HL7 ATTACHMENT SIG MEETING MINUTES
San Diego, CA — January 19 – 22, 2004

Co-Chairs

Maria Ward, PWC

Penny Sanchez, EDS

Nancy Wilson-Ramon,

Christine Stahlecker, CTGHS

Attendees:

Name / Affiliate / Email Address
Mary Lynn Bushman / Empire Medicare Services /
Nancy Wilson-Ramon /
Penny Sanchez / EDS /
Steven Scholze / WPS /
Tamara Unger-Peterson / WPS /
Rob Root / PGBA /
Craig Gabron / PGBA /
Laurie Darst / Mayo Foundation /
Conny Nichols /
Jim Leach / ACI /
Monique Harold / IDX /
Chris Stahlecker / CTGHS /
Pam Kitchens / PalmettoGBA /
Bob Davis / NAHDO/NYSDOH /
Mike Cassidy / Siemens /
Gale Carter / FPTechnologies /
Wes Rishel / Gartner /
Sue Thompson / DHHR WV Medicaid /
Kathleen Connor / Fox Systems /
Shaunna Wozab / Uhin /
Mary Winter / Dairyland Healthcare Solutions /
Gale Carter / FP Technology /
Lenel James / BCBS Association /
Catherine Schulten / Sybase /
Durwin Day / HCSC /
Loraine Doo / CMS /
Stacey Barber / EDS/NC Medicaid /
Cathy Watts / EDS/NC Medicaid /
Brandon Williams / Sierra Military Health Services / ,
Richard Gartee / Medical Manager /
Barb Hollerung / MN Medicaid /
Sheila Frank / Delta Dental Plans Assoc /
Kurt Hartmann / ACS /
Kepa Zubeldia / CLAREDI /
Karen Bone / VIPS /
Helen Gurerich / Ascential /
Rita Scichilone / Ahima /
Bill Braithwaite / Braithwaite Consulting
Dawn Paine / Metlife
Dawn Bellmann / VA/VHA /
Doug Morrow / AOA /
Tom Weaver / AOA /
Mark Charles / Altarum /
Liora Alschurer / AS
January 19 to January 22, 2004 HL7 ASIG Meeting Agenda
Monday January 19

Q1:

  • Welcome & Introductions
  • Review and Approval of Agenda
  • Co Chair Elections
  • Approval of September 2003 Meeting Minutes
  • Update from HHS: HIPAA (general) Claims
Attachment NPRM
  • Status of the X12N TG2/WG5&9 Implementation
Guides comment period SIG Discussion

Q2:

  • Status of the X12N TG2/WG5&9 Implementation

Guides comment period SIG Discussion

  • Discussion of AHA letter to NCVHS on Claims

Attachments

  • Discussion of alternative approaches to Claims

Attachments being discussed in the industry

Q3:

  • Discussion of possible WEDI SNIP Survey regarding Claims Attachments
  • Overview of ballot comments – not detailed

What the different groups of comments are

  • Overview of the ballot review process and orientation to any documents that will be used, e.g. comments spreadsheet
  • How we’re going to proceed with the Ballot review

Q4:

  • Review of CDA for attachments ballot responses
  • Quick Overview of the PIC Document
  • Wrap up – review any tabled items

Tuesday January 20, 2004

Q1:

  • Welcome and Introductions
  • XMLSPY Demonstration

Q2:

  • Q1 Demonstration Discussion
  • Next Steps for Reconciliation of CDA for Attachments
  • Ballot or overflow of X12N comments if needed

Q3:

  • Process for “Emergency Changes” to ASIG documents (related to regulatory issues and need for changes)

Q4:

  • Discussion of PIC document and any suggestions
  • Wrap up and discussion of tabled items

Wednesday January 21, 2004

Q1:

  • Welcome and Introductions
  • Review of DSMO process and improvements in HL7 Process

Q2:

  • Discuss (refine? Revise?) process for completing new Attachments
  • New Attachment Development Updates

Q3:

  • Discuss options for education to the industry

(hospital/payer associations; WEDI; webcasts;

CMS webcasts??; other

  • Discuss progress/options/ideas for Claims

Attachment Pilot

Q4:

  • Final Wrap up & Discussion of tabled items
  • Plan Agenda for May 2-7, 2004

Minutes for the January ASIG Meeting:

Monday Q1

  1. Welcome and Introductions

  • Welcome and Introductions

  1. Approval of April 2003 Meeting Minutes

  • Motion to approve the April ASIG meeting minutes was made and seconded. There was no discussion. All were in favor with the exception one abstention.

