2013 WEDI Report

“The Right Information, To The Right Place, At The Right Time”
F O U N D AT I O N
W O R K G R O U P F O R E L E C T R O N I C D ATA I N T E R C H A N G E
2013 WEDI REPORT
Table of Contents
3
2013 WEDI Report Founding Sponsors
4
Acknowledgements
8
The Health IT Challenge
10
Executive Summary
14
The 2013 WEDI Report
16
Recommendations
16
Patient Engagement
21
Innovative Encounter Models
26
Data Harmonization & Exchange
32
Payment Models
35
Conclusion
36
Addendum 1: 2013 WEDI Report Action Steps
41
Addendum 2: Workgroup Members
46
Addendum 3: 1993 WEDI Report as a Roadmap to 2013
57
Addendum 4: Building the U.S. Healthcare IT Infrastructure: 1993-2013
75
Addendum 5: The 2013 WEDI Report Process
78
Addendum 6: Overarching Themes
82
Endnotes
2013 WEDI REPORT
2013 WEDI Report Founding Sponsors
2013 WEDI REPORT
2013 WEDI Report Executive Steering Committee Members
The Honorable Louis W. Sullivan, M.D.
Honorary Chair
2013 WEDI Report Executive Steering
Committee
Doug Fridsma, M.D., Ph.D.
Director
Office of Standards and Interoperability and
Chief Scientist
Office of the National Coordinator (ONC)
U.S. Department of Health and Human
Services (HHS)
John P. Glaser, Ph.D.
Chief Executive Officer
Health Services, Siemens Healthcare
Lynne Thomas Gordon, MBA, RHIA,
FACHE, CAE, FAHIMA
Chief Executive Officer
American Health Information Management
Association (AHIMA)
Mary Grealy
President
Healthcare Leadership Council (HLC)
Kari Hedges
Vice President
National Programs, Blue Cross Blue Shield
Association
Karen Ignagni
President and Chief Executive Officer
America’s Health Insurance Plans (AHIP)
Charles N. Kahn, III
President and Chief Executive Officer
Federation of American Hospitals (FAH)
Farzad Mostashari, M.D., Sc.M.
National Coordinator
Office of National Coordinator
U.S. Department of Health and Human
Services (HHS)
Matt Salo
Executive Director
National Association of Medicaid Directors
(NAMD)
Steven J. Stack, M.D.
Chair, Board of Trustees
American Medical Association
Robert Tagalicod
Director
Office of E-Health Standards and Services
(OESS)
U.S. Department of Health and Human
Services (HHS)
Susan L. Turney, M.D., M.S., FACMPE,
FACP
President and Chief Executive Officer
Medical Group Management Association
(MGMA)
Bernard J. Tyson
Chief Executive Officer and Incoming
Chairman
Kaiser Permanente
Mark W. Jurkovich, D.D.S.
Practicing Dentist
ADA Member Representative
American Dental Association (ADA)
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2013 WEDI Report Advisors
Lee Barrett
Executive Director
Electronic Healthcare Network Accreditation
Commission (EHNAC)
Gerard Grundler
Managing Principal, Healthcare IT
Services
Verizon
William R. Braithwaite, M.D., Ph.D.
Braithwaite Consulting
Joseph Kvedar, M.D.
Director
Center for Connected Health
Susan Dentzer
Senior Health Policy Adviser
Robert Wood Johnson Foundation (RWJF)
Linda Dimitropoulos
Director
RTI Center for the Advancement of Health IT
(CAHIT)
Lisa Gallagher
Vice President, Technology Solutions
Health Information and Management Systems
Society (HIMSS)
Mark Goettel
Senior Product Manager
Payment Solutions
WEX, Inc.
Kylanne Green
President & Chief Executive Officer
URAC
Marjorie S. Greenberg
Executive Secretary
National Committee on Vital and Health
Statistics (NCVHS)
Chief, Classifications and Public Health
Data Standards
National Center for Health Statistics, Centers for
Disease Control and Prevention (CDC)
Arien Malec
Vice President, Strategy
RelayHealth
Joseph S. Smith
Senior Vice President and CIO
Arkansas Blue Cross and Blue Shield
Walter G. Suarez, M.D., M.P.H.
Executive Director, Health IT Strategy
and Policy
Kaiser Permanente
Chair, Subcommittee on Standards
National Committee on Vital and Health
Statistics (NCVHS)
Ryan Witt
Managing Director
Healthcare Practice
Juniper Networks
Jon Zimmerman
General Manager
Clinical Solutions
GE
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2013 WEDI Report Workgroup Co-Chairs
Rob Alger
Innovative Encounter Models
Vice President, Health Plan IT Strategy
Kaiser Permanente
Liora Alschuler
Data Harmonization & Exchange
CEO
Lantana Consulting Group
Samantha Burch
Payment Models
Vice President, Legislation & Health
Information Technology
Federation of American Hospitals
Rich Cullen
Data Harmonization and Exchange
Executive Director, Inter-Plan Programs
Blue Cross Blue Shield Association
Tina Grande
Payment Models
Senior Vice President
Policy Healthcare Leadership Council (HLC)
Gerard Grundler
Patient Engagement
Managing Principal Healthcare IT
Services
Verizon
Carolyn Hartley
Patient Engagement
President CEO
Physicians EHR, Inc.
Waco Hoover
Innovative Encounter Models
Chief Executive Officer
Institute for Health Technology Transformation
Marcia James
Payment Models
Vice President, Accountable Care
Mercy Health System
Donald T. Mon, Ph.D.
Data Harmonization & Exchange
Senior Director, Center for the
Advancement of Health IT
RTI International
Thomas L. Meyers
Patient Engagement
Vice President, Product Policy
Department
America’s Health Insurance Plans
Marc Probst
Innovative Encounter Models
Vice President and Chief Information
Officer
Intermountain Healthcare
Anu Pujji
Data Harmonization and Exchange
Associate Vice President
OptumHealth
Emily Richmond
Payment Models
Legal and Policy Team
Practice Fusion, Inc.
Robert M. Tennant
Patient Engagement
Senior Policy Advisor
Medical Group Management Association
Jon Zimmerman
Data Harmonization & Exchange
General Manager, Clinical Solutions
GE
Megan Zimmermann
Innovative Encounter Models
Executive Consultant and Chief of Staff
Business Technology Solutions and Services,
Kaiser Permanente
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2013 WEDI Report Writer & Project Managers
Edward D. Jones, III
2013 WEDI Report Writer
Owner & CEO
Cornichon Healthcare Select, LLC
David S. Miller
Consultant
Cornichon Healthcare Select, LLC
President
D&L Innovations, LLC
2013 WEDI Representatives
Jim Daley
Director, IT Risk and Compliance
BlueCross BlueShield of South Carolina
WEDI Chair
Jean Narcisi
Director of Dental Informatics
American Dental Association
WEDI Chair-Elect
Donald Bechtel
Health Services Patient Privacy Officer
Siemens Healthcare
WEDI Past-Chair
Devin A. Jopp, Ed.D.
President & Chief Executive Officer
WEDI
Leanne R. Cardwell
Senior Vice President of External
Relations
WEDI
Samantha Holvey
Director of Community Education
WEDI
2013 WEDI Report Contributors
Ornela Besho
Manager, Dental Informatics
American Dental Association
Bryanne Curry
Director, IT
BlueCross BlueShield of South Carolina
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The Health IT Challenge
F
or the past 20 years, the U.S. healthcare industry has been investing time and financial
resources in the process of designing and implementing transaction standards to improve
administrative efficiency and contain costs of electronic healthcare information exchange.
While the industry has made considerable progress in the design of electronic data
interchange (EDI) standards, it has made less progress in the adoption of these processes for
business use. According to the U.S. Healthcare Efficiency Index,© healthcare claim submission
is currently at 85%, yet other key transactions – including claim remittance, eligibility
verification, claim status inquiries, and claim payments – are at less than 50% usage. The U.S.
Healthcare Efficiency Index© currently is only at 43% efficiency.1 In 2009, the Institute of
Medicine (IOM) conducted a study and determined that the U.S. healthcare system spent
$361 billion annually on healthcare administration,2 about 14.4% of total healthcare
expenditures that year,3 and that at least half of the administrative expenditures were
concluded to be wasteful.4
Low efficiency combined with growing healthcare costs and emerging technologies have
created an opportunity and need for the healthcare industry to examine how to best leverage
technology to streamline the exchange of healthcare information. The opportunity to leverage
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efficiency and quality lies not only in the exchange of administrative information, but also in
driving alignment between clinical information and administrative information in order to
enable new modalities of care and payment. Further alignment with public health information
systems can contribute to improved modalities for measuring and tracking health status and
outcomes. Recognizing these challenges and opportunities, the WEDI Foundation
commissioned the development of the 2013 WEDI Report to provide a roadmap for leveraging
technology to enhance the nation’s Health IT infrastructure in order to lower healthcare costs,
improve healthcare delivery, and achieve better healthcare outcomes through more efficient
exchange of healthcare information between consumers, healthcare providers, and health plans.
The 2013 WEDI Report was a new initiative, yet rooted in a similar project commissioned in
1991 by then U.S. Secretary of Health and Human Services (HHS) Louis W. Sullivan, M.D.
Facing rising healthcare costs and a fragmented healthcare system, Dr. Sullivan asked
healthcare business leaders to create a plan to conduct electronically more cost-effective
administrative and financial transactions, a goal that was being achieved by other industries.
The result was the 1993 WEDI Report, a roadmap of recommendations for standards and the
transition to electronic data interchange. The1993 WEDI Report had a significant impact on
motivating the change from provider-to-payer data exchange relationships to standardized
transaction formats for payment and administration. The 1993 WEDI Report provided the
foundation for the Administrative Simplification provisions of the Health Insurance
Portability and Accountability Act (HIPAA) of 1996, in which WEDI was named an advisor
to the Secretary of HHS.
From the 1993 WEDI Report to the present, there have been a series of legislative and
regulatory initiatives that have modified the original HIPAA administrative standards and
broadened the scope of the Health IT infrastructure. Most notable among these are the Health
Information Technology for Economic and Clinical Health Act of 2009 (HITECH Act) and
Patient Protection and Affordable Care Act of 2010 (ACA). Just as in 1991 when the first
Health IT roadmap, the 1993 WEDI Report, was commissioned, now again the nation needs
a new roadmap for improving existing processes and implementing new technologies to get
“the right information to the right place at the right time.”
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2013 WEDI REPORT EXECUTIVE SUMMARY
Executive Summary
I
n December 2012, The WEDI Foundation leadership commissioned an update to the 1993
WEDI Report in order to provide an opportunity to evaluate progress on recommendations
made in the earlier report, reflect on lessons learned, determine if recommendations for
Administrative Simplification made 20 years prior were still germane today, and identify
immediate future needs. WEDI, in its HIPAA statutory role as advisor to the Secretary of
HHS, could bring together healthcare stakeholders to address critical Health IT implementation
issues and provide guidance on healthcare information exchange issues that were again
confronting the nation. In short, the goal was for the WEDI Foundation (WEDI’s separate
501(c)(3) organization) and WEDI to help the healthcare industry further improve its
information exchange processes in order to lower costs, improve healthcare delivery, and lead
to better healthcare outcomes for patients.
The WEDI Foundation enlisted the founder of WEDI, Dr. Louis W. Sullivan, to serve as the
Honorary Chair of the 2013 WEDI Report Executive Steering Committee, and to enlist
business CEOs and association and government leaders to identify solutions that could be
implemented relatively quickly and driven by business. These solutions are meant to serve as
a guide for the healthcare industry. The intent of the report is that healthcare stakeholder
organizations, including WEDI, will align their efforts to help achieve the objectives outlined
in this report.
The plan for the roadmap began by posing two broad questions related to the efficiency of the
current Health IT infrastructure:
Accelerating
Innovation: Beginning with the adoption of new mobile, smart, and
other technologies, applications (apps), and data transmitted via the Internet and maintained
in cloud storage, what are the opportunities for achieving improved efficiency and lower cost?
Solving
Challenges: What are the challenges to achieving greater efficiency and lower
cost with existing standards applications and terminologies?
Several subsidiary questions were posed within each of these categories – found in the body of
the report – to begin the 2013 WEDI Report project inquiries.
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Four Areas Of Focus
The feedback from the initial Executive Steering Committee meeting provided the foundation
for the four areas of focus of the 2013 WEDI Report. More than 200 volunteers donated their
time to identifying the opportunities, challenges, and action plans for these four megatrend
areas:
Patient
Engagement: Identify ways to enable consumer (patient) engagement through
improved access to pertinent healthcare information.
Payment
Models: Identify requisite business, information, and data exchange
requirements that will help enable payment models as they emerge.
Data
Harmonization and Exchange: Identify ways to better align administrative and
clinical information capture, linkage, and exchange.
Innovative
Encounter Models: Identify business cases for innovative encounter
models that use existing and emergent technologies.
Recommendations
The 2013 WEDI Report comprises 10 recommendations that provide a broad framework for
facilitating improvement in electronic exchange of healthcare information. They are based on
the work of thought leaders from a representative cross-section of public and private sector
healthcare stakeholders, who examined literature, reviewed case studies, polled experts, and
conducted numerous discussions to develop the set of recommendations contained within the
2013 WEDI Report. The 2013 WEDI Report recognizes existing efforts of other entities that
are working to solve or improve issues identified as important to the recommendations made
in this report. The intent of these recommendations is to serve as a common roadmap for
healthcare organizations, including WEDI.
Patient Engagement Recommendations
Standardize the patient identification process across the healthcare system.
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Expand Health IT education and literacy programs for consumers to encourage greater use
of Health IT, with a goal of achieving better care management and overall wellness
Identify and promote effective and actionable electronic approaches to patient information
capture, maintenance and dissemination that leverage mobile devices and "smart" technologies and applications.
Innovative Encounter Models Recommendations
Identify use cases, conventions, and operating standards for promoting consumer health and
exchange of telehealth information in a mobile environment.
Facilitate adoption and implementation of “best-in-class” approaches that promote growth
and diffusion of innovative encounters across the marketplace and that demonstrate value for
patients, providers, and payers.
Identify existing or proposed federal or state-based laws or regulations that create barriers to
the implementation of innovative encounters (including licensure).
Data Harmonization & Exchange Recommendations
Identify and promote consistent and efficient methods for electronic reporting of quality
and health status measures across all stakeholders, including public health, with initial focus
on recipients of quality measure information.
Identify and promote methods and standards for healthcare information exchange that
would enhance care coordination.
Identify methods and standards for harmonizing clinical and administrative information
reporting that reduce data collection burden, support clinical quality improvement,
contribute to public and population health, and accommodate new payment models.
Payment Models Recommendation
Develop a framework for assessing critical, core attributes of alternative payment models –
such as connectivity, eligibility/enrollment reconciliation, payment reconciliation, quality
reporting and care coordination data exchange, and education – and the technology solutions
that can mitigate barriers to implementation.
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Conclusion
A
s initially envisioned twenty years ago, we, as an industry, continue to progress towards a
healthcare system that leverages technology in order to improve care and lower costs.
Health IT is not the cure in and of itself but, when adequately deployed, can serve as a
powerful change agent. The rise of mobile and other technologies creates many opportunities
for the healthcare industry to move forward together to solve many of the challenges that have
plagued the American healthcare system. The steps required to do this are not easy, especially
given the existing resource constraints faced by many healthcare stakeholders. However,
through public and private partnership, the recommendations outlined in this report are
achievable and reality-based. These recommendations should serve as a catalyst and
call-to-action to all stakeholders to truly help implement the Health IT infrastructure that
our nation will need in the future, both short-term and long-term. Much rides on the success
of these recommendations. As our nation moves towards adopting new technologies, care
coordination modalities, and payment models, more responsibility will fall onto consumers
for managing their care and healthcare information. As we consider how to get the right
informatio to the right, place at the right time, we must build systems, tools and education
programs to help Americans be successful in this new paradigm.
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The 2013 WEDI Report
“The Right Information, To The Right Place, At The Right Time”
T
he WEDI Foundation enlisted the founder of WEDI, Dr. Louis W. Sullivan, to serve as the
Honorary Chair of the 2013 WEDI Report Executive Steering Committee, and to enlist
business and association and government leaders to identify solutions that could be
implemented relatively quickly and driven primarily by the private sector. The 2013 WEDI
Report can be looked at as a continuation of the work begun in 1993: it is designed to address
the electronic healthcare information exchange fragmentation problem and to identify
challenges to be solved and potential innovative solutions to be implemented. Similar to
twenty years ago, the healthcare industry is at another pivotal time from a technology
standpoint5, providing a unique and timely opportunity to ask questions and make changes.
The 2013 WEDI Report project was born on the 20th anniversary of its first roadmap and has
identified a new roadmap of recommendations to carry the healthcare industry into the future.
Roadmap Questions To Be Addressed
The 2013 WEDI Report foundational questions relating to Health IT efficiency were
identified as Accelerating Innovation and Solving Challenges:
Accelerating
Innovation: What are the opportunities for achieving improved
efficiency and lower cost as a result of a paradigm shift in technology from electronic data
interchange (EDI) to new mobile, smart and other technologies – applications (apps)6, and
data transmitted via Internet and maintained in cloud storage7 – and adopting those new
technologies to accomplish business processes and exchange healthcare information?8
Solving
Challenges: What are the challenges to achieving the originally envisioned
goals of greater efficiency and lower cost with existing standards applications and
terminologies?
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Within each of these categories were subsidiary questions with which the workgroups began
the 2013 WEDI Report project inquiries:
A C C E L E R AT I N G I N N O VAT I O N :
Can the healthcare industry find a way to more usefully integrate administrative and clinical
data in healthcare information exchange to make the consequences of the transaction flow
from claim to adjudication to payment to reconciliation less costly?
Can the healthcare industry leverage more cost-effectively mobile and portable technology
and devices to facilitate electronic encounters between provider and consumer?
Can the healthcare industry motivate the consumer through education, self-interest,
incentives, or personal health record (PHR) programs such as Blue Button9 to be accountable
for his or her healthcare needs and general wellbeing?
What can be accomplished by key industry stakeholder collaboration that will expedite
innovative solutions in the healthcare industry?
Does the increased use of mobile devices by consumers, and increasingly by business, create
opportunities for the healthcare industry to implement initiatives to enhance patient
engagement and more cost-effective encounters?
S O LV I N G C H A L L E N G E S :
Are the information requirements of EDI standards adopted over the past 20 years still
viable as transaction tools in a rapidly evolving technology environment (mobile, biometric
sensor, cloud server, and social networking), and are they transferrable to new technologies
such as found on mobile devices and executed through apps?
Given the rapidly evolving technology environment, what changes are required to existing
standards and terminologies to achieve the benefits of electronic healthcare information
exchange?
Can the healthcare industry solve the challenge of not having a unique individual identifier?
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Recommendations
T
he 2013 WEDI Report comprises 10 recommendations to provide a broad framework for
facilitating improvement in the electronic exchange of healthcare information. They are
based on the work of thought leaders from a representative cross-section of healthcare
stakeholders from the private and public sectors who examined literature, reviewed case
studies, polled experts, and conducted numerous in-person and remote discussions on their
respective issues. Associated action steps are provided for each recommendation and contained
in summary in Addendum 1.
Patient Engagement
The healthcare industry is currently experiencing a revolution in terms of the adoption and
use of health information technology (Health IT). The availability of high-quality products
combined with historic federal and private sector incentives have encouraged the provider
community to embrace Health IT at a record pace. At the same time, while there are a
number of options for patients and other healthcare consumers to leverage technology to assist
them in improving wellness, coordination of care, and disease management, patient
engagement in this area remains relatively suppressed.
Increased patient engagement would not only lead to improved health outcomes for patients,
but could also lead to industry-wide clinical and administrative efficiencies.
Patient engagement, for the purposes of the 2013 WEDI Report, was defined as dialogue
between patients and key healthcare stakeholders (e.g. physicians, health plans, care
coordinators, and public health). However, the issue spanned several key areas of focus for the
purposes of the 2013 WEDI Report, including patient identification/matching, patient access
to information, and how to leverage existing technology to facilitate consumer access to tools.
A central question considered in this area was the extent to which the patient could serve as
the center of healthcare information exchange and what tools and infrastructure would be
required in order to allow patients to access and manage their own information.
