1. Standards Thomas Sullivan MD. HSCI 709

2. Standards – Why have them? Successful data exchange Not vendor, application or platform dependent Move data across enterprises

3. Purpose of Standards Integrates existing standards into new standards making implementation easier Makes life easier for users and vendors Backward compatibility nice but not always worth it Often unable to fit

4. A Good Standard Applies to all parts of the message construction, transfer and integration Should be practical and relevant Should be able to be updated and modified to include new technologies and uses Dynamic

5. Standards Agreement on how to implement technologies Proprietary Standards Consensus Standards

6. Standards Committees American Society for Testing and Materials ASTM American National Standards Institute ANSI National Institute for Science and Technology NIST International Standards Organization ISO - the 7 layer cake

7. The 7 layer ISO cake 1.Physical (wire from box to wall) 2.Data link 3.Network 4.Transport 5.Session 6.Presentation 7.Application

8. Accepted Standards HL7 ICD9-CM CPT-4 HCPCS NDC DICOM

9. HL7 Applies to Inpatient data ADT (admission, discharge, transfer) Orders Lab measurements Referrals Many others

10. HL7 v. 2.3.X Character based Limited to ISO layer 7 Lower layers not specified and left to vendors ( ? Good)

11. HL7 Messages composed of segments Segments composed of predetermined sequence of fields Cannot insert different data elements than those specified Message construction very limited

12. HL7 (Health Level 7) Standard for health care records and Medical Data Interchange Sanctioned by ANSI Europe has a different standard Current version 2.3.X Version 3.0 radically different Only an application layer standard

13. HL7 v. 3.0 Object oriented and model based HL7 for the multimedia medical record Not backwards compatible with v. 2.3.X Not yet ratified and accepted V. 2.2 is about to be de-certified Integrates DICOM at the information model level

14. DICOM Digital Imaging and Communications in Medicine An international standard The standard for the multimedia medical record Object oriented Radiol, Path, Derm, EKG etc.

15. Conformance Statement A statement by vendors detailing every aspect of functionality and compliance for each device/application DICOM and HL7 v.3.0 Users can review this statement for different devices/apps and determine compatibility Ability to exchange a given type of message

16. Interoperability between Standards How do all the standards work together? A B C Three different ways

17. Tunneling / Encapsulation A B C Data is a payload existing at A and C but moving through B in a way that B understands

18. Re-expression / Mapping A B C Message created at A using one standard It is rewritten in another standard as it is transported by B C then rewrites it to its own standard Data is the same, only format differs Risk compromising the data

19. Harmonization A B C Data model of one standard is incorporated into the data model of another standard DICOM 3 is part of HL7 v3.0 This represents the best approach

20. HIPAA An example of using standards

21. Electronic Transaction Standard Currently 400 different formats for health care claims National standard allow for submitting same transaction to any health plan in US Health plan could send remittance and referral info back to providers

22. Adopt standards for Health claims and encounter information Enrollment/disenrollment in health plan Eligibility in health plan Payment and remittance advice Premium payments

23. Adopt standards for Health claim status Referral certification and authorization Coordination of benefits

24. Standards to be adopted later First report of injury Claims attachments

25. Effective and Compliance Dates Final rule published August 2000 Effective date 60 days later: October 2000 Compliance 2 years later: October 2002 2003 for small health plans

26. How does Transaction Code Set Work Each business group of data=Transaction Set Each transaction set contains groups of logically related data in units = segments N4 segment has demographic info Transaction set has multiple segment Sequence of elements within 1 segment is specified by ASCI X12 standards

27. ASCI ASC X12N 837 Health care claims: Professional …CLP*12345*1*100*40*40*12…. 12345=Provider claim ID number 1=paid as primary 100 = amount billed 40 = amount paid 40 = patient responsibility 12 = PPO

28. A different segment …CAS*PR*1*24**2*16… PR=patient responsibility adjustment reason 1 = claims adjustment reason code 24 = amount of deductible 2 = claims adjustment reason code 16 = amount of co-insurance

29. Chosen Standards ANSI ASC X12N version 4010 For all but pharmaceutical transactions NCPDP For retail pharmacy transactions

30. Penalties < $100 per violation for any person not in compliance Up to $25,000 per calendar year for violations of any 1 requirement Enforcement procedures still to be published

31. Implications Health plans may NOT refuse a standard transaction or delay payment Health plans cannot require any other changes Health plans can require health claims attachments be sent in paper format until standard in effect

32. Sources of Information ASC X12 standard http://www.wpc-edi.com/hipaa NCPDP http://www.ncpdp.org

33. Code Set Standard HIPAA

34. Code Set Any set of codes used for encoding data elements Code sets for medical data elements required in administrative and financial health care transaction standards under HIPAA for diagnosis, procedures, drugs

35. Adopted Code Sets ICD9-CM, Vol 1 & 2 Diagnosis- Injuries Impairments- Other health related prob. Causes of injury, disease, impairment ICD9-CM Vol 3 for hospital inpatients Prevention- Diagnosis Treatment- Management NDC Drugs- Biologics

36. Adopted Code Sets Code on Dental Procedures and Nomenclature HCPCS Medical Supplies- DME Orthotic and Prosthetic Devices Combination HCPCS and CPT4 Physician services- Lab tests Radiologic Procedures- OT/PT services Hearing/vision services- transportation

37. Sources of Information ICD9: Government Printing Office 202-512-1800 CPT4: American Medical Association HCPCS http://www.hcfa.gov/medicare/hcpcs.htm

38. Sources of Information Code on Dental Procedures: American Dental Association 1-800-947-4746 NDC http://www.fda.gov/cder/ndc/index.htm