2015 Health IT Certification Criteria Capture Patient Sexual Orientation and Gender Identity

The 2015 Health IT certification criteria include the capture of sexual orientation and gender identity in the demographics certification criteria. 

As part of an important patient matching initiative by the Office the National Coordinator for Health IT (ONC), patient sex is one of five key attributes that are now part of the certification criteria.  NAHAM News readers will know that NAHAM is developing Recommended Best Practices on the Collection of Key Patient Attributes.  (Learn more in NAHAM News: “Key Patient Matching Attributes Included in 2015 Health IT Certification Criteria”.)

During the development of the 2015 criteria, patient sex was proposed to be captured with the following values: male (M), female (F), and unknown (UNK).  Of significance in the final rule for health IT certification was the decision to use the coding for “sex” to present birth sex. 

The ONC did not adopt recommendations made by commenters from the general public to capture a patient’s sexual orientation or gender identity as part of this criterion. Instead, the ONC proposed the capture of sexual orientation and gender identity (SO/GI) data as part of the proposed ‘‘social, psychological, and behavioral data’’ certification criterion.  Follow the ONC’s narrative on this issue found in the final rule –

Sexual Orientation and Gender Identity (SO/GI)

We [the ONC] did not propose to include a requirement to capture a patient’s sexual orientation or gender identity as part of this criterion. Rather, we proposed the capture of SO/GI data as part of the proposed ‘‘social, psychological, and behavioral data’’ certification criterion.

Comments. We [the ONC] received a significant number of comments from providers, consumers/individuals, and health care coalitions strongly recommending that we consider including sexual orientation and gender identify as a component of the Base EHR definition (e.g., in the demographics certification criterion) or Common Clinical Data Set definition. These commenters suggested that there are mature vocabulary standards for representing SO/GI and there is strong clinical value in having this data to inform decisions about health care and treatment. Commenters indicated that by including SO/GI in the Base EHR or Common Clinical Data Set definitions, providers would be required to possess this functionality for participation in the EHR Incentive Programs, which could have a large impact for evaluating the quality of care provided to lesbian, gay, bisexual, and transgender (LGBT) communities.

Response. We [the ONC] thank commenters for their feedback. Given this feedback, the clinical relevance of capturing SO/GI, and the readiness of the values and vocabulary codes for representing this information in a structured way, we require that Health IT Modules enable a user to record, change, and access SO/GI to be certified to the 2015 Edition ‘‘demographics’’ certification criterion. By doing so, SO/GI is now included in the 2015 Edition Base EHR definition. The 2015 Edition Base EHR definition is part of the CEHRT definition under the EHR Incentive Programs. Therefore, providers participating in the EHR Incentive Programs will need to have certified health IT with the capability to capture SO/GI to meet the CEHRT definition in 2018 and subsequent years. We note that like all information in the ‘‘demographics’’ criterion, certification does not require that a provider collect this information, only that certified Health IT Modules enable a user to do so. We believe including SO/GI in the ‘‘demographics’’ criterion represents a crucial first step forward to improving care for LGBT communities. We have not included it in the Common Clinical Data Set at this time.

Comments. One commenter recommended we consider including structured and coded questions for soliciting SO/GI information as part of certification.

Response. While we [the ONC] thank the commenter for providing this recommendation, we do not believe that the suggested questions have yet been scientifically validated for use in health care settings and, thus, have not adopted them. We do, however, believe that these questions are being used today in health care settings as ‘‘best practices,’’ and would suggest that health care providers and institutions decide whether to include these questions in the collection of SO/GI information. These ‘‘best practice’’ questions and the answers we have adopted are:

·        Do you think of yourself as:

o   Straight or heterosexual;

o   Lesbian, gay, or homosexual;

o   Bisexual;

o   Something else, please describe.

o   Don’t know.

·        What is your current gender identity? (Check all that apply.)

o   Male;

o   Female;

o   Transgender male/Trans man/Female-to-male;

o   Transgender female/Trans woman/Male-to-female;

o   Genderqueer, neither exclusively male nor female;

o   Additional gender category/(or other), please specify.

o   Decline to answer.

Does your Access Department have protocols in place to capture birth sex only, or gender as noted on an official government-issued identification, or do you record only what the patient reports?  Does your information technology have fields or do you attempt to capture sexual orientation or gender identity if different from what is reported on a government-issued identification?  Is Patient Access ready to capture these attributes?

Waiting on CMS to Finalize MOON

Access Departments may expect to provide Medicare patients with the new Medicare Outpatient Observation Notice (MOON). As of mid-day today, August 2, CMS has not finalized the MOON.  A draft MOON, different from an earlier draft notice form, along with instructions and background information, may be found on the CMS webpage here.  NAHAM will provide additional information as we are able to obtain it from CMS.

