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 Questions From 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 Ethnicity County Code Marital Status Living Arrangement Education Occupation E-coding (number) Lab/radiology Pharmacy Gestational. Age Birthweight Admitting vitals Unique patient ID Physician ID Mothers Med Record # EMS Run # Present on Admission Flag Severity Score DNR Functional Status LOS Outlier DRG/MDC Admit/Discharge Time Payer Type Quarter of Discharge Total provider paid amt Observation stays Patient consent field Time 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 *1999 Inventory of 1998 State Data Availability

NAHDO ADMINISTRATIVE SIMPLIFICATION SURVEY 1998 N=33 state agencies responding

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 Issues Data 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 Recommendations and 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?) Patients Relationship to Subscriber: Required

Category 2: Priority Data Elements Recommended as Priorities for Inclusion into 837 Core Data Standards Mothers 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 Recommendation Educate States Education Technical Assistance Other?

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