HL7 White Paper:
Transmitting Images of Documents in HL7 Attachments
Wes Rishel
(Draft 11 20 May 2001)
Introduction......
Definitions......
Functional Approach......
Requirements......
Usage Scenarios......
Scenario: CDO With No On-line Clinical Data......
Scenario: CDO with Some On-line, Structured Clinical Data......
Scenario: CDO with On-line Document Images......
Scenario: CDO with On-line Document Images and On-line Structured Data......
Scenario: Health Plan, Minimal Compliance......
Scenario: Health Plan with Document Image Management System......
Scenario: Health Plan with Aggressive Process Improvement......
Technical Approach......
Description......
Specifications......
Design Considerations......
Choice of Image Format......
Sending Raw Images in BIN Segments......
Appendix 1: Alternative Image Formats......
Appendix 2: Complete Example HL7 Message......
Transmitting Images of Documents in HL7 Attachments1DRAFT 11 20 May 2001
Wes Rishel
Introduction
The May 2001 release of the HL7 LOINC Code Booklets{correct title?} for Claims Attachments include the changes that permit fax-like images of documents to be transmitted as claims attachments under certain specific circumstances. This paper gives the rationale for this addition, the functional approach, the business processes in care delivery organizations and health plans, the technical approach, and the rationale for the technical approach.
This document is written with the assumption that the reader is familiar with the X12N and HL7 implementation guides for claims attachments.[1],[2] Information on these and other X12/HIPAA-related implementation guides is available from the Washington Publishing Company, Gaithersburg, MD.
Definitions
Attachment module — a collection of software functions that enables a user to interpret requests for claims attachments in an X12N 277 transaction and create claims attachments in X12N 275 transactions. This module might be part of a billing system, a medical records system, or a specialized product.
Care Delivery Organization (CDO) — an organization that qualifies as a healthcare provider under HIPAA.
LOINC®— Logical Observation Identifiers, Names, and Codes[3]
Structured data — data sent as discrete observations in a format that makes the information useful for processing by a computer. For claims attachments each element of structured data is available as a LOINC code.
Text data — is natural language information sent as a block of text that can be comprehended by a person but is not amenable to being used in computer-based decision algorithms. For claims attachments this data is sent as a single datum identified by a LOINC code.
User — a person who uses software to accomplish a task.
Functional Approach
The capability to send images is being added to achieve these benefits:
- make attachments available sooner in CDOs that do not have Computer-based Patient Records or other sources of structured clinical data, and yet
- retain the structure and specificity associated with the use of the ORU message and LOINC codes.
The specific approach is to permit a CDO to transmit fax-like images of document pages in most situations where they might otherwise send textual documents as an unstructured block of text. This approach retains the use of LOINC codes and HL7 messages to identify the data being transmitted. The only difference is that the data that accompanies the LOINC code in the HL7 OBX segment is an image rather than being a block of text.
The image may be a fragment of a page or a number of pages. Nonetheless, the entire image must contain data that is described by the associated LOINC code. If a single page contains clinical data other than that which is specified by the LOINC code, the CDO must clearly indicate which data on the page is responsive to the LOINC code. This provision is to relieve the payer from the requirement to examine a large volume of medical record data and make the judgement about which parts are applicable. It is also supportive of the HIPAA privacy regulation that requires minimum disclosure.
Under HIPAA, all health plans must prepare to meet all capabilities specified for claims attachments. The approach described here is limited to monochrome images of document pages that are of the same quality as is produced by facsimile machines on the "fine" or high-resolution setting. This limitation is a compromise between covering all possible claims attachments and placing processing burdens on the systems of health plans.
Some of the details of the approach described here are specific to the six claims attachments that are expected to be part of the initial Notice of Proposed Rulemaking (NPRM): ambulance, rehabilitation services, emergency department, clinical reports, laboratory data, and medications. For other attachments the approach may be expanded to provide better quality images or colors, but only after an examination of the benefits versus the impact on CDO and health plan systems and approval through the HL7 consensus process.
As with any part of the claims attachments specifications, the approach to imaging is subject to change after comments have been received to the NPRM.
Requirements
Purpose. This addition to the claims attachments specifications must permit CDOs to transmit images pages of paper documents for review by health plans as an aid to claims adjudication.
