PRIORITIZATION OF STATE ENCOUNTER DATA NEEDS

FOR PUBLIC HEALTH AND RESEARCH APPLICATIONS

Presentation to the Health Level 7 Government Projects Special Interest Group

by

Denise Love

National Association of Health Data Organizations (NAHDO)

HIPAA Study Objectives

• Educate Public Health Data Standards Consortium (PHDSC) members about the standards setting process and models in practice

• Promote the use of standards in public health where applicable

• Assess current and future public health and research needs not addressed in current standards

• Propose an information model for common state encounter data fields

HIPAA Study Process

• Identification of common state fields

• Cross-walk between 837X12N, UB-92, and selected state definitions manuals

• Written and/or oral interviews of selected state agency staff*

• Literature reviews for select fields*

• Prioritization and feedback from PHDSC (March 21, 2000)– Race and ethnicity became a priority element early in the study

*incomplete, pending feedback from PHDSC

State Encounter Data Study

• Study scope:– limited to statewide discharge/encounter data

systems– concentrated on industry/X12N standards

• Discharge data systems:– a complete collection of demographic, clinical, and

billing data reported for patients admitted as an inpatient or outpatient to a health care facility

Preliminary Findings• States will:

– need education about HIPAA standards– need technical assistance to incorporate into

existing systems– benefit from adopting X12N core standards

• The PHDSC is an effective mechanism for coordinating and facilitating the standards process

• Future study is needed (pilots, data needs assessments)

HIPAA Study: Early Successes

• Education of States• December 7, 1999 teleconference

• HIPAA Implementation Basics

• Over 100 participants, many Medicaid personnel

• Race and ethnicity• used study data to help support a business case

• used by DHHS in X12N Workgroup 2 presentation

• will be included in the next X12N Implementation Guide

State HIPAA QuestionsFrom interviews, follow-up discussion

• Positive reviews about the interactive teleconference and slide format

• “Needs to be more of this type of interaction/education to keep people on board”, FAQs, Listserves

• “What are the best ways to connect into standards process when state funds are limited?”

• “The use of national standards do not necessarily equate to accurate data”

• Medicaid state fields: what will happen to these?• “States need an advocate to express needs and concerns”• “There is a need for states to come together to design a

standard claims attachment”

Study Data Sources• Healthcare Cost and Utilization Project (HCUP) Partners

Inventory, 1999 (Agency for Healthcare Research and Quality)– 42 states responding

• HIPAA Administrative Simplification Survey of States, 1998 (NAHDO and Minnesota Health Data Institute)– 33 state agencies responding

• Interviews with State Health Data Agency staff, 1999– 28 interviews

• National Committee on Vital and Health Statistics Core Health Data Elements, 1996 Report

NON-X12N AND HIGH-PRIORITY DATA ELEMENTS COLLECTED BY STATES

Bold=added after study began

PATIENT DEMOGRAPHICS

PATIENT STATUS

CLINICAL

LINKAGE

FINANCIAL

Race and EthnicityCounty CodeMarital StatusLiving ArrangementEducationOccupation

E-coding (number)Lab/radiologyPharmacyGestational. Age BirthweightAdmitting vitals

Unique patient IDPhysician IDMothers Med Record #EMS Run #

Present on Admission FlagSeverity ScoreDNRFunctional Status

LOSOutlierDRG/MDCAdmit/Discharge TimePayer Type Quarter of DischargeTotal provider paid amtObservation staysPatient consent fieldTime in OR

State Fields in this Study

Data elements selected for initial assessment are those that are:

• often not required for reimbursement, non UB-92 or non 837-X12N

• related to policy analysis and public health surveillance at the state level

• likely to be collected by states even if excluded from HIPAA Administrative Simplification X12N core standards

HCUP Inventory*“Do You Collect Non-Billing Data Elements?

N=42 states responding

Zip 40 Race/ethnicity 27

E-codes 38 Birthweight 15

Unique ID 32 Severity 12

Payer Type 30 Present on admit 7

HMO 30 Readmit Indicator 7

HMO-Mcaid 26 Mom’s Med Rec # 5

HMO-Mcare 23 DNR 3

CHIP 5 Lab 1*1999 Inventory of 1998 State Data Availability

NAHDO ADMINISTRATIVE SIMPLIFICATION SURVEY 1998

N=33 state agencies responding

Unique Patient ID 17 Severity indicator 4

Birthweight 13 Functional status 2

County Code 13 Functional Status 2

More than 1 E-code 11 Injury rel. to employ 3

Present on Adm 8 Living arrangement 1

Admit/discharge Hr 7/6 Operating Time 1

State Agency Questionnaire for Target Elements• How does your state define the data element?

– First year required– First year submitted– Mandated or voluntary– Compliance first year and currently– Reasons for non-compliance

• Impetus behind adding data element• Who resisted and reasons?• Who uses the data element?

– Initiatives linked to its collection/use?– Estimated impact?

Categories of Findings and Recommendations

• Category 1: Data elements currently in the X12N Implementation Guide – can they serve public health/research purposes?

– How can we make states aware of the additional fields?

• Category 2: Priority data elements for inclusion into X12N– for PHDSC review and consensus

• Category 3: Data content issues– no recommendations/unresolved issues

• Category 4: Data elements likely to be addressed through NPRMs– What is the role and process of the PHDSC?