  1. Review Agenda

  • The group reviewed the proposed agenda. Based on the availability of people needed for specific discussions, some of the agenda topics were moved to a more appropriate time slot.
  • At a high level, we discussed what some of the agenda items would include:
X12 Comment Period – we will review and discuss several comments/responses that involved HL7.
WEDI SNIP Survey – HL7 and X12 need to work with WEDI SNIP on the survey. WEDI SNIP will coordinated with HL7 and X12 input.
XMLSPY – How to use the XMLSPY tool. This will help the ASIG in developing the Attachment Specifications. T
Emergency Changes – CMS requested DSMO to discuss how can the SDO’s respond to an emergency change. This may include an abbreviated approval process. The decisions will probably be made at the board level for HL7 but Maria will give us a high level overview of the ongoing discussions.
WEDI SNIP – interested in assisting with the Attachment education. Early in 2004 we want to have a tutorial. Maria believes that the tutorials should be presented at the HL7 meetings. We also need to get the information out to the Hospital associations. We should develop standard presentations to be used.
Pilots – pilots are necessary to prove to the industry that the HL7 (CDA)/X12 solution will work. We need Lorraine Doo to be available for this discussion.
Keep track of LOINC questions/issues for when Clem is available.
Acknowledgements – This will be part of the X12 comment discussion. We need specific instructions for version 3.0. Wes and Mike will work on this. We need the language for the X12 275 Implementation Guide by late February.
Move CMS update from Monday Q1 to Q3.
  1. Co-chair Elections

  • Discussion of the process – Currently there are 4 co-chair positions with a 2 year seat. There are no rules on the number of terms held by a co-chair. Both Maria Ward and Penny Sanchez co-chair positions expire at this meeting. Both Maria and Penny are running for the two open positions. John Quinn, chair of the technical committee, will officially hold the election. The ballot sheet will list Maria and Penny’s names as well as a blank line for a write in candidate. Anyone is eligible to vote. After the elections were held, the votes were counted. The results were that Maria Ward and Penny Sanchez were elected to fill the two co-chair positions.

Monday Q2:

  1. Discuss (refine? revise?) process for completing new attachments

  • Process for Completing new attachments:
Preliminary attachment data content defined or proposal to develop content received by ASIG
Define business use, flow, etc. for specification (DSMO questionnaire)
Co-chair sponsor, facilitator and scribe for outreach identified.
Outreach letter drafted and sent
4-6 weeks for interested parties to respond
Outreach conducted
Refine business use, flow, etc. for specification
  • HL7 approves to create specification
Data content entered into RAQ Build application – tool that connects questions to the answers
Who is the mentor for the process? Need to define.
Database of content submitted to LOINC committee for LOINC assignment (ensure version integrity….facilitator/scribe maintains current version)
LOINC’s received -
Specification written
Specification reviewed and approved by ASIG
Specification to ballot
Attachment available for use:
  • Voluntary adoption (pilot or production)
  • HIPAA mandate through NPRM process (DSMO process)

  1. New Attachment Development Updates

  • Status of attachments currently working on, need to define priority, assign responsibilities. We need to get movement to get these done. The industry is starting to request status of these:
  • AI - With the development of new attachments more participants need to learn more about CDA so we do not have to depend on Wes to be the author of the attachment booklets. Have a small subset of the ASIG committee develop
  • AI – need booklet template for the authors to use.
  • Home Health – claims (outreach completed) (60 days to complete) Spread sheet is done, next step to define LOINC codes. After Shaunna inputs the data in the RAQ Build application, we will schedule a call to discuss the results. #1 priority
  • Home Health – Prior authorization (outreach completed) (60 days) - #1 priority
  • Durable Medical Equipment (preliminary content defined – Medicare and Medicaid) – high priority in the industry but we need facilitator, no one has volunteered for this yet.
  • Children’s Preventative Health Services (preliminary content defined – Medicaid) – coordinate with the pediatric sig, need facilitator. Penny volunteered for this, Co chair sponsor ??, Scribe – WG - #2 priority
  • Periodontal (preliminary content defined – Medicaid and some industry) need to do outreach. Sheila will facilitator. Nancy Wilson Ramon will be the cochair sponsor, Scribe – WG The letter was written but not distributed. - #3 priority
  • Consent (Sterilization, Hysterectomy, Abortion) (preliminary content defined – Medicaid) - #4 priority, Penny will facilitate after the Children Prevent is completed
  • Possible new attachment time - Past filing documentation – bring up on the next NMEH call to see if this is an attachment that should be on our scope. Illinois Medicaid request. Penny will call her about the Feb meeting.

