessions took place in a single conference room laid out cabaret style with round tables and a raised dais at one end. 

The vendors were there, of course, but held back from the full frontal sales pitches that seems increasingly characteristic of HIT forums as the industry heats up.  Instead we got case studies, policy analyses and trends.  The interactive style remained consistent throughout, which lent a sense of industry gestalt to the proceedings.

Bullets over Bel Aire
Here are some of the things that seemed to emerge from the group mind.

Gates' Way to Healthcare

In what must be one of the all time editorial coinky-dinky's in recent memory, an editorial from Bill Gates appears in today's Wall Street Journal -- just one day after Microsoft released its Health Vault Personal Health Record portal! 

But we must admit it's timely.  As Bill points out, "a groundbreaking 1999 report on health-care quality" pointed out that our healthcare system kills nearly a hundred thousand Americans a year, and a 2001 followup "urged swifter adoption of information technology."  And George Bush Jr. even mentioned HIT in his 2006 State of the Union.  Stop the presses!

I'm from Bellevue and I'm Here to Help You
Not to worry, Microsoft is on the case.  "We envision a comprehensive, Internet-based system that enables health-care providers to automatically deliver personal health data to each patient in a form they can understand and use."  That's a relief!  We thought you were building an information silo and hoping patients would somehow deliver information to their providers.  Knowing that your expectation is that all providers will start pushing data back through your narrow, proprieary pipeline is a real relief.  For a minute, there, we thought you were clueless.

Not to Harsh Your Buzz, Dude, But....
Meanwhile, in the non-healthcare press, there's this little line in the Economist about how the industrialized world has managed to make it for nearly 20 years without a major recession, a phenomenon referred to somewhat oxymoronically as "The Great Moderation."  The finding, from a report by Stephen Ceccetti, et al, appears somewhat mundane.  "More than half the improvement in the stability of economic growth in the countries they studied is accounted for by diminished inventory cycles."

You mean it wasn't Windows for Workgroups?

Building the Round Table
That took me back to a book I bought a couple years ago, "Challenge and Consequence....forcing change to eCommerce."  It's a geeky and somewhat breathless account of the evolution of Electronic Data Interchange through the establishment of X12 and other standards development organizations.

Each generation has its challenges and responsibilities.  Some of us born during the period from 1915 to 1950 were challenged to invent electronic commerce....  People worked at this in a spirit of service to company, industry, country, world and each other.  Their work significantly contributed to the outsanding improvment in economies that was experienced during the 1990s, and will continue to be effective for many years to come....

Ralph Notto's book was published in 2005, but most of the content seems to have been written much earlier.  He names names and lists specs.  He tells stories and gives history lessons.  Sometimes he refers to himself in the third person.  As a one-time X12-er, and a strong believer in the win-win proposition of collaborative engagement, I loved every page of it.  But I thought it might be a little over the top in terms of his claims about the economic impact of EDI. 

Until I read that passage in the Economist this morning.

All of Us Is Smarter Than Any of Us
See, solving the problems that HIT can solve is not about developing products, or portals, or PHRs.  It's about everyone coming to the table and agreeing to do things the same way.  That means everybody gives up a bit of control, and they trim their wish lists and moderate their customer promises.  They disclose innovations rather than keeping trade secrets.  They dream about data flowing freely rather than getting bottled up in repositories or being forced through proprietary switches.

We don't need another Bill solution.  We need a Melinda solution.

What's Wrong with Microsoft HealthVault

This isn't a blow-by-blow product review of Microsoft's just-released HealthVault Personal Health Record (PHR) portal.  I'd have to share some personal health information with Microsoft to test the new site out, and I'm about as enthusiastic to do that as I was to put my checking and credit card account numbers into Microsoft Wallet.  Remember Microsoft Wallet?

Part of the geewhiz about MSHV is that it protects patient privacy, sort of ("We do not use your health information for commercial purposes unless we ask and you clearly tell us we may.")  According to Dr. Deborah Peel of the Patient Privacy Rights Foundation, "Microsoft is setting an industry standard for privacy." (link)

Um, no.  They may be setting an example, but they are not even close to setting an industry standard.  And that's the biggest part of what's wrong with HealthVault -- and it's the same thing that cripples all the competing PHR silos being erected across the country.

WEDI, NCHICA to Map HIT Regulatory Timeline

Those of us who work in healthcare IT have this mental cascade of imperatives: regulations, new versions of standards, Medicare mandates and more.  It stretches back in time and on forward into seeming infinity, a dizzying ladder of challenges with strings of letters and numbers indicating the rungs: IPPS, HIPAA, TCS, 4010A1, NPI, ICD-10, 5010, AHIC, ad infinitum.

