Getting Around a Standard Development Organization When Developing a New ASC X12N Implementation Guide: A Case Study

Suzie Burke-Bebee, MS, BSN, RN (March 30, 2003)

Health care data content that is defined and coded comparably between data users promotes access to valid, reliable, and timely health information. Comparable data can be achieved through common health care data standardization and collected as part of a patient’s medical record. Two major purposes for collecting health care data in a patient’s hospital record include diagnosing and treating the patient at the point-of-care and statistically analyzing population health outcomes and quality of care. The following case study describes the management process and outcome of a two-year project conducted by members of the Public Health Data Standards Consortium promoting data standardization. The project succeeded in developing a standard implementation guide to be used for public health reporting at the local, State and national level through the Accredited Standards Committee (ASC) X12N (Insurance Subcommittee).

Introduction

Health Care Data Standards

Common health care data standards promote access to valid, reliable, and timely health information while allowing multiple uses of the data. Two major purposes for collecting health care data in a patient’s hospital record include diagnosing and treating the patient at the point-of-care and statistically analyzing population health outcomes and quality of care. Although the same data could be used for these two purposes, the approach of the data-users examining the health care data varies greatly. For example, clinicians rely on clinical data such as lab results and providers’ notes for decision making in the critical, day-to-day health care operation where as health services researchers study administrative data that aid in policy decisions about health care access, quality and cost impacting the public’s health.

The technical separation of the clinical and administrative data essentially results from the varying utility of the data-users. Coding clinical streams of data, which include text-driven clinicians’ notes becomes much more challenging than defining and coding administrative data, which is simpler because of the single data-element structure. Historically, administrative data has been best suited for insurance reimbursement purposes but the public health and health services research communities continue to find many benefits for population health and research purposes. Administrative data, also known as hospital discharge data, are comprehensive, easily accessible, inexpensive, and unobtrusive as well as covering populations with large numbers of available encounters in multiple year time frames(1,2).

Researchers consider the information gained from studies based on administrative data as preliminary findings acknowledging the limitations of the data, which lacks absolute clinical detail for evaluating health care quality and clinical performance. Health services researchers continue to use hospital discharge data abstracted from records in the absence of the health care industry developing and implementing electronic clinical data standards, which would allow for a linkage to the current administrative data in patients’ electronic record. This electronic linkage process is part of the goal of the Department of Health and Human Services (DHHS or the Department) in building a national health information infrastructure(3), which started with the passage of a law called the Health Insurance Portability and Accountability Act or HIPAA.

Health Insurance Portability and Accountability Act

In August 1996, Congress enacted the Health Insurance Portability and Accountability Act, Title II, Subtitle F, Administrative Simplification (AS), which deals with the adoption of uniform electronic health data standards for the health care industry(4). The overall HIPAA law (Public Law 104-191) as intended by its crafters, is “to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, to simplify the administration of health insurance, and for other purposes.”(5) The section of the law referred to as Administrative Simplification addresses the use of standardized electronic transactions and code sets for administrative and financial purposes to be implemented and used by health care providers, health plans and clearinghouses also referred to as covered entities. Health services researchers and public health (not providing health care services) are not named as covered entities in the transaction and code set portion of HIPAA, and therefore, do not have to comply with this section of the law. Even so, the long reaching “data standards” arm of HIPAA through its transactions and code set section greatly impacts these communities.

Impact of Health Data Content Standards on “Non-covered Entities”

One impact on public health and health services researchers includes the ability of the data standardization process to improve the uniform coding and defining of health care data elements. An obvious positive outcome from national data standardization would be research showing a more meaningful and accurate comparison of health care providers and health insurance plans within and between states. A major challenge faces public health and health services researchers in achieving this outcome. The challenge focuses on these communities becoming accepted health care partners during the development and incorporation of standardized data into the workflow of the business operation. Public health and health services researchers have not traditionally been considered data standards players in the business of health care.

