blue plan clinical initiatives webinar - may 2018€¦ · 10 cie: value proposition • the ability...

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Blue Plan Clinical Initiatives Webinar

MAY 30, 2018

SPEAKERS: JEANIE SMITH, FLORIDA BLUEALBERTO S. LLANES, PHD, ANTHEMCHENA MESLING, REGENCE

NPAG 2018Lake Placid Crowne Plaza

August 26-29, 2018

Hosted by:

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Lake Placid Crowne Plaza

Make Your Hotel Reservations: Click Here

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Tuesday Afternoon Activities

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• Golf at Lake Placid Club

• Bobsled Experience

• AusableChasm Tour

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REGISTER NOW at www.npag.org

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Clinical Information Exchange (CIE):A New Frontier

Florida Blue Update and

Key Lessons Learned

Jeanie Smith, Florida Blue May 30, 2018

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Background

• The current state of healthcare data exchange (aka bi-directional Interoperability) was implemented to enable business system capabilities that support HIPAA-AS and the administrative side of healthcare.

• By effectively re-positioning this infrastructure we can enable business system capabilities that are designed to support the bi-directional exchange of clinical data between physicians, providers, health plans and patients.

• A bi-directional interoperable environment would “connect” clinical data with administrative data to support a “future healthcare system that is focused on clinical care management, clinical performance metrics (HEDIS; Stars; NCQA; MACRA), healthy outcomes, shared risk arrangements, data-driven alternative payment models and population health”.

• The Office of the National Coordinator for HIT (ONC) has published a National Interoperability Roadmap that describes the new “clinical data exchange frontier”: www.healthit.gov/policy-researchers-implementers/interoperability

Clinical Information Exchange (CIE): A New Frontier

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CIE: Definition and Goals

Definition: Clinical Information Exchange (CIE) is the bi-directional electronic movement of health-related clinical data and information between chain-of-trust business partners and organizations according to nationally recognized and generally accepted protocols and standards.

Goals:1. To facilitate access to and retrieval of clinical data to provide safer, timelier,

efficient, effective and equitable coordinated patient-centered care.

2. To provide the capability to electronically move clinical data bi-directionally between disparate health care information systems and physicians while maintaining the meaning of the data and information being exchanged.

3. To provide a secondary use of clinical data for population health, biomedical and clinical research, consumer health informatics as well as institution and physician quality assessment and improvement.


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CIE: Standards and Protocols

• The most critical success factor to implementing CIE and the bi-directional exchange of clinical data and information is based upon the effective and efficient collaboration and coordination between electronic chain-of-trust business partners using generally accepted health care industry technical standards and protocols.

• Health Level 7 (HL7) is a set of international standards, protocols, formats and definitions that support interoperability and is the baseline technical infrastructure to enable CIE.

• HL7 facilitates the bi-directional interoperable interchange of clinical datathat will enable various healthcare systems to communicate with each other in a meaningful way:

• Data is shared and processed in a uniform and consistent manner

• Allows physicians, providers and healthcare organizations to easily share clinical data and information

• Minimizes variability and isolation in medical care

• Reduces administrative costs and improves cycle times

• Automates System-to-System Transactions in a real-time manner


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CIE: Value Proposition

• The ability to bi-directionally exchange clinical data with facilities, physicians, referring or consulting providers and is essential for the effective and efficient coordination of patient care.

• Having the data in an electronic format makes the possibility of bi-directional data exchange easier, more secured and readily accessible.

• The electronic bi-directional exchange of patient data with other physicians, providers and health plans means that physician can finally share patients’ vital medical history quickly, easily and completely.

• Patient data and information can be exchanged regardless of where patients are receiving care.

• Having access to this data and information provides safer, more effective care tailored to patients’ unique medical needs.


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Institutionalizing CIE

HL7 ADT Events (Admission, Discharge, Transfer):• There are 51 different HL7 ADT events:

• A01 – Admission (Patient is admitted to facility)

• A02 – Transfer (Patient is transferred from one level of care to another)

• A03 – Discharge (Patient is discharged from facility)

• A08 – Update (Patient demographics/clinical have been changed)

HL7 ORU Events (Clinical Observation Results: Labs and Radiology):• There are 4 different categories of HL7 ORU events:

• Clinical lab results• Imaging study reports• EKG pulmonary function study results• Patient condition or other data (i.e. vital signs, symptoms, allergies, notes, etc.)