The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) of 2015 requires hospitals and Critical Access Hospitals (CAH) to provide written and oral notification to individuals receiving observation services as outpatients for more than 24 hours. The NOTICE Act required the Secretary of Health and Human Services (HHS) to develop a notice form that explains why the patient is receiving observation services, the implications of receiving outpatient observation services, such as cost sharing, and post-hospitalization eligibility for Medicare coverage of skilled nursing facility (SNF) services. The NOTICE Act also created an effective date of August 6, 2016.  In an April 27, 2016 proposed rule, CMS provided an opportunity for public comments on its proposed hospital and CAH notification procedures for outpatients receiving observational services.

Hospitals and CAHs will be required to furnish a new CMS-developed standardized notice, the Medicare Outpatient Observation Notice (MOON), to a Medicare beneficiary or enrollee who has been receiving observation services as an outpatient for more than 24 hours. The notice must be provided no later than 36 hours after observation services are initiated. 

In its guidance, CMS notes that although hospitals must provide a hard copy of the MOON to CMS beneficiaries and enrollees, hospitals may retain a copy of the signed MOON electronically.  In cases where the beneficiary has a representative who is not physically present, hospitals are permitted to give the MOON by telephone as long as a hard copy is delivered to the representative.

CMS indicates that “When delivering the MOON, hospitals and CAHs are required to explain the notice and its content, document that an oral explanation was provided and answer all beneficiary questions to the best of their ability.” Because oral explanation of the MOON must be provided, as a practical matter that explanation will be provided in conjunction with the delivery of the hard copy notice.  CMS indicates that a Spanish language version of the MOON will be made available.  Where an individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, CMS expects hospitals and CAHs to “employ their usual procedures to ensure notice comprehension”.  CMS will provide guidance for oral notification in its forthcoming Medical manual provisions.

A signature must be obtained from the individual, or an individual qualified to act on their behalf, to acknowledge receipt and understanding of the notice (or in cases of refusal of signature by such individual, signature by the staff member of the hospital or CAH providing the notice).

It is very likely Access Departments will be asked to provide a copy of the MOON notice at the point of entry, much as most Access Departments do with the IMM (Important Message from Medicare). This may be the most practical way to meet the requirement that the notice be given no later than 36 hours after observational services are initiated.  The requirement that a verbal explanation be given as well, Access Departments should anticipate having to provide the oral explanation of the MOON as well.  If the patient has any specific questions about the notice, the form of the notice or his or her observational status, Access Departments can refer the patient to Case Management.

Because the MOON is a CMS standardized notice, it was required to go through the Paperwork Reduction Act process, thus affording the public an opportunity to comment on the proposed MOON. This has caused a delay in finalizing the content and format of the notice by the August 6 statutory effective date. 

Waiting on CMS to Finalize MOON

Access Departments may expect to provide Medicare patients with the new Medicare Outpatient Observation Notice (MOON). As of mid-day today, August 2, CMS has not finalized the MOON.  A draft MOON, different from an earlier draft notice form, along with instructions and background information, may be found on the CMS webpage here.  NAHAM will provide additional information as we are able to obtain it from CMS.

The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) of 2015 requires hospitals and Critical Access Hospitals (CAH) to provide written and oral notification to individuals receiving observation services as outpatients for more than 24 hours. The NOTICE Act required the Secretary of Health and Human Services (HHS) to develop a notice form that explains why the patient is receiving observation services, the implications of receiving outpatient observation services, such as cost sharing, and post-hospitalization eligibility for Medicare coverage of skilled nursing facility (SNF) services. The NOTICE Act also created an effective date of August 6, 2016.  In an April 27, 2016 proposed rule, CMS provided an opportunity for public comments on its proposed hospital and CAH notification procedures for outpatients receiving observational services.

Hospitals and CAHs will be required to furnish a new CMS-developed standardized notice, the Medicare Outpatient Observation Notice (MOON), to a Medicare beneficiary or enrollee who has been receiving observation services as an outpatient for more than 24 hours. The notice must be provided no later than 36 hours after observation services are initiated. 

In its guidance, CMS notes that although hospitals must provide a hard copy of the MOON to CMS beneficiaries and enrollees, hospitals may retain a copy of the signed MOON electronically.  In cases where the beneficiary has a representative who is not physically present, hospitals are permitted to give the MOON by telephone as long as a hard copy is delivered to the representative.

CMS indicates that “When delivering the MOON, hospitals and CAHs are required to explain the notice and its content, document that an oral explanation was provided and answer all beneficiary questions to the best of their ability.” Because oral explanation of the MOON must be provided, as a practical matter that explanation will be provided in conjunction with the delivery of the hard copy notice.  CMS indicates that a Spanish language version of the MOON will be made available.  Where an individual receiving the notice is unable to read its written contents and/or comprehend the required oral explanation, CMS expects hospitals and CAHs to “employ their usual procedures to ensure notice comprehension”.  CMS will provide guidance for oral notification in its forthcoming Medical manual provisions.

