Title: Canopy A WebBased Case Management Solution for your Health System.
1DIA Meeting
Emerging Standards for Health Information
Unexpected Opportunities and Challenges from the
HIPAA Health Reform Acts
David C. Kibbe, MD
Director, Health Information Technology American
Academy of Family Physicians President,
NCHICA Chapel Hill, NC david.kibbe_at_canopysystems.
com
September 17, 2002
2David C. Kibbe, MD Disclosure
- Director of Health Information TechnologyAmerican
Academy of Family Physicians - President-elect, North Carolina Healthcare
Information and Communications Alliance, NCHICA
www.nchica.org - Chairman and Founder of Canopy Systems, Inc.,
whose ASP model Web-based softwareCanopyis
used to support community-wide case management,
utilization management, and disease management
programs at hospitals and integrated delivery
systems nationwide - Email dkibbe_at_aafp.org
3Presentation Topics
- HIPAA As Health Care Reform by Stealth
- Complementary Standards-Setting Activities
- HIPAA 2, HIPAA 3, etc.
- The Office-Based Physician and Standards
- Next generation of office IT will be standards
based - OpenEMR and the Family Physician
- Questions
4Example Information Flows in Book Buying
5Information Flows in Healthcare
6HIPAA The Most Important Health Care
Legislation Since the Passage of Medicare
- Health Insurance Portability Accountability Act
of 1996 PL 104-191 - Administrative Simplification Statute
- Transactions Codes
- Privacy
- National Identifiers
- Security
- Delays and Guidances
- Civil Monetary Criminal Penalties
- Applies to all providers who bill electronically,
or whose agents do so on their behalf
7Health Policy Reform Failures 2001
- Patients Bill of Rights
- Medicare prescription drug benefits
- Mental health parity expansion
- FDA commissioner appointment delay (along with a
number of other key health department leadership
vacancies in the federal government) - Economic stimulus package after 9/11, failed due
to a health care policy reform impasse between
Republicans and Democrats in Congress
8Health Policy Successes in 2001
- HIPAA Transactions and Privacy Final Rules
- Regulatory relief, e.g. less paperwork
- Bioterrorism appropriations
- Small for nurse training and education
9HIPAA Minor Provisions Assume Major Proportions
and Impact
- Major Provisions
- Eliminate job-lock for patients with pre-existing
conditions - Guarantee access to health plan coverage
- Make health insurance portable
- Establish MSAs
- Minor Provisions
- Promote long term health insurance
- Create health data standards for administrative
transactions and privacy of electronically
transmitted health data - Address Medicare fraud and abuse at OIG level
10HIPAA Comprehensive Standards for Health
Information
11Who Must Comply?
- Health Plans
- Clearinghouses
- All providers (physicians, hospitals, nursing
homes, etc.) that transmit any health information
in electronic form for which there is a HIPAA
standard, e.g. claims - Electronic covers transmission over any
computer network, but also magnetic tape, CD,
disk - I.e. virtually all medical practices
12When Do We Have to Comply?
13What HIPAA-EDI standard transactions will affect
doctors?
- Health claims or encounter information transfer
x12-837 - Eligibility status in a health plan x12-270/271
- Enrollment and disenroll actions in a health plan
x12-834. - Referral certification and authorization x12-278.
- Health claim status x12-276/277.
- Health care payment and remittance advice
x12-835. - Health plan premium payments x12-820.
- First report of injury (proposed).
- Health claims attachments (proposed) x12-275.
14An X12-837 Transaction
HL7201
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NM1PR2MEDICARE
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NM1PR2State Farm InsPI123456789
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DTP434RD820011215-20011215
DTP435DT0000000
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HIBH18D820000401BHA2D820000401BHB2D82
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AMTN1162.11
AMTPG1427
AMTB11427
DMGD819360410M
OIYY
MIA137701
MOA0.23
NM1IL1CRUTCHFIELDTOMMYR
MIHC2597224343 N31301 CUSTER
RDAPT 202-222
N4PLANOTX750757491
NM1PR2STATE FARM INSURANCEPINO
NE NM1PR1MEDICAREPI00
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SVD00090006101
CASPR2214.9
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CASCO451049.99
15MDs in Each Stage of Grieving (over loss of
control over health care information)
HIPAA-Meter for Physicians
- Denial and isolation
- Anger
- Bargaining
- Depression
- Acceptance
16Many HIPAA Presentations Imply that Rules Were
Devised to Punish Physicians
- And miss the point that the Primary Objectives of
HIPAAs Administrative Simplification Provisions
are - To improve the efficiency of health care delivery
by standardizing the electronic data interchange
(EDI) of certain administrative and financial
transactions between provider and payers, and by
specifying the medical and administrative code
sets that should be used with the standard
transactions. - To protect the privacy of health care information
by setting standards for privacy and security of
individually identifiable information.
17Beyond HIPAA
- NCVHS
- National Health Information Infrastructure
- Health-E US
- Institute of Medicine
- Leapfrog
- National Quality Forum
- CMS Quality Improvement Organizations (formerly
PROs) - Markle Foundations Connecting for Health
- CDC and bioterrorism defense information network
Standards
18Key Insights from Connecting for Health
- The time is right for accelerating clinical
data standards adoptiontechnical capabilities
exist and interests are aligning (e.g. CHI,
AHA, IOM, Leapfrog) - There are several operable or nearly operable
standards - Everyone needs data
- Consumers and providers to improve health and
health care - Payers to drive improvements in quality and
effectiveness of care - Public health to identify and respond to health
threats - Health services researchers to develop strategies
that improve outcomes - There is extensive overlap in the data needed by
all of these stakeholders (e.g. there is a
community of interest)
19Key Insights from Connecting for Health
- Surveys indicate that the lack of
interoperability serves as a key barrier to
adoption of computerized patient records within
the practicing clinician environment - Many providers are ready to move to adoption of
clinical data standards, but state of readiness
varies across the health care system - Standards adoption is an important enabler for
adoption of computerized patient records.
20CMS QIO
Devices
CDC
JCAHO
Symptoms
Laboratory Clinical Observations
Encounters Diagnoses Procedures
FDA ADE
Providers
Survey/Satisfaction
CMS payment
- Other data categories
- Still Images
- Motion Images
- Physiologic signals
Charges
NCQA
Illustrative, not factual
21Illustrative, not factual
22A New Opportunity
- Bring together the emerging momentum for
standardization with state-of-the-art Web and
Internet technologies to create a national health
information infrastructure
23A New Opportunity contd
- using public domain and open source software to
create multi-purpose electronic health records
that link - Lab results
- Pharmacy data
- Demographic information
- Insurance information
- Encounter data
- Radiology
- Patient functional status
- Lab orders
- Adverse effects
- Diagnoses
- Procedures
- Discharge summaries
24Priority Data Types
- Patient-provider encounter information
- Specialty/location
- Date
- Provider
- Visit level codes (CPT4)
- Diagnoses
- Procedures
25Second Level Priority Data Types
- Radiology
- Patient functional status
- Lab orders
- Adverse effects
- Diagnoses
- Procedures
- Discharge summaries
26Presentation References
- On the AAFP Web site, www.aafp.org/hipaa
27Presentation References
- The AMA Field Guide to HIPAA Implementation
- Kibbe, Hubbard, and Root co-authors
- Covers Transactions, Privacy, andSecurity Rules
- Exercises, worksheets, sampledocuments
- Available from AMA Press
- NCHICA Web Site
- www.nchica.org
- Collaborative HIPAA work products
- EarlyView Tools for Privacy and Securitygap
analysis