© 2011, Data Interchange Standards Association Provider Directory Presentation to: HIT Standard Committee Privacy & Security Work Group Presented by: Don Bechtel on behalf of ASC X12 – April 6, 2011

© 2011, Data Interchange Standards Association 2 X12 Transaction Standards ANSI chartered the Accredited Standards Committee X12 in 1979 to develop transaction standards for electronic commerce. ASC X12 is used in multiple industries: Finance (X12F), Government (X12G), Transportation (X12I), Supply Chain (X12M), Insurance (X12N), and others. Insurance (X12N) provides transactions for several lines of business –Property and Casualty –Health Care – which supports a number of transactions, including: ASC X12 270/271 Eligibility ASC X for Provider Directories ASC X Authorizations, Referrals, and Notifications ASC X Claims transaction And the other HIPAA mandated transactions. And more. Our standards are also available as XML schema as well ASC X12 is a member of the Standards Charter Organization (SCO)

© 2011, Data Interchange Standards Association 3 What capabilities does X12 Std provide for an EHR query to a Provider Directory? The ASC X Provider Directory has several Implementation Specifications that can used –4050X185 Is an Inquiry and Response transaction for a Provider Directory Providers (and consumers) can request a list of providers from a specific geography, from a specific payer network, and by a specific specialty. Responses will provide a list of providers qualified by the request and can provide information about the providers practice. This transaction could be migrated to version If additional business requirements are identified by the this committee, we might be able to incorporate those in version 5010, provided the base standard supports the needed data elements. –4010X109 is the Provider Directory This Implementation Guide provides transaction specifications used to populate a Provider Directory; it has been published for several years. Plans are to bring version 5010X207 forward soon, but we are now waiting to see if additional requirements are needed from HIT Standards Committee.

© 2011, Data Interchange Standards Association 4 What capabilities does X12 Std provide for an EHR query to a Provider Directory? X109 – Provider Directory Available Information Affiliated Hospital Group Network Provider (i.e. doctor or facility) Site Name Identification Numbers Direct Contact Information Demographic Information Languages Spoken Work Schedule Location Logistics Healthcare Delivery Focus Healthcare Specialty Licensing/Accreditation/Certification Name of the affiliated entity Identification Numbers of the affiliated entity More… X185 – Provider Directory – Inquiry/Response Information Provider Name Geographic information Provider area of specialization Network Hospital Participation dates Provider Role Accepting new patients Provider Identification Number Geographic information Provider Age Provider gender Provider Language Site specific assistive aids State licensing information Site ID Provider site location Site location information Provider work schedule information More…

© 2011, Data Interchange Standards Association 5 What information do EHRs need to retrieve from a Provider Directory to enable a health information exchange with another provider? The ASX X12 Provider Directory transaction was developed to allow a provider (or consumer) to inquire and locate a provider within their (payers) network of providers, within a geography, for a specific specialty. To conduct an inquiry, the provider would need to know the electronic address of the provider directory and be able to identify themselves in the transaction. The response will provide one or more providers meeting the qualifications requested. To information returned about the provider will include contact information, which today can include an address, physical location, phone and fax numbers, and individual contact names. This might be expand to include other types of addresses if not already provided. More importantly, it will provide other information about the providers practice that will be useful to make a decision about which provider is preferred, based on specialty, languages spoken, gender, hospital affiliation, actual location … What would be required from the committees perspective? We may be able to accommodate additional information.

© 2011, Data Interchange Standards Association 6 What technical standards (content) that exist today would you recommend for enabling an EHR to query a Provider Directory? The ASC X12 transaction standards are content focused. –They require specific data content for the exchange of information to meet a specific business purpose, usually industry specific. In this case the ASC X transaction would be used. –Implementation specifications are written by ASC X12 to provide more tailored implementation specification for an industry sector, in this case, the transaction was written for use within insurance, and a TR3 was written for a health care specific setting. Provider Directory Implementation Guide (TR3) designated as 4050X109 Inquiry and Response Implementation Guide (TR3) designated as 4050X185 –Specialties are identified by codes from the Health Care Provider Taxonomy Code Set maintained by National Uniform Claims Committee (NUCC), which is chaired by AMA.

