The National Committee on Vital and Health Statistics was convened on Tuesday and Wednesday, September 15 and 16, in the Hubert H. Humphrey Building in Washington, D.C. The meeting was open to the public. Present:
Dr. Detmer introduced and welcomed new member David Takeuchi, Ph.D.
Mr. Scanlon briefed the Committee on the Data Council's and Department's work in the areas of age adjustment, a new data systems directory, survey planning and integration, and early work on privacy regulations. Committee members discussed the need to strengthen the scientific base for decisions about privacy protection.
Dr. Braithwaite briefed the group on public comment on the NPRMs and the status of other NPRMs. The Department has delayed any action on the unique identifier for individuals. The Committee discussed relevant Y2K issues, particularly in relation to implementation of HIPAA.
The Committee spent considerable time discussing two documents, developed in consultation with Committee counsel Deborah Tress and sent forward by the Executive Subcommittee. The documents, which would replace the "groundrules" passed by the Committee last year, interpret the Federal Advisory Committee Act and the Freedom of Information Act in regard to Committee documents and meetings.
After Ms. Greenberg reviewed several policies and practices, members had a wide-ranging discussion aimed at understanding and clarifying the application of FACA and FOIA to the Committee's operations. In this context, they considered whether the draft documents clarified their responsibilities and would help the Committee carry out its duties.
Dr. Harding read a letter from Mr. Gellman (who is away at a meeting), opposing the passage of any Committee guidelines and opposing any restriction on public access to Committee documents at any stage of development. Katheryn Serkes, an audience member representing the Association of American Physicians and Surgeons, spoke several times to call for complete access to documents and deliberations.
Members affirmed the Committee's longstanding and continuing commitment to openness, and they discussed ways to more fully apply this principle in the future. They stated that the Committee has not, does not, and will not hold secret meetings. They were in agreement that the Committee has no authority to release predecisional government documents shared with them as special government employees.
When the discussion of this topic resumed the following day, Dr. Lumpkin suggested that the laws and regulations applying to the conduct of NCVHS business are clear, and no further guidelines or groundrules are needed. The Committee unanimously passed a motion to rescind the "Groundrules for Dealing with Media and Other External Organizations," in effect since late 1997. They expressed appreciation for the staff's interpretation of the Open Meetings Act as a useful reference. They agreed that the rules of a quorum will apply to Workgroups as well as Subcommittees and the full Committee. Finally, they agreed that "virtual" forms of attendance (phone or video conferencing) should be made available for those occasions when members cannot avoid being absent from meetings.
Ms. Foster reported on three new or planned entities that stem from the work of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. The President endorsed the Commission's findings and called for the creation of an Advisory Council on Health Care Quality and a Forum on Health Care Measurement and Reporting. He also established by executive memorandum the Quality Interagency Coordinating Task Force (QuIC). The Advisory Council requires legislation, and has not yet been established; a planning body is now at work to create the Forum; and the QuIC has met and identified five themes and priorities, including developing the information system base, workforce issues, and coordinating federal QI activities.
Committee members focused attention on the development of information systems as a precondition for quality improvement; on access as a dimension of quality; on the problem of proprietary information systems; and on the need for more state representation in the Forum. They also expressed interest in collaboration between the three new organizations and the Committee in its work on quality.
Ms. Foster was asked to report to the Committee again in early 1999.
NCHS is now reviewing 1200 comments on ICD-10-CM, following a comment period that ended in February. The general sentiment seems to be that ICD-10-CM is a significant improvement over ICD-9-CM, and what is needed is fine-tuning. Ms. Pickett described some of the modifications and promised to update the Committee when all of the comments have been reviewed.
Ms. Brooks reported that two clinical data abstraction centers (CDACs) have tested the new ICD-10-PCS, which was posted on the HCFA home page in July. The CDACs found that the new system has great promise; it is very logical, they were able to learn it quickly, and it meets NCVHS criteria for new systems. Phase II of testing is now beginning, using the CDACs. They will issue a report by March, and HCFA will issue a final report by April.
