All Payer Claims Database and All Payer Claims Database and Health Information ExchangeHealth Information Exchange

ARRA Opportunities and ARRA Opportunities and ChallengesChallenges

Anthony Rodgers, DirectorAnthony Rodgers, Director

Arizona Health Care Cost Arizona Health Care Cost Containment SystemContainment System

Challenges of Linking Health Challenges of Linking Health Information Exchanges with All Payer Information Exchanges with All Payer

Administrative and Clinical Data BasesAdministrative and Clinical Data Bases

The Connected Healthcare System

Remote PatientSelf Monitoring

Hospital Care Coordination

Order Entry LabResult Reporting

EHR/HIE

Specialist Referral

E-Prescribing

MCO Medical Medical Mgmt. &Administrative Data

PrimaryCareMedical HomeProvider

Research & Comparative Effectiveness

Diagnostics

Rational for Building a Clinical & Administrative Data Repository

• 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

Labs

Rxs

Other

EHR1 EHR2

EHR3EHR4

PHR5

PHRn

EHR1EHR2

EHR3EHRn

HIE

AggregatedClinical

Database • Repository Couple with HIE

Basic Health Information Exchange with Data Repository

Web Browser

Provider EHR

Health Plan Adm.. Sys

Laboratories

Pharmacies

Web Portal Server

Clinician Data Repository

Master Patient Index

Basic Patient Health Summary

HIE

Record and R

esults D

elivery

Interfaces

HIE Utility Applications

Clinical Data Repository

Federated Model for Data Exchange

Internet

Internet

Data Provider

Source System

OptionalEmulator

Emulator Database

Interface Engine (e.g Cloverleaf)

CDX

AHCCCS Data Center

RLS Index/MPI

Vie

we

rW

eb

serve

r

DS

HIE CDX

Original Data as Received

Converted toCDA XML

Request/Response[Web Services/SOAP]

Request/Response

Request/Response[Web Services/SOAP]

HL7 2.X ADT/MDM Message

NCPDP Message

Publish

Vie

we

r

Patient Record Look up/Response

Request/Response

HL7 2.X MDM Message/ADT Message

NCPDP Message

Publish

Request/Response

Publish

Patient Record Look Up/Response

Patient Record Look up/Response

Used by some Data Providers

Private DMZ DMZ Private

Stores Record and Patient Information

published by Data Provider

HIE Gateway Device

Gateway Device

Public

Distributed DataMarts

Health Information Exchange Platform Architecture

Radiology

Health Data Publication Layer

Clinical Lab

DataSources

Health Data Management Layer

Health Data Integration and Translation Layer

Data Analysis Applications

Web Services Application

Collaborative Knowledge Management

PlatformServices

ValueAddedWebServices

Sec

uri

ty a

nd

Co

nse

nt

Po

licy

Administrative EHRRx History

Infrastructure

Web Services Portal

Healthcare Information Exchange

(HIE)

Provider Electronic

Health Record(EHR)

EHR Repository

EHR Analytics(Public health

Disease Management

Bio-surveillance)

External System

Interfaces

SecurityLayer

Firewalls

Web ServersLoad Balancers

SecurityAuthenticationAuthorization

Consent Management

Portal Services Interfaces and Data Analytics

System and Application Management Repository

Single Sign on

Contract Enforcement

System Administration Management and Monitoring

Tools

Data Translation/ Customization

High Availability Management and Tools

Dat

a In

tero

pera

bilit

y: S

ynta

ctic

and

Sem

antic

Tra

nsla

tion

App

licat

ion

Adm

inis

trat

ion

Man

agem

ent a

nd M

onito

ring

Too

ls

Cus

tom

er a

nd T

echn

ical

Sup

port

Operating Systems

Middleware& TranslationApplications

Administrative Data Repository

HIT Infrastructure Platform Design

HIE/EHR UtilityData Sharing

PartnersAHCCCS

Utility Users(business partners)

Health Plans

AZ HIE-EHR Management

Operations

Admin

Hospitals

ProvidersWith HIT

Physicians

Small/Medium

Practices

Analysis Users

Business Partners

Laboratories Imaging

Suppliers Other vendors

Monitoring

Maintenance

Data Partners are organizations that share or exchange data through the HIE-EHR Utility e.g.· Health Plans· Hospitals· Physicians· Labs· Imaging Labs· Other HIEs – SAHIE, etc· AZ Dept of Health Services· Medicare· Indian Health Services (IHS)· etc.

Utility Users are persons who use the functionality of the portal. e.g.· 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.