Personal health records were defined by NCVHS (2002) as the collection of information about
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an individual’s health and healthcare, stored in electronic format; they gained traction initially
in the early 2000s via Internet-based tools. However, interest has waned considerably and
according to the Markle Foundation (2011), only 10% of Americans use personal health
records10. Challenges related to patient information capture and transfer combined with the
rise of mobile applications and common formats for exporting personal health information
(e.g. ONC Blue Button+) provide new opportunities for using such tools. According to a
recent survey of providers and payers, conducted by WEDI (2013), nearly 34% of respondents
reported offering personal health records to their members or patients.
The patient engagement recommendations seek to identify: challenges to increased consumer
involvement in healthcare, opportunities to utilize existing and future technologies, and
workflows and other levers to meet the goals of improved information exchange to offer a
pathway forward to enhanced consumer involvement and cost containment.
R E C O M M E N D AT I O N S F O R PAT I E N T E N G A G E M E N T A R E :
1. Standardize the patient identification process across the healthcare system.
2. Expand Health IT education and literacy programs for consumers to encourage greater use
of Health IT, with a goal of achieving better care management and overall wellness.
3. Identify and promote effective and actionable electronic approaches to patient information
capture, maintenance and dissemination that leverage mobile devices and “smart” technologies
and applications.
1. Standardize The Patient Identification Process Across The Healthcare
System.
One of the most critical challenges for the healthcare industry is accurately identifying the
patient and tying that identification to the right designated record set held by a healthcare
provider. Even though it was identified as critical in the 1993 WEDI Report, the industry
does not have a standardized, unique patient identifier.
Interoperability – electronic healthcare information exchange – is difficult to achieve across
healthcare providers for a patient’s comprehensive medical record in the absence of
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standardization of patient identification or other widely accepted processes used to achieve
proper matching. This is an acute problem as the nation continues to invest in meaningful use
of electronic health record (EHR) technology when the patient’s electronic “address” differs
across EHR systems. The benefit to standardization is that healthcare providers win by
accurately identifying the patient, accessing “what they want, when they want it;”11 and
consumers win by accessing their information accurately across healthcare providers, especially
in emergency situations. While numerous patient-matching and identity management
initiatives exist (e.g., ONC, NIST, etc.), there is no common strategy that has been adopted by
the healthcare industry.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
A number of factors led to this recommendation. These included the emergence of mobile
technology, the growing use of electronic provider-payment encounters and new tools like
Blue Button+ that are easing access to personal health records.
Through the implementation of this recommendation, patient identification accuracy can be
greatly increased as new technologies open up access for consumers to increase their literacy
regarding health information technology as a means of managing their own health information.
It is expected that by standardizing patient identification, improvements can be gained in
linking patients to correct medical records, and improved information flow can be achieved at
lower costs with reduced medical errors and medical test redundancy. Additionally, it is
expected that these efforts would directly correlate to a reduction in fraud and abuse.
ACTION STEPS:
Short-Term:
Convene industry to identify best practices related to patient matching.
Launch consumer awareness and education campaign.
Mid-Term:
Initiate pilots and explore potential dissemination strategies.
Longer-Term:
Continue consumer awareness and education campaign, and launch adoption campaign.
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2. Expand health IT education and literacy programs for consumers to
encourage greater use of health it, with a goal of achieving better care
management and overall wellness.
The healthcare industry has an opportunity now, and in the years ahead, to leverage mobile,
smart, and other emergent technologies, applications (apps), and cloud storage capabilities to
further engage the patient in managing his or her health and health information to achieve
improved communication with and care from healthcare providers, and better healthcare
outcomes.
Use of smartphone technology began to soar with Apple’s release of the iPhone in 2007, and
applications (apps) using the iPhone and other smartphone devices and tablets that are
evolving quickly have engaged consumers and businesses with tools to better manage
information.
The healthcare industry must continue development of education and literacy programs that
engage the consumer with the use of these smart devices for managing his or her healthcare on
a full-time basis even though for most consumers being a patient is only part-time. An
immediate benefit for consumers is the capability of capturing healthcare history information
electronically, and having it in one place for easy retrieval and updating over time, as necessary.
Other benefits for the consumer are the ability to capture and display critical demographic,
insurance, and health-related information (e.g., medication alerts and tracking), pay increased
attention to healthcare issues, and experience better healthcare outcomes.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
One factor supporting the adoption of this recommendation is that consumer literacy is an
important cornerstone to many innovations in healthcare delivery. Consumer literacy can be
driven through online and mobile Health IT resources that allow for engagement across social
and geographic strata. Through Health IT education and literacy, engaged consumers can
participate in more accurate and efficient, and less costly, healthcare information exchange
with providers.
Consumers can leverage the growing use of mobile, smart, and other technologies and
applications in order to have on-demand access to tools and advice that can enhance their
personal management of their health information. The results of such literacy efforts are
believed to enable individuals to better manage their own health, and therefore lower costs
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across the healthcare system due to preventable illnesses.
ACTION STEPS:
Short-Term
Identify patient-centric curriculum and deployment strategy for standardized Health IT
educational and literacy materials.
Engage and design Health IT educational and literacy program.
Mid-Term
Pilot and test educational and literacy materials.
Longer-Term
Launch Health IT educational and literacy programs.
3. Identify and promote effective and actionable electronic approaches to
patient information capture, maintenance and dissemination that leverage
mobile devices and “smart” technologies and applications.
It is expected that mobile devices will increasingly rely on smart technology rather than stripe
technology to process financial transactions using credit and debit cards and mobile payment
applications. The consumer movement to mobile smart technologies provides an opportunity
to facilitate more efficient exchange of healthcare information among healthcare stakeholders
using these technologies. However, there are barriers to that exchange, namely, trust in
identification of sender and accuracy of critical information for the exchange from a business
and clinical standpoint, as well as ensuring appropriate privacy and security controls pertaining
to the devices and information. This recommendation focuses on the ability to effectively
leverage new technologies to be able to capture patient information at point of care and include
patient-supplied data and then effectively store and transmit healthcare information in order to
“capture once and use many times” regardless of the device.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
There are significant benefits for health plans and healthcare providers leveraging standardized
patient identification and a healthcare-literate consumer base using mobile smart technologies.
These technologies have the ability to capture and display critical demographic, insurance,
and clinical healthcare information more accurately, with reduced error rates in the exchange
of electronic information across healthcare stakeholders, while at the same time improving
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fraud protection. Through the application of this recommendation, the healthcare industry
can expect to diminish claim errors and payment denials and exceptions in order to eliminate
costs that provide no value. Additionally, this recommendation provides for timely and
accurate access to critical clinical and administrative information for healthcare stakeholders
and public health.
ACTION STEPS:
Short-Term
Convene a group of appropriate business and clinical experts to define and approve the
standard technology, data content, and dissemination strategy.
Identify a standard subset of essential health information for use in an emergency situation,
such as an injury or natural disaster, to which a consumer and designated healthcare provider
would have immediate access.
Identify a set of mobile smart technologies and applications, along with health-related Web
sites that are easy to use and tolerant of error in order to provide required healthcare
information to users in a timely manner.
Establish pilot to determine best practices and effectiveness of tested actions.
Mid-Term
Pilot and test business-driven applications using various devices.
Develop implementation strategy for rollout of successful applications on various devices.
Educate media and consumers on the value of utilizing such applications on various devices.
Engage vendors in preparing for deployment of chosen applications on various devices.
Longer-Term
Launch appropriate applications.
Innovative Encounter Models
The healthcare landscape is rapidly changing, we are moving away from one doctor, one exam
room, and one “encounter.” A “typical” encounter is defined as scheduling an appointment,
visiting a doctor’s office and rendering a diagnosis. Technology now allows us to expand
outside of brick and mortar medicine. This impacts how we bill, process claims, maintain
records, report, schedule, and diagnose.
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2013 WEDI REPORT
“Innovative” encounters like email, texting, and telehealth are powerful tools to engage
patients and providers without reference to location or time and allow non-emergent
conditions to be evaluated and in many cases treated without the need for a physical visit.
What makes an encounter innovative is the tool or method of communication and/or the
order in which communication occurs. There are two forms of innovative encounters:
asynchronous and synchronous. An asynchronous encounter shuffles the typical order of events.
For example, instead of scheduling an appointment with a doctor to look at a suspicious mole,
a patient might text a picture of a suspicious mole to an advice nurse to determine if an
appointment is necessary. Doctors and patients need clear protocols for these types of
asynchronous encounters. Synchronous encounters occur in near real-time. For example, a pill
bottle that remotely sends a signal to the care coordinator who, in turn, can check in with the
patient for compliance.
With the proliferation of electronic tools in support of clinical encounters, and the rapidly
growing use of mobile smart technologies by consumers, the demand for innovative encounters
is growing, not only because of convenience, but also because innovative encounters have the
potential to reduce costs for practitioners (e.g., facility overhead) and for consumers (e.g., travel
and time).
As the 2013 WEDI Report effort evaluated innovative encounters, it was noted that the
landscape is new and will continue to evolve, from both innovation and regulatory perspectives.
State regulation today provides challenges to proliferation of innovative encounters.
We are at an historical intersection between technology, consumer behavior, provider, and
payer adoption. Consumer demand for innovative encounters could become a significant
motivator for providers to adopt innovative encounters in their practice models. Health plans
may find that reimbursing for innovative encounters significantly lowers claims when they are
used to prevent more serious (and expensive) encounters. Before either of these theories can be
tested, our recommendation is that the tools, protocols, and criteria for testing these
hypotheses be gathered and evaluated by relevant stakeholders.
Recommendations for innovative encounter models are:
1. Identify use cases, conventions, and operating standards for promoting consumer health
and exchange of telehealth information in a mobile environment.
2. Facilitate adoption and implementation of “best-in-class” approaches that promote growth
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2013 WEDI REPORT
and diffusion of innovative encounters across the marketplace and that demonstrate value for
patients, providers, and payers.
3. Identify existing or proposed federal or state-based laws or regulations that create barriers
to the implementation of innovative encounters (including licensure).
1. Identify Use Cases, Conventions, And Operating Standards For Promoting
Consumer Health And Exchange Of Telehealth Information In A Mobile
Environment.
This recommendation suggests that an environmental scan be conducted of various types of
electronic encounters in order to identify attributes of existing successful encounters that
would encourage their use, and characteristics of use cases where evidence suggests growth
would be impeded. The recommendation provides for an opportunity to identify case
examples of what is working currently and to mine success factors in order to facilitate the
spread of these technologies.
The traditional encounter between a healthcare practitioner and a patient has been in-person
in a physical environment such as a hospital, medical practice, nursing home, or dental office.
With the advent of electronic communication capabilities, there are cases were communications
between practitioner and patient are not required to be in physical contact, but rather can
occur over time or electronically. These are remote encounters that may be conducted using a
variety of methods (e.g. telehealth, email, or messaging, care monitoring, alerts, and tracking
medication usage).
These innovative encounter models allow consumers and providers with limited access to
traditional medical services the potential of improving healthcare delivery and outcomes. For
example, there is limited access to medical specialists in rural or under-served urban
environments, however, innovative encounters using technology can allow for virtual access to
specialists from other regions.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
Reduction in total cost of providing patient care per encounter serves as a critical business driver
for this recommendation. As organizations reduce physical capacity demands by patients
through the use of telehealth, organizations should be able to derive cost savings through time
utilization and provider effectiveness. While costs are a significant driver, it is also expected that
sustained improvement in quality of care using innovative encounter models would be derived,
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2013 WEDI REPORT
as the use of technology would allow for easier follow-up than traditional face-to-face visits.
Fueling the growth of innovative encounters in the foreseeable future is also the rise of
concierge medical services, of which many offer various innovative encounters as part of their
service offering. According to the American Academy of Private Physicians, in 2012, a 30%
growth occurred in physicians offering concierge services.11 Private market demand for their
services is expected to continue to grow as consumers expect services delivered through their
mobile devices.
ACTION STEPS:
Short-Term
Determine the correlation between current market-driven technology development and
major health initiatives.
Map electronic encounters (telemedicine, email, text, and care monitoring) by typical use.
Develop a matrix that shows how innovative encounters are typically used.
Develop a detailed list of stakeholders that are focused on innovative encounters and align
resources for action.
Mid-Term
Partner with existing stakeholders to identify criteria to evaluate and prioritize the efficacy
of technology initiatives specifically related to innovative encounters.
Longer-Term
Develop and/or modify standards and operating rules as required to support innovative
encounters.
2. Facilitate Adoption And Implementation Of “Best-in-class” Approaches
That Promote Growth And Diffusion Of Innovative Encounters Across The
Marketplace And That Demonstrate Value For Patients, Providers, And
Payers.
Consumer demand for innovative encounters could become a significant motivator for
providers to adopt innovative encounters into their practice models. Health plans may find
that avenues for leveraging innovative encounters to lower costs and to prevent future
complications. In order to foster innovative encounters, tools, protocols, and criteria for
testing must be gathered and evaluated by relevant stakeholders.
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2013 WEDI REPORT
BUSINESS DRIVERS & EXPECTED OUTCOMES:
Assuming that innovative electronic encounters are demonstrated to be value-based and
cost-effective, this recommendation targets increasing provider and consumer adoption. In
order to demonstrate this value, it is important to be able to document and track electronic
encounters (as part of physician work flow) for evaluation, cost-benefit, quality, and utilization
purposes. It is expected that a reduction in total cost of providing patient care per electronic
encounter and sustained improvement in quality of care using affordable, innovative
encounter models can be achieved.
ACTION STEPS:
Short-Term
Convene appropriate stakeholders to evaluate encounter models in terms of: patient support
and satisfaction, outcomes, and ease of integration into provider workflow, and liability issues.
Gather and assess existing protocols and suggested payment methodologies related to
electronic encounters (telehealth, email, text, and care monitoring).
Develop criteria to evaluate their efficacy and rank innovative encounters protocols.
Survey consumers to determine awareness and likelihood of using electronic encounters and
willingness to pay for such encounters based on alternative pricing models and perceived
value of the encounter compared to an in-person encounter.
Mid-Term
Continue annual survey of consumer awareness, usage, and satisfaction of electronic
encounters.
3. Identify Existing Or Proposed Federal Or State-based Laws Or
Regulations That Create Barriers To The Implementation Of Innovative
Encounters (Including Licensure).
Today, there are a number of regulatory state-based barriers such as laws, regulations, and
policies that make adoption of innovative encounter models more difficult or less accessible to
patients. Such barriers impede the marketplace’s ability to drive innovation and realize the
benefits of such innovation, which would include lower costs of healthcare and wider access to
quality healthcare delivery by underserved populations and in rural areas of the nation.
This recommendation addresses these issues by focusing on identification of existing and
proposed laws, regulations, and policies that would inhibit market development of innovative
encounter models that are being propelled by adoption of electronic tools used both by
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2013 WEDI REPORT
healthcare providers and consumers. Conversely, this recommendation also will evaluate states
that have modified regulations effectively in order to evaluate successful regulatory frameworks
for encouraging innovative encounters.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
A key business driver for this recommendation lies in opening up access to wider adoption of
telehealth and mobile health technologies. The result is expected to improve access to
healthcare delivery services for consumers and an expected decrease in healthcare service costs
for consumers and providers. Removal of barriers opens access to new healthcare delivery
channels to meet an expected growth in demand for affordable and convenient electronic
encounters.
ACTION STEPS:
Short-Term
Convene appropriate groups that will identify specific regulatory barriers, existing best
practices, and potential solutions.
Mid-Term
Continue monitoring federal and state legislative and regulatory landscape for potential
regulatory barriers and best practices.
Create policy mechanisms and partnerships that can encourage alternative sustainability of
legislation in support of innovative encounters.
Data Harmonization & Exchange
For the past two decades, healthcare information has been loosely classified as “administrative”
or “clinical.” While considerable gains have been made in the exchange of these types of data
respectively, there is increasing recognition that administrative decision-making will be better
served if based on information drawn directly from the clinical record, rather than abstracted
according to purely administrative drivers. Healthcare must explore the extent to which
administrative and clinical functions can be driven from a unified data set to fully implement
new care management and payment reform programs. This data set also can contribute to
improved information for population health.
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2013 WEDI REPORT
Harmonized data standards for reporting, coordination, administration, and research are
critical to the effective operation of the healthcare industry. Much progress has been made, yet
significant work lies ahead in order to reach the goal of ensuring the right information arrives
at the right place and time and that the data drive tangible improvement in care and value.
Quality and cost are the function of shared decisions in an environment where care delivery is
distributed across clinicians in different settings, care coordinators, and centrally, the patient.
In order to enable effective decision making, access is required to a complete record.
Standards and methods for information exchange must recognize and prioritize support for
coordinated care that transcends traditional enterprise boundaries. A more sophisticated level
of integration and interoperability is necessary in order to enable new payment models,
patient engagement, and innovative encounters. The recommendations below address the
need for harmonized data standards for reporting, care coordination, and administration.
Much progress has been made, and the situation is vastly different and advanced, since the
initial creation of the WEDI Report in 1993. These recommendations recognize a higher level
of integration and look ahead to increase value from shared data that support the
informational needs of all stakeholders.
R E C O M M E N D AT I O N S F O R D ATA H A R M O N I Z AT I O N A R E :
1. Identify and promote consistent and efficient methods for electronic reporting of quality
and health status measures across all stakeholders, including public health, with initial focus
on recipients of quality measure information.
2. Identify and promote methods and standards for healthcare information exchange that
would enhance care coordination.
3. Identify methods and standards for harmonizing clinical and administrative information
reporting that reduce data collection burden, support clinical quality improvement,
contribute to public and population health, and accommodates new payment models.
1. Identify and promote consistent and efficient methods for electronic reporting
of quality and health status measures across all stakeholders, including public
health, with initial focus on recipients of quality measure information.
The need for uniform methods of reporting quality information across all stakeholders is
crucial. Quality reporting encompasses many types of information, information capture, and
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2013 WEDI REPORT
workflow. Effective standards and methods for expressing electronic data and measure criteria
are a prerequisite to consolidation and possible simplification of reporting requirements.
Effective and universal standards for quality reporting recognize and support this diversity
while establishing a unified basis for application development and integration.
With the advent of adoption and meaningful use of EHR technology in the Medicare and
Medicaid programs, healthcare practitioners participating in the programs are required to
attest to measures that represent quality and health status. Over time, performance regarding
quality measures will be linked to reimbursement.
Many measures exist today addressing disparate, overlapping, and related goals. Simplifying the
reporting process requires identifying data definitions and formal criteria, which will establish a
consistent basis for evaluation, comparison, and eventual consolidation.
This recommendation provides for reviewing existing metrics and identifying methods and
standard metrics that would provide consistency in reporting quality and health status by
healthcare providers and inform consumer choice in evaluating quality of care received and
outcomes of care. Establishing the basis for uniformity of measurement data is a significant
step toward uniformity of content and criteria.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
Uniform standards for electronic reporting of quality and health status will facilitate consistent
and comparable reporting by healthcare providers, to improve population health and to identify
improvements in healthcare delivery. For health plans, consistently reported quality and health
status metrics based on standards also will improve accuracy of compensation calculations, which
are required across all payment models, and align commercial payers’ needs with Meaningful
Use programs.
Using standards for identifying and measuring quality and health status will encourage viable
and sustainable development of commercial solutions within certified EHR technologies used
in emerging new payment models frameworks. This will lead to lower costs and informed
choice for all stakeholders, improved healthcare delivery and outcomes, and more accurate
payments for services rendered. Using standardized electronic data for disease tracking, health
status, and wellbeing will improve the tracking of the health of the population and identify
necessary and proven interventions.
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2013 WEDI REPORT
ACTION STEPS:
Short-Term
Establish a working group to review existing methods and standards for electronic Clinical
Quality Measurement (eCQM).
Develop action plan for achieving industry consensus on methods and standards.
Design and launch awareness and education campaign.
Mid-Term
Pilot, test, and evaluate effectiveness of standards in achieving defined outcomes.
Develop action plan for achieving industry adoption of standards.
Engage health plans and healthcare providers in adopting electronic Clinical Quality
Measurement standards (adoption campaign).
Longer-Term
Continue awareness, education, and adoption campaign.
2. Identify and promote methods and standards for healthcare information
exchange that would enhance care coordination.
