Content Exchange and Vocabulary Standards for eMRs

Posted on October 14, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

Understanding Terms and Definitions

By Shahid N. Shah MS

As per the HHS rules, vocabulary standards are standardized nomenclatures and e-code sets used to describe clinical problems and procedures, medications, and allergies for eMRs. Some commons terms and definitions are listed below:

Terms and Definitions

  • ASTM’s CCR – for most of your basic patient summary exchange needs the CCR will meet your needs. If you’re moving from low or no interoperability today to some interoperable capabilities then CCR is your best starting place.
  • International Classification of Diseases, 9th Revision, Clinical Modifications (ICD-9- CM) or SNOMED CT® should populate a problem list. If you’re not familiar with both standards and are unsure where to start, go with ICD-9 for problem lists. SNOMED is not commonly supported in the broad EMR industry but ICD-9 support is quite common so start there.
  • Health Level Seven (HL7) Clinical Document Architecture (CDA) Release 2 (R2) Level 2 CCD – for more advanced patient summary exchange needs the HL7 CDA is recommended. If you’re already supporting CCR exchange and it’s not meeting your needs then HL7 CDA is the next logical place to go.
  • For patient summary exchanges, HHS expect the following fields to be populated: problem list; medication list; medication allergy list; procedures; vital signs; units of measure; lab orders and results; and, where appropriate, discharge summary.
  • ICD-9-CM [ACD-10] or American Medical Association (AMA) Current Procedural Terminology (CPT®) Fourth Edition (CPT–4) to populate information related to procedures. Both of these standards are support broadly by most existing vendors so going with either or both is good.
  • For medication lists, HHS requires the use of codes from a drug vocabulary the National Library of Medicine has identified as an RxNorm drug data source provider with a complete data set integrated within RxNorm.
  • For lab results, HHS requires the use of LOINC® to populate information in a patient summary record related to lab orders and results when LOINC® codes have been received from a laboratory and are retained and subsequently available in your EMR. HHS states that in instances where LOINC® codes have not been received from a laboratory, the use of any local or proprietary code is permitted. HHS does not require these local or proprietary codes to be converted to LOINC® codes in order to populate a patient summary record.
  • For the purposes of electronic prescribing, your vendor must be capable of using NCPDP SCRIPT 8.1 or NCPDP SCRIPT 8.1 and 10.6. With respect to a vocabulary standard, your vendor must use codes from a drug vocabulary currently integrated into the NLM’s RxNorm. For the purposes of performing a drug formulary check, your vendor must be capable of using NCPDP Formulary & Benefits Standard 1.0 adopted by HHS (73 FR 18918).
  • There are standards required for insurance data like eligibility checking and submissions of claims. ASC X12N and NCPDP standards (Versions 4010/4010A and 5010 and Versions 5.1 and D.0, respectively) should be used for these transactions. It’s important to realize that Version 4010 is being phased out in favor of Version 5010 so your vendors need to support both at this time and must be able to move exclusively to Version 5010 in the future.
  • For the purposes of electronically submitting calculated quality measures required by CMS or by States, your vendor must be capable of using the CMS PQRI 2008 Registry XML Specification. Going forward, HL7 Quality Reporting Document Architecture (QRDA) Implementation Guide based on HL7 CDA Release 2 may be allowed but for now focus on the CMS PQRI requirements until HHS provides more guidance in the future.
  • For the purposes of submitting lab results to public health agencies, your vendor must be capable of using HL7 2.5.1.
  • For the purposes of electronically submitting information to public health agencies for surveillance and reporting, your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard. At this time HHS not required adverse event reporting nor have they adopted a specific vocabulary standard for submitting information to public health agencies for surveillance and reporting.
  • For the purposes of electronically submitting information to immunization registries your vendor must be capable of using HL7 2.3.1 or HL7 2.5.1 as a content exchange standard and the CDC maintained HL7 standard code set CVX -Vaccines Administered18 as the vocabulary standard.

