HIPAAHIPAA

NCVHS NCVHS --HIPAA TransactionsHIPAA Transactions

and and the National Health Information the National Health Information

InfrastructureInfrastructure

John R. Lumpkin, MD, MPHChairman,

National Committee on Vital and Health StatisticsSenior Vice-President

Robert Wood Johnson Foundation

NCVHS MissionNCVHS Mission

• The mission of the National Committee on Vital and Health Statistics (NCVHS) is to advise on shaping a national information strategy for improving the population’s health.

NCVHS NCVHS

• Formed in 1949• Refined and expanded ICD• 1969 Uniform Hospital Discharge Data Set• 1974 Uniform Ambulatory Care Data Set• 1980 Long Term Care Data Set• 1996 Core Data Set

1974 1974 -- Kerr WhiteKerr WhiteChairman NCVHS Chairman NCVHS

• “With the advent of new technology, data can be collected in any format, aggregated by the computer and arrayed in any desired

output … collecting masses of data untouched by human thought

“Perfect Storm” Forming Around “Perfect Storm” Forming Around Health and Health CareHealth and Health Care

•• 41 Million + Uninsured in America41 Million + Uninsured in America•• Health Care Costs Rapidly RisingHealth Care Costs Rapidly Rising•• Those Covered Paying More for Their Those Covered Paying More for Their

Coverage and More OutCoverage and More Out--ofof--PocketPocket•• State Budget Crises Threatening CoverageState Budget Crises Threatening Coverage•• Quality is not a givenQuality is not a given•• Public Health System is StressedPublic Health System is Stressed•• Seeking Health Information is a Major Internet Seeking Health Information is a Major Internet

TaskTask

Medicare Reimbursements (Part A and B) in Medicare Reimbursements (Part A and B) in Relation to the National Average (2000)Relation to the National Average (2000)

More than 15% Above AverageMore than 15% Above Average (36)(36)00 -- 15% Above Average15% Above Average (68)(68)00 -- 15% Below Average15% Below Average (112)(112)More than 15% Below AverageMore than 15% Below Average (90)(90)Not PopulatedNot Populated

Jack WennbergDartmouthAtlas of Health Care

R2 = 0.49Num

ber o

f Vis

its to

Car

diol

ogis

tsN

umbe

r of V

isits

to C

ardi

olog

ists

0.00.0

0.50.5

1.01.0

1.51.5

2.02.0

2.52.5

0.00.0 2.52.5 5.05.0 7.57.5 10.010.0 12.512.5 15.015.0

Number of Cardiologists per 100,000Number of Cardiologists per 100,000

Capacity Determines Need?Capacity Determines Need?

Jack WennbergDartmouthAtlas of Health Care

What does Greater Per Capita Spending What does Greater Per Capita Spending BUY?BUY?

not more effective or preference sensitive carenot more effective or preference sensitive care1.

00

1.00

1.001.

18

0.98 1.04

1.38

0.97 1.03

1.66

1.00

0.99

0.00.0

0.40.4

0.80.8

1.21.2

1.61.6

2.02.0

Medicare ReimbursementsMedicare Reimbursements Effective CareEffective Care PreferencePreference--Sensitive CareSensitive Care(Discretionary Surgery)(Discretionary Surgery)

Rat

io to

Low

est S

pend

ing

Reg

ion

Rat

io to

Low

est S

pend

ing

Reg

ion

More than 15% Below Average0-15% Below Average0-15% Above AverageMore than 15% Above Average

Jack WennbergDartmouthAtlas of Health Care

Asthma: Outpatient FollowAsthma: Outpatient Follow--upupAfter Acute EpisodesAfter Acute Episodes

•• Core concept: Core concept: Outpatient followOutpatient follow--up up after either ER visit or after either ER visit or admissionadmission

•• Children 5Children 5--17 years old17 years old•• Standard based on Standard based on

national expert panel national expert panel guidelinesguidelines

0

10

20

30

40

50

60

70

80

90

100

Follow-up Rate

White

African-American

Quality of Health Care in US??Quality of Health Care in US??

