Transcript Slide 1

HIMSS Patient-Centered Payer
Roundtable
March 17, 2011
Agenda
Welcome
Call to Order and Roll Call (Paul Oates, Shelley Price)
Topic discussion
The Value of ONC Interoperability Initiatives to the Healthcare Payer
Community (Erik Pupo, Senior Advisor to ONC on HIE )
Topic discussion
HIMSS11: Wrap-up (Paul Oates)
Topic discussion
PCPR next steps (Jeffrey Pankow)
Housekeeping
(Shelley Price)
Adjournment
2
Agenda
Welcome
Call to Order and Roll Call (Paul Oates, Shelley Price)
Topic discussion
The Value of ONC Interoperability Initiatives to the Healthcare Payer
Community (Erik Pupo, Senior Advisor to ONC on HIE )
Topic discussion
HIMSS11: Wrap-up (Paul Oates)
Topic discussion
PCPR next steps (Jeffrey Pankow)
Housekeeping
(Shelley Price)
Adjournment
3
The Value of ONC Interoperability
Initiatives to the Healthcare Payer
Community
Erik Pupo
Introduction
• Objectives of this presentation are:
– Briefly highlight the payer environment and how
interoperability can help
– Showcase the work that ONC is doing for
interoperability and how it supports payers
requirements
– Highlight examples of usage of ONC interoperability
to solve common payer issues
– Answer questions related to ONC efforts in
interoperability
Let’s Begin….
• Notes:
– I wont cover every aspect of interoperability – this is
focused on ONC’s interoperability initiatives and how
they can help you
– I LOVE questions – its not always easy to explain in
slides how interoperability initiatives work so feel free
to ask questions
– Suggestions for improvement – opening a dialogue
with payers to critique and improve interoperability
initiatives is a WELCOME occurrence
The Current Environment for Payers
• Under pressure from healthcare reform – more
regulation and oversight, less flexibility
• Payer revenue will increasingly be driven by risk
adjustment, NOT risk selection
• Health reform will limit risk selection options open to
payers and require more data analysis of the quality
of care provided
• Plans will no longer compare to benchmarks (like in
Medicare Advantage) but to each other (as part of
the healthcare insurance exchanges)
What Payers Need from Interoperability
• Access to current, accurate, and complete
diagnostic information is critical
– Need to be able to match state and federal data
electronically
– Need to be able to submit and receive standardized and
unstructured documentation electronically
– Need to make eligibility data reusable
– Need to give consumers the ability to see their eligibility
and enrollment data online – the healthcare insurance
exchange challenge
– Needto notify consumers to their eligibility for state and
federal programs
Risks to Payers from Interoperability
• There are several risks that payers may have with
interoperability
– We increasingly operate in a world where information is a
valuable commodity. Payers have information that is important to
others and need the ability to share this data, but there is always
risks to sharing
– Creating short term interoperability needed to satisfy Stage 1
meaningful use requirements , while also preparing stakeholders
for Stage 2 of meaningful use
– Assuring that providers know HIE mechanisms for meaningful
use are available and begin to use them
– Converting short term “work-arounds” for exchange to more
robust systems of exchange that cross provider systems and
geographies (conceptual, technical, political challenges.)
Interdependencies of Interoperability
Driver
Organizational
interfaces for
exchange
Issue
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Very spotty now, most
small volume
Multiple approaches
possible given context
in US
HITECH Contribution
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Key Concerns Remaining
State HIE Programs •
Direct, Connect
Workforce
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Programs
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Access to technology •
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Provider willingness
to share data for HIE
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Flexible current focus
is short term oriented
State HIEs limited by
leadership turnover
and resources
Long term vision still
to be developed
Broadband not
universally available
Technology changes
Federal broadband
initiative and related
ARRA support
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“Free rider”
phenomenon
Confidentiality concerns
Competitive concerns
Nothing direct. MU
incentives require
some sharing.