Committee asked a number of questions on such things as NOS codes, DRG revision, mapping, and the guidelines for coding rule-outs. Ms Pickett commented that with the transition to ICD-10-CM the inpatient coding rules for rule-outs will be revised to match the outpatient rules for the reporting of rule-outs. Ms. Brooks remarked on the general attitudinal change regarding ICD-10-PCS and the atmosphere of greater acceptance that they are observing. Asked about moving to a single procedure classification system, she predicted that this would be faced at a later juncture.
Members expressed support for this concept paper, earlier versions of which have been discussed at previous NCVHS meetings. After suggesting several new or strengthened points, they agreed that the paper, as modified, should be sent to the Data Council and posted on the NCVHS Web site. Dr. Detmer said he would activate the Workgroup to consider next steps. The Committee later decided to publish this paper in its 1996-1998 report.
Dr. Iezzoni reported on these Subcommittee activities, for which reports are expected soon:
The group is now reviewing the Department's survey integration activities, and next year will study data issues related to the children's health initiative. In that regard, the Committee slightly revised and approved a draft letter to the Secretary encouraging the use of the SLAITS telephone survey to collect data on the children's health initiative.
Ms. Fyffe reported that the Subcommittee had just held a roundtable to hear the perspective of investigators on balancing privacy/confidentiality rights with control of health care fraud and abuse. The panelists called for stronger penalties for misuse rather than any restrictions on access to medical records.
Dr. Cohn and Mr. Blair said the new workgroup was developing its work plan, and has scheduled its first hearings on the CPR for December 8-9. It is working closely with the Government-CPR group.
The Subcommittee has tabled work on the individual patient identifier, pending further direction from the Department. It may hold a hearing on comments on the NPRMs. At the Subcommittee's request, the Committee approved a letter on the security NPRM, HCFA 0049-P, and a second letter concerning the Paperwork Reduction Act. Both will be sent to the Secretary.
Ms. Greenberg reported on planning for this November 2-3 event, sponsored by NCHS/CDC in collaboration with AHCPR and NCVHS. Its purpose is to raise awareness of the implications of HIPAA for public health and health services research, and to create a mechanism for priority-setting and input into standardization by those constituencies. Committee members offered suggestions for the agenda and invitation list.
Committee members, staff and contractor Susan Kanaan discussed a draft outline of the three-year report. Members made some suggestions and were asked to send Ms. Kanaan any further comments about the outline. The first draft of the report (which will be completed at the end of 1998 and reviewed by the Executive Subcommittee) will be discussed at the November meeting.
These dates were approved for Committee meetings in 1999:
Members suggested several agenda items for the November 1998 meeting.
Dr. Detmer called the meeting to order. He noted that Committee member Robert Gellman and HHS liaison John Fanning are at a meeting of the International Data Protection Commissioners in Europe, a meeting they will report on in November. He welcomed new NCVHS member David Takeuchi, who is moving from UCLA to the University of Indiana. His areas of expertise are mental health, race and ethnicity issues, and quality.
Mr. Scanlon noted that the Data Council celebrated its third anniversary in August, a significant milestone. He reviewed its five major themes:
On the recommendation of the Data Council, the Secretary has approved adoption of a new Department-wide standard for age adjustment for mortality rates. It involves the Year 2000 projected population, and will begin with deaths occurring in 1999. The policy goes into effect in September. An HHS implementation team will be formed to work on educational materials and the effect of the change on rates.
The HHS Directory of Data Systems was last updated in 1995, when it emphasized race/ethnicity data. This year, similar data will be collected, but the directory will include all general purpose data systems. It will be completed in about a month and probably posted on the HHS Web site.
The Council has developed a five-year plan of surveys in conjunction with its budget planning. The idea is to make sure that data needs are addressed and coordinated, and also to identify any resource problems. The Council also has been working with the HHS Budget Office on the Year 2000 budget. The advance plan of surveys will be posted on the Web site.
