Bob's Blog - March 2008

2008-03-05T16:27:00Z

Over the past few months I have had many opportunities to talk to my fellow NAHDOites about the ever changing landscape of data standards. In quoting others on the value of standards, "standards are great especially when you have so many to choose from". We all would like to have just one standard for doing our business. The problem is that our business is too complex for that to be a realistic expectation. The reality is that there is no one standard that will do all our business. With that said, it would seem that the next best alternative would be to find ways to integrate the different emerging standards to meet our evolving business needs. This is not a new concept. In 2003 under contract with CDC, NAHDO developed a white paper on the need to integrate data from different sources as a means to reduce the burden of data collection while improving the quality of data for analysis.

In the intervening 5 years, what has happened is that predictably our data needs have increased along with the growing demands for and uses of the data, while the appropriate standards to message this increased need have lagged behind. A prime example of that is the HIPAA mandated transactions. The current HIPAA version (4010A1) is a 1997 view of the standards. In the past decade, needs to support ICD-10-CM and PCS, the Present on Admission Indicator, Race and Ethnicity, and most recently more clinical content amongst other things, is left unmet by HIPAA mandated transaction sets.

Note: a little birdie is telling me that there is a greater sense of urgency within the Department of Health and Human Services to move to a new version of HIPAA and that an Notice for Proposed Rule Making (NPRM) proposing such a new version of the standards may be forth coming sooner rather than later. I will keep my eyes and ears open and you will be one of the first to hear if my little birdie is on target.

The rapidly increasing demand for clinical content in our administrative record is our most obvious data collection hurdle today. Below are some reporting issues being tackled today in many states.

Driven by new Medicare requirements to collect the Present On Admission indicator for certain hospital visits, many states are also adding this data element as a requirement to their reporting systems.

The standards problem here is significant. Medicare is restricted to using a HIPAA mandated transaction set, the ANSI X12 837 Institutional. That implementation guide does not support the reporting of POA, so a temporary solution was necessary. Medicare got ANSI X12 blessings to use a filler in that format, the K3 segment. The next HIPAA version will support the reporting of POA. For state reporting the Health Care Service Data Reporting Guide, a sister to the institutional guide, does appropriately support POA reporting. Many hospital systems would have difficulty reporting using the version of the standard that appropriately supports the reporting of POA. It would be necessary for those hospital systems to support a newer version of the standard before required by HIPAA. That is the dilemma for reporting POA, use the temporary fix to be consistent with Medicare requirements or use a new version of the standard.
There are some states starting to collect vital signs and laboratory test information to supplement their existing discharge data systems.

Though there are some emerging standards to message this information, there is to date no single solution that could be recommended at this point in time.

There is the claim attachment model. In this case the clinical information would be messaged in a separate transaction using HL7 standards coded with Logical Observations Identifiers, Names and Codes (LOINC).   The claims attachment model provides a linkage number to "connect" the administrative and clinical data streams. The major issue with this solution is the lack of pilot testing necessary to fully evaluate the effectiveness of this solution

Because of the absence of consensus on any single solution, some states are adding these data elements to "filler" areas in existing transmission vehicles, either proprietary or standard formats.   The major issue with this solution is that those "filler" areas area becoming crowded with the rapid increase in demand for this clinical content to be added to the administrative content.
NAHDO member states have championed the need to collect additional clinical content to assess the impact of healthcare associated infections (HAI) on our health delivery systems.

Again because there is not a consensus standard, states have implemented a variety of methodologies to collect this information. With no single way to uniformly collect this information it is difficult to compare results across states borders that out of necessity have had to implement state specific solutions.

Again, because of the absence of consensus on any single solution, some states are adding these data elements to "filler" areas in existing transmission vehicles, either proprietary or standard formats. The major issue with this solution is that those "filler" areas area becoming crowded with the rapid increase in demand for this clinical content to be added to the administrative content.

It is evident that our members are at the forefront of implementing innovative information solutions. I wish I had a crystal ball to find out what solution is going to work the best. Whatever that solution, I strongly believe that our different collection systems need to have the capability to integrate administrative and clinical data.

I do not believe that this means the solution will be housed in the all encompassing electronic health records (EHR). The reason I think that way is that these super "do everything EHR's" are just too expensive and proprietary. In a competitive market place, the competitive edge may trump the single solution, at least in the near term. To me the economics of the Health IT is not unlike supply side economics. Businesses long have recognized that keeping the right amount of inventory on hand is good business. Advances in e-business and the associated standards have made it possible for businesses to better manage inventory to maximize profits.