Healthcare providers need access to comprehensive and meaningful clinical information to
provide timely and cost-effective care. A comprehensive, standards-based record can be organized
in such a way that it is useful at the point of care, engages patients in their own care, and
supports quality measurement and real-time decision support. Consensus on best practice
should prioritize normalization of key data elements that can be captured uniformly without
undue impediments to clinical workflow. This recommendation is closely related to and
assumes availability of standardized patient identification for trust in the identification of a
patient’s designated record sets across providers. In the same vein, it supports uniform quality
reporting standards, forming the basis for a standardized data set.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
Timely information sharing with acknowledgement of receipt of correct information
eliminates delay in providing healthcare services, especially in an emergency situation,
improves care delivery, and reduces cost. Standards for exchange of clinical records ensure
meaning and integrity of shared knowledge supporting care coordination.
Implementing improved methods of access to standard health information for care
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2013 WEDI REPORT
coordination and communication between healthcare provider and patient supports the
Accountable Care Organizations (ACO) and Patient-Centered Medical Home (PCMH) models
and allows the patient to take more responsibility for health outcomes and lifestyle.
All stakeholders benefit from improved care coordination. Consumers have better access to
and interaction with their own medical records, better communication and involvement in
care planning, and better understanding of interventions and engagement in their own care.
Healthcare providers have improved and timely access to appropriate medical information,
which reduces costs, improves care delivery, and leads to more effective care coordination.
Health plans experience lower costs when improved care coordination results in higher quality
outcomes and effectiveness of care management.
ACTION STEPS:
Short-Term
Establish a working group to review existing methods, standards, and implementation
guides for identification of gaps that impede connectivity and timely information sharing for
care coordination.
Develop action plan for achieving industry consensus on methods and standards.
Design and launch awareness and education campaign.
Mid-Term
Pilot, test, and evaluate effectiveness of methods and standards in achieving defined outcomes.
Develop action plan for achieving industry adoption of methods, standards, and
easy-to-understand implementation guides.
Engage health plans and healthcare providers for adopting methods and standards.
Longer-Term
Continue awareness, education, and adoption campaign.
3. Identify methods and standards for harmonizing clinical and
administrative information reporting that reduce data collection burden,
support clinical quality improvement, contribute to public and population
health, and accommodate new payment models.
This recommendation focuses on identifying methods for aligning administrative and clinical
information sets that would result in lower costs of collection and facilitate adoption of new
payment models. Most practitioners today use different systems, different personnel, and
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2013 WEDI REPORT
different workflows to capture and manage clinical and administrative data.
With the proliferation of electronic health record technologies, greater alignment of clinical
and administrative information standards, as well as public health data standards, provides
greater payback for the electronic capture of clinical information while providing a stronger
basis for assessing quality. This, in turn, supports new payment models.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
Timely sharing of harmonized clinical and administrative information with acknowledgement
of receipt of correct information eliminates delay, reduces costs, improves care delivery, and
leads to the potential of more accurate payment models.
A harmonized approach can provide greater payback for use of certified EHR technologies. A
harmonized approach also may support development and implementation of new payment
models by facilitating quality reporting and outcomes measurement.
Benefits of greater alignment of clinical and administrative healthcare information and
population health information accrue for all healthcare stakeholders through lower costs,
improved healthcare delivery and outcomes, and improved choice. Consumers enjoy improved
usability of administrative and clinical information in their own medical record set. Health
plans benefit through improved case and disease management, which improves care
coordination at lower cost. Public health is better able to identify disease outbreaks and
population health interventions.
ACTION STEPS:
Short-Term
Establish a working group to review existing methods, standards, and implementation
guides for identification of gaps that impede linking of clinical and administrative healthcare
information.
Develop action plan for achieving industry consensus on methods and standards that are
consistent with the goals and objectives of ONC’s strategic plan, and with rulemaking on
claims attachments and EHR certification for quality reporting in Stage 3 of Meaningful Use.
Design and launch awareness and education campaign.
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2013 WEDI REPORT
Mid-Term
Pilot, test, and evaluate effectiveness of methods and standards in achieving defined
harmonization outcomes.
Develop action plan for achieving industry adoption of methods, standards, and
easy-to-understand implementation guides.
Engage health plans and healthcare providers for adopting methods and standards.
Longer-Term
Continue awareness, education, and adoption campaign.
Payment Models
With the passage of the Affordable Care Act, a significant number of institutions have been
actively implementing various new payment models. According to a 2011 Rand Health
Technical Report entitled “Payment Reform: Analysis of Models and Performance Measurement
Implications,”12 there were over 100 payment models identified. One example of new payment
arrangements includes Accountable Care Organizations (ACO). According to Leavitt Partners
data published in the January 2013 Becker’s Hospital Review, there are currently 99 hospitalsponsored ACOs, 38 physician group-sponsored ACOs and 27 payer-sponsored ACOs.13
However, with these new forms of payment come new complexities in implementation.
As part of the efforts of this workgroup, a survey was conducted to determine usage,
attributes, and barriers to their implementation. In evaluating the responses, approximately
53 organizations cited barriers to implementing alternative payment models (with number
reporting in parentheses):
Lack of administrative bandwidth (7)
Cost of infrastructure/model implementation or ongoing participation (6
Internal stakeholders (e.g., providers, leadership) not interested in alternative payment
models (8)
Infrastructure challenges related to information/data exchange (7)
Infrastructure challenges related to technology (9)
Managing third party relationships that were impacted by the payment model (e.g.,
technology vendor) (7)
Regulatory barriers (7)
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2013 WEDI REPORT
One recommendation was identified for payment models:
Develop a framework for assessing critical, core attributes of alternative
payment models – such as connectivity, eligibility/enrollment reconciliation,
payment reconciliation, quality reporting and care coordination data
exchange, and education – and the technology solutions that can mitigate
barriers to implementation.
While it is clear that payment models will continue to evolve in the U.S. healthcare system,
there do appear to be some common attributes regarding their implementation that serve as
a basis for the recommendation in this section. From the 2013 WEDI survey on payment
models, it became evident that there is significant variability in the difficulty of
implementing various payment models and in some cases, no standards in place to help
facilitate the exchange of healthcare information. For example, in bundled payment
arrangements, many transactions conducted are transmitted in Microsoft Excel rather than in
standard claim formats (e.g. ASC X12).
This recommendation proposes to create a framework in order to better understand the core
attributes of each payment model, in terms of implementation, and then work to develop
solutions that can help foster their adoption. The recommendation will, in essence, map out the
workflows of each of the implemented payment models and then map where existing tools and
infrastructure exist, where there are challenges, or where modifications should be considered.
BUSINESS DRIVERS & EXPECTED OUTCOMES:
A key business driver for the implementation of this recommendation involves building a
sound business case and methods to evaluate return on investment (ROI) for new technology
solutions. Additionally, as part of physician workflow, there is a need to document and track
encounters and evaluate them for their impact on cost, quality and utilization. Once
attributes and commonalities have been identified, further work needs to be conducted in
order to assess whether the expected return exceeds the cost of implementing change.
Additionally, evaluation will be conducted to assess their accuracy, reliability, and quality.
Ultimately, these tools would be expected to demonstrate measurable reduction of
organizational costs, improved efficiency, and improved health outcomes.
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2013 WEDI REPORT
ACTION STEPS:
Short-Term
Establish a working group to develop the framework and perform a gap analysis of
technology needs – connectivity and functional applications – that would facilitate
implementation of alternative payment models.
As part of developing a framework, ascertain the critical, core attributes, information, and
technology needs and requirements of current alternative payment models.
Develop action plan for educating healthcare stakeholders on technology solutions that
would facilitate implementation of alternative payment models.
Mid-Term
Assess the technology market to determine existing solutions that could facilitate
implementation and adoption of alternative payment models.
Develop action plan for achieving industry adoption of technology solutions for alternative
payment models, including standards, as necessary.
Engage, through media awareness and education, health plans, healthcare providers,
employers, and consumers in critical attributes for implementing alternative payment models.
Longer-Term
Depending on action plan for achieving industry adoption of technology solutions, launch
media awareness, education, and adoption campaign.
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2013 WEDI REPORT
Conclusion
T
he recommendations presented provide an opportunity for the healthcare industry to work
collaboratively to leverage Health IT infrastructure in order to allow the healthcare system
to expeditiously move forward with new modalities of payment and care coordination. The
2013 WEDI Report recommendations serve as a framework for action. These recommendations
will help advance the U.S. healthcare system in order to meet the dual objectives of decreasing
cost and improving quality. They also will contribute to improved information for population
health.
Clearly, a challenge in implementing the recommendations presented is the challenge of
resources available. The healthcare industry today has numerous new regulations already
underway (e.g. ICD-10, ACA Operating Rules, and Meaningful Use). The 2013 WEDI
Report project attempted to remain mindful of these resource constraints, yet focus on a
strategy beyond existing regulation in order to build a sustainable infrastructure to support
the future system of healthcare in our nation. The recommendations presented provide for a
real-world approach that is business-driven, actionable, impactful, measurable, and sustainable.
Through their implementation, it is the conclusion of the 2013 WEDI Report that the
healthcare industry can achieve its goal of getting the right data, to the right place, at the
right time.
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2013 WEDI REPORTE
Addendum 1: 2013 WEDI Report Action Steps
Patient Engagement
Recommendation
Standardize the patient
identification process
across the healthcare
system.
Short-Term
Convene industry to
identify best practices
related to patient
matching.
Mid-Term
Longer-Term
Initiate pilots and explore
potential dissemination
strategies.
Continue consumer
awareness and
education campaign,
and launch adoption
campaign.
Pilot and test educational
and literacy materials.
Launch Health IT
educational and literacy
program.
Pilot and test businessdriven applications using
various devices.
Launch appropriate
applications.
Launch consumer
awareness and education
campaign.
Expand Health IT education
and literacy programs for
consumers to encourage
greater use of Health IT,
with a goal of achieving
better care management
and overall wellness.
Identify patient-centric
curriculum and deployment strategy for
standardized Health IT
educational and literacy
materials.
Engage and design
Health IT educational
and literacy program.
Identify and promote
effective and actionable
electronic approaches to
patient information
capture, maintenance and
dissemination that
leverage mobile devices
and "smart" technologies
and applications.
Convene a group of
appropriate business and
clinical experts to define
and approve the standard
technology, data content,
and dissemination strategy.
Identify a standard subset
of essential health
information for use in an
emergency situation, such
as an injury or natural
disaster, to which a
consumer and designated
healthcare provider would
have immediate access.
Develop implementation
strategy for rollout of
successful applications on
various devices.
Educate media and
consumers on the value of
utilizing such applications
on various devices.
Engage vendors in preparing
for deployment of chosen
applications on various
devices.
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2013 WEDI REPORT
Patient Engagement (continued)
Recommendation
Short-Term
Identify and promote
effective and actionable
electronic approaches to
patient information
capture, maintenance and
dissemination that
leverage mobile devices
and “smart” technologies
and applications.
Identify a set of mobile
smart technologies and
applications, along with
health-related Web sites
that are easy to use and
tolerant of error in order to
provide required healthcare
information to users in a
timely manner.
Mid-Term
Longer-Term
Establish a pilot to determine
best practices and
effectiveness of tested
actions.
Innovative Encounter Models
Recommendation
Identify use cases,
conventions, and operating
standards for promoting
consumer health and
exchange of telehealth
information in a mobile
environment.
Short-Term
Determine the correlation
between current market
driven technology
development and major
health initiatives.
Map electronic encounters
(telehealth, email, text, and
care monitoring) by typical
use, and develop a matrix
that shows how innovative
encounters are typically
used.
Mid-Term
Partner with existing
stakeholders to identify
criteria to evaluate and
prioritize the efficacy of
technology initiatives
specifically related to
innovative encounters.
Longer-Term
Develop and/or modify
standards and operating
rules as required to support
innovative encounters.
Develop a detailed list of
stakeholders that are
focused on innovative
encounters and align
resources for action.
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2013 WEDI REPORT
Innovative Encounter Models (continued)
Recommendation
Facilitate adoption and
implementation of “bestin-class” approaches that
promote growth and
diffusion of innovative
encounters across the
marketplace and that
demonstrate value for
patients, providers, and
payers.
Short-Term
Mid-Term
Convene appropriate
stakeholders to evaluate
encounter models in terms
of: patient support and
satisfaction, outcomes, and
ease of integration in
provider workflow, and
liability issues.
Continue annual survey of
consumer awareness usage,
and satisfaction of
electronic encounters.
Longer-Term
Gather and assess existing
protocols and suggested
payment methodologies
related to electronic
encounters (telehealth,
email, text, and care
monitoring).
Develop criteria to evaluate
their efficacy and rank
innovative encounters
protocols.
Survey consumers to
determine awareness and
likelihood of using
electronic encounters and
willingness to pay for such
encounters based on
alternative pricing models
and perceived value of the
encounter compared to an
in-person encounter.
Identify existing or
proposed federal or statebased laws or regulations
that create barriers to the
implementation of
innovative encounters
(including licensure).
Convene appropriate groups
that will identify specific
regulatory barriers, existing
best practices, and
potential solutions.
Longer-Term
Continue monitoring federal
and state legislative and
regulatory landscape for
potential regulatory barriers
and best practices.
Create policy mechanisms
and partnerships that can
encourage alternative
sustainability of legislation
in support of innovative
encounters.
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2013 WEDI REPORT
Data Harmonization & Exchange
Recommendation
Identify and promote
consistent and efficient
methods for electronic
reporting of quality and
health status measures
across all stakeholders,
including public health,
with initial focus on
recipients of quality
measure information.
Short-Term
Establish a working group to
review existing methods and
standards for electronic
Clinical Quality Measurement (eCQM).
Develop action plan for
achieving industry
consensus on methods and
standards.
Design and launch
awareness and education
campaign.
Identify and promote
methods and standards for
healthcare information
exchange that would
enhance care coordination.
Establish a working group to
review existing methods,
standards, and implementation guides for identification
of gaps that impede
connectivity and timely
information sharing for care
coordination.
Develop action plan for
achieving industry
consensus on methods and
standards.
Design and launch
awareness and education
campaign.
Identify methods and
standards for harmonizing
clinical and administrative
information reporting that
reduce data collection
burden, support clinical
quality improvement,
contribute to public and
population health, and
accommodate new payment
models.
Establish a working group
to review existing
methods, standards, and
implementation guides for
identification of gaps that
impede linking of clinical
and administrative
healthcare information.
Mid-Term
Pilot, test, and evaluate
effectiveness of standards
in achieving defined
outcomes.
Longer-Term
Continue awareness,
education, and adoption
campaign.
Develop action plan for
achieving industry adoption
of standards.
Engage health plans and
healthcare providers in
adopting electronic Clinical
Quality Measurement
standards (adoption
campaign).
Pilot, test, and evaluate
effectiveness of methods
and standards in achieving
defined outcomes.
Continue awareness,
education, and adoption
campaign.
Develop action plan for
achieving industry adoption
of methods, standards, and
easy-to-understand
implementation guides.
Engage health plans and
healthcare providers in
adopting methods and
standards
Pilot, test, and evaluate
effectiveness of methods
and standards in achieving
defined harmonization
outcomes.
Continue awareness,
education, and adoption
campaign.
Develop action plan for
achieving industry adoption
of methods, standards, and
easy-to-understand
implementation guides.
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2013 WEDI REPORT
Data Harmonization & Exchange (continued)
Recommendation
Short-Term
Identify methods and
standards for harmonizing
clinical and administrative
information reporting that
reduce data collection
burden, support clinical
quality improvement,
contribute to public and
population health, and
accommodate new payment
models.
Develop action plan for
achieving industry
consensus on methods and
standards that are
consistent with goals and
objectives of ONC’s strategic
plan, and with rulemaking
on claims attachments and
EHR certification for quality
reporting in Stage 3 of
Meaningful Use.
Mid-Term
Longer-Term
Engage health plans and
healthcare providers for
adopting methods and
standards.
Design and launch awareness
and education campaign.
Payment Models
Payment Models
Short-Term
Mid-Term
Develop a framework for
assessing critical, core
attributes of alternative
payment models –– such as
connectivity, eligibility/
enrollment reconciliation,
payment reconciliation,
quality reporting and care
coordination data
exchange, and education ––
and the technology
solutions that can mitigate
barriers to implementation.
Establish a working group to
develop the framework and
perform a gap analysis of
technology needs —
connectivity and functional
applications — that would
facilitate implementation of
alternative payment models.
Assess the technology
market to determine
existing solutions that could
facilitate implementation
and adoption of alternative
payment models.
As part of developing a
framework, ascertain the
critical core attributes,
information, and technology
needs and requirements of
current alternative payment
models.
Develop action plan for
educating healthcare
stakeholders on technology
solutions that would
facilitate implementation of
alternative payment models.
Longer-Term
Develop action plan for
achieving industry adoption
of technology solutions for
alternative payment models,
including standards, as
necessary.
Engage, through media
awareness and education,
health plans, healthcare
providers, employers, and
consumers in critical
attributes for implementing
alternative payment models.
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2013 WEDI REPORT
Addendum 2: Workgroup Members
VOLUNTEERS
O R G A N I Z AT I O N S
Kristina Moorhead
Christina Beckley
Phillip Deleel
Julie Dooling
Lesley Kadlec
Lisa Brooks Taylor
Danielle Jones
Eric Grindstaff
Kellie Brabec
Jason Mitchell
Dennis McHugh
Jean Narcisi
Ornela Besho
Michael Tutty
Nancy Spector
Mary Lynam
Kim Henderson
Krishna Vucha
Mimi Shaw
Dan Lee
Jon Zimmerman
Karin Lindgren
Mark Lucido
Mark Martin
Sean Kilpatrick
Steve Boyd
Kathleen Harris
Anshu Choudhri
Joel Slackman
Lenel James
Malvi Patel
Matthew Schuller
Richard Cullen
William Alfano
Susan Langford
Carol Poterek
Loran Cook
Barbara Sesny
Leisa Newland
Joel Prater
Candace Marton
Steven Lazarus
Ronald Wilson
LaVonne LaMoureaux
AARP
Accenture
Adirondack Health
AHIMA
AHIMA
AHIMA
Allscripts
Allscripts
Allscripts
American Academy of Family Physicians
American Dental Association
American Dental Association
American Dental Association
American Medical Association
American Medical Association
Argus Health Systems, Inc.
Arkansas BCBS
Arkansas BCBS
AT&T Wireless
Availity, LLC
Availity, LLC
Availity, LLC
Availity, LLC
Availity, LLC
Availity, LLC
Availity, LLC
Banner Health
BCBS Association
BCBS Association
BCBS Association
BCBS Association
BCBS Association
BCBS Association
BCBS Association
BCBS of Tennessee
Beaumont Health System
Billian's HealthDATA
Blue Cross Blue Shield Minnesota
Blue Ridge Hospice, Inc.
Blue Shield of CA
Boost Payment Solutions, LLC
Boundary Information Group
Brentwood Neurology, P.C.
California Health Information Assn.
PAGE 41
2013 WEDI REPORT
VOLUNTEERS
O R G A N I Z AT I O N S
Barbara Patterson
Tamara Tromblay
Hetty Khan
Gladys Wheeler
John Guchemand
Kamahanahokulani Farrar
Robert Anthony
Travis Broome
Vidya Sellappan
Mary Woods
Mary Hoffman
Meghan Butler
Sawrab Nayak
Peggy Lynahan
Paul Keyes
Lou Morentin
Denise Elden
Kateisha Martin
Kathleen Connors de Laguna
Amee Parikh
Eric McLaughlin
Nathan Culkin
Roxana Kahn
Jon Morrill
Julia Chan
Wil Limp
Cheryl MacDougall
Rob Sikorski
Cassandra Skittle
Eric Pupo
James Silveira
Tom Drinkard
Catherine West
Kathryn Ruckle
Jennifer Hasty
Lisa Crymes
Siva Tunga
Tanya Krytlsova
Joanmarie Cifelli
Misty Drucker
Wendy Mariscal
Rajeesh Menon
Scott Emmert
Sue Scharps
Michael Nelson
Kimberly Phillips
Keith Hatch
Terrie Reed
Donald Masser
Anthony Tulio
Katie Monastiere
Calvert Memorial Hospital
CareFirst
Centers for Disease Control and Prevention (CDC)
Centers for Medicare & Medicaid Services (CMS)
Centers for Medicare & Medicaid Services (CMS)
Centers for Medicare & Medicaid Services (CMS)
Centers for Medicare & Medicaid Services (CMS)
Centers for Medicare & Medicaid Services (CMS)
Centers for Medicare & Medicaid Services (CMS)
Cerner Corporation
CGI
CGI
CGI
Christiana Care
CIGNA Health Care
ClearDATA
Cloque Hospital
CMS-Office of Enterprise Management
CMS-Office of Enterprise Management
Cognizant
Cognosante, LLC
Colorado Department of Health Care Policy and Financing
CompuGroup Medical US
CSG Government Solutions
CW Global Consulting, LLC
Davenport University
DaVita
DaVita
Deloitte Consulting
Deloitte Consulting
Deloitte Consulting
Delta Dental of Virginia
Department of Vermont Health Access
DSHS Washington
DST Health Solutions
DST Health Solutions
Edifecs
Edifecs
EmblemHealth
EmblemHealth
EmblemHealth
eMids Technologies
Engaged Health, LLC
Episode Alert, LLC
Equifax Inc.