A signature must be obtained from the individual, or an individual qualified to act on their behalf, to acknowledge receipt and understanding of the notice (or in cases of refusal of signature by such individual, signature by the staff member of the hospital or CAH providing the notice).

It is very likely Access Departments will be asked to provide a copy of the MOON notice at the point of entry, much as most Access Departments do with the IMM (Important Message from Medicare). This may be the most practical way to meet the requirement that the notice be given no later than 36 hours after observational services are initiated.  The requirement that a verbal explanation be given as well, Access Departments should anticipate having to provide the oral explanation of the MOON as well.  If the patient has any specific questions about the notice, the form of the notice or his or her observational status, Access Departments can refer the patient to Case Management.

Because the MOON is a CMS standardized notice, it was required to go through the Paperwork Reduction Act process, thus affording the public an opportunity to comment on the proposed MOON. This has caused a delay in finalizing the content and format of the notice by the August 6 statutory effective date. 

Congressional Report Shows Hopeful Move Towards Patient Matching

Readers of NAHAM News will know of the current prohibition on federal funding for the development of a unique patient identifier.   

Here’s a very brief history.  In 1993 President Clinton proposed a health plan that included the issuance of health security cards to all Americans certifying their right to medical care, putting in place the concept of a unique patient identifier. While the first term Clinton healthcare reform proposal was not successful, in 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  HIPAA included administrative simplification provisions that required HHS to “adopt national standards for electronic health care transactions” and “a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system”.

In 1998, Congress passed Public Law 105-277 (an omnibus appropriations act for fiscal year 1999) that prohibited HHS from spending any funds to “promulgate or adopt any final standard…providing for, or providing for the assignment of, a unique health identifier for an individual…until legislation is enacted specifically approving the standard [Title V, Section 516 of PL 105-277].” Despite numerous calls for further work towards a unique patient identifier, including the 2008 Rand Corporation report, identifying the associated potential administrative cost savings and safety benefits, Congress has maintained this prohibition.

With this congressional prohibition, HHS has since adopted unique identifiers for employers, health care providers, and is now in the process of adopting a unique health plan identifier, but has not adopted a standard unique identifier for individuals. 

Now for what may be a modest breakthrough allowing some HHS engagement on patient matching, even if not by way of developing a unique patient identifier.  In its report accompanying the upcoming fiscal year 2017 appropriations bill for the Department of Health and Human Services (referred each year to as the Labor-HHS bill because it funds the Departments of Labor and Health and Human Services, among other smaller federal agencies), the House Appropriations Committee included the following language:

Unique Patient Health Identifier.—The Committee is aware that one of the most significant challenges inhibiting the safe and secure electronic exchange of health information is the lack of a consistent patient data matching strategy. With the passage of the HITECH Act, a clear mandate was placed on the Nation’s healthcare community to adopt electronic health records and health exchange capability. Although the Committee continues to carry a prohibition against HHS using funds to promulgate or adopt any final standard providing for the assignment of a unique health identifier for an individual until such activity is authorized, the Committee notes that this limitation does not prohibit HHS from examining the issues around patient matching. Accordingly, the Committee encourages the Secretary, acting through the Office of the National Coordinator for Health Information Technology and CMS, to provide technical assistance to private-sector led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information.

The language attempts to clarify this long-standing prohibition by noting that “this limitation does not prohibit HHS from examining the issues around patient matching”.   If recognized by the Department of Health and Human Services, this represents a very positive step forward.  The operative language that HHS will hopefully take up is the Committee’s encouragement that HHS, in coordination with the ONC (Office of the National Coordinator for Health Information Technology) and CMS, “provide technical assistance to private-sector led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information”.

It remains to be seen what impact this language may have on further work on the development of a unique patient identifier.  There are other steps that might also be taken in the meantime.  The application of a unique patient identifier is consistent with NAHAM’s Public Policy Statement: Patient Identity Integrity (October 2015), restated below. 

Patient Identity Integrity requires additional standardized data attributes in the absence of the universally adopted unique patient identifier.

The National Association for Healthcare Access Management (NAHAM) recognizes and supports patient safety as a national health priority.  Patient identification errors through the registration process can delay patient care and increase the potential for patient harm.  Long term downstream effects include increased financial liability, diminished reputation, and decreased physician and employee loyalty.  Patient identity integrity (PII) ensures that healthcare access professionals identify and accurately match the right patient with his or her complete medical record, every time, in every provider setting.  Ensuring the right patient, right record, every time, is the first critical step in providing patient care.

