Payers and Providers Build an HIE: A Major Metro-Region Experiment April 16, 2015

Transcription

1 Payers and Providers Build an HIE: A Major Metro-Region Experiment April 16, 2015 Martin Lupinetti, Executive Director of HealthShare Exchange of SouthEastern Pennsylvania HIMSS 2015

2 Learning Objectives Understand traditional structures of health information exchanges (HIEs) predominantly set up by health systems, compared to the advantages of a truly integrated payer-and-provider regional HIE. Enumerate the advantages of incorporating claims-translated data in an HIE and how this feature affects an HIE s use cases. Appreciate the various services now under development and deployment by a large HIE such as HealthShare Exchange of Southeastern Pennsylvania and how the clinical practitioner including in behavioral health can take advantage of these patient-information resources to both receive and submit electronic patient data to improve case management and interventions at the point of care.

3 Value of Health Information Exchange payer-provider-built health information exchanges: connecting and interoperating EMR and utilization data care-team intelligence INFORMED providers and better care/disease management reduction in unnecessary care

4 Bio: Martin Lupinetti Marty is widely known in the Delaware Valley HIT community for his leadership. As the Executive Director of HealthShare Exchange of Southeastern PA (HSX), he is helping to build the interconnectivity and interoperability in health information that will help to define the future of healthcare in the region, state, and nation. Marty and his staff work integrally with HIT colleagues at some 60 member hospital/health systems, insurers, ambulatory practices, and other healthcare facilities. He has more than 25 years of experience in executive roles, strategic planning, technology implementation and deployment oversight, including with the North Highland Company and the State of New Jersey. In a consulting role initially, he played an integral part in the planning and start-up of HSX.

5 HSX: a Major, Unique, Regional Undertaking purpose-built from the ground up as a major metro-area HIE that includes both providers AND payers (insurers) Claims records reveal recent and past use of medical services and points of care Routing intelligence defines each individual s broader care team Transmission downstream of care summaries to the patient s specialty and primary providers and upstream to care managers informs care

6 Ambitious Scale and Architecture Rivals and competitors, with: potential to work as one system for health information

7 Can We All Play Together? To achieve collaborative, coordinated community and structured joining of payers and providers in their daily work flow

8 Starting with a Big View The Delaware Valley Healthcare Council (DVHC) of HAP (Hospital & Healthsystem Association of Pennsylvania) Advocating for exchange and interoperability 2009 discussions among healthcare entities began 2010 the regional PAVE Project ( Preventing Avoidable Episodes )

9 Going Beyond Health System HIEs Communicating beyond the curtain.

10 No Health System Is an Island Similar markets and population areas in the country are typically served by single or multiple HIEs operated by the dominant hospital/health system in that service pocket a limited, conventional HIE model (a glorified, disseminated EMR). As much as half of readmissions return to a different facility (different hospital /health system).

11 Reaching Across Traditional Boundaries Healthcare systems and payers acknowledged that they could not close these gaps working alone Funding from the Pennsylvania eheatlh Collaborative HSX formed as a corporation with support of federal and state grants and stakeholder contributions, and with a board including significant representation by both hospitals and payers.

12 Addressing Member Concerns: Blockers and Barriers Do no harm proviso applies to HIEs too. Must enhance not compromise healthcare access and outcomes. Put individuals first. Create value for the consumer. Some HIEs succeed. Some HIEs fail. Stakeholders don t want to invest in the latter. Who goes first and commits IT resources? Can an HIE serve both payers and providers equitably?

13 Moving Forward: HSX Comes Together

14 Everyone At the Table: A Trust Community Address common pain points by including the power of insurer data. Consensus sought on use cases most valuable to members (e.g., transmission of hospital discharge summaries). Members could most readily embrace transmission of records using the Direct project protocol (national standards and less expensive).

15 Member-Built HSX Architecture: admission alert will first serve the case-management function recent/past clinical usage information (utilization based on claims data) serves the hospital point-ofcare provider discharge alert serves PCP and other office practitioners, and insurer

16 The HSX Promise Today

17 The Future of Healthcare Delivery: HSX Now

18 Achieving a Balanced Membership Commitment through sometimes challenging implementation periods. Working intensely and closely with two thirds of the healthcare equation (providers and payers) will ultimately permit HSX to best serve the third and most important part consumers. Health Systems 39 acute care hospitals 93%+ emergency department (ED) visits in the region Received Year 1 and Year 2 contributions based on patient volume Behavioral Health Facilities Eagleville Hospital Elwyn Health Plans Three health plans AmeriHealth Caritas Health Partners Plans Independence Blue Cross 62%+ of the covered lives in the region Received Year 1 and Year 2 contributions based on covered lives in the region. Ambulatory Care Participants 16 independent practices as of 4/8/15 and growing!