After phases that focused on the major population-based surveys and on employer surveys, the Data Council is now looking at health care system data as the third phase of its survey integration process. These are surveys and data systems related to plans, providers, capacity, and resources. A report is expected at the November Data Council meeting. The work group is closely consulting with the industry.
The Data Council is looking forward to receiving the Committee's report on the Health Information Infrastructure (discussed below).
Congress is considering various bills relating to privacy, and most of the bills on patients' bill of rights include medical confidentiality provisions; but there is no decisive progress toward privacy legislation. HIPAA mandates that if Congress has not passed medical record privacy legislation by August, 1999, the burden falls on HHS to develop privacy regulations. Thus, HHS is studying what authority the legislation provides for privacy protections.
Dr. Lumpkin asked whether a scientific base exists for assessing the risk of access to health information, and if not, whether the Committee wants to try to stimulate research in this area. He noted that much of the speaking and writing on the subject is subjective, and not scientifically based.
Mr. Scanlon agreed that there is little empirical basis for opinion and decisions in this area, although he pointed out that data disclosure avoidance policies and practices -- e.g., those used by the Department -- are evidence-based.
At his request, Richard Suzman of NIH described a workshop being planned by NIH and the National Academy of Sciences. It concerns confidentiality issues associated with research using large-scale data bases, and it will have open attendance and probably take place in the spring.
The comment period has been closed on four Notices of Proposed Rule Making. Thousands of comments were received from hundreds of people. The comment period for the security and electronic signature NPRM closes October 13. The NPRM on a plan identifier has been drafted and is in clearance; it was delayed by the complexity of defining a plan, but it is expected within a couple of months. There is no schedule yet for the final rules, but the Committee will be notified when there is one.
At present, the implementation teams are reviewing, summarizing and tabulating the comments in their respective areas. The Department will then issue a report that compiles all these components. All the comments are posted on the HHS Web site.
The Notice of Intent on the individual health identifier has been postponed due to the public and Congressional reaction to the hearings held by NCVHS in July. Several amendments were offered (none of which has yet become law) asking the Secretary not to implement an identifier until privacy protections are in place.
Ms. Fyffe asked about the Data Council's attention to the Year 2000 problem, and whether the Committee should consider it. Dr. Braithwaite said many of the comments on the NPRMs addressed this issue, with some favoring the idea of having to implement HIPAA standards and deal with Y2K at the same time, and some opposing it. However, the entire problem has been somewhat overtaken by events: as a result of the delays in publishing the final rules, standards probably will not have to be implemented until after Y2K. He added that solving the Y2K problem is a very high priority for the Department.
Dr. Detmer asked whether Committee members wanted to pursue this issue within the Committee. Mr. Blair noted that it was considered in the deliberations on claims transaction standards, where the Subcommittee learned that for most of the industry, accommodating Y2K is less of a concern than expected because they will be installing new software rather than retrofitting existing programs. Nevertheless, he suggested that the Committee look seriously at the problems of the organizations in the latter category.
Dr. Cohn said the health care industry is becoming sensitized to the Y2K issue, and the Committee should talk with them to understand their issues. Dr. Detmer asked Dr. Braithwaite to let the Committee know what the comments have to say in this regard.
The minutes of the June 16-17 meeting were approved.
Dr. Detmer introduced Deborah Tress, the Committee's legal counsel, and explained that as requested at the last full Committee meeting, the Executive Subcommittee had prepared two draft documents, in consultation with Ms. Tress, for the Committee's consideration.
Ms. Greenberg then discussed the two documents, which expand and clarify the guidelines approved by the Committee last November. They pertain to:
Both are shaped by the requirements of the Federal Advisory Committee Act (FACA) and Section 552 of Title V, United States Code, AKA the Freedom of Information Act (FOIA).