The trouble is, we are supposed to be familiar with all of them; what's more, we frequently get assigned to implementing multiple initiatives at the same time.  Worse, we are often called upon to implement one intiative (say, the National Provider Identifier Final Rule) when the feds have left out a necessary pre-requisite (like NPI Data Dissemination).  When it happens, we say, "What were they thinking?"  But a more important response is to try to prevent it from happening again, as when a number of standards development volunteers contacted congressional staff to let them know they can't implement the ICD-10 coding system until they've adopted a version of the claim standard (X12 v. 5010, for instance) that supports it.

A new collaboration between the North Carolina Healthcare Information and Communications Alliance, Inc. (NCHICA) and the Workgroup for Electronic Data Interchange (WEDI) will serve to connect the dots for regulators, standards developers and industry implementers alike.  It's not a simple calendar, but instead a map that includes dependencies, timelines and comment periods.  Way cool, and way overdue.

Read more about it online at Carolina Newswire and FCW.

Bottom Up, Top Down, Centralized Distributed HIT

Okay, I try not to wade into all this industry noise, but there are a number of things that all came over the transom in the last 60 minutes that make it impossible not to comment.

Freedom's Just Another Word
First, the Joint Commission (aka JCAHO), which basically is the gestapo of patient quality and arbitrary auditing (all welcomed, if feared, by the provider community, which wants a bi-annual report card to show its funders), has started a wiki with a pretty broad scope: they call it "wikiHealthCare," which sounds pretty all-encompassing and grandiose, until you go and visit it.  The first two topic areas are pretty constrained: Smoking Cessation and Smoking Policies on hospital campuses.  Also, they want you to register before you use it.  And they want to limit comments to "healthcare professionals."  And the URL is http://wikihealthcare.jointcommission.org/twiki/bin/view/Home/WebHome . 

Remember how East Germany used to call itself the German Democratic Republic? 

The Absolution of Truth
Google, the ultimate "whatever floats your collective boats" info-arbiter seemed to have been moving in the other direction, but now may have stumbled with the loss of their Google Health "architect," Adam Bosworth.  Bosworth's approach seems sort of anti-Google, which may have been the problem:

It is Google’s vision that these two core capabilities, reliable unambiguous computable medical data and safe systems for trust and authentication and controlled access will dovetail with the consumer needs for discovery about everything in their health arena.

Forget about Googling Adam Bosworth -- Danny Sullivan at Searchengineland has put together all the definitive links.  I'd drill down into the details to try to figure out what Bosworth was imagining when he referred to "reliable unambiguous computable medical data," but I lost interest when he seemed to be slipping into consumer-driven healthcare, which subject I give about the same credence as passenger-driven airline travel.

Maybe now that Bosworth has gone on permanent vacation, do you think this means that Google is going back to letting users decide whom to trust? 

Speaking of trust, the wrong Gates is mucking around in the healthcare space again....

Link to All CMS NPI FAQs

Many moons ago, I wanted to share a query string that would bring up all CMS FAQs that include the term "NPI."  That was preferable to linking to specific items, because new items were being constantly being added.  I did the search query on the CMS site, which created a URL that was a mile long.  I systematically eliminated components of the string until I came up with something that produced the desired results, but was only a furlong or two in length.

I've given this out before, but I didn't have a direct, isolated link on my blog, so here it is.  You can click on the big ugly string, but that often gets broken in pieces when you copy/paste/send via email, so if that's an issue, you can link people to this blog post by copy/pasting the second string.  (I don't use tinyurl because I'm not sure what they are selling to do what they do for free.  I am selling mostly free information with a few fee-based webinars and mostly-free presentations and white papers thrown in).

Big Ugly String to CMS NPI FAQs
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?&p_page=1&p_search_text=NPI&p_new_search=1&p_search_type=answers.search_nl&p_sort_by=&p_gridsort=4%3A2

Short Friendly String to this Blogpost
http://blog.hittransition.com/2007/08/link-to-all-cms.html

State CIOs Invite Bigger Role in RHIO

The organization that represents the CIOs of state governments says its members should take a more active role in their states' Regional Health Information Organizations. This would definitely rate a "Duh Of The Month" here at the HIT Transition Weblog, except that I'd like to take a step backward and say that I'm not entirely sure that it's such a good idea until state governments show more willingness to pay for RHIO development.