  1. Discussion of the AHA letter to NCVHS on Claims Attachments

The AHA letter to the NCVHS included the following three recommendations.

  1. Attachments are rare
  2. Additional information should be requested from other sources than the provider
  3. Attachments should not be requested when the information can be derived from information on the claim
  4. Add data elements to the 837 would be more cost effective
Use of Business process flows to address these issues. The ASIG is not responsible for responding to the AHA letter. We will ensure the White Paper has clearly addressed the AHA issues. The NCVHS draft letter to the Secretary on Claims Attachments is on the January 27 agenda. We will talk to Jeff Blair about the contents of this letter.

Monday Q3:

  1. Update from HHS: HIPAA (general) Claims Attachment NPRM

  • Lorraine Doo provided the update ; new to CMS since August. Maryland health plan, ran Medicaid program in Maryland, she works in the Office of HIPAA Standards and is responsible for Security and Claims Attachments.
  • Planning to publish the NPRM in September, 2004. The previous proposed date of May, 2004 was pushed back due to the Medicare Reform Bill. This will Buy us time to, solicit pilots not only for Medicare but also in the Private and Commercial Industry. We are also hoping to receive industry feedback from plans as well as provider community.

  1. Discussion of possible WEDI SNIP Survey regarding claims attachments

  • WEDI SNIP is interested in surveying the industry to see what attachments are important.
  • We have discussed creating a FAQ to be available on the HL7 website.
  • History – Industry Outreach was performed to determine the attachments types that were being used by the payers and providers. Also the NUCC did a survey at the same time. We drilled down the list to 42 primary attachments. This list was then drilled down further to 24 attachments. The list was then prioritized. We had an industry meeting in Chicago that included providers, medical reviewers, and payers. The 6 proposed Attachment types can be substantiated by the Industry outreach that was performed. The status of the 6, what is in development, what’s on the list to work on next.
  • Also include process flows, acknowledgment, do payers have to do unstructured etc.
  • Open issues that still need addressed from past meetings as well as HIMSS
  • Many organizations issued surveys in the past.
  • Should we do another survey and who should sponsor it? Recommendation from the industry to do a survey. Creating letter, it would be a URL link so the letter would be online.
  • What is the objective of the survey? We have to make sure the education is done so the responders understand what the survey is asking. Should consider splitting the survey into technical vs more business.
  • Is there staffing to look at the results. A lot of this is automated with the WEDI tool.
  • The majority of the group was in favor of exploring the survey.
  • The following items should be included in the survey:
  • Consensus of the attachment types.
  • Intro of the basic CA flow, the attachment types and additional attachment types. Run subsequent survey’s.
  • First address the issue of: Hearing the statement that CA’s are going away. We need real numbers to support this. Provider – saying we should not have to give it to the payer. Provider - Which attachments are still being requested of you. The payer – more or less and why. which attachments do you not still request.
Three different survey’s.
Take the fear factor out of attachments. The fear is that the payers will ask for more with the EDI. Not that it will make it more efficient. The payers are hearing that the provider will send the payers everything all the time. Just the minimum necessary should be sent. Will address both sides of this issue.
Discussion – put together a team. Business process flow and draft a letter/survey. HL7 and X12 would be involved WEDI Snip would just facilitate.
Formulate a working team with HL7 and X12 – get the survey going in a short period of time.
Need to be able to identify the difference between the medical review, fraud and post pay requests.
Are we now suggesting that fraud and post pay are not addressed by the attachments? The part of HIPAA is attachments for claims and claim adjudication. It could be used for these uses with TP agreements but would not be included under HIPAA.
Medical review perceived as pre payment.
There is a difference between what The law needs to do and what the group needs to do.
  1. Overview of ballot comments – not detailed. What the different groups of comments are.