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

Training and Education Help Desk

AHCCCS Members

Utility Applications Level 2

Utility Applications Level 1

Business Partners

Data Administrative and Clinical Partners

Record Locator

Data Exchange/Gateway

Claims Data

Clinical Data

Prescription Data

Formulary DataMedication HistoryEncounter Data

Imaging Data

Imaging Centers

Discharge Summaries

Discharge Clinical Data

Hospitals and Providers

EHR System Vendors

Exchange Master Patient ID

EHR/PHR Master Patient Record

Directory

Clinical Data Management

Medicaid Repository I/F

Diagnostic Image I/F

Data Validation I/F

Provider Registry& IndexBeneficiary Eligibility

Data I/F

Consent Management& Audit

Clinical Data includes SOAP data and notes, medication lists

Exchange Member Index

Laboratory Services

RxHub – Pharacy Benefit Managers

Eligibility Data

Prior Authorizations

Service Authorizations

Remittance Data

Referral Data

EHR User Index

Research Community

NHIN Gateway/ISB

Health Plans and Public Payers

HIE Directory

Health Plan and Payer Index

Patient Data Repository Index

Analytics & Reporting

Health Plan and Payer Admin/Financial Management I/F

Public Health

Medication & Medical Management

Auto Claims Processing and PA

Gateway

Clinical Decision Support

Patient Decision Support

Gateway I/F

Mapping Data Partners and Data Utilities

Administrative Data SetsAdministrative Data Sets

Methodology for Reconciling Encounter Data Completeness

• 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 DataThere 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

• 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

• 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 FieldsCoding definitions are provided for the following data fields:• 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• 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

• 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• 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

• 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 MCOHypothetical Illustration:

* Performance Index equals the Expected Paid divided by the Actual Paid and is controlled by ETG Case mix.

Performance Index (PI) by MCO

1.21

0.890.98

0.00

0.25

0.50

0.75

1.00

1.25

1.50

MCO1 MCO2 MCO3

PI

Expected CostPerformance

Low PI MeansHigher than ExpectedCost per EPC

Significant Lower Cost per EPC

Cost and Quality Value Performance (hypothetical illustration)

Asthma Providers - % Inhaled Steroid Compliance and Overall Performance IndexIncludes Providers with at least 3 Asthma Episodes

0.00

0.50

1.00

1.50

2.00

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

% Inhaled Steroid Compliance

Ove

rall

Per

form

ance

In

dex

Family Practice

Pediatricians

Allergists

General Practice

Pulmonologists

General Internists

All Other

Low Compliance,High Performance

High Compliance,High Performance

(Best Quadrant)

Low Compliance,Low Performance High Compliance,

Low Performance

Low CostBut

Low QualityOutcome

HighQuality butHigh Cost

ValuePerformance

Target

Cost Target

Enterprise Level Data Repository and Decision

Support Infrastructure

Public Health

Claims/Encounter

Clinical Data Sets

Demographic DataPrescription Drug

EHR Data

Evidence-BasedMedicine

Comparative Data Sets

Beneficiary Data Sources

External Data / Profiles

Program Data

Methods/Analytics•Episodes of Care

•Performance Measures•Disease Staging

Data ManagementProcess

•Security Protection•Integration•Translation

•Standardization•Data Validation

Profile and Screens

DataArchitecture

And Data

Cubes

DataArchitecture

And Data

Cubes

Medical Management

Fraud Detection

Cost and QualityAnalysis

Performance Analysis

Eligibility Analysis

ChronicIllness

Sub-databasesRegistries

ChronicIllness

Sub-databasesRegistries

DecisionSupport ReportingApplications

Eligibility Data

Data Warehouse

Health Plan &Provider Decision

Support

Health Plan &Provider Decision

Support

Creating Key Performance Transparency

• 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.)

CostContainment

QualityImprovement

AdministrativeEfficiency

Public Health &Research

Meaningful Use of EHR to better coordinate care andQuality Performance

Meaningful use ofEHR to Reduce Admin. Process Cycle Times

Meaningful Use ofEHR to build PopulationHealth Mgmt. & Research

Meaningful Use of EHR to reduce Duplication, Errors and improveAdmin Efficiency

Strategic HIT Focus Areas

Reduced UnnecessaryCost/Utilization = Reduced PMPM & Lower % Admin Cost

HIT Strategic Performance Metrics

Performance Outcomes

Higher Provider Satisfaction & Reduction in Admin.Cost

Public Health ResponsivenessReduction in Health Disparities

Improved QualityAgainst HEDIS andOther Benchmarks

Meaningful USE Barrier

PERFORMANCE ManagementBarrier

Str

ateg

ic P

lan

nin

g L

og

ic M

ap

Map of Strategic Outcomes for EHR Adoption Efforts

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:– 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

• 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 • 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?