Ms. Greenberg explained several existing or proposed Committee policies in respect to document handling, as follows:
Dr. Detmer invited discussion of the documents, which Ms. Tress explained are intended to apply the requirements of FACA and FOIA to NCVHS operations. A vote on the documents will take place on day two of this meeting.
Members engaged in a wide-ranging discussion aimed at understanding and clarifying the application of FACA and FOIA to the Committee's operations. They also considered whether the draft documents would help the Committee carry out its duties.
From the audience, Katherine Serkes of the Association of American Physicians and Surgeons stated that the organization had not received Committee documents that it requested in a July 14 letter. Ms. Tress, Ms. Greenberg and Mr. Scanlon responded that the letter was not clear about its intent and was not read as a request for documents.
Dr. Harding read aloud a letter from Mr. Gellman, who is unable to attend this meeting. In it, Mr. Gellman asserts among other things that "the new guidelines are no better than the old ones," which he voted against. He advocates "affirmatively making our documents public" and urged that "the new guidelines be defeated ... and the old guidelines be scrapped in their entirety." Mr. Gellman's arguments and recommendations became part of the Committee's consideration of this issue, with several members expressing regret that he could not be present to represent his views.
Ms. Tress pointed out that the laws pertaining to the Committee's operations stand, independent of NCVHS guidelines; however, the Committee does have some latitude in the format, timing and extent of the dissemination of its own documents.
It was the sense of the members present for this discussion that the Committee does not have the authority to release predecisional government documents, which are available to the public subject to the FOIA provisions. Dr. Lumpkin observed releasing predecisional Department documents would have a "chilling effect" on the Committee's relationship to the Department.
Members also affirmed the Committee's historic and continuing commitment to openness in the way it operates.
Ms. Greenberg reviewed the key points of this document, concerning such things as the role of the designated federal official, quorums, public access, and transcripts and minutes.
Members affirmed that contrary to the charges in the July 14 letter from the Association of American Physicians and Surgeons, the Committee has not, does not, and will not hold secret meetings. They agreed that paragraph 13 of FACA has been and will be interpreted very narrowly, to avoid the appearance of secrecy.
They struggled with the issue of what to do if a meeting that initially has a quorum loses it in the course of the meeting. They agreed that in such an eventuality, the Committee can continue to take testimony and gather information, constituted as a working session, but members cannot deliberate in the absence of a quorum. It was stressed that this is another reason why members need to attend meetings in full.
After draft letters concerning NPRM 0049-P were circulated, for discussion the following day, the meeting recessed, to be reconvened in subcommittees and work groups. The foregoing discussion was resumed and concluded the following day.
(This item taken out of agenda order to conclude subject)
At the outset of the discussion of this topic on day two, Dr. Lumpkin suggested that the proposed guidelines be scrapped, given that the Committee's responsibilities as special government employees are clearly laid out in the regulations and its draft guidelines have generated confusion. Dr. Starfield agreed, noting that a procedure exists for requesting documents.
Some members said that having guidelines explicitly applying the regulations to Committee practices would be helpful. Following discussion, however, the members voted unanimously to rescind the "Groundrules for Dealing with Media and Other External Organizations," which have been in effect since late 1997. They expressed appreciation for the staff's interpretation of the Open Meetings Act, as a useful reference. And they agreed that the rules of a quorum (outlined above) will apply to Workgroups as well as Subcommittees and the full Committee. Finally, they agreed that "virtual" forms of attendance (phone or video conferencing) should be made available for those occasions when members cannot avoid being absent from meetings.
Concluding this discussion, Dr. Lumpkin expressed hope that in the future, members would refrain from personal attacks or accusations against other members, even when they are in strong disagreement with them.
The Committee was briefed by Nancy Foster, who as coordinator for quality activities for AHCPR is the key staff person for the Secretary's Quality Improvement Initiative and the Quality Interagency Coordinating Task Force. Dr. Detmer remarked that she and the Committee could expect to see more of each other because of this common interest.
