National Enrolment Service Questions and Answers April 2015
Frequently Asked Questions Introduction A commitment has been made by the sector to implement a National Enrolment Service (previously known as e-enrolment) in 2015. This communication will provide guidance on: what the National Enrolment Service (NES) is, the services that will be available to Practices and, how PHOs can support their Practices to ensure that they are ready for implementation of NES. This is the first of a series of on-going information documents as we progress to implementing this new service. The NES will be a single source of truth for all national enrolment data, which will provide the capability to support Practices by assisting in patient identification and eligibility assessments. NES will integrate directly with the Practice Management Systems via a secure web-based service that links to the Ministry of Health national identity and payment systems, providing relevant data for payment and reporting purposes. Nationally, up to 22,000 patient changes occur between Practices 1 each month. This is in addition to patients enrolling for the first time. The current manual enrolment process is inefficient, processes are duplicated and the process is prone to error in relation to data and patient information. This leads to inaccuracies in the allocation of funding and creates a financial risk for Practices and PHOs when enrolment audits reveal data errors and result in recovery of funding. The health sector is increasingly using electronic systems for the exchange of information. The Health IT Plan sets out a vision that all New Zealanders will have a core set of personal health information available to them and their healthcare providers electronically. The NES is an important component of this plan. In summary the benefits of NES are: A centralised register with real time patient enrolment status enabling more timely payment calculation for enrolled patients, Single source of truth for enrolment data to ensure accuracy of Capitation Based Funding calculations, Validated NHI and up to date patient demographics, supporting accurate identification of patients and clinical safety, Validated addresses using esam service, supporting accurate assignment of deprivation-based funding, Processing and payment cycle reduced from 3 months to 1 month, 1 For the purposes of this communication Practice refers to PHO Contracted Providers of First Level Services. NES Frequently asked questions - 5 May 2015.docx Page 2 of 9
Amended enrolment business rules, due to real time enrolment and more timely funding of patients, Improved eligibility assessment guidance to support practices in decision-making about patient eligibility for publicly funded services, Web services integration with PMSs, creating a seamless experience for the user when interacting with national services. Key NES Services From 1 July 2015 there will be a core set of NES services available to Practices integrated within their PMSs which will include: 1. Patient Identity Information The NHI is the master source of truth for Patient health identity data. When a patient presents, users will be able to search and view the NHI records for a patient from within the PMS, and update the PMS with the most recent demographic data for the patient if the NHI data is more current. Authorised users will also be able to update the NHI record if new information is available, synchronise both the PMS and NHI with the most recent demographic data for the patient, and add a new NHI record if the patient is new to the NZ health system. Training will be provided to all Practices for use of the NHI functions. 2. National Enrolment Service NES will be the single national source of truth for Practice and PHO enrolment data. The purpose of NES is to capture Practice enrolment register changes on a daily basis, which makes it possible to take a snap-shot of NES on a monthly basis. This will allow for payment processing at monthly intervals. 3. Eligibility Look-Up (eligibility to receive publically-funded health services) At the point of patient enrolment users will be able to search to determine whether an identified patient is a verified NZ Citizen by birth before 2006. This will be the first eligibility assessment available. Additional eligibility assessment information will be added over time. Q1. How does the PMSs integrate with NES? NES will be a web-based solution that PMSs integrate with so that Practice staff will not have to go out of the PMS at any stage to access this information. This will require Practices to: have implemented the appropriate PMS upgrade scheduled for rollout in June 2015 be set-up to within NES to enable NES to receive Practice enrolment data. NB. No enrolment data will transfer from PMS to NES until this setup is complete data will not start transferring upon installation of PMS upgrade. NES Frequently asked questions - 5 May 2015.docx Page 3 of 9
be signed up to Connected Health 2. Most Practices already have Connected Health to access electronic Pharmac Special Authorities and esam. If Practices are unsure if they have Connected Health they should check with their support network. Q2. What does validation of an NHI involve? Validating an NHI against the national register will allow users to search for an existing NHI for a patient. If there is no existing NHI for a patient, authorised users can create a new NHI using the patient identity service within the PMS. They can also update and synchronise both NES and NHI Patient Identity Service with the most recent demographic data for the patient. To be able to update the demographic details of a patient on the NES, Practices must first validate the address through esam. Q3. How secure is NES? NES will be hosted in the Ministry of Health s Connected Health Network which will ensure reliability, safety and security of information. The Connected Health Programme is part of the Ministry of Health s National Systems Development Programme. It provides New Zealand with an essential platform for the secure collection, access and exchange of electronic health information between healthcare providers. Q4. Who will have access to NES data, what purposes will NES data be used for and how will that be governed and monitored? Governance of NES The Ministry of Health is hosting the NES, and will provide the appropriate governance structures for the service however the primary care sector maintains the data within NES. Currently there