Category 1: Study Fields Present in X12N Implementation Guide

• External Cause of Injury Code

• Payer Type

• Present on Admission Indicator

• Birthweight

• All dates (procedure, admit, discharge)

• Patient demographics– Race and ethnicity (included during study period)

– (relationship to subscriber, marital status, occupation code as proxies for other demographic fields?)

• Provider paid amount (in 835 Remittance Advice Guide)

Category 2: Priority Data Elements for including into the X12N

• Mothers Medical Record• Do Not Resuscitate• County Code• Data Element Issues:• Is there a strong business case to justify collection?

• What additional information is needed before proceeding?

Category 3: Unresolved IssuesData Content Issues--More Study Needed

• Pharmacy data• Gestational Age of newborn• Laboratory Values• Admitting vital signs• Patient Demographics

– education level– functional status

• Time in operating room• Patient consent with immunization encounters

Category 4: Data Elements likely to be addressed in pending Federal Regulations

• National Provider Identification Number• National Payer Identifier (PAYERID)• Issue:

– Is it possible to gain consensus on a PHDSC position?

– Is this part of the purpose of the PHDSC mission?

– If so, what is the process for submitting a statement or comment from PHDSC?

Preliminary Recommendationsand

PHDSC Actions

Category 1: Study Fields Present in X12N Implementation Guide and Recommendations

External Cause of Injury Codes:– X12N: Requires principal diagnosis, admitting diagnosis,

and principal external cause of injury ICD9 code

Recommendation: Expand required primary E-code fields in X12N:– situational: if principal E-code present, then place of

injury ICD9 code is required

– situational: reserve a field for Adverse Medical Effect of Medical Treatment E-code reporting if a state/jurisdiction requires

Category 1: Present in X12N Implementation Guide Payer Types Present in X12N

Are these sufficient for public health/research?Other issues related to state adoption of these categories?

• Self Pay

• Central Certification

• Other non-Federal Program

• Preferred Provider Org

• Point of Service

• Exclusive Provider Org

• Indemnity

• HMO (Medicare Risk)

• Automobile Medical

• BCBS

• Champus

• Commercial Ins.

• Disability

• HMO

• Liability

• Liability Medical

• Medicare Part B

• Medicaid

• Other Fed Prog

• Title V

• Veterans Admin Plan

• Workers Comp

• Mutually Defined

Category 1: State Fields Present in X12N Implementation Guide

• Present on Admission Indicator:– situational, used to identify the diagnosis onset

• Birthweight (in grams):– required for delivery services

• Recommendations: • Educate States • Gather additional information to document the continued

value to public health and research• Assure Continued Inclusion In Future Implementation Guides

Category 1: Study Fields Present in X12N Implementation Guide

• Patient Demographic Fields in X12– Classified as “Not Used”:

– Patient marital status

– Occupation/student status codes

– For discussion and further study: proxies for other patient demographics?

Category 1: State Fields Present in X12N Implementation Guide

For Discussion: As proxy for other demographic data (e.g. marital status, living arrangement?)

Spouse Stepchild Mother/Father Life Partner

Grandparent Child Dep. Of minordependent

Otherrelationship

Grandchild Employee Emanc. Minor Cadaver Donor

Nephew/Niece Unknown Organ Donor Injured Plaintiff

Foster Child/Ward

Hand/SponsoredDependent

SignificantOther

Child—no resp

Patient’s Relationship to Subscriber: Required

Category 2: Priority Data ElementsRecommended as Priorities for Inclusion into 837

Core Data Standards

• Mother’s Medical Record Number• Do Not Resuscitate• County Code• Recommendation:

– Priorities for inclusion into 837 core standards

– Build a business case and PHDSC consensus and advance through the X12N process

Category 3: Data Content Issues and Recommendations

• Gestational Age• Pharmacy data• Patient demographics:

– education level– income – functional status– county code

• Patient consent/immunization encounters• RECOMMENDATION: UNRESOLVED ISSUES, FUTURE

STUDY NEEDED:– Pilot studies – How are patient demographics interrelated?– Intermediate standards steps: Public Health Implementation Guide for

test elements?

PHDSC Response• Consensus Priorities and Action:

– Mothers Medical Record and County Code Business Case Development

– E-code Workgroup

– Payer Type Workgroup

– Patient ID and Source of Admission Workgroup

– Readmission Workgroup

– Patient Functional Status Workgroup

Workgroup Results So Far..

• Mothers Medical Record business case presented to X12N: out for ballot

• E-code workgroup: developing case for expanded field or fields

• Payer Type workgroup: will track PAYERID, promote typology for mapping

Lessons Learned

• Work on only 3 priorities at one time

• The ability to manage and staff PHDSC workgroups is now limited

• Evidenced by slow progress in:– readmission indicator workgroup– patient functional status workgroup– patient ID, source of admission workgroup

No RecommendationEducate States

EducationTechnical AssistanceOther?

Study Fields Present in current or future X12N Implementation Guides: Promote State Adoption

• Race and ethnicity (next version 4030, situational)• Birthweight• Present on Admission• Mothers Medical Record Number• Recommendation:

• Educate states

• Gather additional documentation of their value

• Assure inclusion in future implementation guides

Summary Comments

• The PHDSC process is valuable and works!– Race and ethnicity, MMR# as examples

• This study just scratched the surface

• States will benefit from adopting X12N standards– Education and technical assistance needed

• An ongoing process of data needs assessment and pilot studies is needed

The Future