university of minnesota information technology in healthcare medical industry leadership institute...
TRANSCRIPT
University of MinnesotaInformation Technology in
Healthcare Medical Industry Leadership Institute
Course: MILI/PUBH 6562Fall Semester B, 2014Stephen T. Parente, Ph.D.
Carlson School of ManagementDepartment of Finance
Class # 3 Health IT Data Structure
The Insurer• Basic data structures• Units of analysis• Health data over time• Health insurance data architecture• Small group exercise
Data Structure Fundamentals
• Simple text/column data • Pre-packaged data• Relational databases
Simple Column Text Data
Patient DOS ProcedureAllowed
Joe 02/03/14 MD Visit $100
Joe 06/05/14 Lab test$60
Joe 02/03/14 Lab test$60
Joe 06/05/14 MD Visit $100
Mary 01/06/14 MD Visit $100
Penny 11/11/14 Eye Exam $80
Pre-packaged databases
• MS-Access databases• SQL databases• SAS databases• SPSS databases• STATA databases• Excel spreadsheets
Relational Databases
• The database stores data in individual files or tables with data items arranged in rows and columns.
• AT LEAST one data item (the key) is common to each table and is used to LINK two or more tables for ad hoc queries.
• Common method to use relational databases is through SQL (structured query language).
Health Data Display by Different Units of Analysis
• By provider • By person• By episode/incident• By transactions• Over fixed units of time
By Person
By Episode
By Transaction
Health Data Representation: Over Time?
Mental Health
Jan Apr July Oct Dec
=Pysch consult
Cumulative CostWell
Sick
Normal
$50K
$0
Insurers’ Role in Health IT
• They are the ‘links’ that connect to everything about a patient in an electronic form.– Employers– Providers– Patients– Government agencies– Researchers
Insurer’s IT Paradox
• They are being held accountable for an insured patient’s total care.
• Best breadth of data–Most all places of service– ‘Standardized’ data
• Worst detail– No clinical info on patient health status and
outcomes.
IS Management Structure
CEO
CIO
Claims
CFOCOO
SystemsMIS Actuarial AccountingUR MCO
Working Group Backbone
HEALTH INSURANCE CLAIM FORM
The Health MIS Pyramid
Hardware
Decision Support Software
Life Support Software
Clinical & Financial Data
Insurer Hardware - Mainframe
Insurance Database Architecture
• Claims• Membership• Provider files• Case management• Utilization review / Demand Management• Decision-support databases• Analytic / Financial data
Claims Data
• Entered manually (10%), submitted electronically (90%) - on average.
• Key items:– Claim ID and date or service– Member / Subscriber ID– Provider of service– Diagnosis & procedure– Charges, reimbursements & copays– Administrative information
Claims Data Example
Claims Data Example
Membership / Subscriber Data
• Member / Subscriber ID (sometimes not person specific!)
• If managed care, assigned gatekeeper• Dates of enrollment• Age, gender, case-mix, health risks• Address• Type of policy, employer• Status of benefits used during enrollment
Subscriber Data Example
Provider Files
• Used to pay bills and identify providers to be included in ‘Panels’ for new products.
• Key Data Items:– Provider ID– Specialty, Board Certification, Education–Malpractice history & insurance– Address– Profiling summary
Provider File Example
Case Management
• Patient tracking systems• Check to see if recommended ‘process of care’
is occurring as part of good quality care.• Patient reminder systems (mail)• Provider reminder systems (phone, mail &
electronic)• Outcomes and cost assessment
Utilization Review / Disease Management
• Either run directly or contracted to 4th party acting as Insurer’s agent.
• Have decision-support systems based on clinical algorithms (and possibly patient’s claims) to manage a patient’s care.
• Common conditions reviewed/managed:– Schizophrenia, depression– Heart disease– Diabetes, Asthma, Glaucoma– AIDS
Support Databases
• Procedure fee schedules• Diagnosis codes• Institutional arrangements for managed care
payment• Pharmacy fee schedules and formularies• ‘Grouper’ algorithms– DRGs, MDCs,– Case-mix and severity
Life Support Systems
• Accounts Receivable– Employers– Consumers– Government
• Claims payment– Error checking– Provider payment– Fee schedules & payment algorithms
• Benefits/eligibility
Analytic / Financial Data
• ‘Cleaned’ versions of claim, provider and membership files designed to:– Generate premium estimates– Adjust provider fee schedules– Profiling of:• population (e.g., all patients with diabetes)• practices• employer groups• patients
Small Group Exercises(Part 1 of a 2 Part Exercise)
• What ‘information’ can health insurance data provide?