PII processes should be prioritized and standardized to include:  principles that guide practice, policies and procedures, training and competency validation, standard scripting, defining acceptable forms of identification, naming conventions, search guidelines and algorithms, banding verification, establishing response guidelines for difficult situations, measuring and tracking duplicate records, and rapid response and resolution to errors.

NAHAM recognizes that current patient identification and matching procedures vary throughout the country.  Using two patient identifiers with a combination of secondary identifiers is standard and compliant practice.  Achieving the goal of eliminating patient identification errors nationally will require a unique patient identifier and/or a standardization of data capture as well as a standardized combination of data attributes that support Patient Identity Integrity.

Readers of NAHAM News will also know that in the meantime, NAHAM is developing a set of recommended best practices around standardized patient data attributes identified in the ONC’s 2015 Health IT Certification Criteria.  Read NAHAM News: Key Patient Matching Attributes Included in 2015 Health IT Certification Criteria (6/23/2016).

 

Congressional Report Shows Hopeful Move Towards Patient Matching

Readers of NAHAM News will know of the current prohibition on federal funding for the development of a unique patient identifier.   

Here’s a very brief history.  In 1993 President Clinton proposed a health plan that included the issuance of health security cards to all Americans certifying their right to medical care, putting in place the concept of a unique patient identifier. While the first term Clinton healthcare reform proposal was not successful, in 1996 Congress passed the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  HIPAA included administrative simplification provisions that required HHS to “adopt national standards for electronic health care transactions” and “a standard unique health identifier for each individual, employer, health plan, and health care provider for use in the health care system”.

In 1998, Congress passed Public Law 105-277 (an omnibus appropriations act for fiscal year 1999) that prohibited HHS from spending any funds to “promulgate or adopt any final standard…providing for, or providing for the assignment of, a unique health identifier for an individual…until legislation is enacted specifically approving the standard [Title V, Section 516 of PL 105-277].” Despite numerous calls for further work towards a unique patient identifier, including the 2008 Rand Corporation report, identifying the associated potential administrative cost savings and safety benefits, Congress has maintained this prohibition.

With this congressional prohibition, HHS has since adopted unique identifiers for employers, health care providers, and is now in the process of adopting a unique health plan identifier, but has not adopted a standard unique identifier for individuals. 

Now for what may be a modest breakthrough allowing some HHS engagement on patient matching, even if not by way of developing a unique patient identifier.  In its report accompanying the upcoming fiscal year 2017 appropriations bill for the Department of Health and Human Services (referred each year to as the Labor-HHS bill because it funds the Departments of Labor and Health and Human Services, among other smaller federal agencies), the House Appropriations Committee included the following language:

Unique Patient Health Identifier.—The Committee is aware that one of the most significant challenges inhibiting the safe and secure electronic exchange of health information is the lack of a consistent patient data matching strategy. With the passage of the HITECH Act, a clear mandate was placed on the Nation’s healthcare community to adopt electronic health records and health exchange capability. Although the Committee continues to carry a prohibition against HHS using funds to promulgate or adopt any final standard providing for the assignment of a unique health identifier for an individual until such activity is authorized, the Committee notes that this limitation does not prohibit HHS from examining the issues around patient matching. Accordingly, the Committee encourages the Secretary, acting through the Office of the National Coordinator for Health Information Technology and CMS, to provide technical assistance to private-sector led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information.

The language attempts to clarify this long-standing prohibition by noting that “this limitation does not prohibit HHS from examining the issues around patient matching”.   If recognized by the Department of Health and Human Services, this represents a very positive step forward.  The operative language that HHS will hopefully take up is the Committee’s encouragement that HHS, in coordination with the ONC (Office of the National Coordinator for Health Information Technology) and CMS, “provide technical assistance to private-sector led initiatives to develop a coordinated national strategy that will promote patient safety by accurately identifying patients to their health information”.

It remains to be seen what impact this language may have on further work on the development of a unique patient identifier.  There are other steps that might also be taken in the meantime.  The application of a unique patient identifier is consistent with NAHAM’s Public Policy Statement: Patient Identity Integrity (October 2015), restated below. 

Patient Identity Integrity requires additional standardized data attributes in the absence of the universally adopted unique patient identifier.

The National Association for Healthcare Access Management (NAHAM) recognizes and supports patient safety as a national health priority.  Patient identification errors through the registration process can delay patient care and increase the potential for patient harm.  Long term downstream effects include increased financial liability, diminished reputation, and decreased physician and employee loyalty.  Patient identity integrity (PII) ensures that healthcare access professionals identify and accurately match the right patient with his or her complete medical record, every time, in every provider setting.  Ensuring the right patient, right record, every time, is the first critical step in providing patient care.

PII processes should be prioritized and standardized to include:  principles that guide practice, policies and procedures, training and competency validation, standard scripting, defining acceptable forms of identification, naming conventions, search guidelines and algorithms, banding verification, establishing response guidelines for difficult situations, measuring and tracking duplicate records, and rapid response and resolution to errors.