Ms. Foster said the activities she would report on stem from the work of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. The President endorsed the Commission's findings and called for the creation of an Advisory Council on Health Care Quality and a Forum on Health Care Measurement and Reporting. He also established by executive memorandum the Quality Interagency Coordinating Task Force (QuIC).
The Advisory Council requires legislation for establishment, something that is not expected this year. It is to be composed of public and private members and staffed and funded by the public sector, with the mission of identifying, tracking and reporting on national aims for improvement.
The Commission envisioned the second body, the Forum, as a companion to the first; nevertheless, plans for it are moving forward in the private sector, with the aim of improving health care quality measurement and reporting to the nation. In the absence of aims identified by the Advisory Council, it will probably look initially at major targets of disease and health care and develop a core set of measures. The body will include purchasers, a major source of strength in the marketplace. A planning group, chaired by Gail Warden and staffed by the United Hospital Fund in New York, has begun work to create the Forum. It began with a June 17 event at the White House and the release of a paper, "Challenge and Potential for Assuring Quality Health Care for the 21st Century." Its initial concerns are a funding stream and a decision-making process, and it is expected to finish its work in January 1999. Ms. Foster said she would supply the Committee with the list of the planning group and the aforementioned report.
The third body, the Interagency Task Force, was created to help the major federal players, in and out of HHS, to coordinate their activities in this area. They have identified five themes (not listed in order of importance):
Ms. Coltin reiterated the Committee's interest in this area, as evidenced by its new Workgroup on Quality, and she asked for Ms. Foster's views on how the Committee might liaison with the work she has described. Ms. Foster affirmed that as soon as the new groups "figure out how to talk to each other," they attach importance to touching base with NCVHS and other relevant groups.
Ms. Coltin noted that the shortage of well-trained personnel to work on measuring quality of care is a priority area, and several NCVHS sub-groups (e.g., the CPR Workgroup) may have links to the quality activities.
Dr. Iezzoni stressed the importance of information systems development as a precondition of the other activities, noting the "primitive" condition of the data now available for risk adjustment. She also urged that the quality bodies look at the entire health care system, including people's homes and alternative delivery systems, and not just at doctors' offices and hospitals. Ms. Foster agreed with both points, and said they would begin in ambulatory and hospital settings or nursing homes because the measures are better there, but then move out to the other settings in a "continuous process."
Asked about links to the work of NCQA, FACT, JCAHO and other quality measurement organizations, Ms. Foster said the people in the new entities are very aware of the need for an appropriate role for the accrediting bodies; however, they have not yet determined what that role will be.
Dr. Iezzoni commented on access as a dimension of quality, with the implication that surveys are needed to capture information on those outside the health care system.
Dr. Mor raised the issue of proprietary risk adjustment systems. He asked whether this has been considered, in view of the fact that several Forum members represent organizations that produce the proprietary measures. Ms. Foster said this is one of the many issues the Forum must resolve before beginning its work. Dr. Iezzoni said that during her testimony, she proposed to the Commission that any risk adjustment method promulgated should be in the public domain; however, they did not agree. Ms. Foster said the QuIC workgroup would focus on the information systems used by the federal players to support quality measurement.
Noting that licensing, regulating, and evaluating health care is a major role for states, Dr. Lumpkin urged that they be better represented in the Forum on Quality than the planning group composition indicates. He noted that the public health/Medicaid link is strong in Maryland, Texas, and New York, making them good candidates.
Dr. McDonald reiterated an earlier point about the inadequacy of institution- based data for evaluating quality, adding that this is not a technical issue but a political and organizational one touching on issues of ownership and privacy.
Dr. Detmer concluded by underscoring the information system dimension and asking Ms. Foster to brief the Committee again in early 1999.