are interim governance structures in place with the NES Steering Group governing the NES service on an interim basis until the Governance Board is established. This interim arrangement will be for a period of time to ensure continuity through these early phases while the NES is established in the sector. The governance board of NES will be a shared ownership model and will include appointments from NHB, SCI, SOG and the National Health IT Board. Additional persons with relevant clinical and technical experience and skills may be appointed at the discretion of the Governance Board. The Chair of the Governance Board will be appointed by the National Health Board. The duration of the Board appointments will be covered by the Boards terms of reference. The National Health Board is also responsible for authorising the Governance Board s Terms of Reference. Set up and Access to NES Data Users of NES will be set up with their own access rights at the appropriate level; ie practice owner, or practice administration, PHO level and DHB level access etc. Training will also be provided at these appropriate levels. More information on the practice set up of NES and training will follow. 2 Connected Health is an environment for the safe sharing of health information. It is a standards-based, commercial model for the delivery of universal connectivity across the New Zealand health sector. NES Frequently asked questions - 5 May 2015.docx Page 4 of 9
Read Only and Modification of NES Practices will be the only users of NES that will have the ability to read only and also modify the data within NES. Training around this is essential at there is data stewardship responsibilities, and NES is the single national source of truth for all enrolment data, therefore the accuracy of the data that will be inputted at general practice level will be paramount, as it will have funding and reporting implications. Practices will only be able to view the information relevant to their practice, and information within the National Identity Service. Practices will only be notified when a patient has transferred from their practice; they will not be notified of the practice that the patient has transferred to. Reporting Access within NES PHOs will have secure access to the aggregated monthly NES data reports, as they do currently and will be able to extract and analyse these reports right down to Practice level within their PHO. This will support service planning, development, delivery, funding monitoring, and planning functions. DHBs will have secure access to the aggregated monthly data reports as they do currently and will be able to extract and analyse these reports down to individual PHO level within their DHB district. This will support service planning, development, delivery, funding, monitoring and planning functions. PHOs and/or DHBs will not have the ability to modify any data within NES. PHOs will still be responsible via the PHO Services Agreement that their Contracted Providers take all reasonable steps to ensure that correct data is entered within the National Enrolment Service, as per the PHO Referenced documents; Enrolment Requirements for PHOs and Providers, and Business Rules for the National Enrolment Service Capitation Based Funding. Q5. Will there still be manual Enrolment Forms that require a signature? Yes. Individual Enrolment Forms will still need to be physically filled in, dated and will still require a personal handwritten signature by the patient (or their parent, or caregiver who is the legal guardian or has custody, or by a legally authorised representative). A name printed electronically on a form is not a valid signature. Enrolment and dis-enrolment records still need to be kept for seven years following the last date on which payment was claimed in respect of the enrolment. Q6. Do Practice staff need to view and keep on record patient eligibility documentation? It is still the responsibility of Practices and PHOs to ensure patients are eligible for publically funded health care and as such sighting the patient s documentation to assess eligibility is recommended. It is the patient s responsibility to provide appropriate documentation to enable the Practice to make the eligibility assessment (as stated in the Enrolment Requirements for Providers and PHOs). The NES eligibility service will be used primarily as a guiding tool for assessing eligibility although phase one of NES will identify a NZ Citizen by birth before 2006. Q7. Determining a patient s entitlement to enrol. NES Frequently asked questions - 5 May 2015.docx Page 5 of 9
Practices will still need to determine a patient s entitlement to enrol which involves a declaration by the patient that they plan to permanently reside in New Zealand for at least 183 days in the next 12 months and they wish to use the Practice as their regular on-going provider of First Level Services. Practices will continue to be responsible for taking all reasonable steps to input correct data into their PMS as this will update NES. This includes dis-enrolling ineligible people within their PMS e.g. when a person is departing for overseas for more than 12 months, is in prison, or when a time-limited visa or permit has expired (as stated in the Enrolment Requirements for Providers and PHOs). Q8. What effects does this have on the Audit and Compliance process? The majority of the audit and compliance requirements for PHOs and Practices will remain, but the risk will be significantly reduced with the NHI compare / add function and the eligibility service. As the NES platform matures and the number of services increases, the risk will continue to reduce as the data integrity becomes richer. More formal notification of this will follow. Q9. Does NES replace quarterly CBF register extract submissions? The purpose of NES is to record enrolment changes on a daily basis which makes it possible to take a snapshot of enrolment on a monthly basis. These will no longer be by way of Practice CBF export to the PHO and then onto the MoH. The monthly enrolment snap-shot for payment purposes will be sourced directly from NES, and will be continually kept up to date directly from the Practice PMS changes. Transition Period to NES for CBF calculations and payments: From 1 July 2015 there will be at least a six month transition period in terms of NES enrolment calculations and CBF payments. All PHOs will still be required to submit their CBF registers quarterly via the normal process over