Presented at the HIPAA COW 2008 Fall Conference Sheboygan, WI – September 19, 2008

1. From National Health IT to StateUniform Companion GuidesRealities and Opportunities to Make Standards Finally Work Presented at the HIPAA COW 2008 Fall Conference Sheboygan, WI – September 19, 2008 Walter G. Suarez, MD, MPH President and CEO - Institute for HIPAA/HIT Education and Research Member, National Committee on Vital and Health Statistics (NCVHS) Member, Board of Directors, Health Information Technology Standards Panel (HITSP)

2. Outline • Why are we here today? • Core Health IT and HIE Concepts • Business Case for NHIN and NHIEs • A National Coordinated Agenda • Where Things Stand Today • Transitioning to State Realities: The Minnesota Statewide Uniform Companion Guide Development Project • Take away messages

3. Why are we here? Some Critical Health Needs and the National HIT Agenda • Avoidance of medical errors • Up to 98,000 avoidable annual deaths due to medical errors • Improvement of resource utilization • Up to $300B spent annually on treatments with no health yield • Acceleration of knowledge diffusion • 17 years for evidence to be integrated into practice • Reduction of variability in healthcare delivery and access • Access to specialty care highly dependent on geography • Empowerment of the consumer • Capitalize on growing consumer trend of active health management • Strengthening of data privacy and protection • HIPAA becomes reality • Promotion of public health and preparedness • Surveillance is fragmented, and importance to homeland security brings heightened awareness

4. Core Concepts

5. Health IT and HIE - Leading Transformation Factors • Electronic Health Records • Personal Health Records • Interoperable Standards • Health Information Infrastructure • Population Health Infrastructure • Robust Security and Privacy And… • A business reason that supports doing all this!

6. What is “Interoperability”? “The ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively and consistently, and to use the information that has been exchanged.” Source: National Alliance for Health Information Technology, July 2005; “Consensus Conventions for the Use of Key HIT Terms” Project – ONC/HHS, 2008

7. “Record” Terms Source: National Alliance for Health Information Technology, Report to the Office of the National Coordinator for Health Information Technology – Defining Key Health Information Technology Terms, April 28, 2008

8. “Network” Terms Source: National Alliance for Health Information Technology, Report to the Office of the National Coordinator for Health Information Technology – Defining Key Health Information Technology Terms, April 28, 2008

9. RHIO and HIE – Distinguishing and Common Characteristics

10. The Business Case for Regional and Nationwide HIE Investment

11. The National Health IT Strategy

12. Federal Government Collaborations Among Health IT Initiatives

13. ONC-Coordinated Federal Health IT Strategic Plan 2008-2012

14. ONC Health IT Strategic Plan (2008-2012)

15. National HIT Agenda and Health Information Exchange • Priorities • American Health Information Community (AHIC) • Business needs and priorities • Use Cases • Networking • NHIN - network of networks • Architecture specifications • Standards • Healthcare Information Technology Standards Panel (HITSP) • Recognized standards Agenda • Policies • State laws and regulations – • State Alliance for e-Health • State-level Health Information Exchange • Health Information Security and Policy Collaboration (HISPC) • Certification • Certification Commission For Healthcare Information (CCHIT) Technology • Criteria development • Testing

16. Setting Priorities - AHIC • Recommendations to Secretary on overall policy directions related to Health IT • Definition of priority areas (breakthroughs) • Development of Use Cases for harmonization of standards • Transitioning to AHIC 2.0 http://www.ahicsuccessor.org

17. Networking – NHIN and the NHIEs • NHIN: the nationwide “Network of Networks”… of Networks • Framework for health information network service providers • Interconnecting NHIEs • Business/Technical Issues: Standards, Sustainability, Security • NHIEs: Local, state, regional HIEs interoperable with NHIN http://www.hhs.gov/healthit/healthnetwork/background/

18. Networking – NHIN and the NHIEs • Phase 1 (2007) – Prototyping • 4 Consortia • Core elements of NHIN • Phase 2 (2008) – Trial Implementations • 15+ sites • Develop the NHIN HIE Specs • Phase 3 (2009) - TBD http://www.hhs.gov/healthit/healthnetwork/background/

20. Where are States with respect to HIEs? Sources: Health Information Security and Privacy Collaborative (HISPC); State-level Health Information Exchange (SLHIE); January, 2008