ICD-10 has been implemented for morbidity and mortality in several countries. Its characteristics include alphanumeric codes, the restructuring of some chapters, and various new features. An evaluation contract awarded in 1994 (with a 20-member technical advisory panel) concluded that ICD-10 is not a significant improvement over ICD-9-CM — not a surprising finding, because the latter has been modified every year since 1985. A clinical modification was recommended to remove some codes, combine the dagger and asterisk codes, and make other revisions.
The contractor created a prototype of ICD-10-CM, which NCHS is now refining. The process has included a review of the minutes of 10 years of ICD-9-CM Coordination and Maintenance Committee meetings, in search of relevant recommendations. The consultations for this process have involved many physician groups and other users, including the American Nursing Association. In contrast with previous years, the nursing representatives are now satisfied that ICD-10-CM includes an adequate representation of nursing diagnoses.
Ms. Pickett described some of the characteristics of ICD-10-CM, including a sixth character, the incorporation of common fourth- and fifth-digit subclassification codes, and the addition of laterality in some chapters. In addition, drug and alcohol and injury codes have been expanded and diabetes codes have been revised.
The comment period for ICD-10-CM was December 1997 - February 1998. The 1200 comments received from 22 organizations and individuals have been compiled and synthesized by a contractor and are now being reviewed by NCHS. The general sentiment is that ICD-10-CM is a major improvement over ICD-9-CM, and fine-tuning is all that is needed. Ms. Pickett offered to return when the review process is complete to report on the recommendations.
Work began on the new procedure coding system in the late 1980s, and a large contract to develop and test a new PCS was let three years ago. Two clinical data abstraction centers (CDACs) were used for the testing. The latest draft was posted on the HCFA home page in July. The CDACs found that the new system has great promise. They were able to train in the medical/surgical part in two days. They went through 2,500 records each using the system, and their review of the NCVHS guidelines for any new coding system found that they met the criteria (e.g., completeness, expandability, reduced training time). The reviewers also found that the logic of the system almost obviates the need for an index.
The CDACs' recommendations include the following:
There are differing views on whether the final code numbers should have embedded meaning, with strong views on each side.
Phase II of testing is now beginning, using the CDACs. They will issue a report by March, and HCFA will issue a final report by April.
Asked about the comments on transactions and code sets, Ms. Brooks said the lack of controversy over continuing the current systems is interesting. However, there is controversy about which coding system is selected as the national standard in the future, and planners are getting additional information about SNOMED and other systems. The most controversial area is local codes.
Dr. Iezzoni asked about the prospects for revising the DRGs, and whether the dichotomy between ambulatory settings and hospitals in respect to rule-outs will be maintained. On the first, Ms. Brooks said the industry has been promised at least a two- year heads-up before any new coding system is implemented, and it will be several years before the DRG revision process begins. Ms. Pickett added that the tools being developed for ICD-10-CM will help with the analysis of the DRGs. As to the dichotomy on rule-outs, she said it was raised in the comments and there is general agreement that the guidelines should be revised with the implementation of ICD-10-CM.
To another question, Ms. Brooks assured Dr. Cohn that no new coding system would be proposed without mapping to the one it is replacing. She told Dr. McDonald that most of the new system maps well to ICD-9-CM, although there are new concepts such as palliative care where there is no trackability. The speakers said NOS codes have been retained, although in most cases they are unnecessary. On another topic, they said testing was being conducted in many settings, not just hospitals.
Ms. Brooks remarked in general on the extent of attitude change they have observed during the years of work on this project: "the issues that drove people crazy early on do not seem to anymore." Asked about the implementation date for ICD-10- CM/ICD-10-PCS, she said it would definitely not be 2000, and she hoped it would be before 2005. They will have a better idea of the industry's readiness by summer, 1999. ICD-10 for mortality becomes effective January 1, 1999, for deaths occurring in 1999.
