Standards

Thomas Sullivan MD.

HSCI 709

Standards – Why have them?

Successful data exchange

Not vendor, application or platform dependent

Move data across enterprises

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

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

Standards

Agreement on how to implement technologies

Proprietary Standards

Consensus Standards

Standards Committees

American Society for Testing and MaterialsASTM

American National Standards InstituteANSI

National Institute for Science and TechnologyNIST

International Standards OrganizationISO - the 7 layer cake

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

Accepted Standards

HL7

ICD9-CM

CPT-4

HCPCS

NDC

DICOM

HL7

Applies toInpatient data

ADT (admission, discharge, transfer)

Orders

Lab measurements

Referrals

Many others

HL7 v. 2.3.X

Character based

Limited to ISO layer 7

Lower layers not specified and left to vendors ( ? Good)

HL7

Messages composed of segments

Segments composed of predetermined sequence of fields

Cannot insert different data elements than those specified

Message construction very limited

HL7 (Health Level 7)

Standard for health care records and Medical Data Interchange

Sanctioned by ANSIEurope has a different standard

Current version 2.3.XVersion 3.0 radically different

Only an application layer standard

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 acceptedV. 2.2 is about to be de-certified

Integrates DICOM at the information model level

DICOM

Digital Imaging and Communications in Medicine

An international standard

The standard for the multimedia medical record

Object oriented

Radiol, Path, Derm, EKG etc.

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

Interoperability between Standards

How do all the standards work together?

A B C

Three different ways

Tunneling / Encapsulation

A B C

Data is a payload existing at A and C but moving through B in a way that B understands

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 differsRisk compromising the data

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

HIPAA

An example of using standards

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

Adopt standards for

Health claims and encounter information

Enrollment/disenrollment in health plan

Eligibility in health plan

Payment and remittance advice

Premium payments

Adopt standards for

Health claim status

Referral certification and authorization

Coordination of benefits

Standards to be adopted later

First report of injury

Claims attachments

Effective and Compliance Dates

Final rule published August 2000

Effective date 60 days later: October 2000

Compliance 2 years later: October 20022003 for small health plans

How does Transaction Code Set Work

Each business group of data=Transaction SetEach transaction set contains groups of logically related data in units = segments

N4 segment has demographic info

Transaction set has multiple segmentSequence of elements within 1 segment is specified by ASCI X12 standards

ASCI ASC X12N 837

Health care claims: Professional…CLP*12345*1*100*40*40*12….

12345=Provider claim ID number1=paid as primary100 = amount billed40 = amount paid40 = patient responsibility12 = PPO

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

Chosen Standards

ANSI ASC X12N version 4010For all but pharmaceutical transactions

NCPDPFor retail pharmacy transactions

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

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

Sources of Information

ASC X12 standardhttp://www.wpc-edi.com/hipaa

NCPDPhttp://www.ncpdp.org

Code Set Standard

HIPAA

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

Adopted Code SetsICD9-CM, Vol 1 & 2

Diagnosis - InjuriesImpairments - Other health related prob.Causes of injury, disease, impairment

ICD9-CM Vol 3 for hospital inpatientsPrevention - DiagnosisTreatment - Management

NDCDrugs - Biologics

Adopted Code Sets

Code on Dental Procedures and Nomenclature

HCPCSMedical Supplies - DME

Orthotic and Prosthetic Devices

Combination HCPCS and CPT4Physician services - Lab tests

Radiologic Procedures - OT/PT services

Hearing/vision services - transportation

Sources of Information

ICD9: Government Printing Office202-512-1800

CPT4: American Medical Association

HCPCShttp://www.hcfa.gov/medicare/hcpcs.htm

Sources of Information

Code on Dental Procedures: American Dental Association

1-800-947-4746

NDChttp://www.fda.gov/cder/ndc/index.htm