Eye Care Associates of Greater Cincinnati
Florida Blue Cross Blue Shield
Food and Drug Administration (FDA)
Geisinger Health System
General Dynamics Information Technology
Great Lakes Caring
PAGE 42
2013 WEDI REPORT
VOLUNTEERS
O R G A N I Z AT I O N S
Peter Wong
Ram Ananthasubramony
Durwin Day
Camille Mastronardi
Mark Kemerer
Tony Harris
Tracy Boldt
Hattie Curry
Donna Wimberg
Debbie Buckman
Hugo Rams Jr MD
Kim Peters
Melissa Wright
Merila Walker
Christopher Gracon
Barbara Sesny
Carol Potter
Carol Walston
Holly Shaw
Jamie Jozwiak
Janet Ferlita
Kathy Giannangelo
Kellie Brabec
Kristina Moorhead
Laura Dowling
Merila Walker
Misty Drucker
Mitch Goldman
Monica Sander
Phillip Deleel
Robert Cooley
Stephen Carter
Victoria Conboy
Ellen Van Buskirk
Jeff Price
Waco Hoover
JoAnne Carlson
Koreen LeMaster Rayl
Rachel Lunsford
Anthony Rizzi
Megan Zimmermann
Rob Alger
Laurie Woodrome
Liora Alschuler
Diana Kwiecinski
Rebecca Dunton
Laura Darst
Elena Elkina
Elitsa Evans
Kathleen Hayden
Maggie Lohnes
Gupton Marrs International
HCL Technologies
Health Care Service Corporation
Health Language, Inc.
Healthcare Assist Services
Healthesystems
Hennipen County Medical Center
Highmark Blue Cross Blue Shield
Horizon Blue Cross Blue Shield
Hospital Sisters Health System
Hugo Rams Jr MD PA
Humana, Inc.
Humana, Inc.
ICC-Centex
Independent Health
Individual
Individual
Individual
individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Individual
Infosys Public Services
Innovative Healthcare Systems, Inc.
Institute for Health Technology Transformation
Inventiv Health
Iowa Medicaid Enterprise
Iowa Medicaid Enterprise
Kaiser Permanente
Kaiser Permanente
Kaiser Permanente
LabCorp
Lantana Consulting Group
Lighthouse Hospice Inc.
Magellan Health Services
Mayo Clinic
McKesson
McKesson
McKesson
McKesson
PAGE 43
2013 WEDI REPORT
VOLUNTEERS
O R G A N I Z AT I O N S
Marian Reed
Megan Callahan
Sheila Miller
Suzanne Travis
David Russell
Mary Beth Navarra-Sirio
Linda Connelly
Carol Germain
Cindy Buege
Melissa Moorehead
Brian Ahier
David Haugen
Jeff Peters
Hope Berhorst
Samuel Rubenstein
Susana Vallelonga
Priscilla Holland
Desiree Ahmann
Jennifer Sprague
Sandy Cho
David Wierz
Elissa Chandler
Anirban Mukherjee
Brett Dunne-Feldman
Davina Huston
Roxanne Hanson
Marsha Trump
Debra Michalek
Kay Hylton Christensen
Thomas Hudson
Dennis Sullivan
Tim Hale
Michelle Taber
Lorrie Pritt
Vera Rulon
Jordana Cohen
Nisreen Hussain
Amy Schumacher
Tina Schrader-Berte
Avis Bishop
Sonya Bess
Robert Tulio
Karen Ryker
Connie Brown
Denise Oviatt
Jeff Breitfelder
John Evans
Betty Westbrook
Trina Wright
Jennifer Searfoss
Jeanette Jepson
McKesson
McKesson
McKesson
McKesson
McKesson
McKesson
Medical Mutual of Ohio
MedImpact Healthcare Systems
Michigan Public Health Institute
Michigan Public Health Institute
Mid-Columbia Medical Center
Minnesota Department of Health
Mirth Corporation
Mo. Dept of Mental Health
Montefiore Medical Center
Morgan Borszcz Consulting
NACHA - The Electronic Payments Association
Nebraska Medicaid
Nephrology Associates of Syracuse, PC
Newton-Wellesley
NextGen Healthcare Information Systems
NextGen Healthcare Information Systems
NIIT Technologies, Inc.
Nova Southeastern University
OK Office of Management & Enterprise Services
Optum
Oregon Health Authority
Orleans Community Health
Palmetto Health
Parkview Health
Partners Healthcare
Partners HealthCare System
PDS Cortex
Peak Vista Community Health Center
Pfizer
Practice Fusion, Inc.
Practice Fusion, Inc.
PricewaterhouseCoopers
Pro Ed Continuum LLC
Pulse Systems
Pulse Systems
RAM Technologies, Inc.
RC Billing
Reid Hospital
RelayHealth
RelayHealth
RelayHealth
Rycan Technologies
Saint Luke's Health System
Searfoss Consulting Group, LLC
Seaview Orthopaedics and Medical Associates
PAGE 44
2013 WEDI REPORT
VOLUNTEERS
ORGANIZATION
Joseph Gonzalez
Alan Guggenheim
Sandy Beck
Hans Buitendijk
Kathleen Ochal
Susan Welter
Alice Shumate
Jonathan Orgel
Ryan Newsome
Lori Grudzien
Catherine Mesnik
Michele Romeo
Brett Johnson
Michael Hamilton
Cindy Underwood
Elinor Schoenfeld
Patrice Kuppe
Jennifer Pawlowski
Gayle Serikawa
Melanie Meyer
Rose Sarcopski
Theresa Dolan
Mary Hyland
Margaret Weiker
Dave McCord, PMP
Michael Richmond
Dawn Sprague
Michelle Koliopoulos
Valerie Breslin Montague
Peter Anderson
Tammy Banks
Patrick Sauer
Susan Hilgers
Paula Kessler
Sue Zimmerman
Susan Thornton Horn
Sarah Lucas
Ramona Nelson
Tawanda Lindo
Charles Drogaris
Diana Wallace
John Jesser
Susan Huggins
Kerry O'Brien
Laurie Burckhardt
Barbara Atherton
Betty Gomez
Carol Poterek
Secure EDI
Sensible Care
Sharp Healthcare
Siemens Healthcare
Siemens Healthcare
Sound Health Care Center
Spectrum Health, Inc.
SRS Software
SRS Software
St. John Providence Health System
St. Joseph Health System
State of New Jersey Department of Human Services
StoneFace Ventures
StrategicHealthSolutions, LLC
Stubbs Prosthetics & Orthotics, Inc.
SUNY Stony Brook University Hospital
Surescripts
Surgical Specialists, PC
TeamPraxis LLC
The Gartner Group
The Health Plan
The Mount Sinai Medical Center
The SSI Group, Inc.
The Weiker Group
TM Floyd & Company
Touchstone Health
TriZetto Group, Inc.
UCPG
Ungaretti & Harris LLP
UnitedHealth Group
UnitedHealth Group
UnitedHealthcare
University of Texas Health Science Center, San Antonio
University of Toledo Medical Center
University of Wisconsin Medical Foundation
University of Washington Hospital and Clinics
University of Washington Medicine
Verizon
Virginia Premier Health Plan, Inc.
VNS CHOICE
Walgreens
WellPoint
WellStar Health System
Winthrop-University Hospital
WPS Insurance
ZirMed, Inc.
ZirMed, Inc.
ZirMed, Inc.
PAGE 45
2013 WEDI REPORT
Addendum 3: 1993 WEDI Report As A Roadmap To 2013
I
n early 1991, then Secretary of Health and Human Services, Louis W. Sullivan, MD asked
healthcare business leaders to help simplify the healthcare industry’s complex and costly
administrative processes. At the time, administrative processes to manage health information,
including billing and claims processes, had become out-of-sync with clinical processes and
burdensome to health care practitioners. The majority of healthcare transactions were
paper-based, formats were non-standard, and if a physician performed the same procedure for
patients with a different health plan, the physician likely would have to use a different local
code for each health plan. Counting the number of health plans, number of physicians, and
number of encounter diagnoses and procedures, one quickly had a complex administrative
nightmare that meant additional work in tracking information for code value assignment, and
inconsistent data that did not lend itself to measurement, such as calculating best practices
through research.
Fundamentally, in the early 1990s, there was an absence of standards for communications
throughout the transaction process. The result was significant inefficiencies, processing errors,
and large administrative costs: wasted time and effort; back-and-forth eligibility dialogues;
repeated filings; denied claims; payment collection debates involving time of payers, providers,
and patients; distrust among stakeholders; confusion over status of claims; telephone and
postage costs; and delay.
Today, stakeholders increasingly take for granted the simplicity and instant ability to
communicate by voice or text wirelessly or through social media,14 access or move large
amounts of information via smartphones and tablets through search engines,15 or record and
retrieve entertainment events on television or through computer streaming when it is most
convenient to view – all at relatively low cost. But in the early 1990s, it was an environment
of landline and paper communications.16 The Internet only had 3 million users,17 73 percent
who lived in the United States, and there were only about 5.3 million cell phone
subscribers.18 In that period, the United States was just beginning to make the transition
from the electric typewriter environment and thin client workstations linked to mainframe
and mini-computers to the emergent electronic standalone DOS workstation environment19
with sparse memory and storage capacity.
While electronic data interchange (EDI) and standardization of data elements and formats was
beginning to show benefits in many industries, it was not taking hold in healthcare with
PAGE 46
2013 WEDI REPORT
diverse and competitive stakeholders and with national health expenditure in 1990 of $724.3
billion, or 12.5 percent of gross domestic product (GDP), even then relatively high compared
to other industries.20
As Secretary of HHS in the early 1990s, Dr. Sullivan had to address the rising cost of
healthcare, the growing pace of healthcare expenditure relative to growth in GDP, and the
lack of standardization in healthcare that kept administrative costs growing with an
increasing population21 and demand for healthcare resources. Dr. Sullivan met with healthcare
industry business leaders and charged them with the mission to determine what could be
accomplished by containing costs from moving from paper to electronic methods in
healthcare administration and what was required to do it in a timely manner (see sidebar
interview of Dr. Sullivan).
As a result of the charge to these business leaders, the WEDI organization was formed. Dr.
Sullivan expressed exasperation with the fragmented healthcare transaction system and high
administrative costs and collectively the participants agreed that a major overhaul was
required. The business leaders also agreed that the federal government had to use its
regulatory authority to foster agreement on industry adoption of standard codes in lieu of
myriad federal, state, and local codes.
Dr. Sullivan assigned four agencies and organizations to work together and come to an
agreement on how to achieve administrative simplification:
The National Committee on Vital and Health Statistics (NCVHS).22
Centers for Disease Control and Prevention (CDC).23
National Institutes of Health (NIH).24
The Workgroup for Electronic Data Interchange (WEDI).25
The specific challenge to WEDI, a non-profit collaboration of government and business, was
to find a way to:
Decrease administrative costs of healthcare.
Eliminate software adaptations of multiple formats.
Agree on one data standard for sending and receiving electronic healthcare information.
Provide the means to allow growth of electronic commerce in the healthcare industry.
As part of its mission, WEDI examined the impact of electronic technology in minimizing
administrative costs of health care transactions. In its 1993 Report, WEDI indicated that the
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2013 WEDI REPORT
savings from using electronic technology in standardized data elements and formats could be
substantial.26 The 1993 WEDI Report became the foundation of the Administrative
Simplification provisions of the Health Insurance Portability and Accountability Act of 1996
(HIPAA),27 which President Clinton signed into law on August 21, 1996.
1993 WEDI Report
T
he work underpinning the 1993 WEDI Report was conducted in 11 Technical Advisory
Groups over a year’s period from a preliminary report published in July 1992 that
outlined steps that would be necessary to achieve the mission outlined by then Secretary
Sullivan. A description of the work conducted for the 1993 WEDI Report and the overall
recommendations of the 11 Technical Advisory Groups are presented in the following
selection from the Executive Summary of the 1993 WEDI Report published in October 1993:
“In November 1991, the Workgroup for Electronic Data Interchange (WEDI) was established
in response to the challenge to reduce administrative costs in the nation’s health care system.
A voluntary, public-private task force, WEDI developed an action plan to streamline health
care administration by standardizing electronic communications across the industry.
In July 1992, WEDI published a report that outlined the steps necessary to make electronic
data interchange (EDI) routine for the health care industry by 1996. The Workgroup
envisioned a health care industry transacting business electronically, using one set of
electronic standards and interconnecting networks. Since that publication, the health care
industry independently pushed forward and made substantial gains with EDI
implementation:
ASC X1228 approved the claim and eligibility standards for trial use.
The Insurance Subcommittee of ASC X12 formed new workgroups to develop other
standards required by the health care industry.
HCFA29 initiated the use of Health Care Claim and Health Care Claim Payment/Advice
standards and developed EDI implementation guides for Medicare Part A Intermediaries and
Part B Carriers consistent with ASC X12 standards.
The private sector began developing EDI implementation guides.
PAGE 48
2013 WEDI REPORT
Efforts toward standardizing data content increased.
EDI awareness and participation heightened.
WEDI reconvened in 1993 to resolve remaining implementation obstacles and to:
Strengthen the understanding of and commitment to EDI among the health care industry,
policymakers, and consumers by:
Developing a targeted plan for using industry resources to educate key audiences on EDI.
Encouraging participation in demonstration projects that prove EDI benefits and cost savings.
Expanding membership to reflect more broadly the key constituencies affected by EDI.
Work for enactment of preemptive federal confidentiality protection for individually
identifiable health care information in an electronic environment.
Develop a strategy to facilitate quick, industry-wide transition to EDI, including universal
identifiers for patients, providers, and payers; health identification cards; coordination of
benefits in electronic environments; and implementation guidance for data standards.
Work with appropriate parties to ensure the health care industry can meet WEDI’s target of
universal adherence to uniform data content by 1996.
Provide additional data to the industry on the cost benefits of EDI, using demonstration
projects as a primary source.30
Monitor the industry’s progress toward the use of data standards and EDI.
Provide basic telecommunications requirements and promote WEDI’s goal of clearinghouse
accreditation by 1994.31
Serve as a resource to work cooperatively with the National Association of Insurance
Commissioners and state governments to coordinate state and national efforts on
administrative simplification.
WEDI expanded its financial analysis to encompass 11 health care transactions. Newly
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2013 WEDI REPORT
available data were added to estimate the potential savings for providers and to update the
estimated savings for payers and employers. Additionally, the cost of implementing EDI was
added to achieve a more comprehensive picture of EDI’s financial impact on the health care
industry.
WEDI’s 1993 financial analysis concluded that combining the estimated implementation
costs and the gross administrative savings potential, the cumulative net savings over the next
six years (to the year 2000) is estimated to total over $42 billion. Although the estimated net
savings may not translate directly to hard dollar savings for the nation’s health care system,
EDI savings will allow health care enterprises to reallocate resources from administrative
activities to enhance quality, patient care, and customer service.
To achieve this large cost savings, WEDI’s 11 Technical Advisory Groups developed the
following major recommendations. These recommendations, along with additional “key”
supporting recommendations,32 are provided, in full, in the Report section of the 1993 WEDI
Report [in Appendices 1-11]. The major recommendations are summarized here by Technical
Advisory Group:
Standards Implementation and Uniform Data Content. Require specific and defined
instructions through implementation guides to support uniform data content and coding
structures.
Network Architecture and Accreditation. Develop a network architecture to support a
broad array of applications, communications, access methods, protocols, and line speeds.
Confidentiality and Legal Issues. Enact the model federal preemptive legislation drafted by
WEDI to preserve confidentiality and privacy rights of individually identifiable health care
information.
Unique Identifiers for the Health Care Industry. Identify unique, standard identification
numbers to promote industry standardization and uniformity of health care data.
Education and Publicity. Develop and promote a comprehensive education and publicity
work plan designed to provide standardized, economically affordable, and geographically
accessible education opportunities for all EDI constituents.
Health Identification Cards. Develop the ASC X12 standard for data content and format for
health identification cards.
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2013 WEDI REPORT
Short-Term Strategies. Continue demonstration projects that are ecumenical, identifiable to
the public, demonstrate industry cooperation, leverage existing infrastructures, add
something new, measure results, and meet aggressive time frames to demonstrate that
technology is currently available to implement WEDI recommendations.
State/Federal Role. Clearly delineate state and federal roles for EDI implementation.
Financial Implications. Provide ongoing analysis of the financial implications of EDI
implementation.
Coordination of Benefits. Automate the coordination of benefits process.
Health Care Fraud Prevention and Detection. Use electronic environments and standardized
data to improve fraud detection.”
It was the expectation from the 1993 WEDI Report, as indicated in several points in the
Executive Summary above, and in the language of the compliance dates outlined in the
HIPAA Administrative Simplification legislation and enabling regulations33 that the
implementation of electronic commerce in healthcare, namely, adoption and use of standard
transactions and identifiers, would have occurred more quickly than it has. For
example, the unique individual identifier and acknowledgment standard have not been
adopted, and the national health plan identifier has only recently been finalized,34 and is not
required to be used in standard transactions until November 7, 2016.
Addendum 4 identifies progress made through the regulatory process in promulgating
standards in the period from the publication of the 1993 WEDI Report to the present that
have been implemented as a direct result of the 1993 WEDI Report and the derivative
Administrative Simplification provisions of the HIPAA legislation and similar provisions of
its successors, the HITECH Act (February 2009) and Patient Protection and Affordable Care
Act (March 2010). The Exhibit below provides a 2013 status35 of the recommendations from
the 1993 WEDI Report.
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2013 WEDI REPORT
Addendum Table 3-1
2013 WEDI Report Recommendations and Status
Technical Advisory Group
1. Standards Implementation and
Uniform Data Content
Recommendation
2013 Status
Require specific and defined instructions through
implementation guides to support uniform data content and
coding structures.
1. Mandate, by federal law, that all health care participants
use ASC X12 standards, beginning with the core transaction
sets: Enrollment, Eligibility, Claims Submission, and Claim
Payment/Advice. Where appropriate ASC X12 standards do
not currently exist (e.g., the National Council of Prescription
Drug Program (NCPDP) interactive standards), the Secretary
of HHS, or other appropriate body, will approve use of other
widely recognized standards for a transitional period to
permit development of equivalent ASC X12 standards.
Complete
2. Require Category I payers (50,000 or more claims or
encounters per year), providers (group practices of 20 or
more physicians, hospitals, and nursing homes), and
employers (with 100 or more employees) to adopt and
implement approved ASC X12 standards by 1994IV; require
Category II participants (remaining payers, providers, and
employers) to implement approved ASC X12 standards by
1996IV.
Complete
3. Develop implementation guides that standardize data and
coding structures supporting the ASC X12 standards. Industry
groups, such as the National Uniform Billing Committee
(NUBC) and the Uniform Claim Form Task Force (UCFTF),
should be consulted.
Complete
4. Establish a health care action group to coordinate
development of implementation guides, perform other industry
supportive functions, and evaluate and report on implementation progress every six months.
Ongoing
5. Develop a program of incentives (such as higher tax credits
and accelerated depreciation) to encourage timely implementation of the ASC X12 transaction sets by Category I and II
participants.
Substituted by
HIPAA Legislation
PAGE 52
2013 WEDI REPORT
2013 WEDI Report Recommendations and Status (continued)
Technical Advisory Group
Recommendation
1. Standards Implementation and
Uniform Data Content
6. Designate WEDI to coordinate a study to identify the need
for claims attachments to eliminate capturing and transmitting unnecessary information. A report of the findings, along
with data analysis and recommendations, will be submitted to
the Secretary of HHS or other appropriate body.
2. Network Architecture and
Accreditation
Develop a network architecture to support a broad array of
applications, communications, access methods, protocols,
and line speeds.