C-CDA (Consolidated Clinical Document Architecture):• Automates responses to requests for additional clinical documentation to health

plans, physicians and practitioners (i.e. Hospital Discharge; Referral Summary; History & Physical; Operative Notes; Procedure Notes; Progress Notes; Consultation Notes)

• Establishes a standard technical format to provide to a facility, practitioner or others who coordinate or provide services post patient's hospital stay.


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Florida Blue CIE Implementation Update and Lessons Learned

• Provider and physician practice outreach, engagement and implementations continue (i.e. Athena Health; Lakeland; Martin Health; Adventist; OHS; HCA).

• Stabilized implementation protocols, standards and techniques (eliminate proprietary data feeds; build a sustainable and scalable platform).

• Electronic chain-of-trust entities beginning to accept and actualize CIE using HL7 version 2.1 standards and protocols (mandated option).

• End-to-end testing continues to be problematic and time consuming; work to establish more robust, stable and sustainable testing protocols, standards, environments and reliability of test data is currently underway.

• Alternative CIE connectivity options continue to mature:• Direct Connect via SFTP (Secured File Transfer Protocol)• EMR “look-in” and Direct Connect Capabilities• Clinical Data Aggregator (Athena Health; Greenway; NextGen, etc.)• EMR Integrator (EMR and provider agnostic; Medivu and Half-Penny)• Availity Clinical Data Exchange Portal (multi-payer solution)


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Florida Blue CIE Implementation Update and Lessons Learned(continued)

• Current Implementation Updates:• Hospital, facility and physician practice connections continue to increase.

• Clinical Data Aggregator Pilot Programs (Athena Health and Allscripts).

• Migration of EMR “look-in” capabilities to systemic integrated solutions.

• EMR Integrator Pilot Programs (Medivu and Half-Penny).

• Adventist Health CIE Program (8 facilities come online in April 2018 with remaining 16 facilities by mid-May 2018).

• HCA Trinity and HCA Memorial Jacksonville pilots were successful and have been migrated to a production status; 42 HCA facilities rollout plan is currently in development with an October 2018 implementation .

• State HIE connectivity and data sharing has been expanded to include commercial product membership; data quality and physician/provider feedback and outreach programs continue.

• CIE work underway with the Veterans Administration (Florida Region)


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Florida Blue CIE Implementation Update and Lessons Learned(continued)

• Physician and Provider Outreach and Engagement Initiatives:• Activities continue along traditional paths (BlueLine articles and provider

bulletins; direct outreach from PSA’s and Network Staff).

• Created a 3-minute overview video of Florida Blue’s CIE initiative; two of our Medical Directors and Florida Blue’s Chief Medical Officer were interviewed; to be released in mid-April:

https://gwcstudios.wistia.com/medias/2akheben8d


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[email protected]: 904-905-5281C: 904-226-4509


DirectTrust Health Information Service Provider (HISP)

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Alberto S. Llanes, PhD

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DIRECT exists in eHRs today. All doctors have it. It was a meaningful use requirement. It can be leveraged by us today.

Health Information Exchanges (HIEs) whether regional or the now national Carequality have real adoption and can be leveraged by us today (although we’ll likely only get results returned when querying for purposes of patient care such as 30 Day Medication Reconciliation.

FHIR is in HL7 trial use. It’s resources are not yet (normative) mature standards. It’s a work in progress and does not currently exist in most eHRs our providers are using today (although Smart on FHIR apps are slowly gaining traction in eHRs, i.e. the EPIC Orchard to name but one of many).

Project Da Vinci is an effort by the payer community to help shape FHIR standards (API) development so it serves our purposes. It does “not” exist in most production eHRs today but we’ll soon have “reference” implementations.

Concepts that can be confusing:

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Health information (typically CCD & CCDA although can be PDF) is received via a secure email format called Direct in a trusted framework administered by DirectTrust.

Anthem will receive and automatically route and process the health information to those who need it within Anthem including insertion into repositories for analytics in a manner less costly than human processing of faxes.

All meaningful use stage II attested health record systems are required to support Direct so there is no additional burden on our partners to provide the information.