Achieving a critical mass
or “tipping point”
Ability to fill gaps
Relevance of
certification standards
to evolving
technology
Interdependencies of Interoperability - continued
Driver
Data
Harmonization
Issue
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Privacy and
Security
Protection
HITECH
Contribution
Limited common
standards
Voluntary
compliance
Vendors benefit
by product
differentiation
No market
“leader”
HIPAA protections
have gaps, state laws
vary and may limit
exchange (e.g., lab
data)
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National standards
Product certification
as meeting
standards
Key Concerns
Remaining
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HIPAA expanded
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Ultimate feasibility of
standards and monitoring
for compliance
Effectiveness of standards in
achieving harmonization
Vendor support for
interoperability
Conveying federal
commitment and real
reassurances
Variability in state laws and
complexity of federal
structure and state variability
creates barriers
Why we need different interoperability initiatives
Information is vital and it comes in many different formats which need to
be addressed and able to be transported
HEALTH
HUMAN SERVICES
“Convergent Drivers”
“Divergent Needs”
• Electronic Health
Records
• Day Care
• Personal Health
Records
• School Vaccines
• School Meal Programs
• Sports Physicals
• Nationwide Health
Information Network
• Disability
Determinations
• CONNECT
• Life Insurance Eligibility
• National eHealth
Collaborative
• ADA and Housing
Assistance
• Regional Health Info
Organizations
• Pre-employment
Evaluations
• HITECH Acts
• ARRA Act
*Center for Information Technology Leadership Standards Levels
In addition to current mountains of historical paper records, there will always be some
new information created in healthcare and human service settings. We need different
ways to transport that information
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Interoperability and Healthcare Reform
Requirements for Payers
• ACO and Medical Home Needs (and requirements)
– Seamless transitions in care
• Longitudinal, cross-organizational records
• Look-up, data queries
• Managed problem, medication, allergy lists +
– Quality and efficiency management data and services
• Including claims and process data, workflow
integration
– Population analytic tools and registries
– Cross-organizational team communications and care
• Including patient communications
– Clinical Decision Support
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How ONC Interoperability Initiatives are
coordinated
Coordination of Interoperability
How does Direct work?
• Direct can be implemented by any two participants, organizations
or a community without a central governance structure
• Enable communications of simple content today and easily
transition to structured and coded documents for clinical decision
support in the future
Direct Project and
Information Exchange
The Direct Project doesn’t replace
other ways information is
exchanged electronically today, but
it might augment them.
The Direct Project supports simple use
cases in order to speed adoption,
but other methods of exchange
might be suited for other scenarios.
The Direct Project was designed to
coexist gracefully with existing
protocols for data exchange.
The Direct Project seeks to replace
slow, inconvenient, and expensive
methods of exchange (like paper,
fax, or carrier pigeon) and provide a
future path to advanced
interoperability.
State HIE
Commercial
HIE
Health information exchange:
a puzzle with many pieces
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Direct Participants
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Ability/VisionShare
Allscripts
American Academy of Family Physicians
Atlas Development
Axolotl
CareSpark/MobileMD/Serendipity Health
Cautious Patient
Cerner
Clinical Groupware Collaborative
Covisint
CSC
eClinicalWorks
Emdeon
Epic
FEI
Garden State Health Systems
GE
Google
Greenway Medical Technologies
Harris Corporation
High Pine Associates
HLN Consulting, LLC
IBM
Indiana State Department of Health
Inpriva
Intel
Kryptiq
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LabCorp
Massachusetts eHealth Collaborative
MedAllies
MIE/NoMoreClipboard.com
Medical University of SC
Medicity
MedNet/ApeniMed
MedPATH Networks
MedPlus
Quest Diagnostics
Microsoft
Mirth Corporation
MOSS
NextGen
NIH NCI
NIST
NYC Dept. of Health and Mental Hygiene
Oregon HIE Planning Team
Redwood MedNet
RelayHealth
Rhode Island Quality Institute
Secure Exchange Solutions
Siemens
South Carolina SDE
Surescripts
Techsant Technologies
TN State HIE
VA
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Real-world Implementation
The Direct Project is being demonstrated in real-world pilots across the country and is in
production use by HIEs, EHRs, and PCHRs
VisionShare (MN)
Rhode Island Quality
Institute (RI)
MedAllies (NY)
Redwood MedNet (CA)
Medical Professional
Services (CT)
VisionShare (OK)
CareSpark (TN)
Direct Project is architected for rapid adoption by:
• Thousands of hospitals
• Hundreds of thousands of physicians
• Millions of providers
• Tens (or hundreds?) of millions of patients
• Many other stakeholders in healthcare
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What is CONNECT?
• CONNECT is an open source software solution that
enables health information exchange – both locally and
at the national level. CONNECT employs Nationwide
Health Information Network standards and services to
ensure that health information exchanges are compatible
with other exchanges throughout the country.
• CONNECT was developed by federal agencies to
support their health-related missions. It is now available
as an open source solution to any organization seeking
to establish health information exchanges using
nationally-recognized interoperability standards.
What makes CONNECT go?
• Three primary components make up the CONNECT solution:
– The Core Services Gateway can locate patients at other organizations,
request and receive documents associated with the patient, and record these
transactions for subsequent auditing by patients and others. Other features
include mechanisms for authenticating network participants, formulating and
evaluating authorizations for the release of medical information, and honoring
consumer preferences for sharing their information. The Nationwide Health
Information Network Interface specifications are implemented within this
component.