Contents. The images transmitted under this specific approach will represent documents that can contain a combination of printed and handwritten information, sketches, EKG traces and other information that might appear in a paper chart. Information can only be sent this way if transmission at the quality level of a fax document is suitable for determining benefits.
Image Source. The images may be scanned images of paper documents, but they may also be images that could have been printed on paper but, in fact, were created electronically using a technology such as Computer Output to Laser Disk (COLD).
Low Equipment Cost for CDOs. It must be possible to create the images for this specification using low-cost software and a scanner costing less than $150. At the same time it should be straightforward to integrate the images into the image document management systems of health plans that have these systems.
No Requirement for Health Plan to Purchase a Document Image Management System. It must be possible for health plans that do not choose to use a document image management system to process claims attachments containing images by printing the attachments on paper.
No Bilateral Specifications. The HL7 specifications must be complete. No supplementary bilateral specifications between trading partners should be necessary for interoperation.
Future Considerations. The general approach used here should permit adaptation to support other claims attachments and attachments specified for other purposes than providing information to support a healthcare claim. An analysis of the requirements of those applications may lead to differences in the types and parameters of image formats that will be specified.
Usage Scenarios See Scenarios.ppt
CDOs and health plans vary widely in the extent to which structured clinical data is available on-line. This section describes how the attachments approach, including the ability to send images, may be used in different organizations. The following scenarios are described.
- CDO with no on-line clinical data
- CDO with some on-line, structured clinical data
- CDO with on-line document images
- CDO with on-line document images and on-line structured data
- health plan with minimal compliance
- health plan with document image management system
- health plan with aggressive process improvement.
Within each scenario, several situations are described. Depending on the specific systems in a CDO and a specific request for attachments, one or more of the situations may apply.
Scenario: CDO With No On-line Clinical Data
Situation: Attachment is a chart document. A CDO determines the need to create a claims attachment, either to accompany a claim or in response to a request. The attachment module determines that the information is of the category for which document images are permitted and a user determines that it has a paper document that satisfies the question stated in the LOINC code.
The user selects the element of the request for which will be answered with an image, places the document on a scanner and the attachment module scans the document and includes its image and LOINC code in the appropriate places in the 275 transaction. If the document contains more information than is requested by the LOINC code, the attachment module permits the user to indicate which part of the document contains the information that is responsive to the request.
At the completion of collecting all attachments the attachment module sends the 275 to the health plan.
Situation: Document is Prepared Specifically for the Attachment. There maybe circumstances where the information to be attached is specifically prepared for the attachment. The process is otherwise the same. The user creates the paper document and handles it as above.
Situation: Structured Data Required. Where the claims attachment specifications do not permit at least one of the requisite pieces of information to be sent as a document image, the attachment module might offer the user two choices:
- key the data into the attachment module so it can be sent as structured data, or
- send the entire set of attachments as paper.
Scenario: CDO with Some On-line, Structured Clinical Data
Situation: All Required Data That Must Be Structured Available On-line. The user determines which data can be retrieved from an on-line system of the CDO and the attachment module retrieves and inserts this information and the associated LOINC codes in the appropriate places in the 275 transaction.
For the remaining requisite information the attachment module determines that the information is of the category for which document images are permitted. The user finds or prepares paper, which the attachment module scans. The software inserts the images and the associated LOINC codes in the appropriate places in the 277 transaction. If a document that will be scanned contains more information than is requested by the LOINC code, the user indicates which part of the document contains the information that is responsive to the request.
At the completion of collecting all attachments the attachment module sends the 275 to the health plan.
Situation: Requirement for Structured Data Not Available On-line. Where the claims attachment specifications do not permit at least one of the requisite pieces of information to be sent as a document image and any of those pieces of information is not available on-line, the attachment module offers the user with two choices:
- key the data into the system so it can be sent as structured data, or
- send the entire set of attachments as paper.
Situation: Requirement for Data Available as Text On-line and as Paper in the Chart. Where a specific piece of information is permitted to be sent as a document image, and is available as on-line structured information but could be scanned from a document, it is to the economic benefit of the provider to send the structured data, because there are fewer manual steps and sending structured data has the potential to accelerate the processing of the claim within the health plan.