2013 Status
Complete
1. Use an International Standardization Organization Open
Systems Interconnection (ISO OSI) structure to facilitate
“any-to-any” connectivity and promote open access to the
network for all participants.
In Process
2. Endorse ASC X12 security guidelines and support the
development of industry security standards to ensure
confidentiality and security of health care data.
Complete
3. Establish performance standards and standard trading
partner agreements for all network participants as a
cost-effective alternative to a formalized clearinghouse
accreditation program.
3. Confidentiality and Legal Issues
Enact the model federal preemptive legislation drafted by
WEDI to preserve confidentiality and privacy rights of
individually identifiable health care information.
Enact the model legislation drafted by WEDI, which is
designed to:
Complete
Preserve confidentiality and privacy rights in individually
identifiable health care information that is collected, stored,
processed, or transmitted in electronic form;
Preempt applicable state laws, except public health
reporting laws;
Establish a mechanism for securing information when
collected, stored, processed, or transmitted in electronic form;
Require publication of the existence of health care data
banks;
Encourage the use of alternative dispute resolution
mechanisms;
Establish penalties.
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2013 WEDI REPORT
2013 WEDI Report Recommendations and Status (continued)
Technical Advisory Group
4. Unique Identifiers for the Health
Care Industry
Recommendation
2013 Status
Identify unique, standard identification numbers to promote
industry standardization and uniformity of health care data.
1. Use the Social Security Number as a patient identification
number.
5. Education and Publicity
1. Use an International Standardization Organization Open
Systems Interconnection (ISO OSI) structure to facilitate
“any-to-any” connectivity and promote open access to the
network for all participants.
Congressional
Hold on
Development 36
2. Use the Social Security Number to identify individual
providers and the Tax Identification Number (which may be a
Social Security Number) to identify provider organizations
(physician group practice, hospitals, etc.). If, for privacy
reasons, the Social Security cannot be Used to identify
individual providers, then HCFA’s Unique Physician
Identification Number should be Used.
In Process
Develop and promote a comprehensive education and
publicity work plan designed to provide standardized,
economically affordable, and geographically accessible
education opportunities for all EDI constituents.
Identify existing organizations to implement the education and
publicity work plan. These organizations should develop the
following products and services:
Complete
Health care EDI education curriculum,
Educational delivery program (train-the-trainer),
EDI health care overview video,
Communications strategy to publicize EDI education activities,
Data base of individuals and organizations to be kept
informed of WEDI developments,
Directory of educational resources,
Electronic bulletin board service to distribute WEDI
information to members,
Information pamphlets, providing basic information to
potential EDI Users and consumers,
WEDI newsletter, providing basic information on WEDI
activities, legislative updates, and educational resources and
events.
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2013 WEDI REPORT
2013 WEDI Report Recommendations and Status (continued)
Technical Advisory Group
6. Health Identification Cards
7. Short-Term Strategies
Recommendation
2013 Status
Develop the ASC X12 standard for data content and format
for health identification cards.
1. Develop an ASC X12 standard for data content and format
for health identification cards by the end of 1993.
Complete
2. Where cards are issued, whether machine-readable or
human-readable, conform to approved ASC X12 standards by
January 1, 1995.
In Process
3. Cards should serve as a vehicle to identify entitlement to
benefits; they should not contain individual health care data.
In Process
Continue demonstration projects that are ecumenical,
identifiable to the public, demonstrate industry cooperation,
leverage existing infrastructures, add something new,
measure results, and meet aggressive time frames to
demonstrate that technology is currently available to
implement WEDI recommendations.
1. Continue ongoing demonstration projects and report
progress to WEDI monthly for purposes of publicity and
education.
In Process
2. Encourage other projects that demonstrate:
Transition to or development of ANSI transactions;
use of EDI in a managed care environment;
Involvement of physicians, hospitals, and other providers
and vendors;
Involvement of community organizations, government, and
business;
Incorporation of other WEDI objectives.
8. State/Federal Roles
State Role:
Facilitate the implementation of EDI. States may require
assistance in understanding concept of EDI and in discerning
their role relative to the federal government. States will be
provided with information kits that explain how to carry out
their EDI responsibilities.
Complete
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2013 WEDI REPORT
2013 WEDI Report Recommendations and Status (continued)
Technical Advisory Group
8. State/Federal Roles
Recommendation
2013 Status
Federal Role:
1. Define the transmission vehicle of EDI.
Complete
2. Establish and enforce uniform, preemptive confidentiality
standards.
Complete
3. Designate federal agencies that can provide states with
additional information on EDI implementation.
Complete
4. Help states and territories resolve public health policy
issues encountered in the implementation of EDI.
9. Financial Implications
10. Coordination of Benefits
11. Health Care Fraud Prevention
and Detection
Provide ongoing analysis of the financial implications of
EDI implementation.
1. Perform ongoing analysis and study of savings.
In Process
2. Perform a continuing analysis of how the potential
savings might be used.
In Process
Automate the coordination of benefits process.
1. Use ASC X12 transactions for COB information exchange.
Complete
2. Develop and implement a uniform and easily-interpreted
set of COB rules.
Complete
3. Require payers to crossover, electronically, claims to
secondary and subsequent payers.
In Process
4. Encourage providers to submit bills to payers on behalf
of their patients.
Complete
Use electronic environments and standardized data to
improve fraud detection.
1. Develop improved audit trails and profiles capable of
identifying fraudulent behavior.
In Process
2. Employ tools that identify suspicious activities, trends, or
patterns.
In Process
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2013 WEDI REPORT
Addendum 4: Building The U.S. Healthcare It
Infrastructure: 1993-2013
T
he 1993 WEDI Report had a significant impact on motivating the change from various
fragmented, proprietary, bilateral provider-payer data exchange relationships to
implementing standardized data elements and formats for payment and administration, thus
facilitating more efficient processing of electronic healthcare information. During the period
1993 to the present, there have been a series of regulatory initiatives that have propelled these
changes, starting with Administrative Simplification provisions of the Health Insurance
Portability and Accountability Act (HIPAA) in August 1996.37 Other initiatives continued
the process of change with modifications in the Health Information Technology for Economic
and Clinical Health Act of 2009 (HITECH Act),38 and Patient Protection and Affordable
Care Act (ACA).39 Pertinent enabling regulations for these legislative initiatives are presented
in Table 4-1 in this Addendum, with operating rule transaction standards presented in Table
4-2.
HIPAA Legislation
The 1993 WEDI Report became the foundation of the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA),40
which President Clinton signed into law on August 21, 1996. The first term in the title of
the law, Portability, guaranteed that an employee could obtain health insurance if he or she
changed jobs. The second term in the title, Accountability, began to identify who, what,
when, and how for specific health care activities and assigned specific roles for accountability
in order to demonstrate compliance. One part of Accountability covers Administrative
Simplification, which was designed to address the fragmented administrative systems in
health care.
The overall objectives of the HIPAA Administrative Simplification provisions were to:
Improve the efficiency and the effectiveness of the health care system via electronic exchange
of administrative and financial information;
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2013 WEDI REPORT
Protect the security and privacy of transmitted and stored administrative and financial
information; and
Reduce or eliminate sources of high transaction costs in health care, which include, but are
not limited to:
paper-based transaction systems,
multiple, nonstandard health care data formats, and
misuse, errors related to, and loss of health care records.
While these objectives appear manageable – simply implement administrative transactions so
that providers and payers filing electronically use the same data element codes and formats,
and do so securely – achieving the objectives has been problematic, as experience over the past
17 years has shown. First, there is a scale problem in getting 698,238 covered entities41 to
electronically use the same data element codes and formats for an estimated 12.9 billion
transactions annually.42 Then, there is the problem in getting consumers of healthcare
resources, who lack focus on managing their own healthcare information, to provide and
facilitate the use of accurate information as well. Finally, there is the problem in getting
diverse healthcare stakeholders with competing interests to come together and communicate
to solve electronic healthcare information exchange issues affecting each stakeholder.
There are four sets of HIPAA administrative simplification standards: transactions and code
sets, privacy, security, and identifiers, with each discussed in turn.43
Transaction Standards
A transaction refers to the electronic transmission of information between two parties to carry
out financial or administrative activities. “Covered entities must adhere to the content and
format requirements of each transaction.”44 The Transaction and Code Sets Rule required
compliance on October 16, 2003, by covered entities: health plans, health care clearinghouses,
and health care providers “who transmit any health information in electronic form with a
transaction covered by Administrative Data Standards and Related Requirements.”45 Under
the HIPAA Transaction Rule, if a covered entity conducts one of the adopted transactions
electronically, it is required to use the standard transaction and adhere to its content and
format specifications.
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2013 WEDI REPORT
The standard transactions included:
Health care claims or equivalent encounter information transaction
Eligibility for a health plan
Referral certification and authorization
Health care claim status
Enrollment and disenrollment in a health plan
Health care payment and remittance advice
Health plan premium payments
Coordination of benefits information.
A modified version of the transaction standards – from ASC X12 Version 4010 to Version
5010 – required compliance on January 1, 2012.46
Transaction standards were modified further with enactment of the Affordable Care Act in
March 2010 with the introduction of a new standard transaction – electronic funds transfers –
and conversion of existing standards to operating rules.47 These modified standard transactions,
with effective dates beginning, annually, January 1, 2013, and going through January 1, 2016,
are examined further in the ACA discussion later in this chapter.
Code Set Standards
Integral to the establishment and use of standard transactions are external medical and nonmedical code sets described in implementation guides that identify diagnoses, treatment
procedures, drug codes, equipment codes, financial codes, location codes, and other codes
necessary to effect a transaction by identifying a value that will populate as specified data
elements in a transaction. Knowledge of how codes are handled in standard transactions will
enhance the likelihood that transaction standards are transmitted error free, elicit a fast
response, and minimize time spent correcting errors and resubmitting transactions.
An example of a medical data code set is the International Classification of Disease, 10th
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2013 WEDI REPORT
Revision Clinical Modification (ICD-10-CM/PCS) ,48 which, by final rule, requires compliance
for all standard transactions on October 1, 2014.49 An example of a non-medical data code set
is zip code, used by each standard transaction, whose value is used to describe the location of a
physical address in the exchange of medical information.
One reason for the change to Version 5010 was to accommodate adoption of ICD-10 data
element format length. Another was to mitigate deficiencies that were impairing the goal of
achieving greater efficiency in using standard transactions. The deficiencies required providers
to use ‘companion guides’ created by health plans “to address areas of [the previous version]
that are not specific enough or require work-around solutions to address business needs. These
companion guides are unique, plan-specific implementation instructions for the situational
use of certain fields and/or data elements that are needed to support current business
operations.”50 A provider’s reliance on identifying different interpretations of situational fields
and data elements for properly submitting claims to multiple health plans is time-consuming
and costly.
Any new code set would have to be included in the implementation guides, which would
involve, as a first step, proposing the code set and supporting its business case as part of the
Designated Standard Maintenance Organization (DSMO) process.51 Healthcare stakeholders
have invested time and money in the development of standards through the DSMO process
and in implementation of standard transactions, including testing52 transactions between
trading partners.
Privacy Standards
The Privacy Rule required compliance on April 14, 200353 by covered entities: health plans,
health care clearinghouses, and health care providers. Privacy standards are designed to
protect patients’ rights, including unauthorized use and disclosure of their protected health
information (PHI).54 The Privacy Rule covers protected health information in any format: oral,
hard copy, or electronic. In contrast, the Security Rule discussed in the next section only
pertains to electronic protected health information, sometimes denoted ePHI.
Unlike transactions and code sets, and the technical safeguards of the Security Rule, the
Privacy Rule is non-technical, mainly policies and procedures relating to uses and disclosures
of protected health information (PHI) that are permitted or required, and those that require
written authorization of the individual prior to use or disclosure of his or her PHI. In addition, The Privacy Rule outlines rights that an individual has with regard to his or her PHI
that are required to be written in a Notice of Privacy Practices and posted by a covered entity.
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2013 WEDI REPORT
Security Standards
The Security Rule required compliance on April 20, 2005,55 by covered entities: health plans,
health care clearinghouses, and health care providers. While the Privacy Rule is focused on
use and disclosure of protected health information (PHI) of any type (oral, hard copy, or
electronic) and patient rights concerning PHI, the Security Rule is about controlling access to
electronic protected health information and making access to such information only to
authorized users.56 Like the Privacy Rule, the Security Rule relies on an assessment of risks to
policies and procedures for compliance.
Under the Security Rule prior to the HITECH Act, covered entities were required to comply
with the Security Rule and their business associates were required to provide satisfactory
assurances that they would safeguard protected health information in any format. Under the
enabling regulations of the HITECH Act – which required compliance by September 23,
2013 – a business associate, whether a contractor to a covered entity or a subcontractor to
another business associate, also is required to implement the Security Rule. Business associates
are subject to the same penalties as covered entities for non-compliance. Business associate
agreements must be updated or amended to incorporate specific compliance responsibilities
pertaining to use and disclosure of protected health information as specified by the covered
entity, as well as providing satisfactory assurances regarding safeguarding the covered entity’s
protected health information through implementation of the Security Rule.
Identifiers
Identifiers are numeric addresses for stakeholders in electronic healthcare information
exchange. A way to think about this from daily life is to consider the definition of a Uniform
Resource Locator (URL) that provides access to a Web site:
“the address of a resource (as a document or Web site) on the Internet that consists of a
communications protocol followed by the name or address of a computer on the network
and that often includes additional locating information (as directory and file names)”57
[emphasis added].
Just as a URL links to a unique destination on the Internet, HIPAA identifiers uniquely link
to a stakeholder in standard healthcare transactions.
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2013 WEDI REPORT
There are four unique identifiers specified in the HIPAA Administrative Simplification
standards:
The National Employer Identifier,58 with compliance required on July 30, 2004.59
The National Provider Identifier,60 with compliance required on May 23, 2007.61
The National Health Plan Identifier (HPID),62 with compliance required by November 5,
2014.63 Covered entities must use the HPID in standard transactions by November 7, 2016.
The National Individual Identifier, for which Congress has a hold on development.64 The
Individual Identifier is discussed further in Addendum 6.
Over the 20-year period 1993-2013, the federal government has implemented the set of
transaction, code set, identifier, privacy, and security standards described above, along with
regulations related to enforcement and breach notification. Together, these are the electronic
business tools that the healthcare industry has to work with in accomplishing electronic
healthcare information exchange for the purpose of streamlining healthcare business
operations, securing protected health information, and improving delivery of care. Two
standards not implemented are acknowledgements65 and claim attachment, and, of course, the
unique individual identifier noted above.
2003: Change In Focus From
Administrative to Clinical Processes
Early in the first decade of the 21st century, the federal government initiated a fundamental
shift in how it implemented healthcare policy, especially as it related to adoption of electronic
processes. Before, going back to the HIPAA legislation in 1996, the federal government was
focused on administrative processes, using the authority of the HIPAA statute relating to
Administrative Simplification.
In December 2002, the Bush Administration began implementing E-Government (E-Gov)
initiatives, after enactment of HR 2458, the E-Government Act of 2002.66 The objective was
to speed up adoption of a number of electronic processes by requiring federal government
agencies to implement without constraints of the Administrative Procedure Act, in an effort
also to spur private sector interest in implementing similar processes. Under E-Gov, HHS
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2013 WEDI REPORT
began to combine administrative simplification and clinical processes in a common initiative
for federal agency adoption, as applicable.
In July 2003, then HHS Secretary Tommy Thompson announced two initiatives designed for
“building a national electronic healthcare system that will allow patients and their doctors to
access their complete medical records anytime and anywhere they are needed.”67
“First, the Secretary announced that the Department has signed an agreement with the
College of American Pathologists (CAP) to license the College’s standardized medical
vocabulary system68 and make it available without charge throughout the U.S. This action
opens the door to establishing a common medical language as a key element in building a
unified electronic medical records system in the U.S.
“Secondly, the Secretary announced that HHS has commissioned the Institute of Medicine
to design a standardized model of an electronic health record. The health care standards
development organization known as HL7 has been asked to evaluate the model once it has
been designed. HHS will share the standardized model record at no cost with all components of the U.S. health care system. The Department expects to have a model record ready
in 2004.
“Today’s announcements are part of the ongoing HHS effort to develop the National Health
Information Infrastructure by encouraging and facilitating the widespread use of modern
information technology to improve the nation’s health care system.”
In May 2004, Secretary Thompson announced the appointment of David Brailer, MD, PhD,
as the first National Health Information Technology Coordinator to manage and accelerate
U.S. “health information technology efforts.69 Then, in July 2004, Secretary Thompson
initiated “a 10-year plan – to be known as the Decade of Health Information Technology
(HIT) – to build a national health information infrastructure in the United States” and
outlined “four collaborative goals” and “12 strategies for advancing and focusing future
efforts.”70
In August 2006, the federal government marked the 10th anniversary of the enactment of
HIPAA Administrative Simplification. If the goals of Administrative Simplification could not
be accomplished within 10 years – longer than originally envisioned by both the 1993 WEDI
Report and in debate in the statutory language of HIPAA Administrative Simplification, how
likely would it be that the healthcare industry could achieve the goals and strategic objectives
of the Decade of HIT, ending in 2014?
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2013 WEDI REPORT
While the federal government was emphasizing clinical initiatives, standards groups and
healthcare stakeholders were engaged in trying to solve a number of problems and eliminate
barriers that impeded efficiency of standard electronic transactions from an administrative
simplification perspective. As a culmination of these efforts, on August 22, 2008, HHS
published two Notices of Proposed Rulemaking (NPRMs): one related to a change in version
of the transaction standards to ASC X12N 5010, and the other related to a change in code set
from ICD-9-CM to ICD-10-CM and ICD-10-PCS, each of which was discussed briefly earlier.
On January 16, 2009, each was published as a final rule in the Federal Register, four days before
b the change from the Bush to the Obama Administration. One month and one day later, on
February 17, 2009, as part of the American Recovery and Reinvestment Act, much of the
work on both administrative simplification privacy and security standards and electronic
health record clinical processes that had been in development earlier in the decade found
statutory enablement in the Health Information Technology Economic and Clinical Health
Act (HITECH Act).
HITECH Act
President Obama signed into the law the American Recovery and Reinvestment Act (Public
Law 11-5), known as ARRA, on February 17, 2009. Included in the legislation – the
so-called stimulus bill – was the Health Information Technology for Economic and Clinical
Health (HITECH) Act.71 The HITECH Act comprised Title XIII (Health Information
Technology) of Division A of ARRA (pages 226-278) and Title IV (Medicare and Medicaid
Health Information Technology; Miscellaneous Medicare Provisions) of Division B of ARRA
(pages 467-496).
The HITECH Act made four broad significant changes that impact electronic healthcare
information exchange. First, it statutorily established the Office of the National Coordinator
for Health Information Technology (ONC), which previously had been established in 2004 by
Executive Order. In addition, it provided for the establishment of two standing committees
within ONC, Health IT Policy Committee and Health IT Standards Committee to advise on
health information exchange and technology in general and on certification of electronic
health record technology specifically.
Second, the HITECH Act provided for Medicare and Medicaid Financial Incentive Programs
for adoption by eligible healthcare professionals and hospitals and their meaningful use of
certified electronic health record technology.72
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2013 WEDI REPORT
Third, with respect to privacy, the HITECH Act required that a business associate implement
the HIPAA Security Rule and certain use and disclosure requirements specified in a business
associate agreement by a business associate’s covered entity. For the first time, business
associates would be regulated by the federal government with respect to compliance,
commencing September 23, 2013. In addition, the HITECH Act provided for more stringent
conditions on marketing of and fund raising relating to protected health information.
Finally, the HITECH Act established the basis for new rulemaking pertaining to Breach
Notification, which was implemented as an interim final rule on August 24, 2009,
with enforcement pertaining to covered entities and business associates commencing for
breaches occurring on or after February 22, 2010. Within that rule, HHS published Guidance
to Render Unsecured Protected Health Information Unusable, Unreadable, or Indecipherable to
Unauthorized Individuals,73 which is unchanged as this is written.
The provisions of the HITECH Act with respect to electronic healthcare information
exchange were twofold: (1) provide for standards pertaining to the creation, capture, and
safeguarding of clinical encounter and code set information, and (2) update, extend
application, and strengthen administrative privacy and security standards.
