standards thomas sullivan md. hsci 709. standards – why have them? successful data exchange not...
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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 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
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
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
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
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