Transcript All Payer Claims Database, Health Information Exchange, And

All Payer Claims Database and
Health Information Exchange
ARRA Opportunities and
Challenges
Anthony Rodgers, Director
Arizona Health Care Cost
Containment System
Challenges of Linking Health
Information Exchanges with All Payer
Administrative and Clinical Data Bases
The Connected Healthcare System
Hospital Care
Coordination
Order
Entry Lab
Result
Reporting
Diagnostics
Specialist Referral
EHR/HIE
E-Prescribing
Remote Patient
Self Monitoring
MCO Medical
Medical Mgmt. &
Administrative
Data
Primary
Care
Medical
Home
Provider
Research &
Comparative
Effectiveness
Rational for Building a Clinical &
Administrative Data Repository
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Facilitates Cost and Quality Transparency
Essential for Continuity of Care Records
Facilitates Population Health Management
Improves Medical Management
Improve Program Evaluation and Decision
Making
• Facilitates Comparative Effectiveness Research
• Enhances Health Policy Formulation Simulation
Focus Building the
State
Level HIT
Infrastructure
EHR1
HI
E
EHR2
EHR3
EHRn
Labs
EHR1
EHR2
EHR3
EHR4
PHR5
PHRn
Rxs
Othe
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Aggregated
Clinical
Database
• Repository Couple with HIE
Basic Health Information Exchange with
Data Repository
Clinical
Data Repository
HIE
Health Plan Adm.. Sys
Interfaces
Laboratories
Record and Results Delivery
Provider EHR
Clinician Data Repository
Master Patient Index
Basic Patient Health
Summary
Pharmacies
Web Portal Server
Web Browser
HIE Utility Applications
Federated Model for Data Exchange
Data Provider
Private
Public
DMZ
DMZ
AHCCCS Data Center
Private
HIE Gateway Device
Source System
DS
Publish
Used by
some Data
Providers
Gateway Device
Stores Record
and Patient
Information
published by
Data Provider
Patient Record
Look up/Response
HL7 2.X MDM Message/
ADT Message
NCPDP Message
RLS Index/
MPI
HIE CDX
CDX
Request/Response
[Web Services/SOAP]
Request/
Response
Viewer
Web server
Interface Engine
(e.g Cloverleaf)
Patient Record
Look up/Response
HL7 2.X ADT/
MDM Message
NCPDP Message
Publish
Original Data as Emulator
Received
Database
Converted to
CDA
XML
Optional
Emulator
Publish
Request/
Response
Internet
Patient Record
Look Up/
Response
Internet
Request/
Response
Request/Response
[Web Services/SOAP]
Viewer
Distributed Data
Marts
Health Information Exchange Platform
Architecture
Value
Added
Web
Services
Security and Consent Policy
Collaborative Knowledge Management
Web Services Application
Data Analysis Applications
Health Data Integration and Translation Layer
Platform
Services
Health Data Management Layer
Health Data Publication Layer
Data
Sources
Radiology
Rx History
Administrative
EHR
Clinical Lab
HIT Infrastructure Platform Design
Infrastructure
Security
Authentication
Authorization
Portal Services Interfaces
and Data Analytics
Healthcare
Information
Exchange
(HIE)
Administrative Data
Repository
Security
Layer
Web Services Portal
Provider
Electronic
Health Record
(EHR)
EHR Repository
EHR Analytics
(Public health
Disease
Management
Bio-surveillance)
High Availability
Management and Tools
Single Sign
on
Contract
Enforcement
Data Translation/
Customization
External
System
Interfaces
System and Application
Management Repository
Load Balancers
Web Servers
Consent
Management
Customer and Technical Support
System Administration
Management and Monitoring
Tools
Data Interoperability: Syntactic and Semantic Translation
Firewalls
Middleware
& Translation
Applications
Application Administration Management and Monitoring Tools
Operating
Systems
Data Partners are organizations that share or
exchange data through the HIE-EHR Utility
e.g.
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Health Plans
Hospitals
Physicians
Labs
Imaging Labs
Other HIEs – SAHIE, etc
AZ Dept of Health Services
Medicare
Indian Health Services (IHS)
etc.
Health
Plans
Small/
Medium
Practices
Physicians
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Analysis
Utility Users
(business partners) Users
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Providers
With HIT
Data Sharing
Partners
AHCCCS
Business Partners are organizations that expose
web content and applications through the Utility
web portal, for gain or mutual benefit; in other
words, transact business through the Utility.
e.g Sonora Quest Care360o.
