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My name is Jean Narcisi. I am Director of the Department of Dental Informatics for the American Dental Association. (ADA). It is my pleasure to appear today on behalf of the ADA before the Subcommittee on Health Data Needs, Standards, and Security of the National Committee on Vital and Health Statistics (NCVHS). I would like to thank you for the opportunity to testify.
My statement summarizes the views and concerns of the ADA and its standards development activities as it relates to the dental profession and electronic transactions of health information addressed by the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191).
As required under the Administrative Simplification subtitle of P.L. 104-191, the Secretary of Health and Human Services is required to adopt standards for specified transactions to enable health information to be exchanged electronically. The law requires all health plans, clearinghouses, and providers who choose to conduct these transactions electronically to comply with these standards. The dental profession will be among those who generate the information for these electronic transactions. The following comments will address the questions we were asked to discuss as well as any other issues that could be of concern to the dental profession.
1. What are your organization's expectations for the results of the Administrative Simplification standards requirements in the Health Insurance Portability and Accountability Act of 1996? In what ways will the outcome affect the members of your organization, both positively and negatively? Of all the features to be addressed by administrative simplification, which ones are of highest priority to your organization? What problems do they currently pose that make them important issues?
The ADA expects that the requirements contained in P.L. 104-191 will result in the establishment of the framework to make electronic data interchange (EDI) a reality to exchange business and health care information in a standardized format. In addition, we believe that it will establish standardized processing methods associated with the transactions. Currently, the percentage of claims submitted electronically by dental offices is very low. We have determined that this is due to the inability of third-party payers to accept dental claims electronically. Because dental insurance represents a very small percentage of business for many third-party payers, many payers continue to place a lower priority on electronic communications with dental offices than with physicians, hospitals and pharmacies. Therefore, the results of the administrative simplification legislation should lead to the implementation of electronic solutions to many information problems that exist in dentistry today.
The ADA has been working towards the establishment of electronic solutions through the development of standards for the dental profession. We believe that EDI will save costs by reducing handling and processing time. The risk of lost paper documents will be eliminated and cost savings will be realized through the elimination of redundant functions in both external and internal environments.
One of the ADA's concerns has always been that standards developed for medicine may be adopted and then required for dentistry in a modified form rather than developed specifically for the needs of the dental profession.
The ADA has been actively participating with ANSI's Accredited Standards Committee X12 for the past several years and has been responsible for defining the data content as it pertains to dental claims. We strongly believe that data content decisions should be made by the ADA if they pertain to dental transactions.
The ADA has been committed to standards for many years and has sponsored a standards program for dental materials, instruments and equipment since 1928. The development of standards is accomplished by volunteers under the auspices of the American National Standards Institute (ANSI) Accredited Standards Committee MD156. The ASC MD156 is an independent committee of ANSI for which the ADA serves as sponsor and secretariat. In 1992, there was interest in the standardization of clinical information systems. After evaluating current informatics activities, the ADA approved a group of projects relating to clinical activities and a task group of the ASC MD156 was created by the ADA to initiate the development of technical reports, guidelines and standards for administrative and clinical applications used in dental practice. The primary goals of the ADA's dental informatics activities are to improve patient care and increase dental office administration efficiency.
Components of the task group include five working groups for clinical informatics. The working groups were established to promote the concept of a dental computerized clinical work station and allow the integration of different components into one system in order to provide for all of a clinician's information needs. Clinical information systems include all areas of computer-based information equipment such as practice management systems, digital radiography and imaging, digital intraoral video cameras, digital voice-text-image transfer, periodontal probing devices, etc. By establishing standards for these modules that serve the clinical needs of practicing dentists, the need for several stand-alone systems in the dental office will be eliminated.
Each ASC MD156 working group has been researching standards already in existence to determine if they could be applicable to dentistry. Participants are also working with other standards developing organizations (SDOs) active in medical informatics in order to coordinate projects.
The ADA also sponsors participation in ANSI activities of the International Organization for Standardization (ISO) Technical Committee 106 on dentistry and acts a secretariat for ANSI for Working Group 2 of ISO/TC 106. Thus, the ADA works both nationally and internationally in the formation of standards for dentistry.
