The trouble with HIPAA
I think you omitted a major problem in your article on the transaction and code sets rules that are part of the Health Insurance Portability and Accountability Act (HIPAA). ("Last-second strategies for the HIPAA transactions rule," September 2003 ACP Observer.)
There is a difference of opinion about many parts of the rule, which makes it almost impossible to proceed. In certain areas, payers and clearinghouses (and providers) do not always see eye-to-eye regarding what the rule says.
For example, most people think the HIPAA rules mean that all local codes go away. Medicaid of Illinois, however, has said that the rules do not say that, and it wants us to continue using local codes.
There is a place to list the subscriber birth date. Some payers say this is a required element, while others say it is not.
There is an element requiring providers' Social Security numbers. An employer identification number can be substituted—but some payers insist that we give our Social Security numbers.
The rules state that we do not need to use national drug codes and that we can instead use HCPCS (J codes). However, Medicaid wants us to use national drug codes!
These examples illustrate that becoming HIPAA-compliant is not a straightforward process. The problem is determining what is HIPAA-compliant to the satisfaction of each payer. It is difficult to change the way we collect data when it is not clear what we need.
Richard Fairley, ACP Member
The ethics case study on disclosing mistakes raises an important question about the role of office systems. ("Must you disclose mistakes made by other physicians?", November 2003 ACP Observer.)
While the article acknowledges the systems' issues here, blame is clearly laid at Dr. Leavitt's feet. Is there an assumption that if Dr. Leavitt never saw this report, he should have remembered that he had ordered it? What is the responsibility of the practice as a whole to ensure that staff never files a report in the chart without the physician signing off? This is a classic latent error within an office that has risen to the fore and injured a patient.
The ethical issues of disclosure are important, but the bias inherent in blaming Dr. Leavitt only guarantees more failure down the line.
Roger Renfrew, FACP
The missed opportunity to follow up a critical radiological abnormality has implications that go beyond ethical concerns. It is critical to focus on processes and systems to prevent these errors, in addition to focusing on changing clinician behavior and office policy.
At our local VHA facility, there is an "unsuspected findings" communication sent from the radiologist to the ordering clinician. This communication is separate from the radiological report.
The additional correspondence obviously requires some effort on the part of the radiologist, but the stakes are high. The investment in time is well worth the effort in terms of assuring timely intervention, protecting the patient and safeguarding the clinical integrity of the clinician.
David A. Nardone, FACP
The hypothetical patient in the case study was found to have lung cancer with mediastinal spread. From the history provided, I am assuming that this would be non-small cell lung cancer with involvement of mediastinal lymph nodes, or stage III disease.
The case study said that the physician has to tell the patient that he has a "terminal condition." This is wrong. Stage 3 non-small-cell lung cancer is not a terminal condition. While it is true that most people die of the disease, at least 15% of patients can be cured with appropriate treatment. Even if this is limited-stage small-cell lung cancer, the same curative potential applies.
There is a common misconception in the medical community that the diagnosis of unresectable lung cancer is an inevitable death sentence. This way of thinking has led to excessive nihilism regarding the treatment of lung cancer and inadequate care for many patients with the disease.
Gregory P. Kalemkerian, ACP Member
Ann Arbor, Mich.
I had to laugh when I read the feature article on medical mistakes. The photograph on page 9 depicts someone looking at an X-ray.
Unless the patient has situs inversus, the physician is holding the X-ray backwards.
Andrew L. Miller, ACP Member
Editor's note: The photo of the physician reading an X-ray was reproduced incorrectly. The image was rotated 180 degrees.
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