Assessment

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Price Adjustment Medical Costing

Posted on July 25, 2010 by Dr. David Edward Marcinko MBA MEd CMP™

End of Life Care Programs

By Dean G. Smith PhD and the Accounting Workgroup

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An alternative to traditional medical resource costing is ‘price adjustment’.  In an international context, this method compares the monetary estimates of resource used, after adjustment for price level differences between countries and over time to standard current values.  In order to attempt comparisons of different cost estimates, analysts must be at least certain as to what items are included in costs and whether costs are being based on opportunity costs, charges, or average costs.

Medicare Cost-to-Charge Ratios

In the US context, the price adjustment approach underlies the use of Medicare Cost-to-Charge Ratios (CCR).  Costs are estimated using the CCR approach by multiplying the number of units of each procedure billed by its Medicare charge and CCR and then summing these costs.  Some health care organizations have begun to invest in sophisticated, computerized cost-accounting systems (CAS) that are capable of providing procedure-specific cost estimates, usually based on relative value units, but these systems often rely on billing data to obtain service units.

The Studies

A couple of studies have used a combination of CCR and CAS to estimate costs (costs to the institution – costs to Medicare are the Medicare charges). In both studies, the CAS was for hospital costs only, with Medicare reimbursement (not institution costs) being used for professional services by using relative value units and a conversion factor from the Medicare Fee Schedule.

Inaccuracy

To overcome the issues of inaccurately (or non-transparently) measuring resource units, it has become more common in clinical trials (a distinct sub-set of possible study methods) to develop case report forms to capture all study end points, including medical service use.  These studies then translate medical service use into costs using standard charges or costs, or a series of representative data sets of charges or costs, to the resource units. These methods have become so common that all submissions to the British Medical Journal are required to document methods using a 35-part form that includes items such as: part 16) Quantities of resources are reported separately from their unit costs; part 17) Methods for the estimation of quantities and unit costs are described; part 18) Currency and price data are recorded; and part 19) Details of currency of price adjustments for inflation or currency conversion are given.

Following these guidelines, a Michigan-based study is collecting data through a resource use data collection form and applying to standard costs per unit of service to produce costs for a RWJ-sponsored palliative care program.

Not the Usual Medical Care

There are a few studies on the costs and cost-effectiveness of end of life programs or the impact of serious illness on patient’s families.  Those studies that do evaluate end of life care programs are usually small in scope, compare the end of life program (e.g., as in hospice) to “usual care,” or have no comparison group, or do not evaluate the costs of the program.

Assessment

Criticisms of studies of only one medical resource/cost item often surround the total costs of care – suggesting that the use of focused studies may not be well received.  In fact, even studies that capture the total costs of medical care services are criticized for not capturing the indirect costs – family expenses on end of life care are substantial and are not factored into most cost-analysis studies. Very few studies try to capture all costs to enable adjustments of costs for selection processes that may influence resource use.

Editor’s Note: Accounting workgroup members:

1 Stephen Seninger PhD: Professor, Bureau of Business and Economic Research, University of Montana, Missoula, MT

2 Ira Byock, MD: Director, Promoting Excellence in End of Life Care, Practical Ethics Center, University of Montana, Missoula, MT

3 Carol D’Onofrio,DrPH: Research Director, Sutter Visiting Nurse Association & Hospice, Piedmont, CA

4 Jennifer Elston-Lafata PhD: Director, Center for Health Services Research, Henry Ford Health System, Detroit, MI 

5 Joe Engelhardt PhD: Research Coordinator, Life Institute VA Medical Center, Albany, NY

6 Carol A. Lockhart PhD: Project Director, Phoenix Care, Hospice of the Valley, Phoenix, AZ

7 Steven H. Miles MD: Professor of Medicine, Center for Bioethics, University of Minnesota, Minneapolis, MN

8 Herbert A. Rosefield: Corrections Care Consultant, Volunteers of America, Raleigh, NC

9 Anne M. Wilkinson PhD:Senior Health Policy Analyst, RAND, Arlington, VA

10 Barbara Volk-Craft RN, MBA  Program Manager: Phoenix Care, Hospice of the Valley, Phoenix, AZ

11 Dean G. Smith, PhD  Professor and Chair, Department of Health Management & Policy, University of Michigan, Ann Arbor, MI

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