According to a Government Health IT article, the National Association of State CIOs (NASCIO) is calling for its members to have a bigger say in how RHIOs develop. “Integrating these regional efforts will become a critical aspect of state CIO responsibility,” states a NASCIO brief. State government CIOs could serve as advisors to represent state health programs' technical interests.

Fine idea... but governments are already more involved in RHIO management than the dollars they offer would seem to justify.

Reasons Require Remarks: Changes within the Standard

The ASC X12 835 Health Care Claim Payment/Advice (often referred to as "Electronic Remittance Advice," or ERA) is supposed to enable providers to post payments and adjustments without manual review.  One important enabling technology is the complex relationship between codes that explain how to deal with each detail:

• The Claim Adjustment Group Code ("Group Code") is a short list of qualifiers to describe the type of adjustment.  These include PR (Patient Responsibility), CO (Contractual Obligation), CR (Corrections and Reversals) PI (Payer Initiated) and OA (Other Adjustment).  This list cannot be changed without a change in the implementation guide.  Since we're several years away from the first possible adoption of such a revision under HIPAA, the codes you see are the codes you get.
• The Claim Adjustment Reason Code (CARC) is a dynamic list, maintained by The Claim Adjustment Status Code Maintenance Committee.  The CARC is a mandatory data element in the 835 -- for each adjustment, you have to give a reason.
• The Remittance Advice Remark Code (RARC) is a more detailed list, primary used to expand upon the basic information provided by the pairing of a Group Code and a CARC.  This segment, however, is not required, and a lot of payers do not include it in their remits.  Like CARC, the RARC is an external code list, which allows for ongoing revisions, additions, and deletions.  RARC is maintained by CMS's Remittance Remark Advice Code Maintenance Committee.  These values go into an optional segment -- Medicare uses that segment as do some other health plans.

A recent modification of the CARC and RARC lists -- and the implicit relationship between them -- constitutes a change in the way the 835 works.  That change is beneficial to all parties, though it may not be appreciated by some.  Most significantly for providers, it will prevent many of the unexplained denials that currently frustrate their ability to automate 835 processing.

Minnesota Schools the Nation in HIT

Once again, the state of Minnesota is showing us all how it is supposed to work.  They're not satisfied with the federal mandate for a single standard -- they want a single interpretation of the standard.  In fact, they insist upon it:

MINNESOTA LEGISLATION
Section 4:  Uniform Electronic Transaction Standards (62J.536)
The Administrative Uniformity Committee (AUC), under the direction of the Department of Health, will adopt uniform transaction standards for claims transactions, eligibility transactions and remittance transactions.  Eligibility transaction standards will be adopted by January 15, 2008 and implemented among plans and providers no later than one year later; eligibility transaction standards will be adopted by July 15, 2008 and implemented among plans and providers no later than one year later; and remittance transaction standards will be adopted by December 1, 2008 and implemented among plans and providers no later than one year later.  The AUC must create a single, uniform companion guide for each of the transaction categories.  For purposes of this requirement, “provider” includes nursing homes, boarding care homes, and home care providers.

All transactions must be electronic by the implementation dates for each type of transaction.  Web-based and direct data entry methods may be used to meet this requirement.

No payers or providers may require the use of additional companion guides or variations in standards.

$146,000 is appropriated for development of the transaction guides.

For more information go to:
http://www.health.state.mn.us/auc/transactions.htm

A single companion guide means you can send the same claim format to any payer in the state.  That's administrative simplification.  Who is powerful enough to bring such a mandate to the table?  Surprise -- it's largely due to the enlightened self interest of the payers and providers themselves.  They see tremendous financial benefit from enabling these transactions, and they work hard to work out their differences.  The state government also deserves credit -- and more importantly, they deserve to be used as a model by other states.

Thanks to EDI Partners for the story.  You can sign up for their excellent, free email newsletter here.

Nachimson Departs: Our Loss is Foresight's Gain

We received news last week that Stanley Nachimson, for years the regulatory voice for HIPAA implementation, has retired from his long career of public service to enter the private sector.  Foresight issued a press release announcing he had joined its board of directors and had "recently formed Nachimson Advisors, LLC., a consultancy under which he will provide health IT advisory services to various clients including WEDI and Cornichon."

After more than 30 years of service to CMS and its predecessors, Stanley has earned all the praise and recognition he must already be receiving from various industry stalwarts.  I would say that he will be missed at CMS were it not for the fact that he has already been missed: The regulatory body's tight-lipped, even secretive approach to NPI implementation stands in stark contrast with Stanley's conversational navigation of the Transactions and Code Sets waters, back in the days leading up to October 2003.