– The Enterprise Service Components provide default implementations of many
critical enterprise components required to support electronic health
information exchange, including a Master Patient Index (MPI), XDS.b
Document Registry and Repository, Authorization Policy Engine, Consumer
Preferences Manager, HIPAA-compliant Audit Log and others.
– The Universal Client Framework is a set of applications that can be adapted
to quickly create an edge system, and be used as a reference system, and/or
can be used as a test and demonstration system for the gateway solution.
This makes it possible to innovate on top of the existing CONNECT platform
• It allows you to build your own HIE or serve as an
intermediary on Exchange
Using Exchange Protocols
CONNECT Implementation Status
Federal Agencies
Federal Agencies & Other Partners
Demo/Pilot
Production
Centers for Disease Control & Prevention
Limited pilot production on NHIN
Centers for Medicare & Medicaid Services
Limited pilot production on NHIN
Department of Defense
Limited pilot production on NHIN
Department of Homeland Security
Department of Justice
Department of Veterans Affairs
Limited pilot production on NHIN
Food and Drug Administration
Indian Health Service
Moving into limited production in 2010
National Cancer Institute
National Disaster Medical System
Social Security Administration
Moving into limited production in 2010
Limited pilot production on NHIN
Other Partners
Orange County ER Connect
Redwood MedNet
Moving into limited production in 2010
Indiana State Department of Health
Moving into limited production in 2010
Iowa Department of Public Health
Iowa Health Systems
MedVirginia
Limited pilot production on the NHIN
New York State Department of Health
Moving into limited production in 2010
Thayer County Health Services
Moving into limited production in 2010
Washington State Department of Health
Moving into limited production in 2010
Examples of Applying CONNECT - ESMD
• Electronic Submission of Medical Documentation (ESMD)
• Proposed solution would leverage the existing CONNECT
architecture designed (reusable solution within CMS):
– Document submission adapter
– Policy engine adapter
– Audit/Logging adapter
• New esMD development contract awarded with focus on
Electronic Document Submission and Electronic Document
Request in support of RAC contractors
– Develop an esMD profile and implementation guide (coordinated
with ONC)
– Incremental esMD transactions can be added to the existing
gateway or a stand-alone esMD gateway modeled after the C-HIEP
design can be implemented
Example of using Direct AND CONNECT –
esMD Architecture
Documentation
Request
Letter
RACs
MACs
CERT
PERM
?
Medicare Private Network
Content Transport Services
ECM
CMS
CONNECT
Compatible
www.cms.gov/esmd
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Example of Using CONNECT - CHIEP
Exchange – Enabling Nationwide
Exchange of Information
•
Support the nationwide exchange of information among larger organizations
AND…..
Expected to support more complex interoperability requirements that require
intermediary assistance
Example of Exchange – Electronic Transmission of
Service Treatment Records (STRs)
When a person leaves the military, VBA needs to review their entire medical record
to make a disability determination. In many cases, the veteran’s records are stored in
several locations including both military and private providers.
Iraq
Bethesda, MD
Quantico, VA
Richmond, VA
Kingsport, TN
Pinehurst, NC
Cherokee, NC
Albuquerque, NM
HIMSS 2010
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Infrastructure Enables Nationwide Exchange
Personal Health Record
and Personal Health Devices
Payers
Enterprise and
Departmental Systems
Including Medical Devices
EHR System
Specialists
Provider
Directory
Audit
Repository
Record Locator /
Document Registry
Patient Identity
Manager
Gateway
Consent
Manager
Core Infrastructure
Document
Repository
NIEM Integration into ONC interoperability efforts
Benefits of Interoperability for Payors
• Standardized content to facilitate the exchange of eligibility
and enrollment information among payers
• Innovative solutions for transporting eligibility and enrollment
data
– Point to Point – small providers and organizations can reuse Direct
backbone for simplified eligibility and enrollment transactions
– Reuse of existing systems – modular approach to support vendors
who want to add this as a feature through CONNECT
– New systems and services to support growing eligibility and
enrollment requirements that are available on Exchange
• Increased access to care through expedited eligibility and
enrollment by standardized and efficient information exchange
– Providers rightfully fear providing care to someone who cannot pay
– Real time access for providers to determine “can you pay?”
Business Benefits of Interoperability
• What ONC wants to do for you by providing various
interoperability options…..
