HIMSS Patient-Centered Payer Roundtable March 17, 2011

HIMSS Patient-Centered Payer Roundtable March 17, 2011

Agenda Welcome Call to Order and Roll Call (Paul Oates, Shelley Price) Topic discussion The Value of ONC Interoperability Initiatives to the Healthcare Payer Community (Erik Pupo, Senior Advisor to ONC on HIE ) Topic discussion HIMSS11: Wrap-up (Paul Oates) Topic discussion PCPR next steps (Jeffrey Pankow) Housekeeping (Shelley Price) Adjournment

The Value of ONC Interoperability Initiatives to the Healthcare Payer Community Erik Pupo

Introduction • Objectives of this presentation are: • Briefly highlight the payer environment and how interoperability can help • Showcase the work that ONC is doing for interoperability and how it supports payers requirements • Highlight examples of usage of ONC interoperability to solve common payer issues • Answer questions related to ONC efforts in interoperability

Let’s Begin…. • Notes: • I wont cover every aspect of interoperability – this is focused on ONC’s interoperability initiatives and how they can help you • I LOVE questions – its not always easy to explain in slides how interoperability initiatives work so feel free to ask questions • Suggestions for improvement – opening a dialogue with payers to critique and improve interoperability initiatives is a WELCOME occurrence

The Current Environment for Payers • Under pressure from healthcare reform – more regulation and oversight, less flexibility • Payer revenue will increasingly be driven by risk adjustment, NOT risk selection • Health reform will limit risk selection options open to payers and require more data analysis of the quality of care provided • Plans will no longer compare to benchmarks (like in Medicare Advantage) but to each other (as part of the healthcare insurance exchanges)

What Payers Need from Interoperability • Access to current, accurate, and complete diagnostic information is critical • Need to be able to match state and federal data electronically • Need to be able to submit and receive standardized and unstructured documentation electronically • Need to make eligibility data reusable • Need to give consumers the ability to see their eligibility and enrollment data online – the healthcare insurance exchange challenge • Needtonotify consumers to their eligibility for state and federal programs

Risks to Payers from Interoperability • There are several risks that payers may have with interoperability • We increasingly operate in a world where information is a valuable commodity. Payers have information that is important to others and need the ability to share this data, but there is always risks to sharing • Creating short term interoperability needed to satisfy Stage 1 meaningful use requirements , while also preparing stakeholders for Stage 2 of meaningful use • Assuring that providers know HIE mechanisms for meaningful use are available and begin to use them • Converting short term “work-arounds” for exchange to more robust systems of exchange that cross provider systems and geographies (conceptual, technical, political challenges.)

Interdependencies of Interoperability

Interdependencies of Interoperability - continued

Why we need different interoperability initiatives Information is vital and it comes in many different formats which need to be addressed and able to be transported • HEALTH • “Convergent Drivers” • Electronic Health Records • Personal Health Records • Nationwide Health Information Network • CONNECT • National eHealth Collaborative • Regional Health Info Organizations • HITECH Acts • ARRA Act • HUMAN SERVICES • “Divergent Needs” • Day Care • School Meal Programs • School Vaccines • Sports Physicals • Disability Determinations • Life Insurance Eligibility • ADA and Housing Assistance • Pre-employment Evaluations In addition to current mountains of historical paper records, there will always be some new information created in healthcare and human service settings. We need different ways to transport that information *Center for Information Technology Leadership Standards Levels 12

Interoperability and Healthcare Reform Requirements for Payers • ACO and Medical Home Needs (and requirements) • Seamless transitions in care • Longitudinal, cross-organizational records • Look-up, data queries • Managed problem, medication, allergy lists + • Quality and efficiency management data and services • Including claims and process data, workflow integration • Population analytic tools and registries • Cross-organizational team communications and care • Including patient communications • Clinical Decision Support