• Name 2 major strengths and weaknesses of claims data as a management tool.
• Poof: You’re a Blue Cross Blue Shield CIO.– You have $50M to spend to upgrade your claims system.– It costs $1M per text/character to enhance your data.– What data fields would you add?– Are there any data fields you would consider deleting or
optimizing?
Intermission
Medical Provider Data
• Patient Diagnosis Information• Treatment plan• Referrals• Outcomes• Explanations for treatment
The Operation• The Hospital submits lots of bills
– Lab work– Blood– Anesthesia– ER room time– Supplies
• Surgeon John submits a claim for surgery.• Dr. Bob submits a claim for IP consultation.• Internal hospital systems affected:
– Inventory– Payroll– Accounts receivable– Medical records
• PPO reimburses hospital.• PPO reimburses Dr. Bob• PPO reimburses Dr. John
Medical Center Data Systems
LifeSupport
Data
Hardware
Medical Data Collection - 1
• Operational data: Transaction-oriented– Hospital pharmacies– Laboratories– Radiology departments– Critical care units– Order-processing units
Medical Data Collection - 2
• Analytic data– Carry all variables of interest– Single record– Data is stored horizontally
Code Systems Standards - 1
• HL7 - American National Standards Institute Health Level – Patient registration data– Patient orders– Clinical information (e.g., vital signs)– Referral information– Clinical trial data– Other operational transactions
Code Systems Standards - 2
• X12 - Data Interchange Standards Association’s Accredited Standards Committee– Insurance enrollment & payment– Administrative messages
Code Systems Standards - 3
• Diagnoses: International Classification of Diseases, Version 9 (ICD9)
• Procedures: Current Procedural Terminology, Version 4 (CPT4)
• Drugs: Food and Drug Administration’s Nation Drug Code (NDC) directory
Code Systems Standards - 4
• LOINC - Logical Observations Identifier Names and Codes (LOINC) database: The Missing Link– Codes, names and synonyms for more than 12,000
observations:• laboratory tests• vital signs• electrocardiograph measurement• input & output measures• clinical impressions• discharge summary
Code Systems Standards Examples
Integrated Delivery SystemIT Network
LifeSupport
Data
Hardware
DecisionSupport
Insurer Only Data
1/31/14
2/6/14
PCP visit
Specialist visit
Laboratory test
Biopsy
Surgery
Sub-Acute Care
Medical Data Available to a U.S. Fee-for-Service Insurer
LifeSupport
Data
Hardware
DecisionSupport
Medical Data Available to a U.S. Staff Model HMO
LifeSupport
Data
Hardware
DecisionSupport
Provider Only Data
1/31/14
2/6/14
White blood cell count high
Cancer metastasized
Referral to specialist
Malignant cancer remains
E/CPR Model A
E/CPR Model B
What are the Pros & Cons of these Models?
Are they out of date as useful data management models?
Data Available to the Average Medical Provider About a Patient’s Care
15% ofCare
25% ofCare
15% ofCare
10% ofCare
35% ofCare
Merging Insurer & Provider Data
1/31/14
2/6/14
PCP visit
Specialist visit
Laboratory test
White blood cell count highBiopsy
Cancer metastasizedSurgery
Referral to specialist
Malignant cancer remains
Sub-Acute Care
Small Group Exercises(Part 1 of a 2 Part Exercise)
• What ‘information’ can health insurance data provide?
• Name 2 major strengths and weaknesses of claims data as a management tool.
• Poof: You’re a Blue Cross Blue Shield CIO.– You have $50M to spend to upgrade your claims system.– It costs $1M per text/character to enhance your data.– What data fields would you add?– Are there any data fields you would consider deleting or
optimizing?
Small Group Exercises(Part 2 of a 2 Part Exercise)
• What ‘information’ can medical data provide?• If you are an insurance company CEO, how vital are
clinical medical records to your business?• If you are hospital administrator, name one pro and
one con to having access to health insurance data? What share of your profit/surplus are you willing to invest for such a link?