Standards and Data Submission. Detailed Mapping Tables September 2009

Transcription

1 Gap Analysis: Mapping the CIHI National Prescription Drug Utilization Information System (NPDUIS) Database Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Detailed Mapping Tables September 2009 Standards and Data Submission

2 Who We Are Established in 1994, CIHI is an independent, not-for-profit corporation that provides essential information on Canada s health system and the health of Canadians. Funded by federal, provincial and territorial governments, we are guided by a Board of Directors made up of health leaders across the country. Our Vision To help improve Canada s health system and the well-being of Canadians by being a leading source of unbiased, credible and comparable information that will enable health leaders to make better-informed decisions.

3 Table of Contents Acknowledgements... i A. Gap Analysis Overview... 1 Purpose... 1 Methodology... 1 Findings... 2 NPDUIS Database and eclaims Standards Background Information... 2 B. Mapping Table Descriptions... 4 C. Gap Analysis Between NPDUIS Data Set and the eclaims Standard... 5 D. Sources Canada Health Infoway Documents Data Types Canadian Institute for Health Information Documents... 15

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5 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Acknowledgements The Canadian Institute for Health Information (CIHI) wishes to acknowledge and thank the following individuals for their contribution to this analysis: Role CIHI Contributors Canada Health Infoway Contributors Lead Paula Freedman Sukhi Burgen Data and Gap Analysis Content Cristina Mihelic Monica Harry Subject-Matter Experts/Consultants Michele Arthur Zee Hua Cheung Michael Gaucher Jordan Hunt Winnie Wong Sponsors/Steering Committee Scott Murray Caroline Heick Infoway CIHI Liaison Committee Dennis Giokas Infoway CIHI Liaison Committee i

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7 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard A. Gap Analysis Overview Purpose The purpose of this gap analysis is to determine the extent of alignment between Infoway s pan-canadian eclaims (Pharmacy) content standards and the NPDUIS Database claims data set. The findings of this analysis, in conjunction with findings from other content gap analyses, will help inform next steps on the part of CIHI, Infoway and jurisdictions in ensuring health system use is considered when creating content standards for the electronic health record (EHR) and vice versa. Methodology CIHI and Infoway subject matter experts collaborated to map the most current complete NPDUIS Database claims data set (38 data elements) to Infoway s pan-canadian eclaims standard. A red yellow green rating scale indicates the degree of alignment for each data element map. Please reference section C for mapping and rating details. 1

8 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Findings Map Rating Summary 21% (8 in total) 63% (24 in total) 16% (6 in total) NPDUIS Database and eclaims Standards Background Information NPDUIS Database The National Prescription Drug Utilization Information System (NPDUIS) Database contains claims-level data on prescription drugs, collected from publicly financed drug benefit programs in Canada. The focus of the current gap analysis is the claims data set portion of the NPDUIS Database, which consists of cost and payment information in relation to prescribed drugs. The information from the claims data set is used to measure and analyze the pattern of drug use in Canada. 2

9 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard eclaims The pan-canadian eclaims standard was developed through the National e-claims Standard (NeCST) Project. The NeCST is a pan-canadian project dedicated to developing an electronic claims standard that can be utilized by all health care providers. Acting as both a partner in and the facilitator of the project, CIHI leads the NeCST Executive Steering Committee (ESC), composed of five private-sector health payors, five public-sector health payors and five health care provider organizations, CIHI and Canada Health Infoway. The ESC is responsible for approving the ongoing scope and work plan for the project, as well as reviewing and endorsing the completed artifacts. Working through a technical architecture group (TAG) and a number of special interest groups (SIGs), the project has developed the messages and vocabulary required for the electronic submission and adjudication of claims. Other messages support predetermination authorizations, benefit coverage extensions, queries and payments. Health Level 7 (HL7) version 3 was selected as the basis for the NeCST standard. 3