• Overall Care 54.9%• Preventive 54.9%• Acute 53.4%• Chronic 56.1%• History 43.4%• Counseling or Ed 18.3%• Immunization 65.7%Elizabeth McGlynn, et al NEJM June 26, 2003 348:26

A. Sehgal- JAMA 2003;289:996-1000

The focus must shift from blaming The focus must shift from blaming individuals for past errors to a focus on individuals for past errors to a focus on

preventing future errors by designing safety preventing future errors by designing safety into the systeminto the system

To Err is Human- Institute of Medicine

Current practice depends upon the Current practice depends upon the clinical decisionclinical decision--making capacity and making capacity and reliability of autonomous individual reliability of autonomous individual practitioners, for classes of problems practitioners, for classes of problems that routinely exceeds the bounds of that routinely exceeds the bounds of

unaided human cognitionunaided human cognition

Daniel R. Masys, M.D.2001 IOM Annual Meeting

HIPAAHIPAA

Health Insurance Portability Health Insurance Portability and Accountability Act 1996and Accountability Act 1996

• PUBLIC LAW 104-191• Title II Subtitle F• It is the purpose of this subtitle to improve the Medicare

program under title XVIII of the Social Security Act, the Medicaid program under title XIX of such Act, and the efficiency and effectiveness of the health care system, by encouraging the development of a health information system through the establishment of standards and requirements for the electronic transmission of certain health information

Transaction Standards Transaction Standards Claims or equivalent encounter information

Coordination of benefits information

Referral certification and authorization

Enrollment & disenrollment in a health plan

Eligibility for a health plan

Transaction Standards Transaction Standards Health care payment & remittance advice

Health plan premium payments

First report of injury

Health claims status

Health claims attachments

Supporting Standards Supporting Standards Privacy

Security

Code sets

Unique identifiers (including allowed uses) for:– Individuals– Employers– Health Plans– Health Care Providers

"Darmok and Jalad at Tanagra"Darmok and Jalad at Tanagra

ConversationConversation

• Vocabulary– What words you choose

• Grammar– How you put the words together

• Context– What environmental factors are influential

Data Flow as ConversationData Flow as Conversation

• Vocabulary (software-independent)– Content Standards: SNOMED, LOINC

• Grammar (software-independent)– Transmission/Structure Standards: HL7,

ASTM, X12• Context

– Conceptual Data Model• HL7 EHR• ISO/TC 215

We stand on the “tipping point” of We stand on the “tipping point” of the rapid enhancement of the health the rapid enhancement of the health

care system into a high quality, care system into a high quality, efficient and effective system. efficient and effective system.

Automation of information systems is Automation of information systems is the transforming technologythe transforming technology

Vision of the NHIIVision of the NHII

• The set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health.

• NOT a centralized database.• Connects distributed health information in

the framework of a secure network with strict confidentiality protections.

NHIINHII

• THE GOAL IS TO PUSH KNOWLEDGE TO THE POINT OF SERVICE (CONTACT)– EXPERT SYSTEMS– DECISION SUPPORT– PRACTICE GUIDELINES

AMERICAN APPROACHAMERICAN APPROACH

• RESPECT INDIVIDUAL PRIVACY• ASSURE CONFIDENTIALITY• ENGINEERED FOR SECURITY

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderPersonalHealth

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderHealthcare ProviderPersonalHealth

Health Care Provider Health Care Provider DimensionDimension

• Encompasses information to enhance the quality and efficiency of health services for individual

• Includes information captured during patient care process

• Integrates clinical guidelines and protocols, specific information from PHD, as authorized, and from Community Health Dimension

Framework for Framework for PMRI (Patient Medical Record PMRI (Patient Medical Record