Dr. Cohn raised a terminology issue about "hierarchically structured" versus "multiaxial." Ms. Brooks said they were still looking for the best way to explain the structure, and she welcomed suggestions. Ms. Coltin raised a question about the deactivation of procedure-like ICD-10-CM codes (the equivalent of V-codes in ICD-9- CM) as to whether the deactivated codes would become orphans because they’ve been deativated from the diagnosis classification but perhaps not picked up by CPT codes. Ms. Pickett remarked that there has been coordination with HCFA on ICD-10-PCS but less collaboration with the AMA. Ms. Coltin encouraged them to collaborate with the AMA, which is now revising its codes, and Ms. Pickett said an NCHS staff member is part of a CPT-5 working group.
Dr. Iezzoni raised the recurring issue of a single procedure classification, which the Committee has advocated, and she expressed concern about the apparent tolerance for a multiplicity of classification systems, contrary to the spirit of HIPAA and despite shifting settings of care. Ms. Brooks said the time to propose a new procedure coding system would be when the issue raises itself more forcefully and people have to come to grips with it.
Dr. Detmer introduced Dr. Mary Jo Deering, Director of Health Communications and Telehealth for the Office of Health Promotion and Disease Prevention and staff to the new NCVHS Workgroup on the National Health Information Infrastructure. He reiterated Mr. Scanlon's statement that the Data Council is interested in the Committee's interest in the NHII and will welcome the Committee's new concept paper if members decide to send it forward to the Department. The next step would be development of a work plan for the Workgroup. He invited comments on the draft paper.
Several members praised the premise and the way it is developed, and suggested that the following points be added or strengthened:
Several references also were suggested, including the government's HealthFinder Web Site, the October 14 JAMA article on the findings of the Science Panel on interactive applications, and a 1991 American Hospital Association study.
With these modifications, the Committee passed a motion approving the concept paper, as revised, and authorizing that it be sent to the Data Council and posted on the NCVHS Web site. Dr. Detmer said he would be activating the Workgroup to consider next steps.
The Subcommittee is preparing a report to the Secretary on its Medicaid Managed Care study, drawing heavily on new research on state approaches to contracts and contract language. It also is developing a report on the Islands and Territories Initiative, after a "truly remarkable" two-day hearing in July with people from the Pacific Islands, the Virgin Islands and Puerto Rico. Dr. Iezzoni said the Subcommittee wants to be responsive to those who met with the Subcommittee by issuing a timely report using their testimony. Mr. Scanlon said new staff is being assigned for that project, and the Department is also working on staff for the Workgroup on Quality. The Subcommittee will next focus on the Department's survey integration efforts, with a report to the Committee slated for November.
One of the issues the Subcommittee will track next year is implementation of the new state Children's Health Insurance Program. At Dr. Iezzoni's request, Dr. Newacheck read a letter prepared by him and Dr. Starfield and approved by the Subcommittee. The letter stresses the importance of the new children's health insurance program as well as its dependence on timely and reliable data, it recommends use of the State and Local Area Integrated Telephone Survey (SLAITS), and it urges that funding sources be identified for this purpose. Committee members expressed support for this idea, suggesting only that the letter add emphasis on the importance of utility for the states as well as the federal government. Mr. Scanlon suggested framing this in terms of a "robust multipurpose mechanism," in the spirit of survey integration. A motion was passed authorizing that the letter be sent to the Secretary, as amended.
The Subcommittee has just completed a roundtable on health care fraud and abuse, in which members talked with representatives of public and private payers and representatives of the HHS Office of the Inspector General and the Department of Justice, among others. Although the overall issue is balancing the need to identify and contain fraud and abuse with the need to protect medical record privacy and confidentiality, this discussion focused on the needs in the first area.
Dr. Lumpkin noted the connection of these issues to administrative simplification and wondered if the Committee should explore or promote the existence of a scientific basis for the least burdensome way to control fraud. Dr. Detmer observed that the Committee should develop a work plan that cuts across the Subcommittees on Standards and Security and Privacy and Confidentiality. Dr. Mor noted the links to the quality agenda as well.
