Obama to Name Kathleen Sebelius to HHS

Kansas Governor Kathleen Sebelius will be tapped on Monday to be Secretary of Health and Human Services (HHS).

Barack Obama will highlight her bipartisanship, executive experience and independent-minded insurance experience. Unlike the previous nominee, Sebelius has not worked in Washington which will test her capacity to guide plans to overhaul the US health care system. And unlike the previous nominee, Sebelius will be nominated for Secretary of HHS only and not the health care role within the White House which is thought to be reserved for someone with the Washington background needed to drive Obama's health care legislation.

Sebelius has a Masters in Public Administration at the University of Kansas. For 8 years she served as a Kansas legislator. In 1994 she won election as Insurance Commissioner where she worked for the next 8 years. Sebelius developed a reputation for staying independent from the insurance companies and even halted a planned merger of the powerful Kansas Blue Cross and Blue Shield.

In 2002 Sebelius became the Democractic governor of a very red state. Her bipartisan appeal contributed to her re-election in 2006 by a wide margin. She remains a highly popular governor.

ICD-10: No Time to Relax

Final rules were published on January 16 for ICD-10 codes and the related electronic transactions. The relaxed compliance dates offer no reason to relax.

ICD-10

The health care industry will switch to ICD-10 on October 1, 2013. Encounters and discharges occurring before October 1, 2013 will use ICD-9, and those occurring on or after that date will use ICD-10. The final rule suggests that compliance activities (gap analysis, design, development, internal testing) should begin in January 2011.

The fundamental driver for ICD-10 is financial - - the inability for ICD-9 to support the growing number of high-priced medical procedures. For more on this, see "More Painful than an Insect Bite? ICD-10 Cost-Benefit for Healthcare Providers".

ICD-10 will be used where ICD-9 is used today. More specifically, ICD-10-CM (Clinical Modification) will be used for diagnosis coding and ICD-10-PCS (Procedure Coding System) will be used for inpatient hospital procedure coding. CPT and HCPCS codes will continue to be used in an ambulatory setting.

According to HHS, ICD-10 will:

• "Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;
• Support comprehensive reporting of quality data;
• Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide; and
• Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes..."

In a bit of a stretch, HHS contends that "ICD-10 will also improve claims processing and payment, and, through the use of health care technology that utilizes ICD-10, assist health care practitioners in making treatment decisions by more precisely matching diagnoses and procedures to the appropriate code. For example:

• Pressure ulcers are a common condition in elderly Medicare beneficiaries with chronic illnesses. Under the current ICD-9-CM system, health care practitioners can identify the severity or location of a pressure ulcer but the coding system cannot link those elements if the patient has more than one ulcer. Under a single ICD-10 code, a patient’s medical history will identify the severity and location of each pressure ulcer;
• ICD-9 has only one code for angioplasty, the widely used procedure for widening a narrowed or obstructed blood vessel. ICD-10 provides 1,170 coded descriptions, with a granularity that pinpoints the location of the blockage and the device used for each patient;
• ICD-9 codes do not provide sufficient detail to distinguish whether a condition occurred on a patient’s left or right side. ICD-10 will improve care by providing that basic type of information; and
• ICD-9 includes separate codes for medication errors and other external causes of injury, which are reported separately from the actual condition. Under ICD-10, information about medication errors and external causes of injury will be embedded in the code for the condition. Therefore a single, more informative code will provide a ready source of information to help medical professionals prevent medical errors and improve quality of care."

PQRI and other quality measures will also be affected by these standards. CMS makes it clear in the final rule that there will be ICD-10 updates to the quality measures in regulations to follow.

CDC and CMS are good sources of information on ICD-10-CM and ICD-10-PCS guidelines and cross-mappings, even including a mapping from ICD-10 (international) to ICD-10 (U.S.).

Electronic Transactions

The HIPAA electronic transaction standards also get a refresh with a compliance date of January 1, 2012. The 5010 version supports the ICD-10 code sets and applies to claims, remittance, eligibility, referrals/authorization, and other transactions . In addition to ICD-10 support, 5010 changes "include structural, front matter, technical, and data content improvements... (and) addresses ... unmet business needs including ... providing on institutional claims an indicator for conditions that were 'present on admission.' " The target date for covered entities to complete internal testing is December 2010, so testing among trading partners can begin January 2011.

The NCPDP standard for electronic pharmacy-related transactions is upgraded to version D.0 to better support Medicare's Part D prescription drug benefit claims processing, including coordination of benefits. The compliance data is also January 1, 2012. In addition, Version D.0:

• "Provides more complete eligibility information for Medicare Part D and other insurance coverage;
• Better identifies patient responsibility, benefits stages, and coverage gaps on secondary claims; and
• Facilitates the billing of multiple ingredients in processing claims for compounded drugs."
  

