Health Plan Leaders Discuss HIE Data and the Value Proposition for Payers

March 13, 2018
During the HIMSS18 Conference in Las Vegas last week, health plan leaders shared how their organizations are leveraging HIE data to improve quality measures, care management and to address gaps in care.

As health information exchange (HIE) organizations continue to evolve, HIE leaders are focused on expanding services and providing data analytics and business intelligence tools to providers and health plans. Many provider organizations view local, regional and even national HIEs as important partners for data sharing for population health management and care coordination.

During the HIMSS18 Conference in Las Vegas last week, there were several educational sessions focused on the value proposition of HIE data for providers and payers. During two separate sessions focused on HIEs and interoperability, two health plan leaders shared how their organizations are leveraging HIE data to improve quality measures, care management and to address gaps in care.

Newly evolving HIE services are creating opportunities for health plans and providers to improve transitions in care, particularly for underserved populations. Philadelphia-based AmeriHealth Caritas is a managed care organization that serves 5.7 million members who receive care through government-funded programs in 17 states and the District of Columbia.

According to Andrea Gelzer, M.D., SVP and corporate chief medical officer, AmeriHealth Caritas, the members that the company serves include Medicaid recipients, dual eligibles, members who need long term services and support (LTSS) and people with intellectual and developmental disabilities (IDDs), and this population faces a number of social challenges, including poverty, language barriers, education, homelessness and food access. Common health issues among this population include health literacy, comorbidities, behavioral health, substance use, polypharmacy and medication adherence. “Our members are on an average of 8 to 9 medications,” Gelzer said.

“Our policy is ‘HIE-first’ for interoperability, so if we’re in a market, and there is an operating exchange, then we participate, and we also push data,” she said. Gelzer said the company uses continuity of care documents (CCDs) to support member transitions of care and for real-time medication reconciliation of hospital and pharmacy medications.

Currently, there are six state/regional HIEs exchanging data with the company’s health plans with 1,000-plus hospitals sending data to its plans via HIEs. Gelzer also said there are currently 1.34 million members in health plans exchanging information with HIEs, with 2.4 million admission, discharge and transfer (ADT) notification alerts received through HIEs, to date.

The company has been working with Healthshare Exchange (HSX) as a founding member since 2014. HSX is a regional HIE serving the Delaware Valley, including the greater Philadelphia and southern New Jersey areas, with 6.25 million patients in its master patient index, as of October 2017. HSX offers CCDs post-discharge from hospitals, among other services. AmeriHealth Caritas is working with HSX to use a data-driven approach to improve medication reconciliation among high-risk plan members.

Gelzer said AmeriHealth Caritas leaders recognized that ineffective medication reconciliation can have grave consequences with significant patient safety concerns. Medication errors are most likely to occur during care transitions and errors can result in serious adverse events, she said. The health plan wanted to improve medication reconciliation with a specific focus on high-risk hospital discharges and collaborated with HSX in this effort.

Patients facing the challenges of low health literacy and social determinants are more likely to fall through the cracks for transitions in care. Using risk stratification to target the most-needy members, high-quality data delivered by the HIE, and automated matching of the CCD data with other medication sources, the plan was able to identify patients needing immediate follow-up.

In the first month the project was operational, AmeriHealth Caritas received data from four hospitals and now, to date, the health plan is receiving data from 15 hospitals. “We’ve received more than 16,000 CCDs through the HIE for this target, high-risk population for medication reconciliation. The volume is good, and the veracity of data appears to be good as well,” she said.

Through this medication reconciliation process, the health plan found significant discordance between discharge and pharmacy medications. “We believe a lot of that is due to medication reconciliation that’s often done in an ER, which is often based on what the patient can tell you, what a patient’s caregiver or family member tells you. That’s not acceptable anymore. That’s a large source of discrepancies, and a root cause to why we see so many medication issues on people hospitalized,” she said.

The health plan has found that care management and pharmacist follow-up with providers positively impacts care, improves transitions of care and supports medication reconciliation.