19 Moving Members Through Deployment Levels Now underway: technical deployment/implementation and engagement & adoption with healthcare providers

20 Phase-In to a Multitude of Accessible Information Direct Messaging and Provider Directory - DirectTrust Certified HISP Services Implementation - Robust Provider Directory Shared with the Members - Noticeable Usage Direct Secure Messaging - Scaled and Widely Adopted Automated Care Team Finder - Scaled and Widely Adopted Clinical Activity History Encounter Notification - Participation Agreement for Membership Development - Broad Adoption of Encounter Notification Service Capabilities by the Membership - Hospital ADT and CCD/A Data Feeds Prioritization and Implementation - Hospital Clinical Data Feeds Labs, Radiology, Transcribed Documents Clinical Data Repository - Clinical Data Repository (CDR)-Based Services Adoption and Usage for Members - Continue Hospital Clinical Data Feeds Implementation - Replace Letters of Commitment with Participation Agreements - Promote User Adoption of HSX Services

21 Confidence to Set Up Multiple Service Offerings Services overview: Discharge Information Allows timely communication after discharge to patient s primary physician Leverages payer database to assist with identifying providers Enhanced Direct Clinical Activity History Pulling from participating payers for clinical history for patient presenting to different care settings (e.g., emergency dept.) Encounter Notification Service By subscription, a list of real-time patient encounters (i.e., emergency department and inpatient admits and discharges) will be sent to participants Clinical Data Repository (CDR) Services Secure access to a centralized repository of health information from multiple hospitals and providers in the trust community

22 Patient Admit Scenario Checks Member Status With Participating Plan Payer Sends Clinical Activity History from Claims Data as a CCD or PDF PCP or Care Team Subscribes to Patients or Members Patient Admitted to Hospital or ED Auto Subscribes to Patient ADT List of Admits Clinical Activity History Clinical Activity History Clinical Activity History Subscribing PCP or Care Team Receives List of Admits for Subsacribed Patients or Members Hospital or ED Receives Payer Clinical Activity History Hospitals or ED Receive Previous Admit Information PCP or Care Team may choose to receive Payer Clinical Activity History

23 Patient Discharge Scenario Checks Member Status With Participating Plan CCD/ A Payer returns PCP information PCP or Care Team Subscribes to Patients or Members ADT CCD/A CCD Patient Discharged from Hospital or ED findcareteam@direct.hsxsepa. org List of Discharges PCP or Care Team Receives Discharge info CCD/A via Direct Secure Subscribing PCP or Care Team Receives List of Discharges for Subscribed Patients or Members

24 Building Out a Complex Entity Prospective new members: national health plans other hospital/health systems rehabilitation hospitals behavioral health facilities large non-affiliated private practices city health clinics ambulatory surgery centers birthing centers home health agencies large private practices long-term care organizations radiology centers retail pharmacy urgent care centers

25 Ready to Step Into an Even-Bigger Picture The goal is the make the HIE s data a ubiquitous tool, so that at the office, clinic, unit, or care-management level HSX becomes more than a noun. It becomes a verb. Need to find that patient information? Just HSX it! Pa. connection & multi-state exchange is also coming

26 Only One Direction: Forward

27 A Major Healthcare Market: Now Connected

28 True Regionality No other top-ten urban center in the U.S. has created this type of payerprovider HIE structure. Four million consumers in immediate service area. Millions more in neighboring Delaware, New Jersey, Maryland, and Western Pa.

29 And Now: Demonstrating the Services Illustrating the advantage of payer participation and of exchange across health systems:

30 Early Phases of Integrating Behavioral Health HSX now piloting the onboarding of behavioral health entities. Creating protocols for super-protected data (mental health, substance abuse). Patients with both physical and behavioral health conditions tend to be high utilizers. HSX mission to address the high utilizers of ED services. Behavioral health and physical health providers working together on behalf of the clients they serve will help to avoid unnecessary readmissions. Access to Direct secure messaging will help to foster communication between PCPs and behavioral health specialists.

31 Status with Three Behavioral Health Providers Eagleville Hospital Elwyn Eagleville to send discharge information messages to Crozer Chester Medical Center, Creative Health Services, Northwestern Human Services Potential use case is to receive clinical information from Einstein Montgomery per the HSX discharge use case Production by end of the second quarter of 2015 for Direct only Intends to receive clinical information via Direct Identified Riddle Memorial Hospital as a potential exchange partner Using HSX template language so they could revise their Notice of Patient Privacy to include participation with HSX and P3N Production in the second quarter of 2015 Northwestern Human Services of Delaware County Interested in Direct secure messaging and Encounter Notification Service for inpatient admissions and ED visits and sending Continuity of Care communications with PCPs Three Mercy Health ambulatory primary care practices are potential exchange partners Working on the contracting and Direct discovery process Go-live date TBD

32 Questions Martin A. Lupinetti, Executive Director HealthShare Exchange of Southeastern Pennsylvania, Inc. Ten Penn Center, 1801 Market Street, Suite 750 Philadelphia, PA O: C: Richard L. Snyder, MD Senior Vice President and Chief Medical Officer Independence Blue Cross 1901 Market Street Philadelphia, PA HSXsepa.org Follow h