A second impact on public health and researchers takes the previous point one step further. The current health care data flow of HIPAA begins with the covered entities: health care providers, health insurance plans, and clearinghouses supplying the flow of administrative data for billing and reimbursement purposes. The same type of data must also go to public health departments for reporting purposes. In the case of the health services researchers such as those at the Agency for Healthcare Research and Quality (AHRQ), the data flow continues from the state reporting systems to the researchers’ databases at AHRQ through the Health Care Utilization Project – HCUP(6,7,8,9). The challenge for public health and researchers lies in the covered entities willingness to use the same ASC X12 data and formatting standards voluntarily for state reporting purposes thus incorporating the same data into the public health and researchers’ workflow.

Case Study – Public Health and ASC X12N Meet

The Department named ASC X12(10) as the developer and maintainer of several transactions within the HIPAA standard transaction sets (Figure 1). One of these transactions provides for the electronic data interchange (EDI) of patients’ health care visits also known as claims or encounters. The transaction, known in ASC X12N (N refers to the Insurance Subcommittee) jargon as the “837”, separates the claim or encounter by three different health care provider services: the hospital, the physician and the dentist. The ASC X12N institutional standard transaction incorporates data found within hospital discharge data systems. For discussion purposes about States’ hospital discharge data systems, this transaction is called the “837 Institutional” claim or encounter.

Figure 1. HIPAA ASC X12 Transactions.

The 837 Institutional standard transaction contains all of the health data content developed by the National Uniform Billing Committee for the Uniform Bill 1992 (UB-92). This is key to States’ hospital discharge data systems because most use the UB-92 as their core data source. The UB-92 and its predecessor, UB-82, have long been recognized as the de facto standard for defining the core data content for billing and reporting of institutional health services. Today 80% of the UB-92 bills are submitted by hospitals to payers through EDI(11). Due to the comparable data of the UB-92, the 837, and States’ hospital discharge data systems, public health and health services research communities are viable albeit voluntary users of the ASC X12N 837 Institutional standard. A 1999 survey by the National Association of Health Data Organization (12) shows forty-two states use hospital discharge data systems of which thirty-one collect discharge data by legislative mandate(13). By leveraging the HIPAA mandate imposed on covered entities to use the 837 for EDI, public health and researchers can wisely incorporate the same data into the public health and researchers’ business workflow by using the same ASC X12N format.

Compliance for HIPAA’s implementation of the transactions and code sets for covered entities was October 16, 2002 although DHHS has allowed for a one-year extension waiver into 2003(14). In the absence of HIPAA’s direct impact on public health and health services researchers, the author explores how participation in the health care data standardization process will benefit public health and health services researchers. The following case study describes the management process and outcome of a two-year project conducted by members of the Public Health Data Standards Consortium. The project succeeded in developing an 837 health care data standard implementation guide through the Accredited Standards Committee (ASC) X12N (Insurance Subcommittee) to be used for public health reporting at the local, state and national level.

ASC X12N Standards Development Process for Implementation Guides

Project Management Framework

The recognition of project management as a practiced discipline has been emphasized most recently in the last decade(15). Many project management professionals dedicated to developing, improving and using project management techniques both in the United States and internationally participate as members of two professional associations: the Project Management Institute (PMI)(16) and the International Project Management Association (IPMA)(17). The former originated in 1969 and currently boasts 100,000 international members; the latter originated in 1965 and affirms 20,000 members mostly in Europe but also from Africa and Asia with institutional contacts in North America, Australia, and South Africa.

In defining a project for project management purposes, Lewis sees it as a multi-tasked job that is done only once and has the requirements of performance, cost, time, and scope (PCTS). Accordingly, project management should facilitate the planning, scheduling, and controlling of the work needed to achieve a successful result i.e., a project delivering products on-time, on-budget, and on-target. According to Levine,(18) a major barrier in planning the project is simply the inability to get started. He relates this barrier to the lack of a project framework that allows for engagement in the process and plan development. Lewis and Levine propose similar project management frameworks offering a comparable structured and staged approach. Lewis represents the project management process through a graphical model called the project life-cycle (Figure 2).

Figure 2. Project Management – a Project Life-Cycle Model.