NAHAM recognizes that current patient identification and matching procedures vary throughout the country.  Using two patient identifiers with a combination of secondary identifiers is standard and compliant practice.  Achieving the goal of eliminating patient identification errors nationally will require a unique patient identifier and/or a standardization of data capture as well as a standardized combination of data attributes that support Patient Identity Integrity.

Readers of NAHAM News will also know that in the meantime, NAHAM is developing a set of recommended best practices around standardized patient data attributes identified in the ONC’s 2015 Health IT Certification Criteria.  Read NAHAM News: Key Patient Matching Attributes Included in 2015 Health IT Certification Criteria (6/23/2016).

 

HHS transgender anti-discrimination rule kicks in July 18

A NAHAM member of our Public Policy and Government Relations Committee forwarded an article from Modern Healthcare, HHS transgender anti-discrimination rule kicks in July 18; Are you ready?

The article notes that providers will be expected to adhere to a new HHS policy against discriminating against patients based on their gender or gender identity.

"Starting [July 18], transgender people can enter bathrooms or hospital wards consistent with their gender identity. The rule does not explicitly require insurers to cover gender-transition treatments such as surgery."

The article questions whether providers are ready.

"In March, the [Human Rights Campaign] found that just 21% of U.S. hospitals it surveyed had specific policies outlining procedures and practices to eliminate bias and insensitivity toward transgender patients."

The rule empowers HHS to suspend or terminate federal funding to any organization that does not address noncompliance. HHS may also contact the U.S. Justice Department to determine if there's been a criminal offense.

The rule is authorized by Section 1557 of the Affordable Care Act. (ACA) and was issued by HHS on May 13, 2016.  See HHS finalizes rule to improve health equity under the Affordable Care Act.

The Section 1557 nondiscrimination provision prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities.

As described by HHS, "Section 1557 builds on long-standing and familiar Federal civil rights laws: Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973 and the Age Discrimination Act of 1975." 

Applicable to providers and insurers, the provisions protect individuals participating in healthcare programs that receive HHS funding, any program HHS administers, and insurance plans offered through the Health Insurance Marketplaces established by the ACA.

A summary of the final rule, Summary: Final Rule Implementing Section 1557 of the Affordable Care Act, indicates -

"While the final rule does not resolve whether discrimination on the basis of an individual's sexual orientation status alone is a form of sex discrimination under Section 1557, the rule makes clear that OCR [Office of Civil Rights] will evaluate complaints that allege sex discrimination related to an individual’s sexual orientation to determine if they involve the sorts of stereotyping that can be addressed under Section 1557. HHS supports prohibiting sexual orientation discrimination as a matter of policy and will continue to monitor legal developments on this issue."

 

Key Patient Matching Attributes Included in 2015 Health IT Certificaiton Criteria

We have previously previewed the development of best practice recommendations for 5 key patient matching attributes based on the 11 specific attributes recommended in the Office of the National Coordinator’s (ONC’s) 2014 report, “Patient Identification and Matching Final Report.”  See NAHAM News, "Considerations for developing data attribute standards for Patient Access" (3/21/2016). These ONC-identified attributes were also referenced in NAHAM’s Access Management Journal (Fall 2015), and we noted that they fit neatly in the following five main categories: Name Attributes, Date of Birth, Addresses, Phone Numbers, and Gender.

The ONC report includes two key findings, reflecting the recommendations of NAHAM as a stakeholder participant in the report’s development, worth pointing out here:

·        Standardized patient identifying attributes should be required in the relevant exchange transactions.

·        Certification criteria should be introduced that require certified EHR technology (CEHRT) to capture the data attributes that would be required in the standardized patient identifying attributes.

This is consistent with NAHAM’s Public Policy Statement: Patient Identity Integrity (October 2015) that calls for standardized data attributes. (See : "NAHAM Public Policy Statement on Patient Identity Integrity" (3/17/16), reiterating NAHAM’s call for standardized data attributes. This also reflects NAHAM’s statement on record to the ONC, which includes: “NAHAM supports the development of standards for data attributes in electronic systems, whether clinical or administrative, and enhanced common capabilities for all healthcare data systems to input standardized data.” (See the ONC's 2014 final report cited above.)

The ONC has since adopted these attributes, as well as the findings above, as part of the now effective 2015 Health IT certification criteria.  The new certification criteria are intended to improve patient matching through the adoption of the specific attributes captured in NAHAM's five key patient matching attributes.  The effort is focused on "transition of care" emphasizing the ability to retrieve and share patient healthcare information across different healthcare providers and systems.  As explained in the ONC's narrative for the 2015 certification criteria -

As a part of the “Create” portion of the “ToC” [Transition of Care] criterion in the 2015 Edition, we [the ONC] proposed to require a Health IT Module to be able to create a transition of care/referral summary that included a limited set of standardized data in order to improve the quality of the data that could potential be used for patient matching by a receiving system. The proposed standardized data included: First name, last name, maiden name, middle name (including middle initial), suffix, date of birth, place of birth, current address, historical address, phone number, and sex, with constrained specifications for some of the proposed standardized data.

