PRIORITIZATION OF STATE ENCOUNTER DATA NEEDS FOR PUBLIC HEALTH AND RESEARCH APPLICATIONS

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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)

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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

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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
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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

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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)

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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

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State HIPAA QuestionsFrom 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

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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

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NON-X12N AND HIGH-PRIORITY DATA ELEMENTS
COLLECTED BY STATESBoldadded after study began
PATIENT DEMOGRAPHICS
CLINICAL
FINANCIAL
Race and Ethnicity County Code Marital
Status Living Arrangement Education Occupation
E-coding (number) Lab/radiology Pharmacy Gestation
al. Age Birthweight Admitting vitals
LOS Outlier DRG/MDC Admit/Discharge Time Payer
Type Quarter of Discharge Total provider paid
amt Observation stays Patient consent field Time
in OR
PATIENT STATUS
LINKAGE
Unique patient ID Physician ID Mothers Med Record
EMS Run
Present on Admission Flag Severity
Score DNR Functional Status
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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

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HCUP InventoryDo You Collect Non-Billing Data
Elements?N42 states responding
1999 Inventory of 1998 State Data Availability
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NAHDO ADMINISTRATIVE SIMPLIFICATION SURVEY
1998N33 state agencies responding
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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?

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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?

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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)

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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?

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Category 3 Unresolved IssuesData 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

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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?

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Preliminary Recommendationsand PHDSC Actions
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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

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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

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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

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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?

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Category 1 State Fields Present in X12N
Implementation GuideFor Discussion As proxy
for other demographic data (e.g. marital status,
living arrangement?)
Patients Relationship to Subscriber Required
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Category 2 Priority Data ElementsRecommended 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

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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?

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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

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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

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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

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No RecommendationEducate States
Education Technical Assistance Other?
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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

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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

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The Future