The project life-cycle is defined through five progressive phases labeled as Concept, Definition, Planning, Execution, and Closeout. The following provides a list of activities found within each phase:

1. Concept Phase (also known as pre-project or proposal phase) – identify and assess a new opportunity; prepare the project proposal including the naming of resource requirements (human and budget); identify project objectives, milestones, constraints, and risks (OMCR); and negotiate the contract terms.

2. Definition Phase (also known as inception, strategic/implementation planning or initiation phase) – define the problem; write the vision and mission statement; update and validate OMCR; and award the contract (or formal decision to go forward).

3. Planning Phase (a continuation of strategic/implementation planning and initiation phase) – develop the project strategy with specific planning and budgeting structures; prepare baselines and plans (tactical and logistical) for resources (human and budget), scheduling (deliverable targets), and risk mitigation (scope and budget creep) identifying scope expansion specifications.

4. Execution Phase (also known as production phase) – work commences with review of OMCR with appropriate corrective action taken.

5. Closeout Phase (also known as termination phase) - conduct project audit and review lessons-learned.

Through a curved line at the bottom of the project life-cycle model, Lewis depicts the planning effort needed to manage a successful project. He associates most project failures as occurring in the Definition Phase. A study supporting this point(19) explored the effectiveness of projects that included a structure called project start-ups (PSU). The PSU structure falls under the high-curved line on the project life-cycle model (Figure 2) and, when used during project management, was found to contribute to a better understanding of the intended project’s purpose, objectives, and scope.

One distinguishing feature of project management from one of general management is scheduling. Scheduling involves the exercise of calculating a deadline for the project and consists of the components: critical paths, activities, events, and milestones. One of the classic scheduling methods that incorporates these components is called the Critical Path Method (CPM). Through CPM, a project’s schedule is estimated according to what tasks need to be done, when the tasks start and end while identifying the precedence relationships between these tasks. The scheduling exercise ultimately helps to further identify the activities, events and milestones in the project’s critical path.

While planning the project’s critical path, factors influencing the success or failure of the project must also be identified and defined. These critical success factors (CSF) allow for a means to control the project by providing a tool to measure the actual project performance against the project plan. Hartman and Ashrafi(20) identified and prioritized ten CSFs linking them to a project metrics (Figure 3).

Figure 3. Ten Most Important Critical Success Factors and Project Metrics.

For the purposes of this case study, the above described project management framework and methodology were modeled with ASC X12N guidelines, called X12N Implementation Guide Handbook(21). The handbook incorporates all policies, procedures and conventions as required by ASC X12N when developing, reviewing and distributing a new implementation guide.

ASC X12N Handbook

The X12N Implementation Guide Handbook is a fairly new phenomenon within ASC X12 and is, in fact, unique to the Health Care Insurance Subcommittee (X12N). Other ASC X12 subcommittees such as Education (X12A), Finance (X12C), Materials Management (X12H), Transportation (X12I), Procurement and Distribution (X12M), and Government (X12G) do not require its use. The handbook specifies twenty-five tasks needed to plan, schedule, and control the successful project of developing a new implementation guide. All twenty-five tasks relate clearly to the project life-cycle model and are easily plugged into the five project management phases (Figure 4).

Figure 4. Twenty-five Tasks within Five Phases for Developing ASC X12N Implementation Guides.

An additional and valuable project management tool for the planning and scheduling of this project is the Work Breakdown Structure (WBS). The WBS frames the project’s scope of work and reflects four levels: Program, Project, Task, and Subtask (Attachment A). Developing a WBS helps to define all the tasks and subtasks and, although sequencing of these activities is not considered part of this tool, the WBS process promotes “sequential” thinking. The ASC X12N Handbook clearly defines the “due process” as requiring a pre-defined task sequence, therefore, sequencing of the twenty-five tasks and fifty-four subtasks is included in the WBS.

