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HIEs, Payers, and Clinical Data Integration: Opportunities and Challenges
Margaret (Peg) EichnerSenior Manager, Health Plan and ACO Services
Ohio Health Information Partnership/CliniSync HIE
John D’AmorePresident & Chief Strategy Officer
Diameter Health
Speakers
John D’Amore, President and Chief Strategy Officer, Diameter Health
▪ Editor of C-CDA standard, extensive research and publication on the use of clinical data to improve care quality and efficiency
▪ Previous work at Allscripts and Memorial Hermann
▪ Adjunct Faculty at Boston University, Metropolitan College
Peg Eichner, Senior Manager, Health Plan and ACO Services, Ohio Health
Information Partnership/CliniSync HIE
• Oversees services to help clients successfully participate in value-driven healthcare
initiatives. Leads CliniSync’s Payer Provider Subcommittee that drove the development
of CliniSync’s data governance model, services and technology to improve the quality,
cost and overall care for populations served.
The CliniSync CommunityNo one is left behind.
• 11.7M Ohio Residents
• >13M Unique Patient Records in HIE
• 157 Participating Hospitals in Ohio, West Virginia and Kentucky
• >500 Long-Term and Post-Acute Care Facilities
• 15,000 Independent and Hospital-employed Physicians
• 7 Health Plans including 5 Medicaid Managed Care Plans
• >40 Connected EHRs
• Medicity and Diameter Health are our Technology Partners
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• Ohio Hospital Association, Ohio Osteopathic Association, Ohio State Medical Association and Ohio Department of Insurance.
Founders
• Physicians, hospitals, health plans, HIT, long-term care, consumer group.
Board of Directors
• Physicians, hospital systems, community and children’s hospitals, health plans, long-term care, behavioral health.
CliniSync Advisory Council
Governance
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We are a non-profit, grass-roots, community and statewide organization that is now financially independent of federal funds.
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Our GoalCreate a More Efficient Flow of Clinical Data for Population-Based Quality Reporting and Care Coordination Purposes
The Historical Challenge The Invitation The Aha! Moment
6Source: 2016 NAIC Report, August 2017, http://www.naic.org/prod_serv/MSR-HB-17.pdf
Ohio Payer Market Share
CareSource
Anthem
United
Aetna
Humana
Others
Unlike some markets,
Ohio retains a large mix of
regional and national
health insurers.
No single plan represents
more than 20% of state!
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CliniSync Payer CollaborationStep 1: Define What Matters • The work is essential to support emerging
models of care
• Completeness of data drives value
• Focus on common high-priority chronic conditions most likely to impact the overall cost and quality of care for a population
• Align with HHS HIPAA Guidance, but policies must reflect stakeholder trust
• Policy should be fluid as to the data set and technology to allow us to learn and grow
• Providers are willing to share data if they receive data (Reciprocity)
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CliniSync Data GovernanceStep 2: Establish the Boundaries
• Align with HIPAA Minimum Necessary Rule
• A covered entity or business associate must make reasonable efforts to limit protected health information to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.
• Must Give to Get• CliniSync’s policies encourage all Participants
to contribute data to the HIE to fill in gaps in care
• To access clinical data, Health Plans must contribute data to fill in gaps in care.
• This data will be available to providers at the point of care to fill in gaps and improve care coordination.
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CliniSync Data GovernanceStep 3: Create a Policy
HIPAA Permitted Uses
Organization’s Active Population to Whom
They are Accountable
At-Risk Subpopulation
(5-10%)
• Available for all active members of population
• Includes analytics-ready core clinical data groups
• Lab/Imaging studies limited to 28 measures related to 5 high priority chronic conditions
• 365 Days +
Quality Improvement
Care Coordination
• Limited to emerging/high/ intensive risk members only
• Includes additional data groups necessary to coordinate for chronic conditions
• 365 Days
• Hospital event notification information only
• Sent near-real time as matches are made between the Active Population Members and activity throughout the CliniSync network
Notifications
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CliniSync Data Governance
• Our Payer Provider Subcommittee (PPS) compared common quality measures across multiple high priority quality reporting programs
• Measures were prioritizedthat a) related to high cost/complex conditions b) appeared in most programs c) related data would be available via the HIE
• As data contribution grows, the list of measures can be updated with Board or Executive Committee Approval
Heart Disease
• Controlling High Blood Pressure
• Functional Status Assessment for CHR
• ACE Inhibitor or ARB Therapy for Left Ventricular Systolic Dysfunction
• Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction
• Hypertension: Improvement in Blood Pressure
• Statin Therapy for patients with cardiovascular disease
• Statin Therapy for patients with Diabetes
• Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet
Diabetes
• Comprehensive Diabetes care: Eye Exam
• Diabetes: Foot Exam
• Comprehensive diabetes care: HbA1c testing
• Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (>9%)
• Diabetes: Medical Attention for Nephropathy
• Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg)
Back Pain
• Use of Imaging Studies for Low Back Pain
Pre-Post Natal Care
• Prenatal and Postpartum Care: Timeliness of prenatal care/Post Partum Care
• Prenatal and Postpartum Care: Postpartum Care
• Frequency of ongoing prenatal care - > or = to 81% of Expected Visits
• Live Births Weighing Less than 2,500 grams
Preventive Care
• Childhood Immunization Status
• Preventive Care and Screening: Influenza Immunization
• Breast Cancer Screening
• Cervical Cancer Screening
• Chlamydia Screening for Women
• Colorectal Cancer Screening
• Pneumococcal Vaccination Status for Older Adults
• Preventive Care and Screening: Body Mass Index Screening and Follow-Up Plan
• Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
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CliniSync Data Governance
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CliniSync Data Governance
• “We are all trying to manage the same patients”
• Looking at the same patient-centric data allows for constructive conversations about how to move the needle
• Both parties can leverage a single connection rather than support one-offs
• Filling in gaps in care helps at the point of care
• You don’t have to wait for that quarterly report to know something needs work
• “If you succeed, we succeed”
Step 4: Remind Them of the Value of Clinical Data Exchange
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Imagine a Future
Imagine a future where…
• care quality is calculated routinely on all patients
• measures are widely available & comparable nationally
• billions are awarded based on higher quality care
• data are transparent to consumers
This sounds like a future for care providers…
…this is already the present for health plans!