Addressing the concern that some commenters had with the adoption of data sharing standards around these and other attributes, the ONC noted that the new Health IT Module will not impose wholesale changes to a hospital's or system's policies and procedures regarding patient matching -
 

We note that systems can continue to use their existing algorithms and patient matching protocols and that our proposed approach was not intended to conflict with any existing practice. We reiterate that the proposed data elements stem from the HITPC's [HIT Policy Committee's] and the HITSC's [HIT Standards Committee's] recommendations and findings from the 2013 ONC initiative on patient matching as described in the Proposed Rule (80 FR 16833-16834). 

The ONC also notes that more work remains to be done -
 

We continue to believe these recommendations represent a first step forward that is consensus-based. We agree that the proposal did not address data quality in the sense that it would improve the “source's” practices and procedures to collect highly accurate and precise data. However, we believe that including standards for the exchange of certain data elements could improve interoperability and provides an overall level of consistency around how the data are represented. We encourage ongoing stakeholder efforts focused on improving patient matching through better data quality processes and will continue to monitor and participate in these activities.

The new Health IT Module, intended to improve patient matching between sending and receiving systems, will include standardized data formats for the patient's name (with separate fields for first name, last name, previous name, middle name, and suffix), data of birth, address, phone number, and birth sex.

[The ONC] have finalized the requirement that Health IT Modules must be able of creating a transition of care/referral summary in accordance with just C-CDA [Consolidated Clinical Data Architecture] Release 2.1 as part of this certification criterion that includes the following data formatted to the associated standards/constraints where applicable:

·        First name

·        Last name
·        Previous name
·        Middle name (including middle initial)
·        Suffix
·        Date of birth—The year, month, and day of birth are required fields. Hour, minute, and second are optional fields; however, if hour, minute, and second are provided then the time zone offset must be included. If date of birth is unknown, the field should be marked as null.
·        Address
·        Phone number—Represent phone number (home, business, cell) in the ITU format specified in ITU-T E.123 and ITU-T E.164 which we are adopting at § 170.207(q)(1). If multiple phone numbers are present, all should be included.
·        Sex in accordance with the standard we are adopting at § 170.207(n)(1)

In subsequent issues of NAHAM News we will highlight each of these attributes as found in the 2015 certification criteria and NAHAM's recommended best practices associated with each one.  NAHAM's Public Policy and Government Relations Committee is developing recommended best practices for Patient Name, Date of Birth, Address, Phone Number, and Sex to address the capture of accurate data to enhance these efforts in standardization. 

Do you have any thoughts on these patient attributes, the standardization of each for purposes of patient transition of care between healthcare providers, or best practices to recommend for the intake of this information from the perspective of Patient Access.  Let us know!

EEOC finalizes rules on financial incentives for wellness programs

In "Final EEOC Rule Sets Limits For Financial Incentives On Wellness Programs," Kaiser Health News reports: "Employer wellness programs can gather medical information from employees and spouses — so long as financial incentives or penalties don’t exceed 30 percent of the annual cost for an individual in the company’s group health plan, according to final rules issued by the Equal Employment Opportunity Commission Monday. Although such penalties or incentives could run into the hundreds or even thousands of dollars, the programs are considered voluntary — and therefore legal, the commission said."

You may find these articles of interest as well: In "EEOC Issues New Rules for Wellness Programs," the Wall Street Journal reports that wellness programs would be considered voluntary as long as employers’ discounts don’t exceed more than 30% of the employee’s health plan cost.

The rub involves what is considered voluntary relative to employee providing healthcare information as a quid pro quo to participation.  As explained by the Wall Street Journal article -

The EEOC issued final rules regarding how corporate wellness programs work with existing antidiscrimination laws, including the Americans with Disabilities Act and the Genetic Information Nondiscrimination Act. Those laws generally prohibit employers from using information about workers’ own health conditions and that of other family members, including spouses, unless the information is collected under a voluntary wellness program.

In "Obama Administration Releases Rules on Wellness Programs,"the New York Times reports that congressional action may be afoot to challenge what some consider the restrictive nature of the rule.

The new rules are more restrictive than those passed under the ACA, which allowed incentives of up to 30 percent of the actual cost of an employee's insurance plan and 50 percent for programs approved by the Internal Revenue Service, the Department of Labor and the Department of Health and Human Services. Only smoking-cessation programs received that approval.