Where the Rubber Hits the Road: Putting Public Health Data into the Main Stream

Concept Phase

On November 2-3, 1998 discussions began at a government-sponsored workshop among public health and health services researchers about HIPAA’s impact on their professional communities. Out of these discussions emerged the establishment of the Public Health Data Standards Consortium to represent the interests of public health and health services research in the standard development process. The Consortium is a voluntary group with member organizations from the State, Federal, and private sectors. Members share a common interest in developing, promoting, and implementing data standards for public health and research and collaborate to ensure that their efforts are integrated with broader health data standards development efforts(22).

Since the November 1998 workshop several Consortium projects have promoted the use of existing national standards and identified priorities for developing new data standards(23,24) with a focus on hospital discharge data. To this end, the Consortium formed an informal workgroup at the end of 2000, called the Health Care Service Data Reporting Guide Work Group (HCSDR WG), with the objective of developing an implementation guide within ASC X12 based on a clear business need for public health and health services researchers (Attachment B)(25,26,27).

Much of the marketing for this project went on during ASC X12 Trimester meetings, through various health care industry and public health listservs, and on a daily basis, through the jobs of the workgroup members. The HCSDR WGs formal membership in July 2001 grew as the project’s outreach generated an increased interest in the project: starting with 23 individual members, ending with 40. The initial outreach through the WGs listserv included eight states, five federal programs or organizations, three national organizations representing States’ interests, and one health care vendor in the private sector. At the end of the project the WGs listserv membership consisted of eleven states, seven federal programs, four national organizations, and two vendors.

Definition Phase

The project’s first critical date included the task of preparing and submitting the project proposal to ASC X12N, which was done on February 5, 2001. Through the proposal preparation the workgroup members spelled out the resources necessary to achieve the objectives, identified the milestones and critical dates within the CPM, and recognized the constraints and risks using the CSFs (Figure 4). One risk identified was the overwhelming volume of text needed to be written for the new 837, therefore, this task was split into two components. One component was the guide’s introduction or the “how-to-use-the-guide” also known in ASC X12 jargon as Front Matter. The second component was the technical specifications for the data content and message format.

Planning Phase

Planning the project’s critical path was best done by looking ahead to HIPAAs compliance date for covered entities (no later than October 2003). Leveraging the mandated implementation date for the 837 offers an appealing business case for covered entities to report hospital discharge data to non-covered entities: public health and researchers required to collect the data. The non-HIPAA-but-comparable reporting guide needed to be published in time for HIPAA compliance. A two-page spreadsheet offered a quick but comprehensive view of the critical path (Attachment C-1 and C-2).

Execution Phase

Coordinating the multiple tasks being performed by multiple people off-site was the project’s biggest challenge. Multimedia including the use of the Internet was a critical component for the project’s success or failure. Outreach to assure that the new reporting guide captured the business needs of the audience planning to implement it in the future was done through WG listserv interaction; participation in weekly ASC X12N 837 WG conference calls, public health caucuses at the ASC X12 Trimester meetings, and the Consortium annual Steering Committee meetings; and through telephone, email, or on-the-job discussions between and by WG members. Additionally, HCSDR WG members made several formal presentations about the progress of the reporting guide to the Consortium’s member organizations across the country.

Major milestones and critical events within the project included obtaining tiered-approval from ASC X12N, which meant building in the voting approval from the 837 WG (authors of the three existing claim/encounter guides), the Health Care Task Group (TG2), and the Insurance Subcommittee (X12N). The ASC X12N consensus process also required approval from or announcement to the following Task Groups: Transaction Coordination and Modeling (TG3), Implementation Guides (TG4), and Architecture (TG8).

Final execution of the project incorporated a Public Review period and an Informational Forum, which allowed for formalized feedback to the HCSDR WG members. These events had the potential to produce major project slippage (months in delay) because reviewer’s comments may reveal serious technical flaws or inadequacies in the new implementation guide (Attachment A – Tasks 16, 17, and 18). For example, two major issues discussed and resolved during these comment periods included the potential of adding physician’s services or a managed care component into the reporting guide. The HSCDR WG had considered these options during the Concept and Definition Phases of the project and, due to the lack of subject-matter expertise to support the business needs, the WG decided that these were out of the work scope for the project.