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HEDIS
• HEDIS = Health Effectiveness Data and Information Set
• Requirement for insurers since early 1990s
• Overseen by the National Committee for Quality Assurance
(NCQA)
• Originally billing based, but becoming increasingly clinical
‒ Billing data: Was a colonoscopy billed in relevant time period?
‒ Clinical data: Recent blood pressure & lab (e.g. HbA1c) values?
• Over 90 measures for all programs
• Publicly available on website
• Part of how government reimburses Medicare Advantage plans
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Timeline of Quality ProgramsSelect programs shown below
1990 1995 2000 2005 2010 2015 2018
PQRS
MU
MIPS
Pay
ers
+ R
isk
Mo
de
lsP
rovi
de
rs
ACOs & APMs
AHRQ Formed (89)& NCQA Independence (90)
To Err Is Human (99), NQF (99) & Crossing Quality Chasm (01)
HEDIS1.0
HEDIS2.0
HEDIS3.0
$35B in Meaningful Use Incentives (09)
ACA Reform (10) & MACRA Legislation (15)
HEDIS: Health Effectiveness Data& Information SetACO: Accountable Care OrganizationAPM: Alternative Payment Model
RHQDAPU: Reporting of Hospital Quality Data for Annual Payment Updates PQRS: Physician Quality Reporting SystemMU: Meaningful UseIQR: Inpatient Quality ReportingMIPS: Merit-Based Incentive Payment System
Initial “Core” Measures• AMI• HF• Pneumonia• Pregnancy
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The Downside of HEDIS
• Payers do not directly administer patient care. Results may be
shared back to providers in retrospect, if at all
• Providers don’t get a full picture for one payer report
‒ Dr. X, your colonoscopy rate among BCBS patients is superb!
…two weeks later…
‒ Dr. X, your colonoscopy rate among Aetna patients is the lowest quartile
• Payers have trouble calculating all HEDIS measures, particularly
those that require clinical data
‒ Mixed-use of CPT Level II & HCPCS
(e.g. G8024 = Diabetes with blood pressure in control)
‒ Demand for chart pulls
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HEDIS vs eCQMs
Advantage of HEDIS
• Payers generally have more longitudinal data than a single EHR
has to calculate quality on a single patient
• Patient attribution is simple
• Plans calculate all measures every year
Advantage of eCQMs
• Providers can calculate quality on all their patients
• “Care gaps” can be closed with timely measurement
• Ready access to clinical data
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Standard Supplemental Data
Electronic files that come from service providers (providers who rendered the
service). Production of these files follows clear policies and procedures; standard
file layouts remain stable from year to year.
Electronic files that may be used as standard supplemental data:
• Laboratory result files
• Current or historic state transactional files in a standard electronic format
• Immunization data in state or county registries (might vary from state to state,
but are consistent for all records in each state’s registry)
• Transactional data from behavioral healthcare vendors
• Electronic health record (EHR) vendor systems
• Data from certified eMeasure vendors
Source: 2017 HEDIS Technical Specifications, General Guidelines
Proper Coding
Challenging Clinical Data
Structured Data
Valid Syntax
Data Loss Due to Complex, HeterogeneousPoint-of-Care Data Collection
UnstructuredText
Omitted Meta-Data
Non-StandardTerminology
MisclassifiedInformation
Poor Standards Implementation
SemanticConflicts
Lab Results
Medications
Diagnoses
Procedures
Allergies
Plan of Care
x
ContentSupportTerminologies + Enrichment
Increasing Clinical Data Yield
Focused NLP
Add Structure + Coding
Auditable Transformations for Complete, Accurate Clinical Picture
Robust Extraction
Scalable with
HL7v3 + FHIR
Lab Results
Medications
Diagnoses
Procedures
Allergies
Plan of Care
x
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The Role of HIEs
• HIEs can establish electronic access to information in
a standard format and in a way that maintains
appropriate data governance
• HIEs can establish standard processes and work with
providers to improve data quality
This improves quality measure calculations
This improves interoperability generally
• HIEs can work with payers and risk bearing
organizations to determine which quality measures are
best supported by available clinical data
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Questions & Thank You
Peg Eichorn
https://www.linkedin.com/in/peg-eichner-8610b410/
Adam Rossbach
https://www.linkedin.com/in/adam-rossbach-58a2224b/ /
John D’Amore
https://www.linkedin.com/in/jdamore/