Patient Protection And Affordable Care Act
On March 23, 2010, President Obama signed into law the Patient Protection and Affordable
Care Act (H.R. 3590) as Public Law 111–148.74 One week later, on March 30, 2010,
President Obama signed into law the follow-on Health Care and Education Reconciliation
Act of 2010 as Public Law 111–152.75 The focus here is on two sections of Public Law
111–148, on 12 of 905 pages:
Section 1104 (Administrative Simplification) in Subtitle B – Immediate Actions to Preserve
and Expand Coverage of Title I – Quality, Affordable Health Care for All Americans,76 and
Section 10109 (Development of Standards for Financial and Administrative Transactions) in
Subtitle A – Provisions Relating to Title I of Title X – Strengthening Quality, Affordable
Health Care for All Americans.77
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2013 WEDI REPORT
Section 1104
The effective date of Section 1104, Administrative Simplification, was the date of enactment,
March 23, 2010.78 Section 1104(a) amends part of the purpose of administrative simplification
as specified in the HIPAA statute in two places, as indicated in bold:
To improve … efficiency and effectiveness of the health care system, by encouraging the
development of a health information system through the establishment of uniform
standards and requirements for the electronic transmission of certain health information and
to reduce the clerical burden on patients, health care providers, and health plans.79
Based on years of experience implementing HIPAA Administrative Simplification, the
amendments focused on moving toward minimization or elimination of variance in the
application and use of standards by requiring uniform standards, and, coincident with need
for uniformity and further adoption of electronic business processes in lieu of paper-based or
non-compliant transactions, minimization or elimination of nonproductive workflows
experienced by the healthcare covered entities.
Section 1104(b) contains the substantive details for accomplishing the amended purpose,
namely, Using Operating Rules for Health Information Transactions.80 Operating rules81 are
defined as “the necessary business rules and guidelines for the electronic exchange of
information that are not defined by a standard or its implementation specifications as adopted
for purposes of this part.”82
Section 1104(b) specified a new standard – electronic funds transfers (EFT) – in addition to
discussing conversion of existing standard transactions to operating rules, and requirements
for financial and administrative transactions.83
Finally, Section 1104(c) provides for promulgation of two new final rules in addition to EFT:84
Unique Health Plan Identifier. “To be effective not later than October 1, 2012, which the
Secretary may do …, on an interim final basis.”85
Health Claims Attachments. To “establish a transaction standard and a single set of associate
operating rules … that is consistent with the X12 Version 5010 transaction standards,” to be
adopted “not later than January 1, 2014, in a manner ensuring that such standard is effective
not later than January 1, 2016,” which may be on an interim final basis.”86
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2013 WEDI REPORT
Section 10109
Section 10109 outlines considerations relating to development of standards for financial and
administrative transactions, namely: “whether there could be greater uniformity in financial
and administrative activities … and whether such activities should be considered financial and
administrative transactions for which the adoption of standards and operating rules would
improve the operation of the health care system and reduce administrative costs.”87
Addendum Table 4-1:
Enabling Regulations of HIPAA, HITECH, and ACA
HIPAA Administrative
Simplification Rule
Status
Federal Register
Publication Date
Compliance Date for
Covered Entities
Other Compliance Date,
If Applicable
Transactions and Code Sets
Final
August 17, 2000; i
modifications: February 20,
2003ii
October 16, 2003
N/A
Privacy
Final
December 28, 2000; iii
modifications: August 14,
2002iv
April 14, 2003
April 14, 2004
(Small health plans)
National Employer
Identifier
Final
May 31, 2002 v
July 30, 2004
August 1, 2005
(Small health plans)
Security
Final
February 20, 2003 vi
April 20, 2005
April 20, 2006
(Small Health Plans)
National Provider Identifier
Final
January 23, 2004 vii
May 23, 2007
May 23, 2008 (Small
Health Plans)
Claim Attachment
Notice of Proposed
Rule Making
September 23, 2005 viii
Enforcement
Final
February 16, 2006 x
March 16, 2006
N/A
Modification to
Transactions and Code
Sets: Version 5010
Final
January 16, 2009 xi
January 1, 2012
Compliance date changed
to October 1, 2014 (See
table note xxi )
Modification to
Transactions and Code
Sets: ICD-10
Notice
January 16, 2009 xii
October 1, 2013
N/A
HHS Secretary’s Delegation
of Authority to HHS’s Office
for Civil Rights (OCR) to
Enforce HIPAA Rule
Notice
August 4, 2009 xiii
July 27, 2009
N/A
Withdrawn, January 25,
2010 ix
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2013 WEDI REPORT
Addendum Table 4-1:
Enabling Regulations of HIPAA, HITECH, and ACA (Continued)
HIPAA Administrative
Simplification Rule
Status
Federal Register
Publication Date
Compliance Date for
Covered Entities
Other Compliance Date,
If Applicable
Breach Notification for
Unsecured Protected
Health Information
Interim Final Rule
August 24, 2009 xiv
September 23, 2009
(Effective date for breaches
of protected health
information occurring on or
after this date, with
enforcement commencing
for breaches occurring on or
after February 22, 2010)
N/A
Enforcement
Interim Final Rule
October 30, 2009 xv
N/A
Modifications to the HIPAA
Privacy, Security, and
Enforcement Rules Under
the [HITECH Act] National
Plan Identifier
Notice of Proposed Rule
Making
July 14, 2010 xvi
Comments to HHS on or
before September 13,
2010
Privacy Rule Accounting of
Disclosures Under the
HITECH Act
Notice of Proposed Rule
Making
May 31, 2011 xvii
Adoption of Operating
Rules for Eligibility and
Claim Status Transactions
Interim Final Rule
July 8, 2011 xviii
January 1, 2013
Adoption of Standards for
Electronic Funds Transfers
(EFTS) and Remittance
Advice
Interim Final Rule
January 10, 2012 xix
January 1, 2014
Adoption of Operating
Rules for Electronic Funds
Transfers (EFTS) and
Remittance Advice
Interim Final Rule
August 10, 2012 xx
January 1, 2014
Adoption of Standard for
Unique Health Plan
Identifier; Additional
National Provider Identifier
(NPI) Requirements;
Change in Compliance
Date for ICD-10
Final Rule
September 5, 2012 xxi
Health Plan ID: November 5,
2014 (Small health plans
have until November 5,
2015); NPI: May 6, 2013;
ICD-10: October 1, 2014
Modifications to HIPAA
Privacy, Security,
Enforcement, and Breach
Notification Rules Under
the HITECH Act and Genetic
Information Nondiscrimination Act (GINA)
Final Rule
January 25, 2013 xxii
September 23, 2013
Technical Corrections to
the HIPAA Privacy, Security,
and Enforcement Rules
Final Rule
June 7, 2013 xxiii
CMS Notice to Industry:
Changed to Final Rule,
effective December 7, 2011
CMS Notice to Industry:
Changed to Final Rule,
effective April 19, 2013
Effective Date: March 26,
2013; Conform Business
Associate Contracts:
September 22, 2014
Effective Date: June 7,
2013
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2013 WEDI REPORT
Table Notes
i HHS, Office of the Secretary, “45 CFR Parts 160 and 162 – Health Insurance Reform:
Standards for Electronic Transactions; Final Rule,” Federal Register, v.65, n.160, August 17,
2000, pp. 50312–50372. Available at: www.cms.gov/Regulations-and-Guidance/HIPAAAdministrative-Simplification/TransactionCodeSetsStands/Downloads/txfinal.pdf; and “45
CFR Parts 160 and 162 – Health Insurance Reform: Standards for Electronic Transactions;
Corrections,” Federal Register, v.65, n.227, November 24, 2000, p. 70507. Available at:
www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Transaction
CodeSetsStands/Downloads/StandardsForElectronicTransactions-Corrections.pdf.
ii HHS, Office of the Secretary, “45 CFR Part 162 – Health Insurance Reform: Modifications
to Electronic Data Transaction Standards and Code Sets; Final Rule,” Federal Register, v.68,
n.34, February 20, 2003, pp. 8381–8399. Available at: www.gpo.gov/fdsys/pkg/FR-2003-0220/pdf/03-3876.pdf.
iii HHS, Office of the Secretary, “45 CFR Parts 160 and 164 – Standards for Privacy of
Individually Identifiable Health Information; Final Rule,” Federal Register, v.65, n.250,
December 28, 2000, pp. 82462–82829. Available at: www.hhs.gov/ocr/privacy/hipaa/
administrative/privacyrule/prdecember2000all8parts.pdf.
iv HHS, Office of the Secretary, “45 CFR Parts 160 and 164 – Standards for Privacy of
Individually Identifiable Health Information; Final Rule,” Federal Register, v.67, n.157,
August 14, 2002, pp. 53182–53273. Available at: www.hhs.gov/ocr/privacy/hipaa/
administrative /privacyrule/privrulepd.pdf.
v HHS, Office of the Secretary, “45 CFR Parts 160 and 162 – Health Insurance Reform:
Standard Unique Employer Identifier; Final Rule,” Federal Register, v.67, n.105, May 31,
2002, pp. 38009–38020. Available at: www.cms.gov/Regulations-and-Guidance/HIPAAAdministrative-Simplification/EmployerIdentifierStand/Downloads/empIDfinal.pdf.
vi HHS, Office of the Secretary, “45 CFR Parts 160, 162, and 164 – Health Insurance
Reform: Security Standards; Final Rule,” Federal Register, v.68, n.34, February 20, 2003, pp.
8334–8381. Available at:
www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/securityrulepdf.pdf.
vii HHS, Office of the Secretary, “45 CFR Part 162 – HIPAA Administrative Simplification:
Standard Unique Health Identifier for Health Care Providers; Final Rule,” Federal Register,
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2013 WEDI REPORT
v.69, n.15, January 23, 2004, pp. 3434–3469. Available at: www.gpo.gov/fdsys/pkg/FR2004-01-23/pdf/04-1149.pdf.
viii HHS, Office of the Secretary, “45 CFR Part 162 – HIPAA Administrative Simplification:
Standards for Electronic Health Care Claims Attachments; Proposed Rule,” Federal Register,
v.70, n.184, September 23, 2005, pp. 55990–56025. Available at:
www.gpo.gov/fdsys/pkg/FR-2005-09-23/pdf/05-18927.pdf.
ix HHS, Office of the Secretary, “Semiannual Regulatory Agenda,” Federal Register, v.75, n.79,
April 26, 2010, p. 21804. Available at: www.gpo.gov/fdsys/pkg/FR-2010-04-26/pdf/20108934.pdf. Please see the discussion in Chapter 2 about administrative simplification provisions of the Patient Protection and Affordable Care Act, which was enacted on March 23,
2010, for the new statutory adoption date deadline of January 1, 2014, and effective date
deadline of January 1, 2016, for health claims attachment standard.
x HHS, Office of the Secretary, “45 CFR Parts 160 and 164 – HIPAA Administrative
Simplification: Enforcement; Final Rule,” Federal Register, v.71, n.32, February 16, 2006, pp.
8390–8433. Available at: www.gpo.gov/fdsys/pkg/FR-2006-02-16/pdf/06-1376.pdf.
xi HHS, Office of the Secretary, “45 CFR Part 162 – Health Insurance Reform; Modifications
to the Health Insurance Portability and Accountability Act (HIPAA); Final Rules,” Federal
Register, v.74, n.11, January 16, 2009, pp. 3296–3328. Available at:
www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-740.pdf.
xii HHS, Office of the Secretary, “45 CFR Part 162 – HIPAA Administrative Simplification:
Modifications to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PCS;
Final Rule,” Federal Register, v.74, n.11, January 16, 2009, pp. 3328–3362. Available at:
www.gpo.gov/fdsys/pkg/FR-2009-01-16/pdf/E9-743.pdf.
xiii HHS, Office of the Secretary, “Office for Civil Rights; Delegation of Authority: Notice,”
Federal Register, v.74, n.148, August 4, 2009, p. 38630. Available at:
www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/srdelegation.pdf.
xiv HHS, Office of the Secretary, “45 CFR Parts 160 and 164 – Breach Notification for
Unsecured Protected Health Information; Interim Final Rule,” Federal Register, v.74, n.162,
pp. 42740–42770. Available at: www.gpo.gov/fdsys/pkg/FR-2009-08-24/pdf/E9-20169.pdf.
xv HHS, Office of the Secretary, “45 CFR Part 160—HIPAA Administrative Simplification:
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2013 WEDI REPORT EXECUTIVE SUMMARY
Enforcement; Interim Final Rule,” Federal Register, v.74, n.209, October 30, 2009, pp.
56123–56131. Available at: www.gpo.gov/fdsys/pkg/FR-2009-10-30/pdf/E9-26203.pdf.
xvi HHS, Office of the Secretary, “45 CFR Parts 160 and 164–Modifications to the HIPAA
Privacy, Security, and Enforcement Rules Under the Health Information Technology for
Economic and Clinical Health Act; Proposed Rule,” Federal Register, v.75, n.134, July 14,
2010, pp. 40868–40924. Available at:
www.gpo.gov/fdsys/pkg/FR-2010-07-14/pdf/2010-16718.pdf.
xvii HHS, Office of the Secretary, “45 CFR Part 164–HIPAA Privacy Rule Accounting of
Disclosures Under the Health Information Technology for Economic and Clinical Health Act;
Proposed Rule,” Federal Register, v.76, n.104, May 31, 2011, pp. 31426-31449. Available at:
http://www.gpo.gov/fdsys/pkg/FR-2011-05-31/pdf/2011-13297.pdf.
xviii HHS, Office of the Secretary, “45 CFR Parts 160 and 162–Administrative
Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care
Claim Status Transactions; Interim Final Rule,” Federal Register, v.76, n.131, July 8, 2011, pp.
40458-40496. Available at:
http://www.gpo.gov/fdsys/pkg/FR-2011-07-08/pdf/2011-16834.pdf. By Notice to Industry,
CMS converted the Interim Final Rule to Final Rule on December 7, 2011. Available at:
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affor
dable-Care-Act/CMS-0032-IFC.pdf. CMS announced on January 1, 2013, the compliance
date for operating rules for eligibility for a health plan and health care claim status
transactions, that it was implementing a 90 day period, until March 31, 2013, of
“enforcement discretion” to give the healthcare industry more time to implement these
operating rule transactions. Available at:
http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/Downloads/01021
3Sec1104ofACAAnnouncement.pdf.
xix HHS, Office of the Secretary, “45 CFR Parts 160 and 162–Administrative Simplification:
Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance
Advice; Interim Final Rule,” Federal Register, v.77, n.6, January 10, 2012, pp. 1556-1590.
Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-01-10/pdf/2012-132.pdf.
xx HHS, Office of the Secretary, “45 CFR Part 162–Administrative Simplification: Adoption
of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice
Transactions; Interim Final Rule,” Federal Register, v.77, n.155, August 10, 2012, pp.
48008-48044. Available at:
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2013 WEDI REPORT EXECUTIVE SUMMARY
http://www.gpo.gov/fdsys/pkg/FR-2012-08-10/pdf/2012-19557.pdf. By Notice to Industry,
CMS converted the Interim Final Rule to Final Rule on April 19, 2013. Available at:
http://www.caqh.org/pdf/CMSEFTERAFinalRuleAnnouncement.pdf.
xxi HHS, Centers for Medicare & Medicaid Services, “45 CFR Part 162–Administrative
Simplification: Adoption of a Standard for a Unique Health Plan Identifier; Addition to the
National Provider Identifier Requirements; and a Change to the Compliance Date for the
International Classifications of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS) Medical Data Code Sets; Final Rule,” Federal Register, v.77, n.172, September 5, 2012, pp.5466454720. Available at: http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/2012-21238.pdf.
xxii HHS, Office of the Secretary, “45 CFR Parts 160 and 164–Modifications to the HIPAA
Privacy, Security, Enforcement, and Breach Notification Rules Under the Health Information
Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules; Final Rule,” Federal Register, v.78, n.17,
January 25, 2013, pp. 5566-5702. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-0125/pdf/2013-01073.pdf.
xxiii HHS, Office for Civil Rights, “45 CFR Parts 160 and 164–Technical Corrections to the
HIPAA Privacy, Security, and Enforcement Rules,” Federal Register, v.78, n.110, June 7, 2013,
pp. 34264-34266. Available at: http://www.gpo.gov/fdsys/pkg/FR-2013-06-07/pdf/201313472.pdf.
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Addendum Table 4-2:
Adoption, Effective, and Compliance Dates for ACA
Transaction Standard Operating Rules
Standard
Adoption Date i
Effective Date i
Health Plan Compliance Date ii
Eligibility for a health plan iii
7/1/2011
7/1/2011
7/1/2011
Health claim status iii
7/1/2011
7/1/2011
7/1/2011
Electronic funds transfers iv
7/1/2012
7/1/2012
7/1/2012
Health care payment and remittance advice iv
7/1/2012
7/1/2012
7/1/2012
Health claims or equivalent encounter information
7/1/2014
7/1/2014
7/1/2014
Claim Attachment
7/1/2014
7/1/2014
7/1/2014
Health plan premium payments
7/1/2014
7/1/2014
7/1/2014
Referral certification and authorization
7/1/2014
7/1/2014
7/1/2014
Table Notes
i Not later than.
ii Not later than. Requires written certification of compliance provided to Secretary of HHS.
Note also that the compliance dates for the first two entries – Eligibility for a Health Plan
and Health Claim Status – reflect the language of provision (h)(5)(b): “Date of Compliance –
A health plan shall comply with such requirements not later than the effective date of the applicable standard or operating rule [124 STAT. 150],” rather than the date specified for these
transactions in (h)(1)(A) [124 STAT. 149]. On December 7, 2011, CMS notified the healthcare industry that the Interim Final Rule [IFR] was now a Final Rule as “[a]fter careful review
and consideration of all comments, we have decided not to change any of the policies established in [the IFR].” See https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affordable-Care-Act/CMS-0032-IFC.pdf. For information on the operating rules mandate (ORMandate) for eligibility and health claim status transactions, including a copy of the operating rules, visit the Council for Affordable Quality Health Care
(CAQH) at: http://www.caqh.org/ORMandate_Eligibility.php.
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2013 WEDI REPORT EXECUTIVE SUMMARY
iii On July 8, 2011, HHS issued an Interim Final Rule for these operating rules. See
Department of Health and Human Services, Office of the Secretary, “45 CFR Parts 160 and
162; Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health
Plan and Health Care Claim Status Transactions; Interim final rule,” Federal Register, v.76,
n.131, July 8, 2011, pp.40458–40496, which is available online at:
www.gpo.gov/fdsys/pkg/FR-2011-07-08/pdf/2011-16834.pdf.
iv On January 10, 2012, HHS issued an Interim Final Rule for adoption of standards for
these operating rules. See Department of Health and Human Services, Office of the Secretary,
“45 CFR Parts 160 and 162; Administrative Simplification: Adoption of Standards for Health
Care Electronic Funds Transfers (EFTs) and Remittance Advice, Interim Final Rule,” Federal
Register, v.77, n.6, January 10, 2012, pp. 1556-1590, which is available online at:
http://www.gpo.gov/fdsys/pkg/FR-2012-01-10/pdf/2012-132.pdf. On August 10. 2012,
HHS issued an Interim Final Rule for implementing these operating rules. See Department of
Health and Human Services, Office of the Secretary, “45 CFR Part 162; Administrative
Simplification: Adoption of Operating Rules for health Care Electronic Funds Transfers (EFT)
and Remittance Advice Transactions; Interim Final Rule,” Federal Register, v.77, n.155,
August 10, 2012, pp.48008-48044, which is available online at:
http://www.gpo.gov/fdsys/pkg/FR-2012-08-10/pdf/2012-19557.pdf. On April 19, 2013,
CMS notified the healthcare industry that the Interim Final Rule [IFR] was now a Final Rule
as “we have decided not to change any polices established in the EFT & ERA Operating Rule
Set [IFR].” See http://www.caqh.org/pdf/CMSEFTERAFinalRuleAnnouncement.pdf. For
information on the operating rules mandate (ORMandate) for electronic funds transfers and
remittance advice transactions, including a copy of the operating rules, visit the Council for
Affordable Quality Health Care (CAQH) at: http://www.caqh.org/ORMandate_EFT.php.
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2013 WEDI REPORT
Addendum 5: The 2013 WEDI Report Process
I
n December 2012, the leadership of the Workgroup for Electronic Data Interchange
(WEDI) convened an advisory group to assess the feasibility of updating the 1993 WEDI
Report. The 1993 WEDI Report was designed to provide healthcare stakeholders with a
roadmap of changes that would need to occur for successful transition to electronic data
interchange standards and as a way of conducting more cost-effective administrative and
financial transactions in healthcare. The 1993 WEDI Report served as a foundation for the
Administrative Simplification provisions of the August 1996 Health Insurance Portability
and Accountability Act (HIPAA)88 and a strategic framework for much of WEDI’s activities
over the past 20 years.