Close Out Phase

Using the project management framework, the CPM process with the CSF tool to evaluate the project’s success or failure along the way resulted in a final evaluation: a project (defined as done only once) coming in on-time, on-budget, and on-target. As an auditing function in the final stage of the project, ASC X12N required that the HSCDR WG review the “due process” with the Implementation Guides Task Group (TG4), which takes a critical vote prior to permitting final publication.

The successful conclusion of the project with final publication of the reporting guide in October 2002 can be misleading. In the future the new ASCC X12N reporting guide must be maintained by the HCSDR WG members through commitment and participation in the 837 WG at the Trimester meetings and any other 837 WG scheduled activities i.e., conference calls. Additionally, the ultimate goal of the Consortium and the HCSDR WG is for the guide to be put into the national health information infrastructure (NHII) and to be used by providers for reporting health care encounters to public health and related entities. Newly acquired work for the Consortium begins in the form of educating covered and non-covered entities about implementing the new reporting guide.

Summary

Implications for Public Health Related to the Health Care Service Reporting Guide

The Consortium recognizes the many challenges ahead in educating public health and health services researchers about the value of data standards. Marketing the new ASC X12N reporting guide adds to the Consortium’s current educational activities. Three activities are in various stages of development, including creating a Web-based resource center focusing on public health and data standards. One such Website created in 2001 by NAHDO provides numerous documents, tools, and Web-links relative to the new reporting guide and other data standards efforts. Additionally the Consortium’s main Website has been maintained by the National Center for Health Statistics, Centers for Disease Control and Prevention since 2000. This Website with its numerous listservs and educational documents provides another forum for getting the standardization message out to the stakeholders(28,29).

Public health and health services researchers must take advantage of the golden opportunity offered today in health care data standardization, namely HIPAA. Being a player at the data-standards table when developing and implementing ASC X12N transactions is a valuable part of building the national health information infrastructure. The Consortium will provide educational materials to promote the skills necessary for public health and their partners to improve data quality within the collection and reporting process.

Attachment B

ASC 12N Implementation Guide Project Proposal Form

Attachment C-1

837 X156 HCSD Reporting Guide Schedule 2001

* Designate Critical Dates: an activity or event that must be met to prevent slippage.
** Designate Milestones: a major accomplishment or phase of work completed.

Attachment C-2

837 X156 HCSD Reporting Guide Schedule 2002

* Designate Critical Dates.
** Designate Milestones. Bold Dates – Early/Late Finishing Dates.

References

(1) Elixhauser, A. (1998). The potential impact of data standards on health services research into quality measurements and improvement. Public Health Data Standards Consortium (PHDSC) Conference Paper, November 2-3, 1998: Health Insurance Portability and Accountability Act: Implications for Public Health and Health Services Research.
(2) Iezzoni, L. (1997). Assessing quality using administrative data. Annals of Internal Medicine (Part 2), 127, 666-674.
(3) National Committee on Vital and Health Statistics (NCVHS) report and recommendations (2001). Information for health: A Strategy for building the national health information infrastructure (NHII). Available on-line: http://www.ncvhs.hhs.gov/nhiilayo.pdf
(4) Health Insurance Portability and Accountability Act (HIPAA) Title II, Subtitle F, Administrative Simplification (AS), 1996. Available on-line: http://aspe.hhs.gov/admnsimp/pl104191.htm
(5) U.S. Department of Health and Human Services (U.S. DHHS), Administrative Simplification – HIPAA Law (1996). Public Law 104-191, 104th Congress. Available on-line: http://aspe.hhs.gov/admnsimp/pl104191.htm
(6) Agency for Healthcare Research and Quality (AHRQ). The Healthcare Cost & Utilization Project (HCUP) main Web page (2002). Available on-line: http://www.ahrq.gov/data/hcup
(7) Agency for Healthcare Research and Quality (AHRQ). The Healthcare Cost and Utilization Project (HCUP), 1988-99: A Federal-State-Industry Partnership in Health Data. Available on-line: http://www.hcup-us.ahrq.gov/overview.jsp
(8) Agency for Healthcare Research and Quality (AHRQ). The Nationwide Inpatient Sample (NIS): Powerful Database for Analyzing Hospital Care (2002). Available on-line: http://www.hcup-us.ahrq.gov/nisoverview.jsp
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(10) U.S. Department of Health and Human Services (U.S. DHHS), Office of the Secretary. Health Insurance Reform: Standards for Electronic Transactions published August 20, (2000). Available on-line: http://aspe.hhs.gov/admnsimp/final/txfin00.htm
(11) National Uniform Billing Committee (NUBC) (2002). The History of the NUBC. Available on-line: http://www.nubc.org/history.html
(12) National Association of Health Data Organizations (NAHDO) & The MEDSTAT Group (1999). Statewide encounter-level inpatient and outpatient data collection activities. Unpublished report for the Agency for Health Care Policy and Research, Center for Organization and Delivery Studies.
(13) Love, D. (1999). Data Inventory for HCUP Partners. Unpublished report from the National Association of Health Data Organizations (NAHDO) for the Agency for Health Care Policy and Research (AHCPR).
(14) Centers for Medicare and Medicaid (CMS) Issues Model Plan to Extend Deadline for Compliance with Electronic Transactions Rule (2002). Available on-line: http://aspe.hhs.gov/admnsimp/PRelease.htm

