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December 8, 2008

Does the NHIN Already Exist?
By Elizabeth S. Roop
For The Record
Vol. 20 No. 25 P.14

A HIMSS white paper has stirred conversation about the prospect of using an already battle-tested structure to help get clinical data moving.

Earlier this year, the HIMSS Financial Systems Steering Committee released “The NHIN Highway Is Already Paved,” a white paper asserting that the existing HIPAA transaction exchange highway is suitable for use in the exchange of clinical and administrative data. As such, it supersedes the need to construct a separate national health information network (NHIN).

“Today, billions of electronic healthcare information transactions travel along an already ‘paved,’ secure information highway—from the point of care to the point of payment and back. The healthcare clearinghouse industry created this existing highway, and HIPAA standardized the vehicles (i.e., transaction sets and message standards by ANSI [the American National Standards Institute]-accredited standards organizations) that travel upon it,” the committee wrote. “In fact, nearly all healthcare claim information in the United States is electronically exchanged along this highway.”

The paper notes that the clearinghouse industry has maintained and expanded the transaction exchange highway for the past 25 years on behalf of the payer and provider sectors, both of which are covered entities. Users adhere to mandated HIPAA standards on privacy and security, and the roadways are certified by the Electronic Healthcare Network Accreditation Commission for performance and integrity.

Emerging regional health information organizations (RHIOs) and health information exchanges (HIEs) that make up the backbone of the NHIN could benefit greatly from the lessons learned by the clearinghouse industry for constructing an exchange that effectively transmits a high volume of data every day.

“Unfortunately, many decision makers are disregarding or are not adequately informed of this existing, fully functional information highway and are investing tremendous funds, time, and effort into the analysis, prototyping, and development of new exchange mechanisms to support RHIOs and HIEs. These regional entities are developing slowly and could benefit from strong coordination with healthcare clearinghouse networks,” the authors wrote.

A Conversation Starter
By issuing the paper, the steering committee’s goal was to present its opinion on one possible solution for achieving the NHIN and to open a dialogue that could stimulate additional ideas about how to accelerate the process.

“They had a point of view they thought was valuable to the industry. Any time that people are provided with an opportunity to have stimulating conversation around important discussions such as this, it can help us move toward the best solutions,” says HIMSS Executive Vice President Carla Smith, CNM, FHIMSS.

The paper identified several similarities between present-day HIEs and RHIOs and those of healthcare organizations in the 1980s and 1990s that sought to share data on subscriber eligibility, claims submission, and payment remittance. At the time, providers were dealing with payers that required varying formats, coding schemes, and transmission mechanisms for electronic submissions. Payers, meanwhile, were dealing with providers with varying capabilities to submit transactions electronically.

Eventually, standardization brought about by HIPAA at the national level and the emergence of clearinghouses to deal with individual provider needs at the local level resulted in a system capable of securely and cost-effectively exchanging millions of transactions every day. In doing so, the administrative sector overcame several of the same challenges confronting today’s HIEs, including the following:

• Finding a sustainable business model: Sustainability was achieved through the adoption of a cost-sharing business model in which providers and payers contribute toward expenses by paying for the transactions they send across the exchange.

• Eliminating communication layers and complications: By introducing the concept of clearinghouses to navigate around unscalable, single, point-to-point exchanges, administrative channels were able to make communications between payers and providers significantly more efficient.

• Adopting equitable levels of technology: Clearinghouses eliminated the problems created by varying technological capacities by enabling even paper-based providers to submit claims electronically.

• Creating standards and coding structures: It was HIPAA that brought clarity to the structure and the code sets for the exchange of administrative information, and ongoing efforts by groups such as the Committee on Operating Rules for Information Exchange continue to refine business rules related to transactions.

• Integrating information sharing into workflow: Administrative transactions evolved from direct data entry portals to employ technology that automatically captures information in providers’ systems, ensuring they are more simply integrated into standard workflows.

The efficacy and security with which the HIPAA transaction exchange network manages the flow of data in wide-ranging formats between a myriad of businesses and organizations is “the most pliable and reliable starting point for the conveyance of clinical data,” according to the authors.

The existing exchange is also federally endorsed and trusted by payers and providers, which is critical to successful clinical data exchange. Further, the network of organizations involved with the transaction exchange are ready and willing to partner with their clinical counterparts to share their knowledge so as to achieve the best solutions for the convergence of clinical and financial data.

“As the ‘once-in-a-generation’ opportunity for data convergence is upon the healthcare industry, there is not ample time to accommodate inefficient and fractured efforts for this endeavor. The industry is changing without a halt, and it would be a disservice to attempt to reinvent the transaction highway for HIEs. Every speed bump must be avoided to build momentum in the ability to exchange clinical data as effectively and efficiently as financial data,” the authors wrote.

Pros and Cons
In making its call for the industry to develop a road map to demonstrate how the existing HIPAA financial transaction exchange highway may serve as the basis for the exchange of clinical data, the HIMSS Financial Systems Steering Committee was floating an idea that it hoped would facilitate a deeper exploration of how to overcome some key challenges threatening to stall the NHIN.

“As hoped for, it has stimulated conversation, debate, and disagreement and has piqued curiosity,” says Smith. “Responses have been that the piece was thought provoking and well written and that it was appreciated in that it gave a group of people an opportunity to think through an issue in a new way. … Overarching feedback has also been that it is clear there is no consensus around the recommendations put forth by the Financial Systems Steering Committee.”