2. Does your organization have any concerns about the process being undertaken by the Department of Health and Human Services to carry out the Administrative Simplification requirements of the law? If so, what are those concerns and what suggestions do you have for improvements?
We are pleased that the American Dental Association, along with the National Uniform Claim Committee (NUCC), National Uniform Billing Committee (NUBC), and the Workgroup for Electronic Data Interchange (WEDI) were specified in P.L. 104-191 for a formal consultative role. The ADA appreciates the opportunity to work with the Department of Health and Human Services and the NCVHS and we look forward to a continued and productive relationship.
The ADA's concern about the process being undertaken to carry out the administrative simplification requirements is that the decision makers may not fully understand the significance of ANSI standards. The ADA believes that where ANSI standards already exist, those standards should be adopted.
The ADA is a member of and very supportive of the work of the ANSI Health Informatics Standards Board (HISB). We were also a member of its predecessor the ANSI Health Informatics Standards Planning Panel. The HISB aims to achieve a unified set of nonredundent and nonconflicting standards that will be compatible with national and international standards. The HISB inventory of standards document pertaining to P.L. 104-191 that Jeff Blair presented to the Subcommittee, includes some of the ADA standards activities. However, I would like to further explain some of the projects we have initiated and are coordinating with other SDOs in order to prepare the dental profession for future electronic administrative and clinical applications.
As I mentioned previously, the ADA has been working with the ASC X12 in order to define the data content placed in the electronic "envelope" used to transmit data for dental claims. Because there was no standardized method of implementing the ASC X12 837 transaction for dental claims, the ADA developed an Implementation Guide based upon the 837 to assist practice management vendors, third-party payers and clearinghouses in the execution of the standard transaction for dental claims. At the time we developed the Guide, the ASC X12 had not begun its work on the development of Implementation Guides for any of the transactions. The ADA was one of the organizations that urged the ASC X12 to initiate the process of developing Implementation Guides for all health care transactions in order to promote uniform implementation of the transactions and obtain widespread acceptance of electronic standards. Now that the process of Implementation Guide development has been initiated within the ASC X12 environment, the ADA will continue to work with the ASC X12 to provide the data content for all dental applications.
The ADA holds a vision of seamless data transfer throughout all facets of health care, independent of profession, discipline or specialty. The ADA further believes that a seamless data interface among systems serving private practice, academia, research, industry, and government programs will offer significant benefits to all system users.
Therefore, the ADA has begun to establish the basic content elements of a Computer-based Oral Health Record (COHR). The objective is to develop COHR features that offer the greatest utility to the profession as a whole, address issues of open architecture and will be technology independent. The baseline version 1.0 of the COHR Concept Model which includes the business process information and data rules was released by the ADA in 1996. While the process and data models described in the COHR were specific to dentistry, the models were developed with the understanding that dentistry is a microcosm representative of the entire health care environment. The COHR was developed as a progression of analytical models founded on clinical and public health principles. It described the health care environment, the fundamental process of health care delivery and the data needed to support these processes. The COHR Concept Model was subsequently converted into a logical data model by the ASC MD156 and includes the data management specifications which could then lead to a physical data model (e.g. a vendor specific implementation). The logical model was expanded and modified through consensus of subject matter experts. This modification evolved the COHR logical model into a generic clinical data architecture for patient health care information independent of health care profession or delivery environment. The ADA's document, which is referred to as the ADA 1000, is a framework for the specification of a clinical data architecture and it applies to the application data interface of a health care information system. A diagram is attached to the written statement as Appendix A which describes an "Architecture of the Health Care Information System". The ADA 1000 could be used to guide the development of databases for patient information in computer-based patient records and other applications.
This ADA 1000 has been approved by the ADA and is currently undergoing the consensus process for future approval as an American National Standard by ANSI. The draft ADA/ANSI 1000 is being coordinated with other SDOs and no overlap or conflict exists since the relevant standards apply to other levels of the Architecture of the Health Care Information System. Harmonization is currently underway between DICOM, ASTM E31, ASC X12, NCPDP, HL7, and relevant ISO standards.