Starting with a Direct pilot and its utility for Anthem (Summary)

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Anthem’s HISP

Allows us to securely request and receive encrypted emails containing CCD’s, C-CDA’s, or any type of file we accept directly from provider eHRs that have attested to Meaningful Use 2 or later

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Easy to do business with

More easily analyzed and mined for data than faxes

DirectTrust Statistics

167 million Direct message transactions between DirectTrust addresses in 2017

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Direct Addresses 1,582,373(Individual and Organizations)

Directory Entries586,843

DTAAP Accredited HISPS43(Direct Trust Agent Accreditation Program Health Information Service Providers), e.g., Anthem, Inc.

Member Organizations121

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Every eHR MU2 or later by law has Direct functionality!

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Source: https://www.healthit.gov/sites/default/files/meaningfulusetablesseries2_110112.pdf

Anthem HISP Production Timeline

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EHNAC Accreditation(mid-February)

Submission of certificates, tests completing initial DirectTrust application materials (done)

Direct Trust Ballots for Anthem for final approval (after partner testing) after which Anthem starts socializing the service with partners. (est. May 24th)

Launch of Anthem HISP Pilot (est. early June)

Pilot lessons learned documented. Launch of first production use. (est. late June/early July)

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Appendix

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Why DirectTrust?Allows us to request and receive health information in a trusted framework of over 100 organizations including most eHRs, regional HIEs, and many large provider organizations.

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Why EHNAC?

EHNAC develops security standard criteria and accredit organizations that electronically exchange healthcare data.

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Member Organizations (1 of 3)

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AllscriptsAmerican Academy of Family PhysiciansAnne Arundel Medical CenterAnthem, INC.Applied Research Works, IncAthenahealthAzuba CorporationBaylor College of MedicineBrightsquid Dental Ltd.Broker’s BrokerCare3CareAccordCarebox Healthcare Solutions, Inc.CareDesignCerner CorporationDataMotion, Inc.DigiCert, Inc.Digital Medical Solutions IncDocketDSS IncorporatedDynamic Health ITeClinicalDirect

EMR DirecteSolutions! Healthcare Information Management, IncezEMRxFlorida- Agency for Health Care AdminstrationGeorgia Institute of TechnologyGlenwood Systems, LLCGSI HealthHawaii HIEHealth Companion, Inc.Health Record Banking AllianceHealthcare Information Xchange of New York Inc.HealtheConnectionsHEALTHeLINKHealthlinkNY, Inc.HealthNauticaHealthShare Exchange Of Southeastern Pennslyvania, IncHealthwiseHNI HealthcareIdenTrustIndiana Health Information ExchangeInformatics Corporation of AmericaInpriva


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INTEGRIS Health, IncIntermountain HealthcareiShare MedicalJanie AppleseedKno2Koble GroupKonica Minolta Business SolutionsLifeWIRE Corp IncLincoln Land Health Information ExchangeLucy JohnsMaxMDMayo ClinicMcKesson Corporation/RelayHealthMedAllies, IncMedAZ.Net, LLC.Medicasoft LLCMedicityMichiana Health Information NetworkMichigan Health Information Network Shared ServicesMirahModuleMD LLCMoxe HealthMRO Corporation

myDoctorsMedicalRecordNextGen/MirthNitor GroupNYeC-HISPOhio Health Information PartnershipOrion HealthPatientMDPeratonPulse Systems IncQuality Health NetworkQuest DiagnosticsReferWellReliant Medical Group, Inc.Rhode Island Quality InstituteRingMD Inc.Rochester Regional Health InformationSan Diego Regional Health Information ExchangeSecure Exchange SolutionsSmartPHRSocialCare by Health Symmetric, IncSoftAge Systems Inc.South Carolina Health Information ExchangeSouth Dakota HealthLink

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SSL CorpState of TennesseeSummit Healthcare ServicesSurescriptsSutter HealthTechsoftTenet HealthcareThe Health CollaborativeTimmaron Group LLCTruven Health AnalyticsUber Operations LLCUpdox LLCUS Department of Veterans AffairsUtiNet, Inc.Vanderbilt UniversityVelaturavitaTrackr, Inc.WalgreensWest Virginia Health Information NetworkWisconsin Statewide Health Information Network (WISHIN)World CongressZeOmega

Traditional use of Direct and Anthem’s specific intended use

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Backup:

Direct Implementation Views (High-Level to Detailed)

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Simplified Directed Exchange Illustration

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Medium Complexity Directed Exchange I l lustrat ion (DirectTrust Provided)

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More Detai led Specif ic Directed Exchange I l lustrat ion (VA Provided)

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eAuth Overview

Chena Mesling

34© 2018 Regence. All rights reserved.