That held true for the industry experts asked to provide their thoughts on the concept of using the transaction exchange for sharing clinical data. Many believe that the idea has merit but is not the solution to all the problems plaguing the NHIN establishment.
“What they assert is true, but what they focus on is incorrect,” says Alton Brantley, MD, PhD, a principal with CCI Group. “They are making the point that the highway is already paved, and that is a true statement; there is a connection between most healthcare providers and their insurers through the clearinghouses.”

However, Brantley says the existing exchange is more of a toll road than a highway. It is generally built from private connections among providers, clearinghouses, and payers, and the transaction fee required to exchange information across that connection comes with a clear cost benefit: In return for that fee, the provider’s claim is processed and reimbursement is received.

But things are not so clear cut when it comes to exchanging patient information, which is the dilemma most HIEs continue to struggle with.

“There is no way of measuring that cost benefit,” says Brantley. “How do you put an expense ratio on information about a patient? The economics of that are that there is a definite cost but an indefinite benefit. Much of the argument for RHIOs and health information has been based on the fact that we can’t quantify the value and therefore can’t quantify what the investment should be.”

Dan Garrett, managing director of HIT for PricewaterhouseCoopers’ Health Industries Advisory Practice, concurs. While the steering committee presents a solid argument for leveraging an information exchange that has already proven its feasibility, the sustainability model that works so effectively for exchanging administrative data does not translate directly to exchanging clinical data.
The return on investment (ROI) required to link to a clearinghouse for reimbursement purposes is fairly clear. However, it is a different matter when ROI is tied to the cost of accessing patient data.

“You have a built-in resistance to paying for that,” says Garrett. “It’s not like financial data. You can’t say it costs X dollars to produce and consume that data. In this case, [providers] aren’t doing this as a natural course of business, which gets us right back to where we are with everything else. ... We will have the basic sustainability issue no matter whose platform you use.”

The nature of the transactions must also be considered, according to Adam Wright, a research scientist with Brigham and Women’s Hospital in Boston and senior medical informatician in the Clinical Informatics Research and Development Group at Partners HealthCare.

For the most part, data crossing the HIPAA exchange network could be characterized as many transactions (those from providers) going to few end points (the clearinghouses and, subsequently, the payers).

“Clinical information is usually point to point, so the number of end points is vast. Imagine trying to build all those sorts of connections,” says Wright. “Administrative exchanges are made to go from a large number to a small one. Clinical is large to large. Authentication is a problem.”

For instance, when a physician submits a claim to the clearinghouse, it is done in compliance with HIPAA standards. The physician’s identity is authenticated via his or her provider number issued by the payer to whom the claim will ultimately be submitted. The identity of the patient to whom care was delivered is authenticated via his or her payer-issued member number. The clearinghouse only needs to validate those two pieces of information and the accuracy of the claims codes before submitting the claim to the payer on behalf of the provider.

In the exchange of clinical information, the lines are murkier. Multiple providers may be seeking access to any individual patient’s information for a variety of reasons. As such, it becomes necessary to authenticate not only the identity of the patient and providers, without the benefit of existing identifiers, but also the appropriateness of the information request to ensure the patient’s privacy.

“Administrative data is typically a ‘push’ transaction, while clinical exchange is typically a push-and-pull transaction,” says Wright. “There are multiple sources of truth. The primary care physician and the specialist will add to the information. Which is accurate?”
A final concern is the differences between the types of information targeted for exchange. While the administrative data are highly structured and designed for machine interpretation, patient data are often less structured.

Brantley notes that the claims-related data crossing the HIPAA transaction exchange feature fixed data fields and standard formatting designed for batch processing.

“I’m not saying that the connectivity that the clearinghouses provide might not be a reasonable alternative for the secure transfer of information. It is worth looking into, but that is not the bottleneck,” he says. “The bottleneck is having the definition of what is to flow and what is to change. A number of panels have been convened to get harmonization and definition of standards. The problem is having standards that sufficiently capture the complexity of healthcare without making them so rigid that we can’t explain what we don’t know.”

Adds Wright: “The HIPAA transaction set already exists. The landscape for clinical data exchange standards is much murkier. … We have a bunch of technical work ahead of us over the next few years. The government, through HITSP [the Health Information Technology Standards Panel], has spurred progress, and I think we’ll get there. We’re just not ready yet. … The financial side had other industries and histories to look at, [and] some of the lessons that have worked well for administrative data exchange will provide lessons we can use for clinical data exchange.”

More Exploration Warranted
The commentary from industry experts regarding the HIMSS Financial Systems Steering Committee’s proposal to link the exchange of clinical data to the existing financial transaction highway echoes the feedback already heard from other groups, both inside and outside of HIMSS.

However, the paper has achieved its goal of opening a dialogue surrounding alternatives to the construction of an entirely new information exchange infrastructure.

“Many groups don’t agree with the conclusion of the thought piece. It is clear that there is no consensus on the topic at this time,” says Smith. “But there is always room in HIMSS for the release of new ideas so that other groups can think them through [and] we can have a robust dialogue.”

Garrett makes the additional point that the concept of piggybacking the sharing of clinical data onto the HIPAA transaction exchange has merit if for no other reason than the fact that the administrative exchange has proven to be financially sustainable and has successfully established trusted relationships among the payers and providers utilizing it.

Exploring the methods by which that has happened can be a valuable exercise in the quest to construct the NHIN. The suggestions offered by the white paper could be just the impetus the healthcare industry needs to seek out ways to accelerate creation of the NHIN.

“It’s a free economy, and we are looking for solutions,” says Garrett. “Let’s challenge the industry to step up.”

— Elizabeth S. Roop is a Tampa, Fla.-based freelance writer specializing in healthcare and HIT.