(15) Lewis, J. (2001). Fundamentals of Project Management: Developing Core Competencies to Help Outperform the Competition (2nd ed.). New York: Amacom.
(16) Project Management Institute (PMI) (2002). Available on-line: http://www.pmi.org/info/default.asp
(17) International Project Management Association (IPMA) (2002). Available on-line: http://www.ipma.ch/
(18) Levine, H. (2002). Practical Project Management: Tips, Tactics, and Tools. New York: Wiley
(19) Halman, J. & Burger, G. (2002). Evaluating effectiveness of project start-ups: an exploratory study. International Journal of Project Management, 20 (1), 81-89.
(20) Hartman, F. & Ashrafi, R. (2002). Project management in the information systems and information technologies industries. Project Management Journal, 33 (3), 5-15.
(21) Accredited Standards Committee (ASC) X12N: Implementation Guide Handbook. Available on-line: http://www.wpc-edi.com/transfer/handbook.pdf
(22) Public Health Data Standards Consortium (PHDSC): Integrating data standards through partnerships (2001). Available on-line: http://www.cdc.gov/nchs/data/phdsc/phdsc0206.pdf
(23) The Lewin Group with NAHDO & the Public Health Data Standard Consortium Education Work Group (2001). Public Health Data Standards Consortium Education Strategy: Final Report. Available on-line: http://www.cdc.gov/nchs/data/phdsc/phdsc0206.pdf
(24) National Association of Health Data Organizations (NAHDO) (2000). Prioritization of data needs for State encounter data sets for public health and research applications: A Summary report to the Public Health Data Standards Consortium. Available on-line: http://www.nahdo.org/project/matrix%20docs/Final2.pdf
(25) Public Health Data Standards Consortium (PHDSC): Web-based Resource Center hosted at NAHDO. Special Projects: Health Care Data Standards Reporting Guide (2002). Adopting Standards for Encounter Data Systems. Available on-line: http://www.nahdo.org/project/Adopting%20Standards%20for%20Encounter%20Data%20Systems.htm
(26) Public Health Data Standards Consortium (PHDSC): Health Care Service Data Reporting Guide Work Group (2002). Available on-line: http://phdatastandards.info/about/committees/hcs.htm
(27) Accredited Standards Committee (ASC) X12N: Health Care Service Data Reporting Guide: 4050X156 (2002). Available through Washington Publishing Company on-line: http://www.wpc-edi.com/HealthCare_40.asp
(28) Public Health Data Standards Consortium (PHDSC) (2002). Available on-line: http://www.cdc.gov/nchs/otheract/phdsc/phdsc.htm
(29) Public Health Data Standards Consortium (PHDSC): Web-based Resource Center Work Group suggested Web sites for health data standards (2002). Available on-line: http://www.phdatastandards.info/knowresources/websites.htm