Att X - Background and Historical Information

Attachment X: Background and Historical Information

Summary Background

The sections below describe new efforts underway to increase participation of hospitals as well as to increase the use of electronic health records (EHRs). At the end of the summary is the listing of the specific activities for which approval is sought.

The integration of NHAMCS and DAWN into the NHCS will provide nationally representative data on the utilization of health care provided in hospital inpatient departments as well as care delivered in outpatient departments (OPDs), and emergency departments (EDs), including estimates of substance-involved ED visits.

This integration is part of a broader strategy to improve efficiency and data quality by:

• minimizing redundancy in data collection;

• broadening the capability to collect data on patient movement through the health care system; and

• identifying opportunities to exploit administrative and electronic clinical data systems to augment primary data collection.

Initially, NCHS expected that the integration of NHAMCS and DAWN into NHCS would be a transition period of several years, beginning with the recruitment of hospitals to participate by having them send UB-04 administrative claims data or a state file electronically to NCHS. Concurrently, NCHS planned to conduct the developmental work necessary to prepare for the acceptance of EHR files from participating hospitals.

NCHS expected that this integration of NHCS would take time; however, after several years of recruitment, as of December 2014, only 100 of the 581 sampled hospitals had been recruited. Early on in the recruitment effort, hospitals indicated that they were already burdened with a growing number of reporting requirements that posed a challenge for their participation in NHCS. The demand on hospitals to produce quality of care reporting over the past few years has increased tremendously. Much of this reporting is often mandatory; in contrast, NCHS healthcare surveys are voluntary surveys.

First steps to explore participation issues:

NCHS has taken a number of steps to explore these issues more fully in order to inform a revised approach to the implementation of NHCS.

1. NCHS conducted focus groups with representatives from less than nine participating hospitals who participate in NHCS and those who are not yet participating. We gathered information on what were major hindrances to participating and what would incentives to participation be for their hospital.

2. NCHS and CDC leadership met with the leadership from the American Hospital Association and the Federation of American Hospitals and

3. NCHS conducted a stakeholders meeting that included key representatives of the Office of National Drug Control Policy, Office of the National Coordinator for Health IT (ONC), SAMHSA, Agency for Health Research and Quality (AHRQ), Food and Drug Administration (FDA), Assistant Secretary for Planning and Evaluation, Centers for Medicare & Medicaid Services (CMS), and American Health Information Management Association.

Several common themes emerged from these discussions. First, from all perspectives, the value of the NHCS should be clearly articulated. Hospitals who have been asked to participate in NHCS report that they understand the value of the data the survey produces; reporting that they have used the data from the NHDS, NHAMCS and DAWN. However, while they are supportive of the intention of NHCS to reduce redundancy in data collection, they are not able to realize such a benefit because of the myriad of other mandatory reporting requirements that are not fulfilled by participating in NHCS. Stakeholders, including FDA and SAMHSA, rely on the data collected by NHCS. In some cases, these data are required by the agency to meet their legislative mandates.

Following the stakeholders meeting, FDA and SAMHSA initiated interagency agreements with NCHS worth a combined contribution of nearly $6 million in support to NHCS. NCHS also had follow-up discussions with AHRQ, CMS, and ONC.

Plans to transition to EHR data collection:

In 2014, the Division of Health Care Statistics (DHCS) forged the groundwork to move from manual data collection to electronic data collection by developing a national electronic standard for reporting patient-level data to NCHS and by conducting small pilot studies testing the feasibility of collecting EHR data from hospitals. Electronic standards serve as the foundation that supports the ability to exchange health information from EHR systems. A prominent standards development organization, Health Level Seven International (also known as HL7), develops standards that are utilized by more than 90% of the information systems vendors serving healthcare. In collaboration with the NCHS Classifications and Public Health Data Standards Staff, DHCS developed an HL7 Implementation Guide (IG) for the National Health Care Surveys.  This HL7 IG is intended to be the national electronic standard for reporting data items to NCHS. This should ease the burden on health care providers and increase the likelihood that they will be able to electronically transfer information from their EHR systems. It also supports NCHS’ request to be recognized as a specialized registry under ONC Meaningful Use (MU) regulations that incentivize eligible hospitals and providers who use EHR systems that adhere to the MU requirements to exchange health information (See section A3 for more details).

It is envisioned that hospitals using the HL7 IG will be able to submit data to fulfill the requirements of the surveys by full automatic extraction of the data from the providers’ EHR or data repository. This IG was published by HL7 as a Draft Standard for Trial Use on January 15, 2015. The HL7 IG was identified as the best available standards and implementation specifications for clinical health information interoperability in the 2015 Interoperability Standards Advisory released by ONC.

2014-2016 Recruitment Strategy:

Starting with the 2014 data collection, which began in September 2014, a new recruitment strategy was put in place to specifically target hospitals with 300 or more staffed inpatient beds. These hospitals are further along in EHR adoption and are more likely to have substance-involved ED visits. Based on additional subsequent information from SAMHSA, we understand that hospitals with 500 or more staffed inpatient beds are even more likely to have larger numbers of substance-involved ED visits, leading NCHS to now request approval to increase the sample size to 581 to allow for more hospitals with 500 or more staffed inpatient beds to help with the integration of DAWN data into NHCS (See section B1 for more details). These hospitals were released before NCHS adopted the strategy to target hospitals with 300 or more staffed inpatient beds to make estimates.

Timing for NHAMCS discontinuation:

Once NHCS participation has reached 250 hospitals with EDs, NCHS will evaluate whether NHAMCS should continue alongside NHCS or be replaced entirely by NHCS. NHAMCS will be operating in tandem with NHCS, until the NHCS is fully implemented; assuring that the data collected in the two surveys can be compared.