Dr. McDonald commented on the "meaning creep" of the word "fraud" in that unintended error by providers can be interpreted by payers as fraud. The proportion of each in the total estimates is not known. Dr. Harding noted that enforcement people tend to regard privacy arguments as "a shield that people use to keep people from getting at them." Their solution is not to limit access but to stiffen the penalties for misuse of records.
Ms. Greenberg thanked Ms. Fyffe for putting together the session on this topic. Mr. Scanlon added that future sessions will focus on employers' views and other facets.
The Workgroup is completing its work plan, which will be presented to the Committee in November. They have begun to solicit public and industry opinion and have scheduled the first of what will be a series of hearings, to be held on December 8- 9 in Washington. The Workgroup seeks feedback on the basic "value proposition" in this area and on its initial focus, and on what criteria it should use in regard to standards. The plan is to write a letter to the Secretary after the first hearing, informing her of the issues around value proposition and the Workgroup's plans for next steps.
The Workgroup is working closely with the Government CPR initiative.
The Subcommittee has deferred further action on the unique health identifier for individuals, pending further direction from the Department. They may hold hearings to address the responses to the comments on the NPRMs. They would like the full Committee to have a panel to discuss the development of immunization registries throughout the country, something Dr. McDonald has been working on.
The Subcommittee asked for action on its draft letter on the security NPRM, HCFA 0049-P. Following discussion in which some modifications were made, the Committee passed a motion authorizing that it be sent to the Secretary. A second letter concerning the Paperwork Reduction Act was also approved.
Ms. Greenberg reminded the group that NCHS/CDC is sponsoring this November 2-3 event in conjunction with AHCPR and the Committee. It is aimed at creating greater awareness of the implications of HIPAA among the public health and health services research communities, and to create a mechanism for these groups to identify shared priorities and have input into the standardization process. She shared the draft agenda and invitation list and asked for suggestions. The planning for the event began with a January 1998 meeting in which many organizations participated, with Dr. Friedman representing NCVHS. Attendance at the November meeting will be by invitation, with the goal of gathering people who will take the message back to their organizations and help with consensus-building. This meeting is intended as a "launching meeting" for an ongoing process in which growing numbers of people will be involved.
Committee members expressed strong support for the idea and offered many suggestions of people and organizations that should be included. They also commented on the topics for the four white papers being commissioned as background material. Dr. Lumpkin cautioned Ms. Greenberg not to assume that the participants "know what EDI is."
The Committee reviewed an outline for the 1996-1998 report and offered their comments to Susan Kanaan, who will write it. The report will give a brief overview of Committee activities and accomplishments in the three years since the last annual report, together with a list of relevant NCVHS documents posted on the Web site. Dr. Detmer will write the Foreword. Some members expressed hope that the report would properly reflect the gamut of Committee activities, and there was discussion of how this document relates to the separate report to the Secretary on HIPAA-related activities. The Committee approved printing the concept paper on the NHII with this report. It was suggested that the framework of that paper might serve as a template for the presentation of the Committee's work on information policy and on standards.
It was agreed that the archival copy of this report should include hard copy of all the documents referenced.
Committee members were asked to send Ms. Kanaan any further comments about the outline. The first draft of the report (which will be completed at the end of 1998 and reviewed by the Executive Subcommittee) will be discussed at the November meeting.
These dates were approved for Committee meetings in 1999:
The following agenda items were suggested for the November 1998 meeting:
Ms. Coltin said the Subcommittee on Populations wants to deter work on the quality agenda until it has finished its report on Medicaid managed care.
The group supported Dr. Detmer's suggestion that the Committee focus in 1999 on post-acute care, both short- and long-term.
Dr. Detmer then adjourned the meeting, with thanks for everyone's work.
I hereby certify that, to the best of my knowledge, the foregoing summary of minutes is accurate and complete.
/s/
Don E. Detmer March 19, 1999
_______________________________________________________
Chair Date