 

The rules will go into effect 2017.  See this earlier WSJ article on employer-sponsored wellness plan: "Your Company Wants to Make You Healthy."

New Overtime Rule, effective December 1, 2016, likely to impact healthcare workforce

On May 18, 2016, the U.S. Department of Labor issued a new rule affecting the regulations on overtime pay: Defining and Delimiting the Exemptions for Executive, Administrative, Professional, Outside Sales and Computer Employees.

The standard salary threshold for full-time salaried “white collar” workers will be increased from $455 per week to $913 per week (or from the current annualized $23,660 to $47,476).  This number is based on the 40^th percentile of full-time salaried workers in the lowest-wage Census region (currently the South) and will be adjusted accordingly every three years.  The highly compensated employees (HCE) salary threshold for full-time salaried workers is increased from $100,000 to $134,004 per year.  This number is based on the 90^th percentile of full-time salaried workers nationally, and will be adjusted accordingly every three years.

The effective date for the new thresholds is December 1, 2016.  These threshold levels will automatically update every three years, beginning January 1, 2020.  The Department of Labor will post the new salary levels 150 days in advance of their effective date, beginning August 1, 2019.  More information may be found on the Department of Labor's webpage.

Kaiser Health News reports: "Starting in December, anyone making up to $47,476 a year will qualify for overtime. But in the health care industry that wouldn't necessarily mean the workers are going to get paid more."

In Overtime pay rules will affect millions of healthcare workers, Modern Healthcare reports:

The new Obama administration rule is expected to affect a total of 4.2 million workers. The increase to $47,476 will start this December and will affect employees who clock in more than 40 hours a week. The policy updates rules that date back to the 1930s and require employers to pay 1.5 times a worker's regular salary for any work past 40 hours a week.

Healthcare professions that will likely be affected by the overtime threshold increase are nurses, medical and physical therapist assistants, medical and pharmacy technicians, and paramedics. Average mean salaries in these professions range from $25,710 to $47,010. That includes approximately 4.1 million workers, according to 2015 data from the U.S. Bureau of Labor Statistics.

Medicaid-funded home-care providers for individuals with disabilities or facilities with 15 beds or fewer are exempt from implementing the new rule until March 17, 2019.

 

What changes for Medicare's Hospital Star Rating?

In "Critics of Medicare's Overall Hospital Star Rating Push for Changes, "Kaiser Health News staff writer Jordan Rau reports: "Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious. The Centers for Medicare & Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. ... Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses."

That is the headline leader in today's Kaiser Health News (Wednesday, May 18, 2016).

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.

The proposal was delayed under criticism from hospital groups as well as Members of Congress.

Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare website. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating.

While the goal of getting quality ratings into the mix for patients as consumers of healthcare, the formula to be used for star rating isn't perfect, and risks sending the wrong general message about specific facilities or healthcare systems.

The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.

Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.

Ransomware: Why Hospitals? Why Now?

RealClear Politics has run a series of articles on 2016 security issues.  The fourth and final part, Ransomware: Crime for a New Century, takes a look at this new form of cybecrime and how hospitals have proven particularly vulnerable to the attacks.

This particular question and its two answers caught our attention: 

Why Hospitals? Why Now?

There are two major factors that make the health care industry especially vulnerable to cybercrime in 2016.

First, health care has historically lagged behind other industries in adopting computerized records systems. It has been decades since banks kept account records on paper, but as recently as 2008, less than 10 percent of U.S. hospitals had even a basic electronic health records system.

The second factor is a strong push by the federal government in recent years to hasten the adoption of EHRs. The 2009 stimulus bill deployed a carrot-and-stick approach to speed the conversion to digital records. Funds were set aside to help finance the purchase of EHR systems, and in return, providers were required to meet minimum standards and to demonstrate “meaningful use” of these systems to improve the efficiency and quality of care.

The rush to adopt this technology caused serious growing pains, and the rollout of these systems is often an ordeal. For example, a New York City official last month compared the new system for the city’s hospitals to the 1986 Challenger disaster. A 2013 RAND Corp. study of U.S. physicians found that “the current state of EHR technology appeared to significantly worsen professional satisfaction in multiple ways,” and in many hospitals, the focus has been on just getting the systems functioning at the most basic level.

One conclusion offered - Perhaps these attacks are the inevitable growing pains of an industry rushing to catch up to the digital age...However, as health care providers inevitably become more dependent on digital technology, it will only be more important for hospitals to get cybersecurity right.

Healthcare costs vary from town to town, state to state

"The National Chartbook of Health Care Prices 2015" using data from the Health Care Cost Institute (HCCI), and the report, "Prices For Common Medical Services Vary Substantially Among The Commercially Insured," released by HealthAffairs, show price differences for common medical procedures across the same areas and across the states.

