Health Information Exchange Business Drivers and Technical Frameworks for Payer Provider Technology Networks Presenter: Kimberly Harding DirectorofProvider of Connectivity Solutions Blue Cross Blue Shield of Florida Sources of Information Adapted from: Dept. of Health and Human Services (Dept. of HHS) Office of the National Coordinator Health Information Technology (ONC), American Health Information Community (AHIC), Health Information Standards Panel (HITSP) 2
Scope of Federal, State, and Employer/Purchaser Business Drivers related to Payer Provider Business Drivers for Health Information Exchange Federal and State Business Drivers Employer Group and Direct to Consumer Purchaser s Business Drivers Promote payment changes and reforms that accelerate the pace of quality improvement Enable alignment with national priorities for quality of care through incentives, a legal framework for data sharing, and patient centered t t quality measure set standardization Promote and influence the health insurance product design and health insurer performance requirements that will align incentives with goals of improved quality and efficiency Engage health care providers in joint efforts that will transform health hcare delivery dli 3
Business Drivers for Provider Payer Care Coordination HIE Concepts and Framework Strategic Objectives for Business Drivers for Payers and Providers Align with state, regional, and national priorities for quality of care through incentives, a legal framework for data sharing, and patient centered quality measure set standardization Promote and influence the health insurance product design and health insurer performance requirements to align incentives with goals of improved quality and efficiency Champion Payer Advocacy Provider Adoption of EMRs for Meaningful Use for Patient Centered Longitudinal Data Sets for performance reporting and analytics and Disease Management to support Value Based Medicine Goals by Payers Promote Standardization of Quality Metrics, and Quality Measures Driven Clinical Decision Support for Value Based Medicine Outcomes 4
Business Value Categories for Provider Payer Health Information Exchange Patient Safety Medical Cost Savings/Cost Avoidance Admin Cost Savings EMR Meaningful Use Incentives Improved Quality Outcomes (Star/HEDIS ratings) Green Technology NCQA PCMH Certification (Level 1 3) 5
Technical Framework: Sample Payer Based Uses Cases for Health Information Exchange Handoff of longitudinal clinical summary during care transitions, referrals, specialist visits, routine PCP visits Reviewing i historical i Lb Lab results and Medication Mdi i Reconciliation Immunization History Health Home receiving information on admissions and discharges Provider Member Review copy of their clinical information and their medication history Secure messaging to provider Determining compliance with guidelines, school admission etc. Health Outbreak Tracking Reviewing trends in lab results Public Health Payer Longitudinal clinical summary view for case managers Sharing Care Plans with providers Generating quality of care reports with most recent data Readmission tracking CMS Quality reporting using up to date data Secure messaging between providers 6
HHS/ONC AHIC Use Cases that Support Payer Provider Data Exchange (2006 2009) Common Data Transport General Laboratory Orders & Order Sets Medication Gaps Clinical Note Details Newborn Screening Medical Home: Problem Lists & Practice Based dregistries i Maternal and Child Health Long Term Care Assessments Prior Authorization in Support of Treatment, Payment, & Operations Personalized Healthcare Consultations and Transfers in Care Immunizations & Response Management Consumer Empowerment: Consumer Access to Clinical Information Medication Management Quality Harmonized Consumer Empowerment (Registration & Medication History) Harmonized Bio surveillance (Visit, Utilization, and Lab Result Data) 7