10 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard B. Mapping Table Descriptions The table in section C documents potential eclaims Standards mappings for National Prescription Drug Utilization Information System (NPDUIS) Database data elements. The table heading descriptions below provide guidance on how to use and interpret mapping table content. Column Heading Data Description Name of NPDUIS claims data element. Description The standard definition or decryption for data element based on NPDUIS documentation. Primary eclaims Standard Message Model Main message specification containing the eclaims attribute to which the NPDUIS data element maps. Secondary Model Message specification referenced by primary or additional message specification containing the eclaims attribute to which the NPDUIS data element maps. Section Section within primary message specification containing the eclaims attribute to which the NPDUIS data element maps. Sections correspond to a concept or a concept element group. Attribute The eclaims attribute to which the NPDUIS data element maps. Comments Addition notes on eclaims attributes, data nesting and associations and mapping rationale. Map Rating A colour-coded system that identifies the extent of mapping between the NPDUIS data elements eclaims concepts/attributes. Green: The CIHI concept and value domain has a complete equivalent in the eclaims standard. Yellow: The CIHI data element concept and value domain does exist in the eclaims standard, but variances in definition or code set exist. Red: The CIHI concept and value domain has no equivalent in the eclaims standard. 4

11 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard C. Gap Analysis Between NPDUIS Data Set and the eclaims Standard Map Rating NPDUIS Claims Data Data Claim Identifier Service Provider Identifier Description Unique claim identifier submitted by the jurisdictions The service provider (pharmacy) that dispensed the prescription Service The postal code Provider (geography) of the Postal Code dispensing service provider (pharmacy) Service Date The date the prescription was dispensed eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Results See CMET: Billable Pharmacy Dispense COCT_MT300000CA See CMET: Billable Pharmacy Dispense COCT_MT300000CA Nested within is another CMET: Service Delivery Location COCT_MT240003CA Nested within is another CMET: Service Delivery Location COCT_MT240003CA COCT_MT300000CA Billable Pharmacy Service Delivery Location Service Delivery Location Supply Event Act Results Identifier id addr Dispense Time (Effective Time) Additional note: The invoice type would describe the invoice as an Rx Dispense versus a Health Care Service, Health Care Goods, etc. Open Billable Pharmacy Dispense CMET; within this, the Service Delivery Location CMET is nested Postal code is part of address data type Includes date and time 5

12 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Patient Submitted Identifier Description Identifier of the patient to whom the prescription was dispensed; in public programs, this is usually the health care number of the patient eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Covering Insurance Covered Party Identifier Insurance policy ID of the covered party; if missing can use name and date of birth. For invoice: In good faith invoices, the policy identifier, covered party identifier and policy holder identifier are not present; therefore, this attribute cannot be made mandatory. For newborns and children not registered to date, such as adopted children (that is, without a covered party identifier), the parents policy is specified (in PolicyOrAccount.id). The newborn/child is noted as the covered party. Sex The sex of the patient to whom the prescription was dispensed Covering Insurance Person Patient/ Person Gender Information associated through the policy/account Patient Birth Year The year the patient to whom the prescription was dispensed was born Covering Insurance Person Patient/ Person Date of Birth Information associated through the policy/account Patient Province Identifies the province/territory (geography) of the patient to whom the prescription was dispensed and Results CMET A_ Account Payee Payee Person addr (Payee Address) If the patient is also the payee, then the patient province map is in the CMET A_Account Payee. If the patient is not the payee, then there is no map in eclaims for patient province. Address data type includes province. 6