the transition period. The Practices who are ready will have their registers inputted into NES, as well as the current CBF system, this will allow for variance and quality checking. During this parallel run PHOs will still be paid their capitation funding via the CBF system. This will manage the financial risk through a controlled transition environment over at least a six month period. Exception reporting will be provided so that PHOs and Practices have a window of opportunity to fine tune any data inaccuracies over that time before they are paid via the monthly NES process. Q10. How do Practices get paid their monthly capitation payments? For payment purposes a snap-shot of NES will be taken at 00:00 on the first day of every month. Payment will be made based on this snap-shot and paid to PHOs on the 15 th of the month. This will mean payment will be two weeks in arrears and two weeks in advance. Q11. What are the new business rules that come into effect with NES? As we progress to the NES there is an opportunity to make amendments to the enrolment business rules and requirements that are having less-than-optimal impacts on patients and Practices. Currently these business rules are being worked through PSAAP negotiations. However the new metrics to be implemented inside the NES are: NES Frequently asked questions - 5 May 2015.docx Page 6 of 9
Metric New Current Enrolment status updated Daily Quarterly Enrolment register calculated (NES snap-shot) Capitation Based Funding (CBF) Payment Monthly First day of the month Monthly 15 th of the month Quarterly Monthly Contractual Reporting Quarterly Quarterly With the NES it will be possible to capture all changes to patient enrolments within Practices and their respective PHOs (including patient transfers and date of last consultation) on a daily basis. Other business rules in regards to patient stand-down and pre-enrolments etc, and all the business rules relating to the current register submission process are being reviewed at PSAAP. More information will follow in the next few months once these changes are worked through and finalised. Q12. What will happen with the Preliminary Enrolment Process for Newborns? A Practice can still enter a pre-enrolment code B following notification of the birth of the newborn. The B code will then be accepted for funding at the start of the following month (at the time of the NES snapshot). The Practice must have updated the newborn s enrolment status to E within their PMS if they have completed the enrolment process before the fourth NES snap-shot (12 weeks) otherwise the enrolment will expire within NES and not be included in the CBF calculation. If the Practice has knowledge that the newborn will not complete the enrolment process then they should amend the B code in their PMS accordingly before the fourth NES snap-shot (12 weeks). Q13. What other effects will NES have on PHOs? Register Certification PHOs will no longer have to submit certification of registers signed by PHOs Chief Executive Officers (or delegated senior manager). CBF Register Submissions and Payments Without the requirement for Practices to submit CBF register extracts to the PHOs, PHOs will no longer need to complete any data processing prior to register submission to the MoH. However PHOs will still receive the CBF payment allocation for their Enrolled Population, on the 15 th of the month. PHOs will then distribute CBF payments to their Practices based on the payment outcomes report they receive. The advantages of NES being updated daily means that NES will be correct at the time of the register snapshot. NES Frequently asked questions - 5 May 2015.docx Page 7 of 9
Practice Changes PHOs will still be responsible for notifying the DHB and MoH on Practice changes; for example: i. Practice closures, ii. new Practices and iii. Practice splits or mergers. iv. PHOs will also be responsible for notifying the DHB and MoH on Practices entering into, existing or changing between health entitlement programmes such as Zero Fees for under 6, under 13 and Very Low Cost Access prior to a register snap-shot. The formal PHO notification process for these changes will be communicated as part of the PSAAP negotiations. Reporting PHOs will still be required to submit monitoring data reports to their DHBs and the MoH on a quarterly basis as per the contractual obligations of the PHO Service Agreement between PHOs and DHBs. This includes service utilisation data, clinical performance indicators, immunisation and provider information. Q14. What are the impacts on Very Low Cost Access (VLCA) and Under 6 and 13 Funding Schemes All three funding schemes are voluntary opt-in schemes at a Practice level. PHOs will need to notify the Ministry of Health on an exceptions basis any changes to the opt-in and opt-out of Practices to these schemes. VLCA, Under 6 and 13 will be calculated monthly and paid monthly along with the capitation funding for those Practices who opt-in. Q15. What are the impacts on Health Promotion, Services to Improve Access and Management Fees These funding streams will also be calculated monthly and paid to PHOs monthly based on monthly PHO enrolled population numbers. Q16. What are the impacts on CarePlus? Currently the Ministry of Health is finalising maximising CarePlus nationally and reviewing the need for monitoring and reporting on CarePlus enrolments. The majority of PHOs are now funded at 100% maximisation, with the aim of having all PHOs at 100% by 30 June 2015. Once all PHOs are funded via this mechanism then the CarePlus function within the PMSs for CarePlus enrolments becomes redundant and may not need to be included in NES going forward. The impact of this change to not include CarePlus in NES needs to be fully identified by all PHOs, and communicated back to the Ministry of Health. NES Frequently asked questions - 5 May 2015.docx Page 8 of 9
Q17. What will happen if Practices change PHOs? As per the PHO Services Agreement this requires a six month notice period aligned to the planning year. Where 6 months notice is given, movement may occur on 01 July or earlier with agreement. Q18. Will NES integrate with Births, Deaths and Marriages and Immigration New Zealand? These services will be added to the NES platform in phase two of the project. Once these services are integrated it will provide greater enrichment of data and an extension of the eligibility assessment functionality. NES Frequently asked questions - 5 May 2015.docx Page 9 of 9