Laboratories
Imaging
Suppliers
Durable Medical Equipment
Pharmacies
SureScripts
RX Hub
Other HIEs
etc
Laboratories
Imaging
HIE/EHR Utility
Business Partners
AHCCCS
Members
Hospitals
Suppliers
Other
vendors
Admin
Operations
Monitoring
AZ HIE-EHR Management
Training and
Education
Help Desk
Maintenance
Utility Users are persons who use the
functionality of the portal. e.g.
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Physicians
Small/medium Practices
Analysis users (TBD)
Emergency Depts
Dept of Public Safety
AZ Department of Health Services
etc
Administrative and management users use the
portal to access administrative and management
applications supported by the portal.
Mapping Data Partners and Data Utilities
Data Administrative
and Clinical Partners
Claims Data
Remittance Data
Formulary Data
Medication History
Imaging Data
Prescription Data
Discharge Clinical Data
Eligibility Data
Service
Authorizations
Gateway I/F
Clinical Data
Discharge Summaries
Prior Authorizations
Referral Data
HIE Directory
Clinical Data
Management
EHR/PHR Master
Patient Record
Directory
Encounter Data
Business Partners
Imaging Centers
EHR System Vendors
Health Plans and Public
Payers
Hospitals and
Providers
Laboratory Services
Public Health
RxHub – Pharacy
Benefit Managers
Research Community
Utility Applications Level 1
Data Exchange/
Gateway
NHIN Gateway/ISB
Record Locator
Medicaid Repository
I/F
Exchange Member
Index
Exchange Master
Patient ID
Data Validation I/F
Diagnostic Image I/F
Consent Management
& Audit
Beneficiary Eligibility
Data I/F
Health Plan and Payer
Admin/Financial
Management I/F
Utility Applications Level 2
Analytics & Reporting
Medication & Medical
Management
Clinical Data includes SOAP data and
notes, medication lists
Auto Claims
Processing and PA
Gateway
Provider Registry
& Index
EHR User Index
Health Plan and Payer
Index
Patient Data
Repository Index
Clinical Decision
Support
Patient Decision
Support
Administrative Data Sets
Methodology for Reconciling
Encounter Data Completeness
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Number Claims Converted to encounters
New day encounters
Adjudicated new day encounter
Pended encounter
Resolved pended encounter
Total adjudicated and percent adjudicated
Paid member months
Claims per member per month
Adjudicated encounter per member month
Methods of Aggregating Data
There are four different form types of claims/encounters types:
 HCFA 1500 Encounters (Form A) - Used primarily for professional
services, including: physician visits, nursing visits, surgical services,
anesthesia services, laboratory tests, radiology services, home and
community based services, therapy services, Durable Medical
Equipment (DME), medical supplies and transportation services.
Services must be reported using appropriate HCPCS procedure
codes.
 UB-92 Encounters (Form B) - For facility medical services, such as
inpatient or outpatient hospital services, dialysis centers, hospice,
nursing facility services, and other institutional services. Services
must be reported through the use of revenue codes and bill types.
 Universal Drug Encounters (Form C) - For prescription medicines
and medically necessary over the counter items.
 Dental Encounters (Form D) - For dental services.