HIE Context Diagram Adapted from ONC AHIC Consultations and Transfers in Care Workflow/Use Case A. Discharging/ Transfer Setting PERSPECTIVES/ROLES B. Information Exchange C. Receiving Setting D. Patient (PT) Information Sources & Recipients May be one or more of those listed below: A.1 Determine need to transfer patient A.2 Select next setting of care discuss with patient/family A.3 Initiate plan & coordinate discharge/transfer A.4 Discharge/ Transfer PT & transmit available transfer data A.5 Transmit additional PT data upon completion A.6 Provide access to additional PT data 2 3 Provider to Provider HIE Events PT Match/Query/ Retrieve PT Medical Record/Clinical Summary Data Exchange Provider to Payer HIE Events 4 Member Subjectdata matching 5 Bi Directional Provider to Payer Secured Msg 1 2 3 4 5 C.1 Receive & review PT data & determine ability to accept PT C.2 Accept PT & coordinate transfer C.3 3Receive & review PT data & evaluate/manage PT D.1 Receive discharge/ transfer data C.4 Access additional PT data 3, 4 C.5 Continue to manage PT Healthcare Payers/Insurers Laboratories Diagnostic Imaging Clearinghouses, Health Info Service Providers Medication Network Intermediaries Healthcare Entities (i.e. hospitals, clinics) Secured Message Ctrs, PHRs/Health Record Banks 3, 4 5 8
Application of ONC AHIC Care Coordination Use Case for Provider Payer Health Information Exchange Event 1. Administrative data is exchanged to support eligibility determine and coverage authorization for the transfer between discharging setting and payer. 2. Patient/Member Core data set available at time of transfer coordination is communicated via information exchanges to receiving setting. 3. Patient/Member Core Set of data available at time of patient care coordination event, and is communicated via information exchange to the receiving setting and other recipients of information. 4. Core set of data available after patient care coordination event, and is communicated via information exchanges to the receiving setting and other recipients of information. (i.e. ADT completed discharge summary, pending lab results) 5. Provider and/or Receiving i setting requests and views additional i patient data from other sources provided via HIE 9
Framework for Payer-Provider Channel Maturity Model B2B / EDI Capabilities use industry interoperability standards HL7 & allow machine to machine execution. Provider Integration Engines Multi payer advanced solution enables seamless integration into provider systems. Multi Payer Platforms A focus of transactions in the Clinical Operations area with the Claims Attachment (275/277 ) and Authorizations (278), CCD, CCR, LOINC, SNOMED and HL7 Point Solutions This is a capability that will remain a point solution but is a potential springboard for expansion IVR (Interactive Voice Response), manual phone calls, faxes provide, single payer/direct data entry are stop gap solutions before entering into a multipayer platform solution 10
Sample Bi Directional Health Information Exchange Interoperability Standards for Payer Based Use Cases System to System Interoperability Standards HL 7 2.3.1/2.5.1/HL 7 CDA (Clinical Document Architecture) ASTM CCD (Continuity of Care Record) Structured Terminologies for Health Information Exchange LOINC 2.27 SNOMED CT 2009 Security NIST/FIPS (National Institute Standards and Technology/Federal Information Processing Standards) Publication 180 3 2008 11
Integrating the Healthcare Enterprise (IHE) Information Technology Infrastructure (ITI) Domain Patient Administration Management (PAM) Integration Profile Patient EncounterConsumer (PEC) Actor Encounter Management Option Patient Encounter Management Transaction Patient Demographics Supplier Patient Identity Management [ITI 030] Patient Demographics Consumer Patient Encounter Supplier Patient Encounter Management [ITI 030] Patient Encounter Consumer 12
IHE PAM Profile HL 7 Events for Payer Provider Networks Admit inpatient (A01) Transfer patient (A02) Discharge patient (A03) Register outpatient (A04) Pre admit patient (A05) Change patient class to inpatient (A06) Change patient class to outpatient (A07) Update patient information (A08) Cancel admit inpatient (A11) Cancel transfer of patient (A12) Cancel discharge of patient (A13) Cancel pre admit of patient (A12) Create New Patient (A28) Update patient information i (A31) Merge two patients (A40) Change patient identifier list (A47) Unsolicited observation message (R01) Unsolicited specimen oriented observations message (R22)
For More Information on the Dept. of HHS ONC HIE Frameworks ONCStrategicPlan and Reports: http://www.hhs.gov/healthit/resources/reports.htmlhhs html ONC/AHIC Use Cases and Requirements Documents: http://healthit.hhs.gov/portal ONC Meaningful Use Standards and Certification Final Rule: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov standards_ifr/1195 ONC Privacy and Security: http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov privacy_and_security/1147 The Nationwide Privacy and Security Framework for Electronic Exchange of Individually Identifiable Health Information: http://healthit.hhs.gov/portalserver.ptcommunityhealthit_hhs_gov privacy security_framework/1173 14