Thursday, January 21, 2010

Attaching Backwards and Forwards

Claims Attachments
I met with the Claims Attachments workgroup today.  This is one of the groups that have made CDA what it is today, and they didn't even know it.  This group has been working for more than 10 years to get Attachments part of US regulation.  Their work was done on time.  The specifications were ready shortly after CDA Release 1.0 became a standard more than 8 years ago, and they were updated again about 4 years ago to support CDA Release 2.0.  We've simply been waiting for the powers that be to finish the regulation required by the HIPAA laws.

It is because of the work of this group that we have the narrative structures and codes for more than 10 different kinds clinical documents already specified when HL7 and IHE began the work on CDA Release 2.0 Implementation guides 4 years ago.  Their efforts contribute the standardization of Discharge Summaries, Referrals, Consultations, History and Physicals, Laboratory Reports, ED Reports, Nursing Notes, Operative Notes, Procedure Notes, Progress Notes, and yes, even the CCD.  These have appeared or soon will appear in numerous implementation guides from HL7, IHE and ANSI/HITSP.

Even though the attachments regulation has never been finished, implementation guides that are compliant "computer-decision variants" (otherwise known as Level 3 documents) of the Laboratory claims attachment implementation guide are being exchanged today in at least three different states (one state-wide), and similar documents are being exchanged world wide!  The same is true for human decision variants (Level 1 and 2) for at least three different document types in the Clinical Reports guide.  The only thing holding Clinical Reports back from being "computer-decision variants" are differences between the attachment requirements for use of billing codes and minor structural variances from the CCD work that followed after those guides were done.

Continuing the spirit of recognition from yesterday, these are results to be very proud of.  I'd like to commend the committee on a job very well done.  In the ten years since your inception, you've very quitely and very much in the backgroup changed the healthcare landscape.  The tables in the AIS guides of LOINC codes for different document types are the very same tables that I and others used in HL7 and IHE in creating our very first (and second and third) implementation guides.

As it stands today, the most recent proposed regulation is two years old, and there is no known date when it will be final.  The Health Reform bill now in jeapardy has provisions in to to bring this back in both the House and Senate versions (with different dates).  My hope is that some useful form of the Healthcare reform bill passes, and that it does set forth a reasonable deadline for the Claims Attachments regulation that many of us have been waiting for.

What I recommended to this group for a direction to move forward in was to revise the Clinical Reports Attachment Implementation Guide to:
  1. Reference existing specifications from ANSI/HITSP, IHE and HL7, and as the basis for the reports that can be exchanged for either the Human Decision Variant (Level 1 and 2) or Computer Decision Variant (Level 3)
  2. Reference the templates in the CCD specification for use with the Computer Decision Variant
  3. Document how to add billing codes to the clinical content in a way that will allow existing documents used in clinical exchanges to be created so that they
    1. Can easily have billing codes added to them (using the translation code mechanism of CDA)
    2. Or can be easily produced in a way that they can be used both for clinical and administrative purposes.
However, to accomplish this goal, the Claims Attachment Workgroup will need the help of EHR Vendors.  The group is currently composed of mostly payers and a few providers, with little EHR vendor representation.  Given where we stand on Healthcare reform and proposed timing, the time to start on this project is now.  Attachments needs to take advantage of all of the work that is being done for meaningful use, and needs to have new guides ready for a new regulation should Healthcare reform pass.  Please consider sharing your time with this workgroup in HL7. 

I know we all have our heads wrapped around the impacts of the meaningful use NPRM and IFR, and the pending certification NPRM.  However, we also need to be looking forward to the future when meaningful use is real.  I'd very much like to see alignment of CDA implementation guides across both the administrative and clinical spectrum.  You may feel like its too soon to consider now, but I know that if we don't think about it, we'll certainly be scrambling to deal with it later.  I've been there and done that several times, and I'd rather not have a year like the last one where everything that needs to be done with standards is needed yesterday.

We also discussed issues outside of the scope of attachment content, but certainly of interest to this community.  Several people expressed interest in exploring how healthcare information exchanges could readily support the exchange of attachments between payers and providers instead of, or in addition to traditional models using X12N transactions.  There are a lot of ways this could be made to work, and it could very well bring together some very powerful synergies between payers, providers and patients.  I'm still thinking about this one.


P.S.  I haven't forgotten about the μ ITS, I'm still thinking about the details.


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