A task force of the Office of the National Coordinator for Health Information Technology has developed 15 recommendations to improve the intersection of clinical and administrative data and corresponding policy and standards frameworks.
In 2020, the ONC Health Information Technology Advisory Committee (HITAC) asked the Intersection of Clinical and Administrative Data Task Force (ICAD) to make recommendations to support the convergence of clinical and administrative data and improve data interoperability across the ecosystem, to enhance patient access and improve health care efficiency. The charge focuses on reducing the burdens associated with prior authorization, which is seen as emblematic of broader integration issues.
The task force gathered input from ONC’s Health Information Technology Advisory Committee (HITAC), the National Committee on Vital and Health Statistics (NCVHS), and other federal agencies as well as industry stakeholder groups to help inform its analysis of the current landscape. Based on the task force findings, a HITAC report describes nine guiding principles describing the ideal state and offers 15 recommendations to improve the intersection of clinical and administrative data and corresponding policy and standards frameworks.
Among those 15 recommendations are:
• Establish a Government-wide Common Standards Advancement Process. The HITAC recommended that ONC, working in concert with CMS and other relevant federal agencies, establish a single consistent process for standards advancement for relevant standards for healthcare interoperability, including transactions, code sets, terminologies/vocabularies, privacy and security used for conducting the business of health care, irrespective of whether that business is clinical or administrative. The HITAC recommends that the standards advancement process incorporate multiple rounds of development testing and production pilot use prior to adoption as national standards.
• Converge Health Care Standards. The HITAC recommended that ONC, working in concert with CMS, the National Library of Medicine (NLM), voluntary consensus standards organizations, and other federal agencies, harmonize standards to create a consistent set of standards for Code Sets, Content, and Services that are evolved together to address multiple workflows, both clinical and administrative. The harmonized standards should use an underlying data model that is sufficiently comprehensive to serve both clinical and administrative needs.
• Harmonize Code and Value Sets. The HITAC recommended that ONC work with CMS, NLM, and relevant value set authorities to harmonize code and value sets to serve clinical and administrative needs. Where specialized code and value sets are needed, they must be mapped to more general code and value sets. As an example, in order to streamline prior authorization workflows, the code and value sets used to encode orderables, procedures, or referrals must be reusable across or cleanly mappable or cross-walked to the code and value sets used to determine administrative authorization for payment for the relevant orderable, procedure, or referral.
• Make Standards (Code Sets, Content, Services) Open to Implement Without Licensing Costs. End-user licensing of adopted standards, code sets and vocabularies is burdensome. In order to drive innovation and make standards-based capabilities available to the widest set of actors, the HITAC recommends that converged standards (and their included component code sets, etc.) named in certification programs be available to implementers without licensing costs for developers implementing the named standards. Ideally, such converged standards would be available via one of the business models that support full and open access to standards (e.g., NLM national licensing for code sets or standards development business models, such as those deployed for HL7 FHIR or Internet standards, that support member prioritization for the advancement of standards while making the resulting standards and implementation guidance available through broad usage licensing). The HITAC recognizes the need for financial support for the development and curation of standards.
• Establish Standards for Prior Authorization Workflows. The HITAC recommended that ONC work with CMS, other federal actors, and standards development organizations to develop programmatic (API) specifications to create an authorization (digital prior authorization or related determinations such as Medical Necessity) such that the authorization and related documentation can be triggered in workflow in the relevant workflow system where the triggering event for the authorization is created. As an example, when an authorization is required for payment for a procedure or referral for evaluation or treatment, the prior authorization workflow should be enabled in the relevant ordering or referral clinical workflow.
ICAD stressed that its overarching goal is to support the convergence of clinical and administrative data and improve data interoperability across the ecosystem, to enhance patient access and improve healthcare efficiency. It also seeks to enable innovation and continuous improvement, minimizing the need for special effort on the part of ecosystem participants.