The study used data from the Health Care Cost Institute to assess national commercial claims and compare 242 medical services prices across 41 states and the District of Columbia between Jan. 1, 2012, and Dec. 31, 2013. Prices were standardized to reflect costs in September 2015. The study also looked at city data. No state data was available for Alabama, Arkansas, Hawaii, Idaho, Montana, Michigan, South Dakota, Vermont and Wyoming.

National Public Radio, in "That Surgery Might Costs You A Lot Less In Another Town," offers a way to select your state for comparing to the national average for three common procedures.

Congressional Quarterly reported that Alaska, along with Wisconsin, North Dakota, New Hampshire, and Minnesota in their respective order, had the highest average health care prices.  Residents in Alaska paid twice the costs of the national average.  See "Health Costs Differ in States and Cities, Report Finds". Only 15 states had health care costs below the national average. Florida, Arizona, Tennessee, Maryland and Nevada had the lowest in the country.

USA Today reports in "Huge health care price differences even within same area, by state" (April 25) that prices can differ within an single urban area, showing disparities in MRI costs within a 100-mile radius of San Francisco.  While some residents in different cities in the same state could see significant price differences, in other states, differences between cities were minimal.

The USA Today article also indicates the amount of out-of-pocket for the patient also shows wide disparities, pointing to several explanations, including the fact that some insurance policies require consumers to pay the insurer's negotiated rate, while others require the insured person or the insurers and the consumer to pay the entire sticker price.

In San Francisco, that left one person facing out-of-pocket costs of more than $1,900 for that same lower back MRI that cost less than $500 in the same area. Insurers also often need to include certain expensive hospitals in their networks to get contracts with some employers. Then they will  sometimes put those hospitals in a pricing tier that requires higher out of pocket costs.

Explanations for the variation in healthcare costs vary.  The HCCI report points to wages, rent, market power and the lack of transparency as reasons for wide disparity in prices in its new report. USA Today notes a 2013 report on health care spending by the Institute of Medicine (IOM), which reported about 70% of the variation in spending in the commercial insurance market is due to differences in price markups by doctors and hospitals, which it said most likely reflects these providers' regional market power.

CMS backs away from two-midnight rule

A NAMAH member shared this with NAHAM News, found in Modern Healthcare (Monday, April 18). 

The CMS will not continue to impose an inpatient payment cut to hospitals under the two-midnight rule following ongoing industry criticism and a legal challenge. It will provide a onetime bump to hospitals to offset the cuts. 

The original rule may be found in the CMS Fact Sheet: Two-Midnight Rule.

The agency imposed the cut because it estimated the two-midnight policy would increase Medicare spending by approximately $220 million because of an expected increase in inpatient admissions. 

Hospitals will also see a temporary increase of 0.6% in fiscal 2017. That would make up for the 0.2% reduction to the rates the past three years.

This addition, plus other increases outlined in the proposed rule, will result in a net increase of approximately $539 million to hospital inpatient prospective payment systems providers in 2017.

The decision to drop the proposed cut came after a September ruling in Shands Jacksonville Medical Center v. Burwell. A federal judge partially sided with the American Hospital Association and scores of other hospitals around the country, ordering HHS to better justify the cut and re-open the policy to comments.

As reported by Modern Healthcare, hospitals had challenged a 0.2% reduction for inpatient services meant to offset estimated costs to Medicare associated with the two-midnight rule. The rule directs CMS payment contractors to presume hospital stays are appropriately billed as inpatient admissions rather than outpatient observation visits if they span two midnights.

The policy was intended to reverse a trend toward higher rates of observation stays, which experts attributed to defensive billing practices by hospitals wary of having their admissions challenged by Medicare's audit contractors.

Even though September's ruling didn't outright demand the CMS rescind the pay cut, the agency felt it was the best thing to do given the industry's apprehension.

CMS explains its adjustment in its Fact Sheet: Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Proposed Rule Issues for Fiscal Year (FY) 2017 -

"CMS is proposing to take action regarding the -0.2 percent adjustment it implemented in the FY 2014 IPPS/LTCH PPS final rule to account for an estimated increase in Medicare expenditures due to the Two Midnight Policy.  Specifically, in the FY 2014 IPPS/LTCH PPS final rule, CMS estimated that this policy would increase expenditures and accordingly made an adjustment of -0.2 percent to the payment rates.  CMS believes the assumptions underlying the -0.2 percent adjustment were reasonable at the time they were made.  Additionally, CMS does not generally believe it is appropriate in a prospective payment system to retrospectively adjust rates.  However, in light of recent review and the unique circumstances surrounding this adjustment, for FY 2017, CMS is proposing to permanently remove this adjustment and also its effects for FYs 2014, 2015, and 2016 by adjusting the FY 2017 payment rates.  The impact of this proposal is to increase FY 2017 payments by approximately 0.8 percent."