– Improved timeliness of benefits adjudication – quick
transmission of information
– Improved completeness of information available to payers
for analysis – making information available nationally
– Decreased fraud and waste costs due to more information
available for detection – the holy grail of payer
interoperability
– Closer tie-in to elimination of healthcare disparities –
opening up a wealth of information to a larger group within
the population to improve their care
Additional Business Benefits of
Interoperability
• Benefits also include:
– Improved Coordination of Benefits across all federal and private payers and
citizens
• Federal Agencies, Private Health/Dental Insurance, Accident Insurance
• Primary and tertiary payers sharing information helps to maximize benefits
to patients and payers
– Medicaid reconciliation across state boundaries
– Helping to meet Meaningful Use Stage 1 national priorities
• Coordination of Care Referrals, Transfers
• Check ‘eligibility’ status electronically/Submit claims electronically from/to
public and private payers
– Provider priority of billing
– Eventual development of citizen-accessible eligibility and enrollment summary
• Coordination of Care, Coordination of Benefits, Consumer Empowerment
Questions?
• I would be happy to answer questions on:
– The role of payer organizations in interoperability
– How you can help ONC and its interoperability
initiatives
– What is the future of interoperability?
Agenda
Welcome
Call to Order and Roll Call (Paul Oates, Shelley Price)
Topic discussion
The Value of ONC Interoperability Initiatives to the Healthcare Payer
Community (Erik Pupo, Senior Advisor to ONC on HIE )
Topic discussion
HIMSS11: Wrap-up (Paul Oates)
Topic discussion
PCPR next steps (Jeffrey Pankow)
Housekeeping
(Shelley Price)
Adjournment
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HIMSS11 Payer Program
• HIMSS11: February 20-24, 2010 in Orlando, FL
–
31,225 attendees; 1,000+ exhibitors; 400+ edu sessions
–
266 payers: CIOs, CFOs, COOs, CMOs, Innovation and R&D, IT
Strategy, Health Information Systems,
• Pre-conference events
–
Symposia: Secondary Use of Data (106); 5010/ICD-10 (230)
• Conference events
–
Payer Breakfast (80 attendees)
–
PCP Roundtable w Wes Richel, Gartner (50 attendees)
–
VIP tour of interoperability showcase
–
ACO conference: Leading From the Future
•
Clinical Integration: the foundation for ACOs
•
Strategic Directions of ACOs from the Provider Perspective
•
ACO Building Blocks: Why a High Quality Data Organization Matters
•
ACOs: IT from the Payer Perspective (Lewis Sandy, SVP, UnitedHealth Group)
•
The Payer Perspective: An Update from CMS (Don Berwick, CMS Administrator)
•
Building and Sustaining ACOs Through the Meaningful Use of HIT
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Agenda
Welcome
Call to Order and Roll Call (Paul Oates, Shelley Price)
Topic discussion
The Value of ONC Interoperability Initiatives to the Healthcare Payer
Community (Erik Pupo, Senior Advisor to ONC on HIE )
Topic discussion
HIMSS11: Wrap-up (Paul Oates)
Topic discussion
PCPR next steps (Jeffrey Pankow)
Housekeeping
(Shelley Price)
Adjournment
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Roundtable: Next Steps
• Governance
• New Groups
– Thanks to those who volunteered at HIMSS11
– Reaching out soon
• Leadership
• Speakers Bureau
• Website Workgroup
• FY12 – planning
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Agenda
Welcome
Call to Order and Roll Call (Paul Oates, Shelley Price)
Topic discussion
The Value of ONC Interoperability Initiatives to the Healthcare Payer
Community (Erik Pupo, Senior Advisor to ONC on HIE )
Topic discussion
HIMSS11: Wrap-up (Paul Oates)
Topic discussion
PCPR next steps (Jeffrey Pankow)
Housekeeping
(Shelley Price)
Adjournment
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Housekeeping
• The Call for Proposals for HIMS12:
– open March 21 – May 23, 2011.
– http://www.himss.org/asp/education_annualConf_callProposal.asp
• The Call for Reviewers for HIMS12:
– open March 21-May 23, 2011.
– http://www.himss.org/asp/education_annualConf_reviewer.asp
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Wrap-up
• Web page
– http://www.himss.org/advocacy/about_patientCenterPayer.asp
• Next meeting
– 3rd Thursday of the month from 4-5pm EST
• Thursday, April 21, 2011
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Leadership and Contact Information
Chairperson:
Paul Oates
Senior Enterprise Architect
CIGNA Healthcare
[email protected]
Vice Chairperson:
Jeffrey Pankow
Director, IT
Excellus BCBS
[email protected]
HIMSS Staff Liaison:
Shelley Price
Director, Payer and Life Sciences Initiatives
HIMSS
[email protected]
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