13 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Description Patient Identifies the postal Postal Code code (geography) of the patient to and whom the prescription Results was dispensed eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments CMET A_ Account Payee Payee Person addr (Payee Address) If the patient is also the payee, then the patient postal code map is in the CMET A_Account Payee. If the patient is not the payee, then there is no map in eclaims for patient postal code. Prescriber Identifier Prescriber Type Specialty Prescriber Province Prescriber Main Postal Code Identifies the prescriber who wrote the prescription The specialty/type of COCT_MT290000CA the prescriber who Billable Clinical wrote the prescription. Service This is as submitted by the jurisdiction due to data quality issues this code is not validated and should not be used for analysis. Identifies the province/territory (geography) of the prescriber who wrote the prescription Identifies the postal code (geography) of the prescriber who wrote the prescription COCT_MT290000CA Billable Clinical Service COCT_MT290000CA Billable Clinical Service, which is embedded in Adjudication Billable Pharmacy Dispense COCT_MT300000CA Prescriber Role Health Care Provider Provider Person Provider Person Prescriber ID Provider Type Data type includes postal code. If in future this ID comes from a registry, it may be possible to capture further details, such as address and specialty code The provider role is available, but eclaims does not capture specialty type. There is potential to obtain prescriber specialty (provider expertise) in a jurisdictional provider registry if the jurisdiction provider ID is supplied. Provider Address (addr) Data type Ad.Basic includes use: home/workplace/ temporary/physical/ postal; supports city, province, postal code, country and address lines. Can be used to specify jurisdictions for out-ofjurisdiction providers. Provider Address Provider address (addr) includes use: home/workplace/ temporary/ physical/postal; supports city, province, postal code, country and address lines 7

14 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Program Code Jurisdiction Code Submitted DIN/PDIN Description Identifies the plan/program responsible for financing the claim (seniors drug plan) Jurisdiction of source of financing/payor. For example, the public drug program in Ontario would have the jurisdiction of Ontario (ON). Mainly applicable to public programs. Identifies the drug product eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments and Results CMET A_ Account Payor Payor Role Details id (Payor Identifier) Submitted Product/ Service Code Used to identify the payor in the context of a health claim. Currently eclaims is not used for public programs but the payor role and ID could identify public program payors. eclaims does not explicitly identify the jurisdiction for a payor. Yellow map rating recognizes the jurisdiction which administers publicly funded drug programs can be inferred from the Program Code (eclaims Payor Identifier). Example: Ontario administers the Ontario Drug Benefit program. Claimed Qty The quantity of drug submitted to the plan/ program for payment Details Submitted Unit Quantity Accepted Qty Supply Days The quantity of drug accepted by the plan/ program, either towards a deductible or for payment The number of days worth of drug product dispensed Results Submitted Information/ Pharmacy Dispense Unit Quantity Dispensed Days Supply 8

15 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Total Cost Claimed Amt Drug Cost Claimed Amt Professional Fee Claimed Amt Markup Claimed Amt Description The total prescription cost submitted to the plan/program by the patient for payment The drug cost component of the total prescription cost submitted to the plan/ program by the patient for payment The professional fee component of the total prescription cost submitted to the plan/ program by the patient for payment The markup component of the total prescription cost submitted to the plan/ program by the patient for payment eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Identifier Details Details Details Total Billed Amount netamt code Submitted Line Amount Submitted product/service code will identify if it is for drug cost, markup, professional fee, etc. Submitted invoice line amount is the amount billed for the invoice line product or service. This is the result of submitted unit quantity multiplied by the submitted unit amount price. A separate attribute submitted product/service codes can represent such concepts as office visit, drug X, wheelchair and other billable items, such as taxes, service charges and discounts 9

16 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Total Cost Accepted Amt Description The total prescription cost accepted by the plan/program, either towards a deductible or for payment eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Accepted is not differentiated from intent or paid in eclaims. Total intent and adjudicated paid are the same and is the actual amount to be paid. Drug Cost Accepted Amt The drug cost component of the total prescription cost accepted by the plan/ program, either towards a deductible or for payment There is another element in eclaims Allowable which equals the plan amount allowed but not necessarily paid. For example, the annual allowable amount for massage is $500 and the client has already claimed the full amount for the year, so there will be no further payments for massage. Accepted is not differentiated from intent or paid in eclaims. Total intent and adjudicated paid are the same and is the actual amount to be paid. There is another element in eclaims Allowable which equals the plan amount allowed but not necessarily paid. For example, the annual allowable amount for massage is $500 and the client has already claimed the full amount for the year, so there will be no further payments for massage. 10