A Medication subrogation standard is adopted with the same compliance date as the other transactions for all but small health plans (the subrogation process allows Medicaid to recover payments from a payer that has primary financial responsibility).

Costs and Benefits

CMS estimated costs and benefits as follows (click on the picture to expand):

News Analysis

Eight years after the original HIPAA rule was issued, use of electronic transactions remains stubbornly and abysmally low (see Healthcare's Indefensible Administrative Costs). This suggests a major industry challenge in updating the electronic transactions and preparing for cutover to ICD-10.

Systems changes will be required across the health system to accommodate the coordinated cutover of the electronic transactions. Then, on a single date for the industry, process and system changes will go into effect to support two code sets (ICD-9 for events before the date and ICD-10 after). Many systems will require iterative major upgrades to effectively support these requirements, each with full deployment to their customer base in fairly tight timeframes.

This suggests a level of execution and capability that has only happened once before. That event was Y2K - - which caused one CEO to ruefully recount how he gave his CIO an unlimited budget, yet the CIO managed to exceed it. And which will now cause healthcare technology companies to ponder how they avoid a repeat of the sales collapse that immediately followed.

The Lighter Side of NCVHS

So who says that the complex and important work of the National Committee on Vital and Health Statistics (NCVHS) can’t also be light-hearted?

The following are transcript excerpts from the NCVHS full committee meeting on September 16-17, 2008. The award for the best one-liner goes to Larry Green, University of Colorado.


MR. REYNOLDS: … I would ask that if you have any conflicts of interest related to any issues coming before us today would you please so publicly indicate during your introduction. I have no conflicts.

** A number of other participants introduce themselves having no conflicts. **

MS. MCCALL: Carol McCall. I am with Humana, member of the committee, no known conflicts.

MR. HOUSTON: No known conflicts, you sound like an attorney. John Houston, University of Pittsburg, and member of the committee, no known conflicts either.

.....

DR. MIDDLETON: I think we are allowed three newbie questions right?

MR. REYNOLDS: No, you are not new anymore Blackford. If you go back and read the early minutes of today's meeting you are no longer new.

.....

MS. TRUDEL: … Both of those standards underwent significant revision as a result of the first round of pilots and we are very much hoping that both or at least one of them will be in a place where we can move forward.

MR. REYNOLDS: Let me just volunteer a comment: Hot dog that is great!

..…

DR. TANG: The other piece is data. … Data might be the third dimension to this matrix and I think it will relate very tightly to the data stewardship presentation … How does NCVHS with it's policy focus and data middle name fit into this matrix? …

MR. REYNOLDS: Did all of you notice that since Paul's part of the committee that he is now given the committee a middle name? I am not sure we have adopted that yet, but we have noted that the comment was made.

..…

MR. WALLEN: … you've beaten the PHR and the EHR to death, and so I won't go into any of that.

MR. BLAIR: But you noticed they're not dead yet.

..…

DR. GREEN: I'd like to ask a two-part question. One is in this area, the personal health record, what's going on in mental health? Secondly, with your example, when you are sequestering information that say relates to mental health, depression, you don't know you're depressed, the way you use SNOMED to search the record for this, could you say a little bit more about how you actually managed to succeed in sequestering the fact that this person has depression given that that word might appear in a lot of places?

DR. CARR: Can you speak up, Larry?

MS. GREENBERG: Could you speak up a bit?

DR. GREEN: I could, but I'm finished.

..…

DR. FRANCIS: … it's actually possible to identify some categories of sensitive information, and do it in a quite fine-grained way which I think is nifty. …

MS. GREENBERG: “Nifty” is in fact the correct technical term.

..…

DR. CARR: … the next one is data integrity. I know that's a word that Bill always struggles with, but it's really a statistical concept not an ethical one.

..…

DR. STEINDEL: … we need the one-page picture, and we ought to look at it that way.

MS. MCCALL: I'm in just ecstatic agreement.

..…

** The meeting continues the next morning with another round of introductions. Everyone says “no conflicts”, until: **

MR. HOUSTON: John Houston, University of Pittsburgh Medical Center, member of the Committee, and no conflicts, no known conflicts.

MS. MCCALL: In his subconscious there are many. Carol McCall, Humana, member of the Committee, no conflicts.

ONC roadmap - On the road to Abilene?

Today, Rob Kolodner, Office of the National Coordinator (ONC) for Health Information Technology, released ONC's strategic plan for the next 5 years.

The ONC synopsis focuses on 2 goals: Patient-focused Health Care and Population Health. ONC defines Patient-focused Health Care as "enabling the transformation to higher quality, more cost-efficient, patient-focused health care through electronic health information access and use by care providers, and by patients and their designees." Population Health "enables the appropriate, authorized, and timely access and use of electronic health information to benefit public health, biomedical research, quality improvement, and emergency preparedness." Themes of privacy and security, interoperability, adoption, and collaborative governance apply to each of these goals.