UB92 Encounter Types
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Beneficiary member ID
Service provider ID
Bill type
Total bill amount (from the last encounter
detail line containing revenue code ‘001’)
• Service begin date
• Service end date
Breakdown of Key Data Elements:
HCFA 1500, Universal Drug Encounters, Dental Encounters
Key Encounter Fields
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Beneficiary member ID
Service provider ID
Procedure code
National Drug Code (Form Drug only)
Procedure modifier (HCFA 1500 only)
Diagnosis code (Form HCFA 1500 only)
Service begin date
Service end date
Tooth number (Form Dental only)
Tooth surface number (Form Dental only)
Common Claims Data Fields
Coding definitions are provided for the following data fields:
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Admission Types
Admission Source
Bill Type Codes
Category of Service
County Codes
Diagnosis Codes
EPSDT Type Codes
Patient Status
Pharmacy Codes (NDC)
Place of Service Codes
Procedure Codes
Procedure Modifier Codes
Revenue Codes
Sub-capitation Codes
Units of Service
Provider Data Sets
For each provider, the following information is included:
• Provider Demographic data
• Provider status
• Categories of service type
• Service rates
• Licenses/certifications
• Specialties
• Medicare coverage
• Restrictions
• Service/billing addresses
Provider Types
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01 Hospitals
02BPharmacy
03CLaboratory
04AClinic
05AEmergency Transportation
06ADentist
07DPhysician
08ANurse-Midwife
09APodiatrist
10APsychologist
11ACertified Registered Nurse
Anesthetist
12AOccupational Therapist
13APhysical Therapist
14ASpeech/Hearing Therapist
15AChiropractor
16ANaturopath
17APhysicians Assistant
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19ARespiratory Therapist
20ANursing Home
22BHome Health Agency
23APersonal Care Attendant
24AGroup Home
(Developmentally Disabled)
25AAdult Day Health
27ANon-Emergency
Transportation Providers
28ACommunity/Rural Health
Center
29ADME Supplier
30AOsteopath
31ARehabilitation Center
33AHospice
35BAdult Care Home
36AHomemaker
37ADevelopmentally Disabled
Day Care
Categories of Services
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01Medicine
02Surgery
03Respiratory Therapy
05Occupational Therapy
06Physical Therapy
07Speech/Hearing Therapy
08EPSDT
09Pharmacy
10Inpatient Hospital (Room & Board
and ancillary)
11Dental
12Pathology & Laboratory
13Radiology
14Emergency Transportation
15DME and Appliances
16Out-Patient Facility Fees
17ICF
18SNF
19ICF/MR
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20Hospice Inpatient Care
21Hospice Home Care
22Home Delivered Meals
23Homemaker Service
24Adult Day Health Service
26Respite Care Services
27IHS Outpatient Services
28Attendant Care29Home Health Aid
Service
30Home Health Nurse Service
31Non-Emergency Transportation
32Habilitation
37Chiropractic Services
39Personal Care Services
40Medical Supplies
42DD Programs (DD Day Care
Programs)
44Home & Community Based Services
(Other)
45Rehabilitation46Environmental
47Mental Health Services
48Licensed Midwife
98Case Manager
Methodology Aggregating Data for
Categories of Service Report
• By creating a two-digit coding definition called a Category Of
Service (COS) can perform cost and utilization comparisons. The
COS is determined based on an encounter’s procedure code, bill
type, revenue code, or pharmacy NDC code. This is not part of the
encounter but is determined by the business user.
• For HCFA-1500 and Dental encounters, the COS assignment is
determined by the range or description of each HCPCS procedure
code.
– For example, AHCCCSA assigns COS 12 (pathology & laboratory) to
HCPCS procedure code G0001 (Routine venipuncture of finger/heel/ear
for collection of specimen/s).
– For UB-92 encounters, the COS assignment is based on the bill type
and revenue codes used on the individual encounter.
– For Universal drug form encounters, the COS is based on the NDC
code. A current list of the AHCCCSA assigned COS is summarized in
the following table.
Cost Performance Score by MCO
Hypothetical Illustration:
Significant Lower
Cost per EPC
Expected Cost
Performance
Low PI Means
Higher than Expected
Cost per EPC
* Performance Index equals the Expected Paid divided by the Actual Paid and is controlled by ETG Case mix.
Cost and Quality Value Performance
(hypothetical illustration)
Value
Performance
Target
Low Cost
But
Low Quality
Outcome
Cost
Target
High
Quality but
High Cost
Enterprise Level Data Repository and Decision
Support Infrastructure
External Data / Profiles
Public Health
Evidence-Based
Medicine
Comparative
Data Sets
Beneficiary Data
Sources
Claims/Encounter
Clinical Data Sets
Demographic Data
Prescription Drug
EHR Data
Eligibility Data
Program Data
Methods/Analytics
•Episodes of Care
•Performance Measures
•Disease Staging
Decision
Support
Reporting
Applications
Medical Management
Data
Warehouse
Data Management
Process
•Security Protection
•Integration
•Translation
•Standardization
•Data Validation
Profile and Screens
Fraud Detection
Data
Architecture
And
Data
Cubes
Performance Analysis
Eligibility Analysis
Cost and Quality
Analysis
Chronic
Illness
Sub-databases
Registries
Health Plan &
Provider Decision
Support
Creating Key Performance Transparency
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Inpatient Cost and Utilization
Pharmacy PMPM cost
Diagnostic PMPM cost
Percent LTC members in home and community based settings
Bed days and admissions per 1000
ER Cost and Utilization Per 1000
Overall for long term care PMPM cost
Member satisfaction level
Provider satisfaction level
Enrollee healthcare access
Quality of care rates against HEDIS targets
MCO program cost effectiveness level
Health plan administrative performance and efficiency levels:
claims and business process cycle times and per transaction
cost for administrative activities (e.g. claims, eligibility
screening, etc.)