NPI Contingency Policy is Posted

This just released: CMS has posted its contingency policy online.

Consumer Directed Health Care and Real Time Claims

Just got done with the first day of the X12/WEDI Real Time Adjudication Conference.  Some are now abbreviating this as RTCA (for Real Time Claims Adjudication),  What's RTCA, you say?  Well, that's one of the questions we're debating.

Basically, the concept means the patient walks in, gets treatment and the provider can submit the claim, get the health plan's payment amount (but not necessarily the payment) and the patient responsibility amount -- all before the patient leaves the office.  The provider gives the patient the bill and receives payment or at least an accurately quantified promise. 

The WEDI/X12 conference was just announced a few weeks ago, but there are a couple hundred movers and shakers here in Reston, Virginia.  Why the sudden interest?  In an acronym, CDHC: Consumer Directed Health Care.  Or, more to the point, CDHC as manifest in High Deductible Health Plans.  The Cure for Healthcare is making the patients responsible for their own care.  But giving the patients more responsibility can't reduce healthcare costs if they walk out the door and don't pay.  That's not patient responsibility -- that's industry irresponsibility.

The good news for us is, it's a perfect storm for introducing a new technology: RTCA.  RTCA could capture that elusive patient responsibility that is the core premise of CDHC.  There are lots of incentives for everyone to make this work -- and soon.

Dissemination Update

My readers are so smart and well-connected, they really help me stay on track.  Which is to say, when I go off the track, they put me back on the rails.

In the case of yesterday's Preview of the NPI Data Dissemination Policy (DDP), there are at least two things I may have been wrong about.  One I would be happy to be wrong about, but if I am wrong about the second, I am not so thrilled.

First, somebody more familiar with the various instruments avaible to regulators says that CMS could issue a "notice with comment" that doesn't actually go through a second draft.  In other words, you can comment about what they say they're going to do, but they can ignore it  -- in fact, they can institute the policy immediately. 

If so, that's good news -- sorta.  At least in terms of time-to-data, it eliminates that second round of regulatory hoop-jumping I cautioned you about.

It might not be such a great thing if the DDP isn't exactly perfect the first time out of the box.  Sure, I know it's been through about two years of internal revisions, but how could it be considered complete if "industry experts" don't get to weigh in on what it says?   Ahem.

Putting the NPI Granularity Issue to Bed

The NPI Granularity Issue is something the late-to-the-party healthcare industry is just beginning to grasp, much less grapple with.  But understanding it now is key to our overall success, so it needs to be addressed before we come up with systems that contain both internal and external time bombs waiting to go off.

The Granularity Issue is contained in the way the industry answers the following question: "I've just enumerated six subpart NPIs for my provider organization.  Do I send the same six NPIs to everyone, or do I send only one to those who know me by one number now?"

Despite clear and compelling arguments that the only answer that will prevent disaster is "all six!," CMS-as-regulator has waffled on this most fundamental of questions.  In the hopes that they will change their stance, I've got some new evidence I'd like to present.  The source?  CMS itself.

Prior Posts on the NPI Granularity Issue

I had to do some research to write an editorial on NPI and the Granularity Issue.  Some of that included reminding myself what I'd already said on the challenge of ensuring that NPIs actually become the uniform standard for provider identification.  For those who would rather not find the bits and pieces from old posts, I've collected them here.

CMS Commits to NPI Realities

Readers might think I've been a little critical of CMS of late.  True, I didn't like their timing on adding the NPI to the Medicare 855 Enrollment forms.  Or the way they did it.  Or the way they pressed organizational providers to define subparts according to Medicare's view of the world.

More recently, I chided them on their new requirements for provider taxonomy on Institutional claims.  Not on adding taxonomy per se, but on their peculiar "payer mandate" that employs a baroque logic it expects IT-strapped providers to decrypt in order to send claims that will get paid.

Blue Health Data Reaps Payoff of Standards

The St. Paul Pioneer Press covers Blue Cross Blue Shield of Minnesota's participation with 19 other Blues plans in an initiative to leverage the intelligence in patient data to lower costs and increase the effectiveness of care.  The new system, dubbed "Blue Health Intelligence" goes into testing this year, with a rollout next year. According to the article, patient identification will be concealed, but suggests provider information may be included: "Although patient names and other personal identifiers are stripped out, specific doctors with their treatment patterns typically are identified when insurers mine their databases for information." (Note to the folks in Chicago: You'll want all the NPI granularity you can get in that data.)