21. Policies - HISPC • Phase 1 (2006-2007) • 34 Teams (33 State, Puerto Rico) • 1) Assessments of privacy/security variations; 2) Analysis of solutions; 3) Develop implementation plans • Phase 2 (July-Dec 2007) • Each team to implement a foundational component of their implementation plans • Phase 3 (2008-2009) • 7 Multistate Collaboratives developing common, replicable multistate solutions http://healthit.ahrq.gov/privacyandsecurity

22. Policies – State-level HIE • Funded by ONC • Develop reports and tools: • State-level HIE Development Workbook • RHIO Governance roles • Consensus model HIE policies http://www.staterhio.org

23. Policies – State Alliance for eHealth • National Governors Association’s initiative supported by ONC • Initial work (2006/2007) done through 3 Taskforces: • Health Information Protection • Health Care Practices • Health Information Communications and Data Exchange • Reconfigured Taskforces to focus on: • Privacy and Security • Public Programs Implementation • Taskforce reports provide severalrecommendations to states on privacy, security, Public program (i.e. Medicaid) roles in HIEs, need for harmonizing cross-state regulations on medical practice http://www.nga.org

24. Standards – The Health Information Technology Standards Panel (HITSP)

27. HITSP Information Resources Please take a copy of the introductory CD-ROM available at this kiosk or visit our website (www.hitsp.org) for a downloadable copy of the CD’s content Also available on www.hitsp.org News, organizational details and information on upcoming meetings HITSP Public Document Library Interoperability Specifications (ISs) and Executive Summaries Use Cases HITSP Webinars (Free!)

28. Standards in the National HIT Agenda American Health Information Community Priorities (AHIC) Healthcare Information Technology Standards Panel (HITSP) Secretary Currently “Accepted” 60 (2007) Interoperability Use Cases Specifications One Year - Testing and Implementation Certification Commission for Healthcare Information Technology (CCHIT) (Stark and Anti-kickback) Secretary Currently “Recognized” 52 (2006) Verified Federal Systems and Healthcare Contracts (Executive Order 13410) Use Nationwide Health Information Network (NHIN)

29. Certification – The Certification Commission for Health Information Technology (CCHIT)

30. CCHIT – Certification Commission for Health Information Technology CCHIT SCOPE OF WORK

31. CCHIT – Certification Commission for Health Information Technology • Results to-date: • A total of nine inpatient EHR products have been certified, representing 36% of the inpatient EHR vendors in the market • Four additional inpatient EHR product applications were received recently, bringing total to 50% of the inpatient EHR vendor market • Over 60 ambulatory EHR products representing more than 35% of the outpatient EHR vendors in the market • 14 additional ambulatory EHR product applications recently received, bringing total to close to 50% of the inpatient EHR • Moving into specialty areas (i.e., cardiovascular, child health), network services

32. NHIN – Completing the Cycle

33. Transitioning to State Realities: The Minnesota Statewide Uniform Companion Guide Development Project

34. Background • In 2007 the MN Legislature passed a law amending the “MN Health Care Administrative Simplification Act of 1994” (MN Statutes §62J.50 -§62J.61) and requiring the development, adoption and use of state uniform companion guides • Part of Minnesota’s commitment to the increased use of health IT for both administrative and clinical activities • Initial set of transactions subject to the new law includes Claims (837P, 837I, 837D, NCPDP), Claim Payment (835), and Eligibility (270/271) • State law covers allhealth care providers and group purchasers (health plans, Medicaid, employers and others) doing business in the state; the law requires them to conduct these transactions electronically and use the standard companion guides

35. Background • Commissioner of Health, in consultation with the MN Administrative Uniformity Committee, is charged with developing state uniform companion guides • Companion guides are to be based on billing and coding rules from the Medicare program, but can depart from them based on state health care industry’s consensus • Companion guides will be required to be used, along with the HIPAA Implementation Guides, when conducting any of the transactions they cover

36. The Minnesota Uniform Companion Guide Development Project Summary of State Law

37. Summary of State Law(MN Statutes § 62J.536) • Part 1 - Requirements for all health care providers and group purchasers to implement uniform electronic transactions • All group purchasers and health care providers in MN must exchange claims and eligibility information electronically, using the transaction standards prescribed by HIPAA and the companion guides and timelines established by the state law • Group purchasers may not impose any fee on providers for the use of the transactions prescribed in this legislation • Direct data entry, web-based methodology allowed, so long as it is consistent with data content component of HIPAA implementation guides and MN uniform companion guides