WEDI’s informal advisory group determined that a 2013 WEDI Report should document the
state of Administrative Simplification and the impact it has had on healthcare industry
information exchange, barriers to achieving future cost-effective exchange, and how those
barriers could be overcome. In addition, the updated Report should identify specific high level
areas where innovation might be implemented in such a way to accelerate the movement to
more efficient healthcare information exchange, while at the same time, having a positive
impact on the delivery of quality healthcare. The purpose of the 2013 WEDI Report was
neither to develop solutions nor to compromise existing research, test cases, or implementation
of regulations, but rather to suggest areas of inquiry that might be promising for avoiding or
overcoming barriers or for accelerating innovation and that could be business-driven.
Toward those ends, the WEDI Board of Directors approved the 2013 WEDI Report project in
late January 2013 and, after an open WEDI Request for Quotation (RFQ) procedure, WEDI
selected Cornichon Healthcare Select, LLC89 as the project manager and report writer in early
March 2013. The first order of business was to enlist the former Secretary of Health and
Human Services in the George H.W. Bush Administration, Louis W. Sullivan, M.D., to serve
as Honorary Chair of the Executive Steering Committee as Secretary Sullivan was responsible
for initiating the 1993 WEDI Report project in 1991. The next order of business was to
select members of a 15-person Executive Steering Committee: chief executive officers (CEOs)
of major healthcare stakeholder businesses, leaders of major healthcare associations, and heads
of government agencies responsible for healthcare programs, initiatives, and regulations; and
empanel Advisors who had experience in designing or implementing healthcare information
exchange standards and safeguards.
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First Executive Steering Committee Meeting. The Executive Steering Committee
and Advisors had its first of two in-person meetings in a half-day session on April 2, 2013, at
the Ronald Reagan Building and International Trade Center in Washington, DC. During that
meeting, Steering Committee Members and Advisors recommended focusing attention in the
2013 WEDI Report project on potential short term “wins” and identifying priority issues that
would be actionable, measurable, impactful, and sustainable. Specifically, the 2013 WEDI
Report should address the electronic healthcare information disconnect in administrative and
clinical processes, identify roadblocks to avoid or overcome, and deliver recommendations that
would enhance value throughout the healthcare system, at a lower cost.
Establishing Workgroups. Based on recommendations from the April 2 Executive
Steering Committee Meeting for topics to be addressed in the 2013 WEDI Report, WEDI’s
leadership later that month created four workgroups: Patient Enablement, Payment Models,
Innovative Encounter Models, and Data Harmonization and Exchange. Also, based on
recommendations from that meeting, WEDI’s leadership established a common framework of
analysis for each workgroup to use in identifying and addressing priority issues. Using this
framework, the focus for each workgroup was threefold:
Leveraging and evaluating current knowledge, methods, and approaches to identify barriers
to greater efficiency and lower cost of exchange of electronic healthcare information,
Identifying potential remedies that would enhance such exchange more efficiently, at lower
cost, and greater value to healthcare stakeholders going forward, and
Recommending further action beginning in 2014 and continuing through 2015-2017 that
could lead to improvements in electronic healthcare information exchange.
The characteristics of the common framework of analysis are shown here:
Healthcare Stakeholder Lessons Learned, 1993-2013
Barriers to success
Critical issues resolved and unresolved
Healthcare Stakeholder Business Cases for Electronic Information Exchange
Business rules and compliance
Privacy and security
Education and technical literacy
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2013 WEDI REPORT
Need for federal regulation and enforcement
Innovation
Return on investment (ROI)
Action Needed for Success
Industry and regulatory requirements
Avoidance of barriers
How can success be accelerated and measured
What are incentives for enhanced cooperation
Identifying productive innovation
Prioritized Recommendations
Short term wins (2014-2016)
Longer term wins (2017-2020+)
In early May 2013, the 2013 WEDI Report leadership team enlisted Co-chairs for each
workgroup, who are listed at the beginning of this report. Once the Co-chairs were onboard,
WEDI’s leadership issued invitations through several media for volunteers to participate in
the workgroups, and established a one-hour weekly call, beginning in May, for each
workgroup to tackle its mission and identify priority issues that would meet their mission
statements, described in the report text.
During June and early July, each workgroup was given access to an outside firm in
Washington, DC that specialized in providing literature reviews and reference materials in
support of their priority issue investigations. During August, each workgroup was given the
opportunity via teleconference to present its priority issue areas to the other workgroup
Co-chairs to determine intersection of interests and collaborative requirements. In September,
each workgroup prepared preliminary recommendations based on their inquiries over the
summer months.
Second Executive Steering Committee Meeting. The Executive Steering
Committee and Advisors had its second in-person meeting in a half-day session on September
25, 2013, at the Willard Hotel in Washington, DC. Co-chairs of the workgroups presented
their preliminary recommendations for review and comment by Executive Steering
Committee Members and Advisors. Thereafter, WEDI’s leadership, through an iterative
consultation process with Steering Committee Members, Advisors, and Co-chairs, prepared
the final 2013 WEDI Report document for approval and public release on December 5, 2013.
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Addendum 6: Overarching Themes
F
ive overarching themes emerged during the development of this report: Data; Patient
Identifier; Literacy and Education; Technology and; Harmonization of Administrative and
Clinical Data.
Data
If there is no information on what each data element is, then the data values are not meaningful
or useful. Take as examples of data values, 29455, 2135551212, and 1234567898765432. If
the data elements are a zip code, a telephone number, and a credit card number, respectively,
there is then potentially meaningful and useful information – at a minimum what the value
represents. If there is a set of information based on data value linkages, say, a growing
incidence of contagious disease in the same zip code for a set of patients reported by physician
practices and hospitals, then the information translates to intelligence that can be acted upon,
if necessary. In healthcare, this flow of information is primarily from the patient -> practice
-> population -> public health officials, with actionable feedback on this intelligence moving
back through the data/information stream that may inform, through research, best practice
and quality measurements. The overarching idea in each of the workgroups was what is the
business or clinical value proposition for collecting a particular data element: does it provide
meaningful and useful information and potential intelligence value – i.e., why are we
collecting the data and for what purpose?
Patient Identifier
Each of the workgroups wrestled with the notion that the lack of a unique patient identifier
could be a major impediment to efficient electronic healthcare information exchange. There is
no unique individual identifier that could be tied to a patient’s designated record sets at
multiple healthcare providers. This problem exists because, after passage of HIPAA
Administrative Simplification in August 1996, Congress “took action to withhold funding for
evaluation and policy development”90 of a national individual healthcare identifier, and has
had a “hold” on promulgation of federal regulation that would create a unique individual
identifier, such as the social security number. Also, several states have enacted laws prohibiting
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2013 WEDI REPORT
use of the social security number for any purpose other than that originally intended. The
question then is: does the lack of a common, unique identifier create a barrier that cannot be
overcome, with the result that its absence precludes achieving greater efficiency in electronic
healthcare information exchange?
On two accounts, the answer may be no. First, there are many identifiers in use that may be
used alone or in combination to uniquely characterize or define an individual, including the
18 protected health information (PHI) identifiers that must be removed to de-identify health
records.91 In the absence of a commonly accepted unique identifier for an individual, the
patient is the sole source of any interoperable data exchange transaction process that would
facilitate secure exchange of such information among providers. Currently, the healthcare
system must rely on an enabled patient through self-interest or incentive to compile and
transfer such information to multiple providers.
A variety of technology options currently are available so that an individual would benefit as a
sometimes patient by carrying a minimal set of current healthcare information that would be
useful not only in periodic contact with checkups and referrals, but potentially life-saving in
an injury visit to an emergency department following an accident. A provider, in an emergency
situation, would have current and actionable healthcare information for informed decisions,
such as medications, allergies, chronic conditions, and contact information. Pointers to a
patient’s designated record set numbers and identifiers from other providers ideally would be
included, thereby saving time in collecting that information.
The second reason that the answer may be no is that the same result may be achieved via
rapidly evolving biometric technology. Hand vein identification is currently being used, and
the Apple iPhone 5S has introduced biometric finger image security for the device.92 As a
result, the healthcare industry may end up with a capacity for a digital unique identifier
that can be used in healthcare by default as smartphones and tablets proliferate.
Literacy And Education
There is a steep learning curve with respect to understanding the complexities of healthcare
information exchange. This is especially the case with respect to the formats and language
underpinning the electronic data interchange (EDI) standard transactions and code sets,93
and the functional requirements underpinning electronic health record certification criteria
and measures.94 Healthcare information exchange is complex, compared to the growing
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simplicity and transparency of workflows and functions associated with apps in the mobile
smart phone and tablet environments. Consumers increasingly use these devices in their daily
lives, so to drive cost out of the healthcare system and make workflows and transactions more
user-friendly in healthcare, the healthcare industry must begin to embrace these tools and
educate healthcare stakeholders on their use, whether provider, payer, or patient – all familiar
now with the new tools as consumers. If technology facilitates creating a bank deposit by
taking a picture of a check using a smart phone app, shouldn’t a consumer as a sometimes
patient be able to deliver a onetime-created electronic, interoperable accessible patient history
to a healthcare provider or have the provider access it as necessary?
The nation, through educational institutions and associations, is beginning to engage more
seriously in educating healthcare workforce members on use of electronic health information
systems and tools. At the same time, it must also address consumer literacy, namely, engaging
consumers in valuing the importance of and taking responsibility for their healthcare
information and treatments, and following prescribed healthcare treatment regimens.
Education and literacy initiatives are critical for achieving efficiency by the healthcare
workforce and for enhancing patient trust through healthcare information access and
exchange, both prerequisites for achieving lower cost and higher quality healthcare delivery.
Technology
Technology is always changing.95 In the early 1990s, in an environment of high healthcare
administrative costs and growing rate of health care inflation, then George H.W. Bush
Administration Secretary of Health and Human Services (HHS), Louis W. Sullivan, M.D.,
brought the healthcare industry together to address lack of standardization when other
industries were benefitting from lower costs through standardizing their business transaction
processes. Secretary Sullivan also indicated that the growing pace of healthcare expenditure
relative to growth in gross domestic product (GDP),96 was an important factor in determining
what could be accomplished by containing costs from moving from paper to electronic
methods in healthcare administration (see sidebar interview of Dr. Sullivan).
Another problem for healthcare was healthcare stakeholders were not communicating – across
stakeholder groups and within stakeholder groups – as all were using proprietary,
non-conformable data elements and formats for transactions. Healthcare provider workforce
members had to use myriad codes and formats – so-called local codes – in order to process
transactions, which escalated administrative costs. The 1993 WEDI Report project was a
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catalyst that facilitated stakeholders to begin talking about moving away from proprietary
codes at the very time that standardization was necessary to take advantage of anticipated
technology changes with respect to growing use of desktop PCs, transition from DOS to
Windows operating systems, tape to disc, and personal desktop printers. Electronic business
practices were moving from the information technology (IT) center to the workforce member
desktop, just as today they are moving from the laptop to the tablet and smartphone where
applications are accessed by touching an app icon.97 The nation has an opportunity now to
plan to use these devices and their applications to create cost reducing interaction within the
healthcare industry and exchange of healthcare information amongst healthcare stakeholders.
But the solutions have to be simple and transparent to the consumer to be embraced in a
timely manner in order to achieve cost reducing benefits.
Finally, from the perspective of 2013, it may be difficult to understand what the state of
technology was in the early 1990s in the United States at the time of the 1993 WEDI Report.
Consumers take for granted today the instant ability to access or move information via
smartphones and tablets, or to record and retrieve or stream via the Internet entertainment
events on television or computer when it is most convenient to view. However, in 1990, the
Internet had 3 million users, 73 percent who lived in the United States.98 Today, 70 percent of
American adults have high-speed broadband connection at home (May 2013 data), a
statistically significant 4 percentage point increase from April 2012 survey data.99
Harmonization of Administrative and Clinical Data
From issuance of the 1993 WEDI Report through the middle of 2003, the federal
government focus was on administrative processes, using the statutory authority from the Health
Insurance Portability and Accountability Act of 1996 (HIPAA).100 Addendum 4 describes
how then George W. Bush Administration Secretary of HHS, Tommy Thompson, changed
the focus to align more closely administrative and clinical flows of information in an
electronic health care system that would allow patients and their doctors to assess their
complete medical records anytime and anywhere they are needed….”101 Secretary Thompson
stated that the focus of the policy was to “transform the delivery of health care by building a
new network to link health records nationwide,” and outlined “four major collaborative goals”
and “12 strategies for advancing and focusing future efforts.”102 That was the first of three
strategic plans issued by the federal government between July 2004 and September 2011,
with each of the three predominantly focused on clinical information strategies.103
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Smoothly integrating administrative and clinical data transactions has been a challenge.104
These transactions are created, received, maintained, and transmitted using complex systems
involving approximately 800,000 entities, over 300 million individuals, and billions of
annual transactions. Another factor is that myriad federal, state, and local authorities, and
associations have established rules of operations. At the federal HHS level, the Centers for
Medicare & Medicaid Services (CMS) is responsible for administrative transactions, code sets,
and identifiers; the Office for Civil Rights (OCR) is responsible for administrative privacy and
security enforcement; and the Office of the National Coordinator for Health Information
Technology (ONC) is responsible for specifying certification criteria for electronic health
record (EHR) technology in conjunction with CMS’ role in providing financial incentives
under Medicare and Medicaid for adoption and meaningful use of certified EHR technology.
A hallmark of the 2013 WEDI Report project is having each of these entities not only
participating as Executive Steering Committee members or Advisors to the 2013 WEDI
Report, but also serving as participants in its workgroups in fashioning priority initiatives to
facilitate minimizing collaboratively the impacts of electronic disconnect in the integration
and exchange of administrative and clinical healthcare information.
Endnotes
1 The U.S. Healthcare Efficiency Index© is available online at: http://UShealthcareindex.org.
2 Yong, P.L., Saunders, R.S., and Olsen, L. The Healthcare Imperative: Lowering Costs and
Improving Outcomes: Workshop Series Summary. Institute of Medicine. Washington, DC: The
National Academies Press, 2010, p.146.
3 See Cuckler, G., et al., “National Health Expenditure Projections, 2012-22: Slow Growth
Until Coverage Expands And Economy Improves,” Health Affairs, v.32, n.10, October 2013,
p. 1822, which is available at: www.healthaffairs.org.
4 Cutler, D., Wikler, E., and Basch, P. “Reducing Administrative Costs and Improving the
Health Care System,” New England Journal of Medicine, November 15, 2012, pp. 1875-1878.
5 Now, as in 1993, technology is changing rapidly, with proliferation of mobile smart phones
and tablets replacing portable personal computers; bandwidth abundant and expanding geographically into hard-to-reach areas such as rural communities; and storage capacity large and
continuing to grow, carried not only on smart cards, flash drives, and other devices, but also
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accessed virtually when needed on networks of cloud servers.
6 App is short for application software but is frequently used to mean mobile app (more specific) or computer program (more general). See: http://en.wikipedia.org/wiki/App.
7 Cloud storage is a model of networked enterprise storage where data is stored in virtualized
pools of storage generally hosted by large third party data centers. See:
http://en.wikipedia.org/wiki/Cloud_storage.
8 Consumers rapidly are adopting these new mobile technologies – smart phones and tablets –
that are transforming the way information is created, accessed, transmitted, and maintained.
For example, in the banking industry, a check can be deposited directly from a smartphone via
an app by taking a photo image of it; how can healthcare benefit from these kinds of technology applications. Gartner, Inc., identified the top ten strategic technology trends for 2014, nine
of which involved mobile, cloud, and Internet technologies that will affect the way the nation
conducts business, including healthcare in the years ahead. The nine technology trends germane to healthcare identified by Gartner are: mobile device diversity and management; mobile apps and applications; the Internet is everything; hybrid cloud and IT as service broker;
cloud/client architecture; the era of personal cloud; software-defined anything; Web-scale IT;
and smart machines. The tenth non-germane technology for healthcare information exchange
is 3-D printing. Gartner, Inc., Gartner Identifies the Top Ten Strategic Technology Trends for 2014,
press release, October 8, 2013, which is available online at:
http://www.gartner.com/newsroom/id/2603623.
9 Information on managing health information with Blue Button is available at:
http://www.healthit.gov/bluebutton.
10 See:
http://www.markle.org/publications/401-americans-overwhelmingly-believe-electronic-person
al-health-records-could-improve-t.
11 David Miller discussion with Jennifer L. Young Pierce, M.D., MPH, at Medical
University of South Carolina (MUSC), Charleston, SC, August 5, 2013.
12 Schneider, E.C., Hussey, P.S., and Schnyer, C. Payment Reform: Analysis of Models and
Performance Measurement Implications. Rand Health Technical Report. Santa Monica, CA: Rand
Corporation, 2011.
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13 Becker’s Hospital Review, “8 Key Issues for Hospitals and Health Systems,” January 2013,
which is available at:
http://www.beckershospitalreview.com/hospital-management-administration/8-key-issues-forhospitals-and-health-systems-2013.html.
14 Social network communication of personal business exchange of information (LinkedIn in
May 2003), for mass exchange of short bursts of information (Twitter in July 2006), and for
mass exchange of social information initially and then business information as well (Facebook
in September 2006, with the advent of access outside of educational institutions to any
individual or entity with a registered email address) were recent technological innovations
used worldwide that were preceded in the 1990s by programs such as Lotus Notes that had
attributes that were usable only in a local area network environment.
15 Google was launched as a search engine in December 1998, a paradigm shift in the way
information is accessed and used.
16 It was in the period 1991-1993 that the World Wide Web was made commercially viable,
and later in that decade that using the Web to access information took off.
17 Worldmapper, Internet users 1990,” Map No. 335, which is available online at:
http://www.worldmapper.org/display.php?selected=335. On a per 100 persons basis, the
Internet users value was 0.78 in 1990 and 77.86 in 2011, based on World Bank data (see
http://www.indexmundi.com/facts/united-states/internet-users.) Today, 70 percent of
American adults have high-speed broadband connection at home (May 2013 data), a
statistically significant 4-percentage point increase just from April 2012, based on survey
data. See Zickuhr, K., and Smith, A., Home Broadband 2013, August 26, 2013, which is
available online at: http://www.pewinternet.org/Reports/2013/Broadband/Findings.aspx.
18 Today, 91 percent of the adult population in the United States owns a cell phone, with 56
percent of the population smart phone adopters. Smith, A., Smartphone Ownership 2013,
June 5, 2013, which is available online at:
http://pewinternet.org/Reports/2013/Smartphone-Ownership-2013.aspx.
19 With the early office products, such as Windows Office 3.0 (later branded Office 92) in
August 1992, and the popular Windows 95 launched in August 1995, business activities
began to be performed in the PC environment, printed, and exchanged on paper. Moving files
electronically in this environment only became routine later in the 1990s.
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20 Hartman, M., et al., “National Health Spending in 2011: Overall Growth Remains Low,
But Some Payers and Services Show Signs of Acceleration, Health Affairs, v.32, n.1, January
2013, pp. 87-99. In contrast, the latest data for national health expenditure (NHE) is $2.8
trillion in 2012, over 3.8 times greater than the 1990 figure, and 17.9 percent of GDP. See
Cuckler, G., et al., “National Health Expenditure Projections, 2012-22: Slow Growth Until
Coverage Expands And Economy Improves,” Health Affairs, v.32, n.10, October 2013, p.
1822, for the latest NHE estimate, and the May 2013 issue, “Tackling The Cost Conundrum,”
v.32, n.5, for more information on healthcare expenditures and actions to control cost. The
Health Affairs references are available at: www.healthaffairs.org.
21 In 1990, the census population of the United States was 248,709,873. United States
Census Bureau, 1990 Census, which is available online at:
http://www.census.gov/main/www/cen1990.html. The 1990 census population figure is 60
million fewer than the 2010 census figure of 308,745,538. United States Census Bureau,
“U.S. Census Bureau announces 2010 Census Population Counts, Apportionment Counts
Delivered to the President,” December 21, 2010, which is available online at:
http://www.census .gov/2010census/new/releases/operations/cb10-cn93.html.
22 www.ncvhs.hhs.gov.
23 www.cdc.gov.
24 www.nih.gov.
25 www.wedi.org.