© 2011, Data Interchange Standards Association 7 Implementation Guide Descriptions for the ASC X Transaction ASC X X109 – Provider Directory The purpose of this implementation guide is to provide standardized data requirements and content for all users of ASC X12 Health Care Provider Information (274) transaction. This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for creation of a provider directory. ASC X X185 – Provider Inquiry and Response The purpose of this implementation guide is to provide standardized data requirements and content for all users of ASC X12 Health Care Provider Information (274) transaction. This implementation guide provides a detailed explanation of the transaction set by defining data content, identifying valid code tables, and specifying values that are applicable for creation of a provider directory. The intention of the developers of the 274 is represented in this guide.

© 2011, Data Interchange Standards Association 8 What gaps exist today in the recommended standard for such exchanges? If the definition of a Health Care Provider is broadened beyond what is defined by HIPAA, for example, to include Public Health Agencies, then this may be a gap in our Implementation Guide, but not necessarily in our standard. –This means that this may be corrected without modification to the base standard, a much faster fix process, especially given that this is not a HIPAA mandated transaction, it can avoid the regulatory process. We may have a gap in the type of communication channels to be identified if it is not part of what we have traditionally included: – address, telephone, fax, individual contact name Others could be made available –These would most likely be Implementation Guide gaps, not gaps in the Standard. If the standard requires an address type not defined by ASC X12, that would require more significant data maintenance to the standard; but this is very doable.

© 2011, Data Interchange Standards Association 9 What certification criteria would we suggest for an EHR query of a Provider Directory? There are a variety of test tools on the market today that will validate transaction conformance to the ASC X12 transaction standard. –Most entities exchanging ASC X12 transactions today have some form of transaction validation (conformance verification) built into their system –Usually done at the front end to avoid processing problems once the transaction is acquired and accepted for processing –These could be added to the set of tools used by certifiers today to validate the transactions being produced by an EHR –These typically do not verify content other than physical attributes. –Some translators/validation editors can verify contents as well. Those that can produce a 999 Acknowledgement transaction, would be capable of providing deeper content editing, code set validation, conformance with the implementation guide specifications, and some level of context editing/validation. –These are not ASC X12 products, but rather commercial products.

© 2011, Data Interchange Standards Association 10 What standards are needed to define the structure and content of a Provider Directory? Are there such standards available today? The standards were identified in slides 3, 4, 6, and 7 of this presentation. These transaction standards are available today. The Content of the Provider Directory is specified based in the ASC X12 version X109 or not yet released X207 Implementation Guides. The structure of a Provider Directory is not defined by ASC X12, as these are transaction standards. –However, some structure guidance might be taken from the implementation guides where closely related data elements are collected into a data segment, and data loops. However there is no requirement to do this.

© 2011, Data Interchange Standards Association 11 What standards are needed to support the submission (publishing) of directory content to a national Entity-Level Provider Directory? Available today? This would utilize the ASC X transaction with the X109 or the X207 Implementation Guides as discussed in earlier slides. The X109 is available today. The X207 will be ready soon, but we are waiting to see if more requirements will be provided by the HIT Standards Committee, that ASC X12 might incorporate before publishing.

© 2011, Data Interchange Standards Association 12 Any other points important to be considered with respect to standards for Provider Directories? ASC X12 believes that the Provider Directory needs to provide more than just an electronic address of providers. In todays healthcare system, many patients/consumers are required to use providers within their Health Plans network of providers, failure to do so may have increased out of pocket cost to the patient. Keeping this relationship in mind with these queries is important. Were not sure we fully understand the use-case of this directory, if it is just to find an electronic address to exchange data, then our standard goes beyond this scope. But again, we believe that more information is really necessary, namely: the providers specialty if youre looking for specific services for a referral, whether the provider is taking additional patients, are the providers characteristics compatibility with the patient (location, gender, language, hospital affiliation, etc), all of which are provided by ASC X12 Provider Directory including electronic addresses.

© 2011, Data Interchange Standards Association 13 Work we are doing today on standards for provider directories ASC X12 Insurance Subcommittee has an active work group for Provider Directories, which meets each trimester. ASC X12 is ready to accept new requirements for this directory and is prepared to make changes/adjustments to the Implementation Guides or the Base Standards as identified by industry stakeholders or ONC. ASC X12 as a member of the SCO, is preparing to hear more information on Provider Directory requirements at our April 21 st meeting, at which Walter Suarez is scheduled to provide information. The SCO has been planning a joint project that would include: HL7, IHE, NCPDP, and GS1 to jointly develop a Provider Directory that would satisfy the varying requirements from each industry segment these organizations represent. –The scope of this project will be discussed and decided during their April 2011 meeting, following Walters presentation.