Critical mass in the use of CPR's combined with exchange of health information between providers and access to information by patients will be facilitated by the Nationwide Health Information Network.

ONC defined the criteria for success as:

Health IT becomes common and expected in health care delivery nationwide for all communities, including those caring for underserved or disadvantaged populations;

Your health information is available to you and those caring for you so that you receive safe, high quality, and efficient care;

You will be able to use information to better determine what choices are right for you with respect to your health and care; and

You trust your health information can be used, in a secure environment, without compromising your privacy, to assess and improve the health in your community, measure and make available the quality of care being provided, and support advances in medical knowledge through research.

Is this The road to Abilene? Or the road to a better health system? Will health systems revolt over the massive investments needed to deploy enterprise systems, where many of the benefits don't accrue to the providers? Or can investments and benefits be better aligned? And will Health Information Organizations be sustainable?

There is solid momentum and engagement by HHS, healthcare providers, and healthcare IT companies. As an example of the energy level, CCHIT just reported that they had over twice as many volunteers as available roles in unpaid positions. There's clear value to patients and public health if these goals can be achieved.

Certification Commission for Healthcare Information Technology (CCHIT) chair Mark Leavitt has talked about the critical need to address the mis-aligned costs and benefits in the health system. Leavitt positions CCHIT as the enabler to a more virtuous cycle. The critical ingredient still missing in this equation is provider incentives of sufficient substance to close this loop. Whether this is the Road to Abilene or not, depends on whether providers can buy in at a reasonable sustainable cost.

Making Sense of National Healthcare IT

Avance Health Analysis

Recent news of HITSP's submissions to The Community (AHIC) June meeting, prompted a reader to ask: How do the various national healthcare initiatives (AHIC, HITSP, HHS, CCHIT and NHIN) fit together?

Is the relationship between these organizations Rube Goldberg-esque? Or is there some more coherent design?



The mission of American Health Information Community ("The Community" or AHIC) is to provide "input and recommendations to the Department of Health and Human Services (HHS) on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected in a smooth, market-led way." AHIC is presently reorganizing itself to ensure its viability beyond the term of the current administration, by establishing "AHIC 2.0" as a sustainable public-private organization. AHIC is the focal point for guidance to HHS on priorities for interoperability and develops the use cases for these priorities.

The Healthcare Information Technology Standards Panel (HITSP) mission is to "harmonize and integrate standards that will meet clinical and business needs for sharing information among organizations and systems." HITSP takes its guidance on priorities and use case definition from AHIC and proposes standards (like those to be presented today at the AHIC June 2008 meeting) to the HHS Secretary.

The HHS Secretary can accept the recommendations which starts the clock on a one year cycle of testing and implementation. At the end of this cycle, the HHS Secretary can choose to "recognize" these standards. Once standards are recognized, by Executive Order, they are incorporated into new Federal Systems and Healthcare Contracts.

Recognition of these standards also serves as input to the Certification Commission for Healthcare Information Technology (CCHIT). CCHIT is a recognized certification body (RCB) for Electronic Health Records (EHR) with the goal of accelerating EHR adoption. CCHIT establishes its roadmap and criteria for Electronic Health Records based in part on the recognized standards from the HHS Secretary.

These recognized interoperability standards are also incorporated by the Nationwide Health Information Network (NHIN), a network of networks promoting Health Information Exchange.

HITSP keeps on rolling

Chair of HITSP, Dr. John Halamka, announced that he will be presenting 4 new harmonized interoperability specifications to Health Human Services Secretary Leavitt and the American Health Information Community (AHIC) at the June 3 AHIC meeting. These specifications focus on Medication Management.





These specifications and definitions include:

Medication Dispensing Status provides a medication prescriber the dispensing status of an ordered prescription (dispensed, partially dispensed, not dispensed).

Medication Orders defines the transactions between prescribers (who write prescriptions) and dispensers (who fill prescriptions)

Medication Formulary and Benefits Information performs two tasks: 1) performs eligibility check for a specific patient's pharmacy benefits and 2) obtains the medication formulary and benefit information.

Patient Generic Health Plan Eligibility Verification provides the status of a health plan covering the individual, along with details regarding patient liability for deductible, co-pay and co-insurance amounts for a defined base set of generic benefits or services. The base set of benefits includes coverage status and patient liability for medical, chiropractic, dental, hospital inpatient, hospital outpatient, emergency, professional physician office visit, pharmacy and vision services that are included in the patient's generic health plan benefit.

Dr. Halamka announced he will also be presenting a technical note on Document Reliable Interchange to support a secure communication of a clinical document over a network.