17 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Professional Fee Accepted Amt Markup Accepted Amt Program Paid Amt Program Drug Cost Paid Amt Description The professional fee component of the total prescription cost accepted by the plan/ program, either towards a deductible or for payment The markup component of the total prescription cost accepted by the plan/ program, either towards a deductible or for payment The total prescription cost paid for by the plan/program The drug cost component of the total prescription cost paid for by the plan/program eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Results Results Payment Intent Total Intent Payment Amount Line Amount (with Product/Service Code) Accepted is not differentiated from intent or paid in eclaims Accepted is not differentiated from intent or paid in eclaims Total intent and adjudicated paid are the same and is the actual amount to be paid Product/Service Code will identify the product or service being adjudicated (that is, product identifier, office vist, markup, fees). 11

18 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Program Prof Fee Paid Amt Description The professional fee component of the total prescription cost paid for by the plan/program eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Results Line Amount (with Product/Service Code) Adjudicted Product/Service Code will identify the product or service being adjudicated (that is, product identifier, office visit, markup, fees). Product/Service Code uses the ActDetailsCode set. The code set contains various codes for fees (first fee, final fee and fee-for-service top-off). The NPDUIS data element likely maps to multiple codes within the code set. A specific Professional Fee or Dispense Fee code could be added in the future to increase alignment. Program Markup Paid Amt The markup component of the total prescription cost paid for by the plan/program Cost The total prescription Sharing Amt cost paid for by either the patient or a third party Previously Paid Amt The total prescription cost paid for by a third party Results Line Amount (for Associated Product or Service Code) This could be captured by the ActDetailscode set, which contains codes for markup, upcharge and fee-for-service top-off Not captured in eclaims Not captured in eclaims 12

19 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Patient Paid Amt CIHI Disp Metric ID i Submitted PDIN Flag Submitted Province Code Description The total prescription cost paid for by the patient The units in which it is assumed the submitted quantity values are measured A flag to identify PDINs plan-/ program-specific drug codes Identifies the jurisdiction that assigned the PDIN (FK from Province table). This data element refers to PDINs only and will be set to CA for all DINs. eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments Results Detail code unitquantity For the NPDUIS Database, this is sometimes assumed by calculating differences among ActDetailscode, which includes payment, deductable and copayment details PQ.Basic data type Physical quantity (includes amount and units of pressure, temperature, length, mass and other commonly used units) Not captured in eclaims Not captured in eclaims i. Non-submitted data element. 13

20 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard Map Rating NPDUIS Claims Data Data Third Party Insurance Flag Description A flag indicating whether or not the patient has third-party insurance eclaims Map Primary eclaims Standard Message Model Secondary Model Section Attribute Comments The pharmacy messages are all third-party insurance at this time. Carrier ID (authorcarrierrole.id). The unique identifier of the policy carrier made up of OID root and extension that identifies the insurance carrier (a flag would not be required). 14

21 Claims Data Set Data s to the Canada Health Infoway Pan-Canadian eclaims (Pharmacy) Standard D. Sources The following is a list of standards and/or documents referenced or sourced by this project: Canada Health Infoway Documents FICR_MT600201CA, Pharmacy FICR_MT610201CA Results NeCST Pharmacy Implementation Guide COCT_MT110101CA Account Payor Identified COCT_MT300000CA Billable Pharmacy Dispense Universal COCT_MT110200CA Account Payee Universal COCT_MT290000CA Billable Clinical Service Universal COCT_MT240003CA Service Delivery Location Contact Data Types Data Type Specification (With Revisions) R PQ.Basic Ad.Basic Canadian Institute for Health Information Documents NPDUIS Claims Data Set,

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