26 The 1993 WEDI Report stated that its “financial analysis concludes that combining the
estimated implementation costs and the gross administrative savings potential, the
cumulative net savings [from 1994] (to the year 2000) is estimated to total over $42 billion.”
27 HIPAA was enacted on August 21, 1996 as Public Law 104-191 in the 104th Congress.
The Administrative Simplification provisions of the statute are in the relatively short 14-page
Subtitle F of Title II, which is available online at the Department of Health and Human
Services’ (HHS) Office for Civil Rights (OCR) Web site:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/index.html..
28 Accredited Standards Committee (ASC) of the American National Standards Institute (ANSI).
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29 Health Care Financing Administration (HCFA) is now known as Centers for Medicare &
Medicaid Services (CMS).
30 See Table 4-1 in Addendum 4. Each promulgated regulation is required to provide
cost-benefit information pertaining to the provisions of the regulation.
31 The Electronic Healthcare Network Accreditation Commission (EHNAC) has been
providing clearinghouse accreditation since 1994.
32 Supporting recommendations for each Technical Advisory Group are presented in Table 3-1.
33 See Addendum 4, Table 4-1.
34 The Final Rule for adoption of the standard for the unique health plan identifier was
published in the Federal Register on September 5, 2012. See 77 Federal Register 54664-54720.
35 Thanks to David Miller and Lee Barrett for providing the 2013 status of the 1993 WEDI
Report recommendations. Each of them played significant leadership roles in the 1993 WEDI
Report project and subsequently in development and implementation of standards referenced
herein. Standards are denoted “Complete” if promulgated rather than implemented.
36 The National Individual Identifier is controversial. Congress has a long-standing hold on
any regulatory development regarding this identifier. Prior to enactment of HIPAA, the de
facto individual identifier had been the Social Security number – which is the source of
controversy about its use as a standard. In addition, a number of states have restricted the use
of the Social Security number as an identifier for any matters other than Social Security.
Further, large health plans have invested considerable resources in developing unique
individual identifiers for their members as a workaround.
37 HIPAA was enacted on August 21, 1996 as Public Law 104-191 in the 104th Congress.
The Administrative Simplification provisions of the statute are in the relatively short 14-page
Subtitle F of Title II, which is available online at the Department of Health and Human
Services’ (HHS) Office for Civil Rights (OCR) Web site:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/index.html.
38 The HITECH Act was enacted on February 17, 2009, as part of the American Recovery
and Reinvestment Act of 2009 (ARRA), which was Public Law 111-5. HITECH Act
administrative simplification provisions are available online at:
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http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/hitechact.pdf.
39 ACA was enacted on March 23, 2010, as Public Law 111-148. Public Law 111–148,
published as 124 STAT. 119–1024, is available at:
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
Administrative simplification provisions in ACA are available from the Center for Medicare &
Medicaid Services (CMS) in a document that is available online at:
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Afford
able-Care-Act/Downloads/Summary-of-ACA-provisions-for-Administrative-Simplification.pdf.
40 Op. cit.
41 Department of Health and Human Services, Office of the Secretary, “45 CFR Parts 160
and 164: Modifications to the HIPAA, Privacy, Security, Enforcement, and Breach
Notification Rules Under the Health Information Technology for Economic and Clinical
Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the
HIPAA Rules,” Federal Register, v.78, n.17, January 25, 2013, p. 5670, which is available
online at: http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf. By broad
category and number, covered entities comprise hospitals (4,060), nursing facilities (34,400),
ambulatory providers (419,286), outpatient care centers (13,962), medical diagnostic and
imaging services (7,879), home health service (15,329), other ambulatory care service (5,879),
durable medical equipment suppliers (107,567), pharmacies (88,396), health insurance
carriers (730), and third party administrators working on behalf of covered health plans (750).
42 The Council for Affordable Quality Healthcare, “Measuring Business Efficiency in
Healthcare,” 2012, which is available online at: www.ushealthcareindex.org/index.php. The
estimate, with the percentage electronic in parentheses, is based on the number of claim
submission (85%), eligibility verification (40%), claim status inquiries (40%), claim payment
(10%), and claim remittance (46%) transactions.
43 The Centers for Medicare & Medicaid Services (CMS) is responsible for enforcing
compliance with transactions, code sets, and identifiers, and the HHS Office for Civil Rights
(OCR) is responsible for enforcing compliance with privacy and security rules.
44 Centers for Medicare & Medicaid Services (CMS), “Transactions & Code Set Standards,”
April 17, 2013 (last update), which is available online at:
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Trans
actionCodeSetsStands/index.html?redirect=/TransactionCodeSetsStands/.
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45 45 CFR 160.103.
46 On September 26, 2007, the National Committee on Vital and Health Statistics
(NCVHS) recommended to HHS Secretary Michael Leavitt: “The Secretary should expedite
the development and issuance of a Notice of Proposed Rulemaking (NPRM) to adopt the ASC
X12N Version 5010suite of transactions.” Letter from Simon P. Cohn, MD, MPH, Chair,
National Committee on Vital and Health Statistics (NCVHS), to Michael O. Leavitt,
Secretary, U.S. Department of Health and Human Services, “Revisions to HIPAA
Transactions Standards Urgently Needed,” September 26, 2007. This document is available at
http://www.ncvhs.hhs.gov/070926lt.pdf. The NPRM was published in the Federal Register on
August 22, 2008 (73 Federal Register 49741) and the final rule on January 16, 2009 (74
Federal Register 3295).
47 Operating rules are defined as “the necessary business rules and guidelines for the
electronic exchange of information that are not defined by a standard or its implementation
specifications as adopted for purposes of this part.” 124 STAT.147. Additional information on
operating rules as they relate to the Committee on Operating Rules for Informational
Exchange (CORE) is available online at: www.caqh.org/CORE_rules.php.
48 The ICD-10-CM/PCS rule comprises two parts: International Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, and International
Classification of Diseases, Tenth Revision, Procedures Coding System (ICD-10-PCS) for inpatient
hospital procedure coding only. Non-inpatient (ambulatory) providers will continue to use
CPT-4 and Healthcare Common Procedure Coding System (HCPCS) codes for coding
procedures.
49 Department of Health and Human Services (HHS), Office of the Secretary (OS), “45 CFR
Part 162: HIPAA Administrative Simplification: Modifications to Medical Data Code Set
Standards to Adopt ICD-10-CM and ICD-10-PCS; Final Rule,” Federal Register, v.74, n.11,
January 16, 2009, pp. 3328-3362. The original compliance date was delayed one year from
October 1, 2013, to October 1, 2014. HHS, OS, “45 CFR Part 162: Administrative
Simplification: Adoption of a Standard for Unique Health Plan Identifier; Addition to the
National Provider Identifier Requirements; and a Change to the Compliance Date for the
International Classification of Diseases, 10th Edition (ICD-10-CM and ICD-10-PCS) Medical
Data Code Sets; Final Rule,” Federal Register, v.77, n.172, September 5, 2012, pp.
54664-54720. Resources pertaining to ICD-10 are on the Centers for Medicare & Medicaid
(CMS) Web site ICD-10, which can be accessed at:
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http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10.
50 Department of Health and Human Services, Office of the Secretary, “45 CFR Part 162:
Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability
Act (HIPAA) Electronic Transaction Standards; Proposed Rule,” Federal Register, v.73, n.164,
August 22, 2008, pp. 49746. The final rule was promulgated on January 16, 2009 at 74 Federal
Register 3295-3328.
51 Information on the DSMO process is available at 68 Federal Register 8382. Also, see
“HIPAA-DSMO Transaction Change Request System,’ which is available at:
http://www.hipaa-dsmo.org/Main.asp.
52 Level 1 (internal readiness) and Level 2 (production readiness) testing was required in the
final rule for implementation of Version 5010, but was not required in the ICD-10 final rule.
See 74 Federal Register 3302-3303. “[HHS has] not established dates for Level 1 and Level 2
testing compliance for ICD-10 implementation. We encourage all 115 industry segments to be
ready to test their systems with ICD-10 as soon as it is feasible.” See 74 Federal Register 3336.
53 Small health plans had an additional year to comply.
54 Protected health information means individually identifiable health information: (1) Except as
provided in paragraph (2) of this definition, that is: (i) Transmitted by electronic media; (ii)
Maintained in electronic media; or (iii) Transmitted or maintained in any other form or
medium. (2) Protected health information excludes individually identifiable health information:
(i) In education records covered by the Family Educational Rights and Privacy Act [FERPA], as
amended, 20 USC. 1232g; (ii) In records described at 20 USC. 1232g(a)(4)(B)(iv); (iii) In
employment records held by a covered entity in its role as employer; and (iv) Regarding a
person who has been deceased for more than 50 years. 45 CFR 160.103.
55 Small health plans had an additional year to comply.
56 Key attributes of the Security Rule are described in Hartley, C., and Jones III, E. HIPAA
Plain & Simple: After the Final Rule. Foreword by Louis W. Sullivan, M.D. 3rd Edition.
Chicago, IL: American Medical Association, 2014, p. 14.
57 See: http://www.merriam-webster.com/dictionary/url.
58 The Employer Identification Number (EIN), issued by the Internal Revenue Service
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(IRS), was selected as the identifier for employers.
59 Small health plans had an additional year to comply, until August 1, 2005.
60 The National Provider Identifier (NPI) is a unique identification number for covered
health care providers. Covered health care providers and all health plans and health care
clearinghouses must use NPIs in administrative and financial transactions adopted under
HIPAA. The NPI is a 10-digit, intelligence-free numeric identifier (10- digit number),
meaning that NPIs do not carry other information about health care providers, such as states
in which they live or their medical specialties. NPIs must be used in lieu of legacy provider
identifiers in the HIPAA transaction standards. Covered providers also must share their NPI
with other providers, health plans, clearinghouses, and any entity that may need it for billing
purposes. A September 5, 2012, final rule extended the NPI: “This final rule also specifies the
circumstances under which an organization covered health care provider must require certain
non-covered individual health care providers who are prescribers to obtain and disclose a
National Provider Identifier (NPI).” 77 Federal Register 54664.
61 Small health plans had an additional year to comply, until May 23, 2008.
62 After a lengthy delay since enactment of HIPAA Administrative Simplification statutory
provisions, the Patient Protection and Affordable Care Act, enacted on March 23, 2010, set a
statutory effective date deadline of October 1, 2012, for the unique health plan identifier. A
September 5, 2012, final rule adopted a standard for the health plan identifier: “This final
rule adopts the standard for a national unique health plan identifier (HPID) and establishes
requirements for the implementation of the HPID. In addition, it adopts a data element that
will serve as another entity identifier (OEID), or an identifier for entities that are not health
plans, health care providers, or individuals, but that need to be identified in standard
transactions.” 77 Federal Register 54664. Also, see the Centers for Medicare & Medicaid
Services (CMS) Webinar presentation, Health Plan and Other Entity Enumeration System
(HPOES) that is available at:
http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Affor
dable-Care-Act/Downloads/Health-Plan-and-Other-Entity-Enumeration-System.pdf.
63 Small health plans have until November 5, 2015, to comply.
64 The National Individual Identifier is controversial. Congress has a long-standing hold on
any regulatory action on this identifier. Prior to enactment of HIPAA, the de facto individual
identifier had been the Social Security number – which is the source of controversy about
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requiring it as a standard. Since the enactment of HIPAA, a number of states have restricted
the use of the Social Security number as an identifier in matters other than Social Security, and
large health plans have developed unique individual identifiers for their members as a
substitute.
65 Trading partners are allowed to use one of two acknowledgement standards in conjunction
with standard transactions, but it is not a mandated standard transaction under HIPAA.
66 Visit the National Archives site for more information on the E-Government Act at:
http://www.archives.gov/about/laws/egov-act-section-207.html.
67 HHS, “HHS Launches New Efforts to Promote Paperless Healthcare System,” news
release, July 1, 2003, which is available at:
http://archive.hhs.gov/news/press/2003pres/20030701.html.
68 Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT).
69 HHS, “Secretary Thompson, Seeking Fastest Possible Results, Names First Health
Information Technology Coordinator,” news release, May 6, 2004, which is available at:
http://archive.hhs.gov/news/press/2004pres/20040506.html.
70 HHS, The Decade of Health Information Technology: Delivering Consumer-Centric and
Information-Rich Healthcare, fact sheet, Wednesday, July 21, 2004. Available at:
http://archive.hhs.gov/news/press/2004pres/20040721.html.
71 Op. cit.
72 Information on this program is available on the Centers for Medicare & Medicaid Services
(CMS) Web site, EHR Incentive Programs, which is available online at:
http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/.
73 See the HHS Office for Civil Rights (OCR) Web site:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/breachnotificationrule/brguidance.html.
Accessed November 6, 2013.
74 ACA was enacted on March 23, 2010, as Public Law 111-148. Public Law 111–148,
published as 124 STAT. 119–1024, is available at:
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
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75 Public Law 111-152, published as 124 STAT. 1029-1083, is available at:
http://www.gpo.gov.fdsys/pkg/PLAW-111publ152/pdf/PLAW-111publ152.pdf.
76 124 STAT. 146-154.
77 124 STAT. 915-917.
78 124 STAT. 154.
79 The purpose is in Section 261 of Subtitle F – Administrative Simplification – .of the
HIPAA statute, which is available from the Office for Civil Rights (OCR) at:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/index.html#261. Section 1104(a)
is at 124 STAT.146.
80 124 STAT. 146-153.
81 See Exhibit Table 4-2: Adoption, Effective, and Compliance Dates for ACA. Transaction
Standard Operating Rules.
82 124 STAT. 147. Additional information on operating rules is available from the
Committee on Operating Rules for Informational Exchange (CORE), which is available at:
http://www.caqh.org/CORE_rules.php.
83 “(A) In General – The standards and associated operating rules adopted by the Secretary
shall – (i) to the extent feasible and appropriate, enable determinations of an individual’s
eligibility and financial responsibility for specific services prior to or at the point of care; (ii)
be comprehensive, requiring minimal augmentation by paper or other communications; (iii)
provide for timely acknowledgment, response, and status reporting that supports a
transparent claims and denial management process (including adjudication and appeals); and
(iv) describe all data elements (including reason and remark codes) in unambiguous terms,
require that such data elements be required or conditioned upon set values in other fields, and
prohibit additional conditions (except where necessary to implement State or Federal law, or
to protect against fraud and abuse).” 124 STAT. 147.
84 124 STAT. 153.
85 The Unique Health Plan Identifier was discussed earlier in this Addendum in the section
on Identifiers.
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86 The Secretary of HHS issued a NPRM for a claim attachment on September 23, 2005 (70
Federal Register 55989-56025), which was withdrawn on January 25, 2010 (75 Federal
Register 21804).
87 124 STAT. 916.
88 HIPAA was enacted on August 21, 1996, as Public Law 104-191 in the 104th Congress.
The Administrative Simplification provisions of the statute are in the relatively short 14-page
Subtitle F of Title II, which is available online at the Department of Health and Human
Services (HHS) Office for Civil Rights (OCR) Web site:
http://www.hhs.gov/ocr/privacy/hipaa/administrative/statute/index.html.
89 Cornichon Healthcare Select, LLC is owned by Edward D. Jones III, who also served as
Chair of the WEDI Board of Directors for two years in 2003-2004.
90 Fernandes, L., and O’Connor, M. “Patient Identification in Three Acts,” Journal of
AHIMA, v.79, n.4, April 2008, which is available online at:
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_037463.hcsp?dDocNa
me=bok1_037463.
91 These identifiers are listed at 45 CFR 164.514. See:
http://www.oshpd.ca.gov/Boards/CPHS/HIPAAIdentifiers.pdf.
92 Mawad, M., and Ewing, A., “Apple Sets Off a Biometrics Arms Race,” Bloomberg
BusinessWeek, August 26-September 1, 2013, pp. 41-42, which can be accessed online at:
http://resourcecenter.bUSinessweek.com/reviews/apple-sets-off-a-biometrics-arms-race.
Mossberg, W.W. “Two Steps Forward for the iPhone: Fingerprint Technology, Operating
System Make 5S the Leader of the Smartphone Pack,” Wall Street Journal, September 18, 2013,
p. D1.
93 See Jones III, E., and Hartley, C., HIPAA Transactions: A Nontechnical Business Guide for
Health Care. Foreword by Kepa Zubeldia, MD. Chicago, IL: American Medical Association
(AMA) Press, 2004.
94 See Hartley, C., and Jones III, E., EHR Implementation: A Step-by-Step Guide for the
Medical Practice. 2nd Edition. Chicago, IL: AMA, 2012.
95 “Technology, in some way or another, has been a change agent in business since the
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industrial revolution. But never has it changed the game so thoroughly and intrinsically than
it has today because every company, no matter what its industry, has to play along. The
Internet, increasing mobility, the use of completely new algorithms and software that change
point-of-sale operations and the way companies interact with their customers – all are things
that no industry will escape.” See Ram Charan, “The CEO of the Future,” Chief Executive,
July/August 2013, p. 46.
96 National health expenditure in 1990 was $724.3 billion, or 12.5 percent of gross domestic
product (GDP), even then relatively high compared to other industries. See Hartman, M., et
al., “National Health Spending in 2011: Overall Growth Remains Low, But Some Payers and
Services Show Signs of Acceleration,” Health Affairs, v.32, n.1, January 2013, pp. 87-99. In
contrast, the latest data for national health expenditure (NHE) is $2.8 trillion in 2012, over
3.8 times greater than the 1990 figure, and 17.9 percent of GDP. See Cuckler, G., et al.,
“National Health Expenditure Projections, 2012-22: Slow Growth Until Coverage Expands
And Economy Improves,” Health Affairs, v.32, n.10, October 2013, p. 1822, for the latest
NHE estimate, and the May 2013 issue, “Tackling The Cost Conundrum,” v.32, n.5, for more
information on healthcare expenditures and actions to control cost in today’s economic
environment. The Health Affairs references are available at: www.healthaffairs.org.
97 This paradigm shift follows others since the 1993 WEDI Report that has transformed the
way information is accessed and communicated. Google was launched as a search engine in
December 1998, a paradigm shift in the way information is accessed and used. Another
paradigm shift, LinkedIn, occurred in May 2003 with the advent of social media for initially
personal, and now communication of business qualifications. Twitter was launched in July
2006 for mass exchange of short bursts of information, and Facebook in September 2006
outside of educational venues for mass exchange of social information initially and increasingly
business information as well.
98 Worldmapper, Internet Users 1990,” Map No. 335, which is available online at:
http://www.worldmapper.org/display.php?selected=335. On a per 100 persons basis, the
Internet users value was 0.78 in 1990 and 77.86 in 2011, based on World Bank data (see
http://www.indexmundi.com/facts/united-states/internet-users.)
99 Zickuhr, K., and Smith, A., Home Broadband 2013, August 26, 2013, which is available
online at: http://www.pewinternet.org/Reports/2013/Broadband/Findings.aspx.
100 When we refer to HIPAA, we are referring to the relatively short 14-page Subtitle F –
Administrative Simplification – of Title II of Public Law 104-191, enacted on August 21,
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1996, which is available online at: http://aspe.hhs.gov/admnsimp/pl104191.htm.
101 HHS, “HHS launches new efforts to promote paperless health care systems,” news
release, July 1, 2003, which is available online at:
www.hhs.gov/news/press/2003pres/20030701.html.
102 HHS, “Thompson launches ‘decade of health information technology’,” news release,
July 21, 2004, which is available online at:
www.hhs.gov/news/press/pres2004/20040721a.html.
103 These plans are outlined at goal, objective, and strategy levels in “Invest in Strategic
Knowledge” in Hartley, C, and Jones III, E., EHR Implementation: A Step-by-Step Guide for the
Medical Practice, 2nd Edition. Chicago, IL: American Medical Association (AMA), 2012, pp.
242-250.
104 See Addendum 4 for a discussion of administrative simplification and electronic clinical
initiatives from 1993-2013. Also, the Health Level Seven (HL7) Draft Standards for Trial use
DSTU) for Electronic Health Record (EHR) Systems that coincided with Secretary Thompson’s
initiation of the “Decade of Health Information Technology” in July 2004 had more
integration of administrative simplification and clinical standards than survived in the
Meaningful use EHR constructs. For HL7’s EHR-DSTU, see the 1st edition of Hartley, C, and
Jones III, E., EHR Implementation: A Step-by-Step Guide for the Medical Practice. Chicago, IL:
AMA Press, 2005, chapter 6.
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