The result of the ADA's work will be a standard or a "blueprint" against which commercial vendors can build their databases and the interfaces for passing data among various systems.
3. What major problems are experienced by the members of your organization with the current transactions specified under the HIPAA? For generators of the data, how readily available is the information that you need to provide for the transactions and how meaningful is that information from a clinical perspective?
The ADA is very supportive of the intent of the act and believe that most of the transactions specified under the law are appropriate. However, the majority of the current electronic dental transactions are being transmitted using proprietary formats while only a very small percentage of electronic dental claims are transmitted using the newly developed ASC X12 standards. Therefore, the ADA encourages that electronic dental claims transactions continue to be submitted in the current electronic formats, with migration to require ASC X12 formats only. The ASC X12 837 is the only approved ANSI draft standard for trial use in existence for dental claims at the present time. However, the ASC X12 Interactive Claim standard will soon be finalized and when approved it will be the preferred standard to be used for dental claims transactions.
The ADA supports the adoption of standards for the financial and administrative transactions listed in P.L. 104-191, except with regard to health claims attachments. The ADA believes attachments are not needed in dental claims transactions, as only administrative data are necessary to process the claim. Standardization of claims attachment information should be limited to a well defined set of possible attachments and eventually eliminated as a requirement. If the claims transactions consisted of uniform data content and the third-party payers were required to standardize their processing methods, attachments could be eliminated.
Claims attachments, as specified in the law, are not synonymous with the patient health records or detailed clinical information, though some attachment information may be derived from a patient's clinical record. While the ADA is fully supportive of ongoing efforts to develop a computer-based patient record, and we are active participants in the development of such standards, we believe this is an issue separate from the insurance transactions currently being considered by NCVHS and beyond the mandates of P.L 104-191.
With respect to the availability of the information that the generators of data need to provide for the transactions and how meaningful the information is from a clinical perspective, dental claims data in its current form does not provide researchers with the ability to study treatment patterns and the outcomes of care. Only the service provided to the patient and not the condition being treated is reported in a dental claim. Therefore, the ADA is concerned that the administrative simplification legislation will reach beyond its core focus on administrative and financial transactions and seek premature standardization of clinical transactions for the computer-based patient record and supporting code sets. Although the ADA believes that a comprehensive clinical coding system is essential for the computer-based patient record, we do not believe that CPR coding issues should drive the code standards for the claims transactions.
Recognizing the need for standards in clinical terminology and the limitations of the current coding systems, the ADA engaged in the difficult task of creating a clinical terminology and coding system which will provide the profession with comprehensiveness and varying degrees of utility. We are currently developing a microglossary of the Systematized Nomenclature of Medicine (SNOMED) so that patient history, findings, services and outcomes can be represented accurately. In addition, we are developing a comprehensive glossary of the dental terms. Standardized terminology must have explicit definitions. A collective guide is important for consistent interpretation of terms by the profession and aggregate data analysts. This work is being paced accordingly with the other agencies of the ADA involved in the development of standards for the Computer-based Oral Health Record and the Computer-based Patient Record.
While standards for administrative transactions are essential to streamline claims processing, electronic patient record standards need to be developed for optimal patient benefit, with assurance of confidentiality safeguards. The ADA recommends that the Secretary of DHHS move forward with the adoption of current ANSI standards for the specified transactions in the law. However, adoption of standards for clinical transactions and supporting code sets should be deferred until the appropriate frameworks, data dictionaries, cross mappings and harmonization of the current and proposed standards can be fully developed. Furthermore, the ADA believes that the ANSI HISB should be assigned the responsibility for the coordination of the computer-based patient record and other clinical standards.
4. How can the goal of administrative simplification best be achieved while meeting the business needs of all stakeholders?
The ADA would like to emphasize its shared commitment to advancing standardization and administrative simplification. The following points summarize our statement and recommendations for achieving the goals intended by administrative simplification:
Thank you for the opportunity to present our perspectives on issues associated with administrative simplification. The ADA looks forward to a continued and productive relationship with the NCVHS and the Subcommittee on Health Data Needs, Standards, and Security.