“The next step is work to push our CCDs to hospital ERs, and then they will have the fill data, and that will hopefully make reconciliation a lot more effective.” And, she noted that health plans that invest in interoperability can leverage this capability at scale.

“If you are a large commercial insurer and have plans in 50 states, until you see value from HIEs, it’s hard to justify the resources to participate in HIEs in 50 states. We are seeing value.”

In another session, an executive leader at Anthem, the second-largest health insurance company in the U.S. with 40 million members, detailed how the health plan is using HIE data for HEDIS (Healthcare Effectiveness Data and Information Set) and quality reporting, care management, to help close care gaps and for value-based care payment arrangements.

Dirk Rittenhouse, director of clinical data acquisition and analytics at Anthem, says the health plan works with a number of HIE organizations, including Kansas Health Information Network (KHIN), based in Topeka, Kan. HIE data provides a more accurate member profile and Anthem utilizes analytics capabilities provided by KHIN for value-based care, population health and predictive analytics, he said.

“The type of data that we are looking for out of HIEs is clinical data that is incremental and additive,” he said. “HIEs are great for payers; they have dealt with the governance issues and the connectivity issues.”

Created in 2010, KHIN has health data on 5.2 million unique patients with 9,900 providers connected to the HIE and more than 25 million patients available for query through connections with other exchanges.

“We connect EHRs (electronic health records) to the KHIN network to offer providers with a longitudinal health record at the point of care and that data has to be gathered in a centralized data warehouse to provide analytics and business intelligence back to providers and payers,” Laura McCrary, executive director of KHIN, said.

She continued, “Connectivity is the first thing we have to do; there’s no magic to it, it’s just hard work. Up until 2015, it was the only thing we did. Then we realized the opportunity with the HIE data to actually capture it, aggregate it and provide it back. So, we take the data and listen to what doctors and hospitals say they need.” To this end, KHIN developed a number of analytics dashboards for providers, such as dashboards for high-risk patients, quality metrics, readmissions, disease registries and population health. “The payers want to see data as well. But, none of the payers want the same thing, so you have to be flexible and meet the payers where they are at,” she noted.

Rittenhouse noted that the original purpose of HIEs was to connect clinicians and providers at the point of care. “Using data for quality management and analytics was a serious afterthought, and a lot of the work needs to be done in the next phase in order to improve the quality of CCD-As,” he said. “As health plans move to value-based contracting, clinical data will be part of those contracts and health plans can leverage the HIEs to make those connections for this data, because providers have dozens, maybe 20 or more, payer contracts and are already participating in HIEs.”

He added, “We’re committed to the digitization of medical records and we expect, as a byproduct, to be able to leverage that semantic interoperability for analytics. We’re in this in a big way; HIEs have a lot of potential.”

McCrary says KHIN is evolving in its strategic focus: “It’s used to be ‘Let’s just get data into the HIE.’ Now, we want good, high-quality data. We are moving from a focus on interoperability to data quality and quantity.”

Sponsored Recommendations

Enhancing Remote Radiology: How Zero Trust Access Revolutionizes Healthcare Connectivity

This content details how a cloud-enabled zero trust architecture ensures high performance, compliance, and scalability, overcoming the limitations of traditional VPN solutions...

Spotlight on Artificial Intelligence

Unlock the potential of AI in our latest series. Discover how AI is revolutionizing clinical decision support, improving workflow efficiency, and transforming medical documentation...

Beyond the VPN: Zero Trust Access for a Healthcare Hybrid Work Environment

This whitepaper explores how a cloud-enabled zero trust architecture ensures secure, least privileged access to applications, meeting regulatory requirements and enhancing user...

Enhancing Remote Radiology: How Zero Trust Access Revolutionizes Healthcare Connectivity

This content details how a cloud-enabled zero trust architecture ensures high performance, compliance, and scalability, overcoming the limitations of traditional VPN solutions...