Map of Strategic Outcomes for EHR Adoption Efforts
Strategic Planning Logic Map
Strategic HIT
Focus Areas
HIT Strategic
Performance Metrics
Performance Outcomes
Reduced Unnecessary
Cost/Utilization =
Reduced PMPM &
Lower % Admin Cost
Cost
Containment
Meaningful Use of
EHR to reduce
Duplication, Errors
and improve
Admin Efficiency
Quality
Improvement
Meaningful Use of
EHR to better
coordinate care and
Quality Performance
Improved Quality
Against HEDIS and
Other Benchmarks
Meaningful use of
EHR to Reduce
Admin. Process
Cycle Times
Higher Provider
Satisfaction &
Reduction in Admin.
Cost
Meaningful Use of
EHR to build
Population
Health Mgmt. &
Research
Public Health
Responsiveness
Reduction in
Health Disparities
Administrative
Efficiency
Public
Health &
Research
Meaningful USE
Barrier
PERFORMANCE Management
Barrier
Clinical Data Repository
Strategies and Approaches
• Big Bang: building the mother of all clinical and
administrative data repositories interface via HIE.
• Incremental: Start with well defined electronic clinical
data sets from a common EHR for example:
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Build around the Medicaid or other payer claims database
Build a clinical data repository from linked EHRs,
Build a data mart with public health database,
Build around an integrated hospital system with EHR)
• Data Mart to Data Mart: Start with a smaller distributed
data mart approach linking each data mart and pull data
to run data analysis or other applications.
• Centralized Data Warehouse: Use clinical data
repository and administrative data repository under the
management of a trusted authority.
New State Level Roles and Responsibilities
Governor’s role:
• Decide who will lead state level development of HIE ( State Designate Entity
(SDE))
• Appoint a HIT Coordinator for the state (agency level position)
• Assign and accountable party to develop and implement Strategic HIT plan
for the state
– Ensure effective governance of HIE in the state
– Develop state level directories and enable technical services for HIE
– Remove barriers and create enablers for HIE (Lab, hospitals, clinicians, health
plans, and other information data partners)
– Convene stakeholders
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Assure the participation and integration of public health programs, Medicaid,
and private delivery systems in health information exchange
Assure the development of effective privacy and security requirements for
HIE
State’s will be awarded grants in the range of $4.0 to $40.0 million.
(
New CMS Roles and Responsibilities
• CMSO
– Set expectations for public accountability and transparency,
– Develop a Medicaid Roadmap and Strategic Framework for
wide-spread adoption of EHR technology in Medicaid and
integrating planning with other federal agencies,
– Set overall state Medicaid performance standards,
– Establish the policy and HIT standards for Medicaid,
– Provide evaluation and dissemination of best practices,
– Participate in national policy and consensus standard making
bodies,
– Leverage successful HIT Medicaid Transformation grantee
initiatives and provide continued support,
– Support the work of the Multi-Collaborative for Medicaid
Transformation and other
– Provide adequate technical support for Medicaid programs and
Medicaid providers
New Medicaid Roles and Responsibilities
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State Medicaid Agency Role:
– Participation in development of a specific State roadmap for HIT
adoption and use as it relates to Medicaid as well as the state’s plan of
HIE,
– Set Medicaid-specific performance goals related to EHR technology
adoption, use, and expected outcome,
– Establish leadership accountability for assuring return on investment
and provider public reporting on clinical quality,
– Arrange or provide technical assistance and training of Medicaid
providers in planning, adoption, and use of EHR,
– Provide forums and opportunities for input from stakeholders,
– Collaborate and coordinate with other HIT initiatives in the public and
private sector,
– Continue to bring successful Medicaid Transformation Grant initiatives
to scale,
– Initiate, where appropriate, State legislation to create legal and
regulatory authorities for HIT,
– Ensure existing quality reporting processes are aligned
Questions?