  • Total responses to the version 2.1 Ballot – 30 yes votes, 14 no votes, 3 abstain and 1 did not vote.
  • Scope of the Ballot – the ballot only included the things that changed between version 2.0 and 2.1. There were only cardinality changes made.
  • Some of the comments received were out of scope. We need to decide whether to consider these comments or not. If after discussion with the commenter they do not withdraw or change their vote, we would consider it not related to the ballot.

Monday Q4:

  1. Review of CDA for attachments ballot responses.

  • See the spreadsheets for updated details.
  • All negative comments should be resolved.
  • Negative votes:
  • Keith Boone – Out of scope. Ask him to withdraw his vote on the basis that we’ll discuss it at the May meeting. Need to understand why this is important. Take under advisement. If there is a change in the CDA R1 schema then we should consider a change in CA. Nancy called Keith and he understood that his comment was out of scope and will withdraw his comment.
  • Michael Marsh – Out of scope. SVG is for sending diagrams such as VISO or Power point. Ask him to withdraw on the basis that we’ll add these suggestions in a future version.
  • Matthew Greene – Not related. Ask him to withdraw. We will also ask him to contact the other 11 negative votes received based on his comment. – Penny will contact Matthew.
  • Affirmative votes with comments:
  • Durwin Day – HCSC question about lack of being able to ask ‘why’ the payer received some value or code – example why unusual/non standard procedure was performed.

  1. PIC

  • Sheila and Nancy have identified 2 issues and they need to spend some time discussing. They will discuss this Tuesday morning during first break and then bring back the results to the group
  • Proxy clause
  • Process improvement committee – what they think we should use but we have comment on what we want changed on how we want to operate. If we do not respond by the May meeting we will have to operate the way the document states.

Tuesday Q1:

  1. Welcome and Introductions

  • Welcome and Introductions

  1. XMLSPY Demonstration

  • Mike Cassidy presentation – XMLSPY is a set of XML tools used for creating. Validating and tweaking XML-based files. This tool is free to HL7 committees who are using it to promote HL7.
  • The main components of XML that we deal with are schemas, instance documents, style sheets and HTML. We have 3 schemas (data types, header and body).
  • Mike showed the portability of HTML files. With a Lab example displayed in Netscape, MS IE, Opera, AOL and Acrobat Reader, the results were the same for each browser. These examples showed the reader friendly results of using a style sheet. Mike slightly modified the style sheet and displayed the document in a browser so we could see the difference and the ease of making the changes.
  • These tools are easy to use.
  • To use the validation tool, Mike selected the examples in the Attachment specifications and copied them into the XMLSPY tool. The validator will state if it is a well formed example and if it is valid. The tool will identify the errors with a description in the file. Errors display one at a time.
  • Style sheets can be modified to suit the viewer of the data.
  • Displays a graphical representation of the schema. This is much easier to read.
  • Great tool to use for development purposes.

Tuesday Q2:

  1. Electronic Health Records Update

  • Outreach to the industry before the ballot goes out. First ballot 1600 items they got it down to 200 items. Total of 200 functions.
  • Direct Care Functional group, Supportive Functional group, Information Infrastructure Functional group – these are the 3 categories broken down into key components. This is the model.
  • They try to clarify what the functions are by a clear definition. They include 7 Rationales for why the function is included in the model.
  • Citation column in the model. in the industry that justifies the industry importance.
  • Care settings are included in the model.
  • The model included some basic scenarios. They tried to include all of the functions in the scenarios.

  1. Review of CDA for attachments ballot responses.

  • Nancy updated the spreadsheet.
  • Mike Cassidy’s comments – Affirmative with comments. Most of them are typos.
Ambulance weight data conflict/confusion with wording and the cardinality. Accept proposed wording
Deprecated LOINC’s – accept the comment and correct the specifications as appropriate. Penny will work with Mike
LOINC modifier codes – The specifications say that X12N is the owner of the code. The X12N 277 guide points to HL7 as the owner. Non-persuasive. We determined that HL7 does own the document and they belong with the LOINC suite of documents. Penny will make the appropriate changes to the documents.