The article points out that the data can be used for research purposes as well as patient care and cost control. "What sets Blue Cross's effort apart is its size — it's twice the size of the Medicare database."  From a healthcare IT perspective, what makes the data valuable is that standards have enabled the normalization of data on tens of millions of people.  Just as significant is that this data is in the hands of a private company that plans to use it for competitive advantage.  Great news for the free-market-will-control-healthcare-costs crowd, but of some concern to those who see market forces driving high-cost patients out of the insurance pool. 

HIPAA ROI Found Hiding In AHIP Survey

An interesting report entitled "An Updated Survey of Health Care Claims Receipt and Processing Times, May 2006" was just released by America's Health Insurance Plans (AHIP).  You can read about it and download the free report here.  As is oftentimes the case, it's not what the report says that's important, it's what the survey numbers themselves reveal.  Basically, electronic claims volumes are up -- a lot -- since the pre-HIPAA days of 2002.  But the sponsors don't trumpet the success of the industry's collaborative effort for Administrative Simplification, but instead suggest that “these data clearly show the best way to speed claims payment and to further reduce administrative costs is not through costly, new ‘prompt pay’ mandates, but rather to continue encouraging greater use of electronic claims submission.” (AHIP president and CEO Karen Ignagni)

Whuzzat?  Prompt pay laws are generally targeted toward outliers -- excessive waits resolving individual claims -- not on improving average turnaround times, which is where the data is focused.  More to the point, the survey reports huge -- really huge -- increases in electronic claims submission for the window of time framing implementation the HIPAA Transactions and Code Sets rule.  Based on aggregate data representing 25 million claims from 26 large and small US health plans, "the percentage of claims received electronically was 75 percent in 2006, up from 44 percent in 2002."  But wait, there's more....

Statewide RHIO Envisioned, NAHIT CEO Leads Cheer

At a November 17 conference held in advance of dedicated planning, some of the potential partners in an Oklahoma RHIO expressed a desire to reach out to include the state's many small rural delivery points. Others were content to focus on two urban RHIOs, one for each of the state's major metropolitan areas, Oklahoma City and Tulsa. The conference, sponsored by the Oklahoma Hospital Association, featured as its keynote speaker Scott Wallace, President and CEO of The National Alliance for Health Information Technology (NAHIT) and Chair of the Commission on Systemic Interoperability.

Attachments NPRM Comments Extended

Breaking News:  Comment period for Claims Attachments regulation extended by another 60 days.  A welcome announcement for those who are parsing not only the regulation text, but the thousands of pages of technical standards they will mandate.

Payer Disclosure is Attachment NPRM Achilles Heel

I'm still slogging through the Claims Attachment NPRM at a few pages a day.  I've got highlights in four different tones and exclamated comments written in the margins in blue, black and red ink.  So far, though, there's really just one thing that I can say must be changed. 

We are proposing that health care providers may submit an unsolicited electronic attachment only when a health plan has given them specific advance instructions pertaining to that type of claim or service. (FR Vol. 70 No. 184 p. 55999)

Hmm.  Wouldn't that, technically, run against the definition of an unsolicited attachment?  And what's this about "specific advance instructions."  Where can I find those?  Are they machine readable?

But okay, certainly we could just tell payers they have to provide this notice somewhere -- maybe in a pdf on their website, or an Excel table.  The rule has to tell them to publish that notice, otherwise they can simply "not tell" providers what to send, and providers won't be able to send them any unsolicited attachments, right?  And these payer guidelines have to pretty much match what they accept and process for paper claims, otherwise the Admin Simp goal is undone -- it will continue to be more advantageous for providers to send paper.  So they did say something about that, right?

Well, no.  There's nothing in the rule that mandates a payer must disclose their attachment requirements,  What's more, there's plenty of proof that payers don't (and probably won't) share that information in any consistent way.  Read on.

HITSP Hits Harmonization

The American National Standards Institute (ANSI) has been awarded the contract to lead the harmonization effort in healthcare IT, along with partners Healthcare Information and Management Systems Society (HIMSS), the Advanced Technology Institute (ATI) and Booz Allen Hamilton.  The contract is one of three awarded by HHS under the sponsorship of David Brailer's Office of National Health Information Technology Coordinator.  The contract goes under the moniker ONCHIT1.