Information) StandardsInformation) Standards

InteroperabilityInteroperabilityData

Data

Quality

Quality

ComparabilityComparability

HL7 &DICOM HL7 & ASTM

HL7

HL7

ASTM& HL7

IEEE

PMRIPMRI

Laboratories

ASCX12N &

NCPDP

NCPDP &ASC X12N

NCPDP &X12N

Radiology

HospitalPharmacy

Knowledgebases

Physiologicalmonitors

Medicaldevices

Bedsidecomputer

PatientRegistration/Admissions

Billing

Clinicalcontent

Orders&results

CommunityPharmacies

PharmacyBenefits Mgrs

Payers

HL7

HL7&

ASTM

HL7

IEEE

(Adapted from Electronic Health Records: Changing the Vision, Eds. GF Murphy,MA Hanken, and KA Waters. Philadelphia: W. B. Saunders Company, 1999)

Interoperability StatusInteroperability Status

Comparability StatusComparability Status

ConvergenceSNOMED RT/NHS Clinical Terms

Message Specific Codes• DICOM• NCPDP• IEEE• HL7*• X12N

Nursing Codes• HHCC*• NANDA*• NIC*• NMMDS• NOC*• OMAHA*• PCDS*• PNDS

Drug Codes

•First Data Bank*•Multum *•NDC

Diagnoses & Procedure Codes• Alternative Link*• CDT-2*• CPT-4*• HCPCS*• ICD-9-CM/ICD-9-V3*• ICD-10-CM*• ICD-10- PCS• ICIDH-2

Other Codes•Health Language Center•UMDNS (ECRI)*•DEEDS•UPN (HIBCC)/UPC (UCC)

Clinically Specific Codes• DSM*• Gabrieli• LOINC*• MEDCIN• MedDRA• SNOMED V3*• NHS Clinical Terms*

* Fully or partially included in theUMLS Metathesaurus as of March 1, 2000

The Health Informatics The Health Informatics PipelinePipeline

Foundation Foundation HIPAA StandardsHIPAA Standards

Financial &

Administrative

Interoperability

Comparability

Data

Qua

lity

Privacy &Security

NHIINHII

Population Population HealthHealth

(Preparedness)(Preparedness)

Healthcare ProviderPersonalHealth

Population Health DimensionPopulation Health Dimension

• Supports the identification of health threats, assessment of population health status, focussing programs and services, research and evaluation

• Encompasses population-based health data and resources, statutorily authorized data in public health systems and the Health Care Provider Dimension, and other anonymous data

SNOW AND CHOLERASNOW AND CHOLERA

• DATABASE ANALYSIS

• GIS SYSTEM

The Need for The Need for Solutions is UrgentSolutions is Urgent

ClincalSite

State PHDept

LocalPH Dept

CDC

CDCResponse

Team

LocalResponse

Team

FBIResponse

Team

ContractorResponse

Team

HHSLRN

Level ALab

LRNLevel B,C

Lab

Contaminated Bldg.Outbreak Community

RegularLab

2.1 - suspicion

1

2N

34N

4.11

4P

4.124.1 - suspicion

5

6N6P

6.1 - new case

4.13

4.2

6.116.12

6.2

6.13

0 - specimen

2P

FBI

7 8 9

1010

11

12

13

10 - New Event

14

1415

14

15

15

Hospital

Vaccination Center

Example Data Flow

C. Broome - CDC

A Word of CautionA Word of Caution

The real danger is not that computers will begin to think

like men, but that men will begin to think like computers

Sidney J. Harris

NHIINHII

Population Health

(Preparedness)

Healthcare ProviderPersonalPersonalHealthHealth

Pew Internet Project

Personal Health DimensionPersonal Health Dimension

• Supports the management of individual wellness and health care decision-making

• Includes a personal health record, created and controlled by the individual or family

• Includes non-clinical information such as self-care trackers, health materials, local public health and health care services

Consumer attitudes Consumer attitudes towards PHR towards PHR

• Consumers are eager to obtain health information online and facilitate transactions

• Consumer concerns about Internet privacy are strong and well-documented

• Users will want to be able to control their PHR as much as possible

• The more educated about PHR, and the more experience consumers have with it, the more open they are to the concept

“We have wonderful technology, but some grocery stores have better technology than our hospitals and

clinics.”Secretary Tommy ThompsonChicago Medical School CommencementJune 7, 2002

Arthur C. Clarke LawsArthur C. Clarke Laws

Third Law:"Any sufficiently advanced technology is

indistinguishable from magic."