38. Summary of State Law(MN Statutes § 62J.536) • By January 15, 2009, ALL health care providers and group purchasers in MN must submit/accept the HIPAA electronic eligibility transaction (270/271) • By July 15, 2009, ALL health care providers and group purchasers in MN must submit/accept the HIPAA electronic health care claim/encounter information transaction prescribed by HIPAA (837s, NCPDP) • By December 15, 2009, ALL health care providers and group purchasers in MN must submit/accept the electronic health care payment/RA transaction prescribed by HIPAA (835)

39. Summary of State Law(MN Statutes § 62J.536) • Part 2 - Requirement for the development and use of single, uniform, statewide companion guides for the identified transactions: • Each named transaction must use a single, uniform companion guide to the HIPAA implementation guides statewide • Companion guides to be developed as follows: • Commissioner of Health, in consultation with MN-ACU develops companion guides at least 12 months prior to the timelines required for transaction • Commissioner of Health issues a Notice of Proposed Rulemaking requesting industry comments on ‘draft’ companion guides • Commissioner of Health promulgates rules establishing and requiring group purchasers and health care providers in MN to use the uniform companion guides

40. Summary of State Law(MN Statutes § 62J.536) • No group purchaser or health care provider may add or modify the companion guides through their own companion guides or other requirements • Commissioner shall not require data content that is not essential to accomplishing the purpose of the transaction • Health care providers also includes dentists, chiropractors, nursing homes, boarding care homes and home care providers • Other ‘group purchasers’ subject to law includes Workers Compensation and medical component of Auto Insurance

41. What are the MN Uniform Companion Guides Doing? • Eliminate proprietary companion guides • Reduce/eliminate Situational Variability of loops, segments and data elements in the HIPAA Implementation Guides • Reduce/eliminate Interpretative Ambiguity of loops, segment and data elements in the HIPAA implementation Guides • Reduce and standardize the codes used in data elements, within a code set • Identity and define loops, segments and data elements that are not considered for processing by entities in Minnesota

42. What the MN Uniform Companion Guides are NOT Doing? • Replace HIPAA IGs • Make implementation inconsistent and incompatible with, or in violation of the HIPAA Implementation Guides • What is Required by HIPAA IG is Required by MN CG • What is Not Used in HIPAA IG is Not Used in MN CG • What is Situational in HIPAA IG is further defined in MN CG • Disclaimer from the Guide: “… the [companion guide] supplements, but does not contradict, disagree, oppose, or otherwise modify the HIPAA Implementation Guide in a manner that will make its implementation by users to be out of compliance.”

43. Why is this Project Important? • Multiplicity of companion guides and payer-specific requirements • Providers need to customize transactions on a payer-by-payer basis • Inconsistencies in transaction requirements significantly increases administrative burden • Quality of care delivered to consumers is being affected

44. The Minnesota Uniform Companion Guide Development Project Understanding Companion Guides

45. What are Companion Guides? • A Companion Guide is a document that clarifies, supplements and further defines specific data content requirements contained in the Implementation Guides established for each of the HIPAA transactions • Generally, companion guides cover four core areas: • Define transaction instructions (EDI information) between trading partners • Further define requirement of loops, segments, data elements • Further define data element content • Further define data coding used in transaction

46. 1000s of Companion Guides… While there is ONE HIPAA Implementation Guide, there are 1000s of companion guides developed by each payer in the market….

47. The Minnesota Uniform Companion Guide Development Project Process for DevelopingMN Uniform Companion Guides

48. Process for Developing MN Uniform Companion Guides • Use MN-AUC Committee and Workgroup Structure • Establish Companion Guide Development Teams • Develop Principles and Guidance Document • Develop Consensus Building Approach and Decision Making Process Document • Develop Standard Master Template Companion Guide Document • Establish Project Workplan and Timeline

49. Cycle for Companion Guide Development • Draft of Companion Guide is prepared • Notice proposing adoption published - 30-day comment period • Comments are addressed, changes made to guide • Notice adopting guide is published • A one-year period of transition for compliance starts • Six-month into process, technical review is done • Revisions to adopted companion guide are published for public comments • Notice adopting final revised companion guide for compliance is published • Compliance starts • Annual review and update…

50. www.health.state.mn.us/auc