The first order of business is the development of a body to be known as the Healthcare Information Technology Standards Panel or HITSP.  Perhaps in anticipation of winning the contract, ANSI claims that this panel already includes 100 members.  A core group of 18 organizations will constitute the Standards Harmonization Collaborative.

Claims Attachments NPRM

The Notice of Proposed Rulemaking for the HIPAA Administrative Simplification: Standards for Electronic Health Care Claims Attachments was published in the Federal Register today, after many months of anticipation and delay.  In an interesting and creative twist, the regulators include an extensive excerpt from a recent HL7 white paper in the preamble, including graphics depicting different scenarios.  Not your gray, run-of-the-mill three-column column law.  (I can hear the high-fives and war whoops in my HL7 buddies' offices right now!)

Attachments NPRM Resubmitted, Messenger Lives to Tell About It

The proposed rule for Electronic Claims Attachments has been resubmitted to OMB.  How do I now?  Apparently, Dave Feinberg is hard to silence.  Yesterday I asked him to add me to his personal distribution list and today the following message was waiting for me when I got to work:

Attachments NPRM Withdrawn, Messenger Shot

I just got off the phone with Dave Feinberg.  Someone had forwarded me a message he had posted that included the text of an announcement from the Office of Management and Budget: the regulatory request for an Electronic Claims Attachment standard under HIPAA had been withdrawn.

This is truly big HIT news.  As recently as last week, the Claims Attachment NPRM (Notice of Proposed Rule Making) was anticipated to be released in September.  This followed years of hard and diligent work by people inside and outside the government.  The final hurdle was to get it released by the OMB.

What was OMB looking for?  Well, among other things, it was looking for ROI.  (Aren't we all?)

And though the Attachments rule would help eliminate an avalanche of paperwork from the healthcare system, good numbers on costs and benefits are extremely hard to come by.  Was that the problem?  We don't know. So far, all we have is the OMB announcement.

As a veteran standards development wonk and policy watcher, it's no surprise that Dave was first with the news.  He's the guy that posts all the notices to industry listservs when new comment periods begin for both regulations and the technical standards.  Back when I was at the hospital, it was a Dave Feinberg announcement that got me to approach my CFO and tell him our claims were about to get redesigned, and there weren't enough providers at the table to protect our interests (Dave's message, in typical fashion, addressed only the former issue -- I got the emotional content from other sources).  Guys like Dave do an incredible service to the industry by spreading the word, sticking to the facts, and smarting us up about how things work.

ICD-10 vs. Regulatory Inertia

Congressional HIT advocate Nancy Johnson (R-CT) has drafted legislation that would require a conversion to The International Statistical Classification of Diseases and Related Health Problems Revision 10 (ICD-10) coding for diagnosis and procedure information in electronic healthcare transactions by October, 2006.  What's the problem?  The electronic transactions mandated by HIPAA won't support ICD-10.  What's more, even the most optimistic estimates see adoption of the new 5010 transactions (most of which are still in draft) no earlier than 2009, with a two year implementation window extending to 2011 or later.

Health IT Office is Official - Brailer to Staff Up

Hot off the wire:  David Brailer will get some deputies and cast off the unfortunate "ONCHIT" acronym.  Read on for highlights and a link to the federal publication.

Underappreciated HIT Challenge #2 - Alphabet Soup

In HIT (that's "Healthcare Information Technology") we swim in alphabet soup.  We start with the SDOs ("Standards Development Organizations"), some of which are DSMOs ("Designated Standards Maintentance Organizations") as designated by HIPAA (you get the picture).  It seems like each week brings a new, critical TRA ("Three Letter Acronym") which you must immediately incorporate into your vocabulary. 

One of my favorite bits of jargon is "Mynorca" (the expansion of an acronym into its component words).

"Mynorca" is "acronym" spelled backwards.

As difficult as it is to decode the organizational abbreviations into words, getting the products of these organizations (and the people who create them) to work together is a much more significant challenge.  The buzzword here is "harmonization."  Lucky for you, this one is not an acronym.  But while harmonization is getting a fair bit of play in the HIT community -- and even a federal project to boost the effort -- it remains a murky conundrum.

The Top 5 Underappreciated Challeges Facing HIT

Healthcare IT is full of known problems: The decades of underinvestment, the incredible reliance on paper, the built-in complexity of the care environment and the added-on complexity of the reimbursement environment.  There are lots of people working on those problems, which is why I like to look for the ones nobody notices.  Well, not nobody, necessarily, but not enough people.

Here, off the top of my head, are a handful...