Use of LOINC Codes Not Required in the Systems that Maintain On-line Structured Clinical Data. It is not an operational requirement to precode the on-line data with LOINC codes. Just as with the paper chart. There are two alternatives. (1) The attachment module might contain a feature that maps LOINC codes to the local codes used in the systems of the CDO, or (2) a user can examine the patient's on-line records to determine which parts of the are relevant to which attachment requests.
However, if the CDO has chosen to precode the on-line data with LOINC codes the process of preparing attachments can achieve an extra level of efficiency by automating the retrieval of the data from the on-line system without having to maintain a mapping table. In any circumstance it is likely that a user would review the retrieved data before directing the attachment module to include it in the 275.
Scenario: CDO with On-line Document Images
Situation: All Required Data May Be Sent as Document Images. The attachment module determines that the information is of the category for which document images are permitted and the user determines that the CDO has document images or paper documents which satisfies the questions stated in the LOINC codes.
The user retrieves the appropriate document images from its document image management system. If the vendors of the document imaging management systems and attachment module have provided an interface, the images are transferred and converted to the format required for claims attachments automatically. Otherwise the user prints the document image and scans it into the attachment module.
The attachment module includes the images and LOINC codes in the appropriate places in the 275 transaction. If a document image contains more information than is requested by the LOINC code, the user indicates which part of the document contains the information that is responsive to the request.
Situation: Not All Required Data Available in the Document Image Management System. If the set of requested information includes information which is not available on-line and it is permitted to send this information as document images, the user retrieves or prepares the data and the attachment module scans paper documents as described above.
Situation: Structured Data Required. Where at least one of the requisite pieces of information is not permitted to be sent as a document image, the attachment module offers the user two choices:
- key the data into the system so that it can be sent as structured data, or
- send the entire set of attachments as paper.
At the completion of collecting all attachments the attachments system sends the 277 to the health plan.
Use of LOINC Codes Not Required in the Document Image Management System. It is not an operational requirement to precode data in the document imaging system with LOINC codes. Just as with the paper chart, a user can examine the patient's records in the Document Imaging System and determine which pages are relevant to which part of the attachments. If there is an automated interface between the attachments module and the Document Image Management System it might map between LOINC and the coding used in the Document Image Management System.
However, if the CDO has chosen to precode data in the document imaging system with LOINC codes the process of preparing attachments can achieve an extra level of efficiency by automating the retrieval of images from the document image management system without having to maintain a complex and dynamic mapping table.
Scenario: CDO with On-line Document Images and On-line Structured Data
The attachments system assembles the complete set of required information by retrieval of on-line structured data, on-line image data, and scanning of document images as described above.
At the completion of collecting all attachments the attachment system sends the 277 to the health plan.
Sub-case: Structured Data Required. Where at least one of the requisite pieces of information cannot be sent as a document image and is not available on-line, the software provides the user with one of two choices:
- key the data into the system, or
- send the entire set of attachments as paper.
Sub-case: Required Data Available as Structured Data and as Document Image. Where a specific piece of information may be sent as a document image, and is available both as on-line structured information and as an image, it is to the economic benefit of the provider to send the structured data, because this has the potential to accelerate the processing of the claim in the health plan.
Scenario: Health Plan, Minimal Compliance
A health plan receives 275s that have a mixture of structured data, images, or a mixture of both. Its mapping software creates human readable paper outputs by converting the structured data into human readable form. At the same time it prints the document images with headers constructed from the LOINC codes that are included with the images. The paper is then handled as it would be if it had been received from the CDO by courier.
Scenario: Health Plan with Document Image Management System
A health plan receives 275s that have a mixture of structured data, images, or a mixture of both. Its mapping software creates human readable outputs using COLD or other imaging technology by converting the structured data into human readable form. At the same time it creates COLD outputs of the document images with headers that are constructed from the LOINC codes that are included with the images. In each case the software uses the LOINC codes to construct indexes that can be used for searching the Document Image Management System for specific kinds of data. The document images are then used in adjudication exactly as they would have been if the health plan had received paper attachments and scanned them into the Document Image Management System. Some improvements in efficiency of claims adjudication, medical review, or clinical management may be possible because adjudicators can search the system for specific kinds of data in prior attachments.