OIC WAC 284-43-2050(4)(5) Prior authorization processesOIC WAC 284-43-2050(4)(5) Prior authorization processes

• As of Q12018, Regence is compliant with these terms of the mandate for an

online authorization process: • Providers can Check Eligibility & Benefits via Availity Provider Portal• Providers can view Pre-authorization lists on the Regence Provider Websites• Providers can view a list of pre-service requirements, terms and conditions on the Regence Provider Websites • Providers can view Medical Policies, including documentation requirements on the Regence Provider Websites• Providers can submit a PA request online via Availity electronic authorization (eAuth) submission process• Providers can submit clinical documentation along with their eAuth submission• Providers receive immediate acknowledgement that their eAuth was submitted successfully• When information is transmitted telephonically, Regence business processes include a written

acknowledgement of the information via FAX • Authorization requests can be submitted at all times, including outside normal business hours via fax

• Regence continues to add eAuth enhancements and further streamline the

customer experience related to the online authorization process: • Providers will be able to check if PA is required within the eAuth flow, and receive instant notification that pre-

authorization (PA) isn’t required, or that a request needs to be submitted elsewhere • Providers will be able to submit an eAuth request at all times, including outside normal business hours

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What is eAuth?What is eAuth?

• Objectiveso Provider can submit PAs onlineo Provider can view status of PA requests via Availity provider web portalo Select procedures can be auto-approved via clinical criteria submitted with the request

• Rationaleo Mandate: Regence must comply with WA mandate to have an online pre-authorization process.

Includes submitting request, uploading documents, and determining if PA is necessary.

Online submission is quickly becoming industry standard.

o Build electronic inquiry capabilities for providers giving them real-time access to information without having to phone or fax Regence

o Build internal operational efficiencies for Regence teams

• Primary benefitso Quicker determination time, resource efficiency, improved experience for members and

providers. o Aligns with feedback from our consumers asking that their health “plan and provider work well

together”


What is Availity?What is Availity?

• Availity is Regence’s Provider Portal. • Tool supporting multi-payer views, transactions and member eligibility

• Via Availity, providers already have the capability to perform numerous electronic transactions with Regence, including: • Check Eligibility & Benefits• Referrals• Member ID cards and Benefit Books• Care Gap Alerts• Claims Submission and Status check• …and more

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eAuth – Laying the foundationeAuth – Laying the foundation

• Regence launched the first phase of eAuth in February 2018, laying the foundation for a suite of online transaction capabilities in the future

• Via Availity, our providers can now: • Submit pre-authorization requests and attachments to Regence electronically, using HIPAA 278

transaction industry standard• Receive real-time confirmation of a successful transaction with an authorization number for

reference • Current Benefits:

• eAuth is faster and easier than fax/phone transactions• Enhanced provider experience. eAuth adds value within a tool that is already widely used for

other transactions• Efficiencies will also improve turn-around times for determinations, benefitting providers and

members alike • Provider Feedback & Engagement:

• Very positive. Volumes/usage continue to grow. Training & outreach are ongoing.


eAuth – Building on the Foundation eAuth – Building on the Foundation

• Our eAuth Roadmap includes addition of these Enhancements in the coming year:

• eAuth Dashboard

o View transaction history

o View status, including final disposition of the authorization determination

o Inquire about an eAuth request

• Check for Pre-auth requirements before submitting a PA - instant notification that PA isn’t required, or that a request needs to be submitted elsewhere

• Change or cancel a PA (if the PA hasn’t already been completed by the plan)

• Incorporate a component of auto approvals into the eAuth flow. Providers will respond to specific clinical criteria questionnaires

• Future Benefits

• Automates some of the approvals

• Decreases determination time significantly

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QUESTIONS?QUESTIONS?

blue plan clinical initiatives webinar - may 2018€¦ · 10 cie: value proposition • the ability...

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