In health care a vital part of our inventory is data. I am not alone in my belief that we need a model of "e-health" that will allow us to affectively manage our inventory. We need the right amount of data to make the right decisions on treatment as well as on making health policy. This is what I call the Goldilocks Principle.

The strength of NAHDO is that its members know data. NAHDO members have a long history in the data trenches. We have a lot of lessons learned to be shared. Most recently NAHDO has been working with the states of Mississippi, Washington, Idaho, Oregon, and Alabama to share the lessons learned from other states to help make the case for new data systems in each of those states that align with existing systems across the country.

Our challenge is to find ways to share our members vast experience and to get local, regional, state, and federal health policy decision makers to value that experience. Our school of hard knocks has taught us how to develop sustainable systems on a shoestring budget. Many of these systems have been managing valuable inventory (data) for more than 2 decades now. Our data systems are robust and mature. Our systems are also evolving as evidenced by the claims data bases championed by the State of Maine and the steady infusion of new data elements to meet today's needs, such as Present on Admission and new clinical content. It is important to note that when NAHDO members first started developing state reporting systems clinical content of the diagnosis and procedure codes was not part of a typical claim. Now any claim for any payer would be rejected without that information being reported.

We invite you all to join us in finding ways to meet this challenge. As an idea to start the ball rolling we suggest that NAHDO develop minimum guidelines on what a model state reporting system (inpatient and outpatient) looks like and how it might be made sustainable. For NAHDO sustainability, conformance to these guidelines for each state would be validated for a reasonable fee. We think this process will help our members educate stakeholders about their own data and help target improvement opportunities.

The fact that NAHDO member systems continue to stand the test of time is evidence of our worth to the "e-health" world. We do ourselves a disservice by not valuing that experience.

We welcome comment on this idea as well as any others that will let the "e-health" world know about the value NAHDO members bring to the health care discussions.

As always I am wowed and amazed by the often underfunded accomplishments of NAHDO members in managing our most important inventory, data.

Bob Davis

Bob’s Blog March 2007

2007-04-11T01:45:00Z

Inspired by a recent French Experience

I am writing this on the airplane returning from a trip to France. The main purpose of this trip was to visit my son and his wife. They are currently living in a rustic part of the French Alps. They live in a very small village high in the Alps called Les Terrasses. The closest town to purchase supplies is called La Grave. It is 1000 vertical feet down to La Grave and obviously the same coming back. With snow, going down is a fun ski. No matter what, coming back with provisions on their backs is an effort. My son and daughter-in-law do not have a car or a TV in France. What they do have is a simpler life. What they do have is happiness.

After spending a week with them, I take home a lesson about striving for a simpler life. I could not stop thinking how this lesson could and should be applied to the world of health data standards.
As you know much of my professional duties are to be your “eyes” and “ears” at X12 and HL7 meetings. Much of the conversations at each of these organizations are devoted to the development of sophisticated and secure messages. X12 being about messaging administrative data content and HL7 being about messaging clinical data content. The complexity increases when we acknowledge the need to harmonize these two message standards along with others. I could not help thinking from my French experience and lessons learned from my son and his wife that there must be a simpler path. In thinking about a simpler time I think of the letter that a wife might have sent to a frontier exploring husband by Pony Express. I am sure that letter said, “I love you.” Today with all our sophisticated computers and WI FI connectivity the message sent by today’s wife to her globetrotting husband is the same, “I love you.” WOW! In 200 years the data content has not changed!!!

Are the questions our first public health epidemiologists asked different than those being asked by today’s epidemiologists? I think not. What is different are all the bells and whistles our “new” tools have enabled. Caution: With bells and whistles also comes bunches of hoops to jump through. I am sure that in 5 years there will be new technology that will add new complexity to sending those ever constant messages. For me the simpler way is to first recognize our “JOB ONE” is not the vehicle used to transport the message, but rather the content of that message. The next step is to do something about it. I think the NAHDO work group for the Present on Admission Indicator is a small example of how the time is being spent to make data content all it can be to be relevant when our kids’ kids are doing our jobs. My son and daughter-in-law selectively use new technology in their simpler life. The technology is only useful when it enriches the quality of their lives. The same lesson applies to the world of health data standards. Our technology is only useful when it enriches the quality of our data. When the technology gets in the way of the necessary relationships to make the data useful, then a simpler more personal solution is needed.

In closing, I want to thank my son and his wife for their living example of how making things simpler can make things better. I hope this can be a lesson for all of us in the health data standards world.