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Standards

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

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Standards

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  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 • Physical (wire from box to wall) • Data link • Network • Transport • Session • Presentation • 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

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