NHIN Designs: Medical Billing Framework

Trustworthy Designs for the Nationwide Health Information Network:

Medical Billing Framework

by Latanya Sweeney

Given the medical billing framework and proposed meaningful uses for the national health information infrastructure, this paper shows how the billing framework can strategically help achieve meaningful uses quickly.

The existing medical billing framework has national connectivity, and its existing communication, data, and authentication standards are sufficiently expandable to serve as a necessary backbone for a national health information infrastructure. Doing so offers strategic advantages: (1) providers are already wired and using the billing framework, processing billions of claims a year; (2) the mechanism to check patient insurance eligibility can easily expand to additionally provide relevant patient information (e.g., problems, medications, and allergies) at the time and place of service; (3) a national program already exists that captures quality measures through claims processing; and, (4) payment incentives on claims can drive ongoing provider compliance. Growing independent regional data centers, as has been the primary focus so far, leaves a critical gap in connectivity, data consolidation, national analytics, and timeliness. To close the gap, this paper proposes an amended billing framework (the Backbone), and shows how the Backbone can help achieve meaningful uses. It recommends an open consortium of stakeholders to guide ongoing Backbone operations to insure interoperability. Included are detailed examples of maintaining active allergy and medication lists (a meaningful use objective for the year 2011).

Sweeney, L. The Medical Billing Framework as the Backbone of the National Health Information Infrastructure. Data Privacy Lab AdvanceHIT Series Working Paper 1001. October 2009. (

Series: AdvanceHIT Trustworthy Designs for the Nationwide Health Information Network.

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