How ONC Interoperability Initiatives are coordinated

Coordination of Interoperability

How does Direct work? • Direct can be implemented by any two participants, organizations or a community without a central governance structure • Enable communications of simple content today and easily transition to structured and coded documents for clinical decision support in the future

Direct Project andInformation Exchange The Direct Project doesn’treplace other ways information is exchanged electronically today, but it might augment them. The Direct Project supports simple use cases in order to speed adoption, but other methods of exchange might be suited for other scenarios. The Direct Project was designed to coexist gracefully with existing protocols for data exchange. The Direct Project seeks to replace slow, inconvenient, and expensive methods of exchange (like paper, fax, or carrier pigeon) and provide a future path to advanced interoperability. State HIE Commercial HIE Health information exchange: a puzzle with many pieces

Direct Participants • Ability/VisionShare • Allscripts • American Academy of Family Physicians • Atlas Development • Axolotl • CareSpark/MobileMD/Serendipity Health • Cautious Patient • Cerner • Clinical Groupware Collaborative • Covisint • CSC • eClinicalWorks • Emdeon • Epic • FEI • Garden State Health Systems • GE • Google • Greenway Medical Technologies • Harris Corporation • High Pine Associates • HLN Consulting, LLC • IBM • Indiana State Department of Health • Inpriva • Intel • Kryptiq • LabCorp • Massachusetts eHealth Collaborative • MedAllies • MIE/NoMoreClipboard.com • Medical University of SC • Medicity • MedNet/ApeniMed • MedPATH Networks • MedPlus • Quest Diagnostics • Microsoft • Mirth Corporation • MOSS • NextGen • NIH NCI • NIST • NYC Dept. of Health and Mental Hygiene • Oregon HIE Planning Team • Redwood MedNet • RelayHealth • Rhode Island Quality Institute • Secure Exchange Solutions • Siemens • South Carolina SDE • Surescripts • Techsant Technologies • TN State HIE • VA

Real-world Implementation The Direct Project is being demonstrated in real-world pilots across the country and is in production use by HIEs, EHRs, and PCHRs Rhode Island Quality Institute (RI) VisionShare (MN) MedAllies (NY) Redwood MedNet (CA) Medical Professional Services (CT) CareSpark (TN) VisionShare (OK) • Direct Project is architected for rapid adoption by: • Thousands of hospitals • Hundreds of thousands of physicians • Millions of providers • Tens (or hundreds?) of millions of patients • Many other stakeholders in healthcare

What is CONNECT? • CONNECT is an open source software solution that enables health information exchange – both locally and at the national level. CONNECT employs Nationwide Health Information Network standards and services to ensure that health information exchanges are compatible with other exchanges throughout the country. • CONNECT was developed by federal agencies to support their health-related missions. It is now available as an open source solution to any organization seeking to establish health information exchanges using nationally-recognized interoperability standards.

What makes CONNECT go? • Three primary components make up the CONNECT solution: • The Core Services Gateway can locate patients at other organizations, request and receive documents associated with the patient, and record these transactions for subsequent auditing by patients and others. Other features include mechanisms for authenticating network participants, formulating and evaluating authorizations for the release of medical information, and honoring consumer preferences for sharing their information. The Nationwide Health Information Network Interface specifications are implemented within this component. • The Enterprise Service Components provide default implementations of many critical enterprise components required to support electronic health information exchange, including a Master Patient Index (MPI), XDS.b Document Registry and Repository, Authorization Policy Engine, Consumer Preferences Manager, HIPAA-compliant Audit Log and others. • The Universal Client Framework is a set of applications that can be adapted to quickly create an edge system, and be used as a reference system, and/or can be used as a test and demonstration system for the gateway solution. This makes it possible to innovate on top of the existing CONNECT platform • It allows you to build your own HIE or serve as an intermediary on Exchange

Using Exchange Protocols

CONNECT Implementation Status Federal Agencies & Other Partners Demo/Pilot Production Centers for Disease Control & Prevention Centers for Medicare & Medicaid Services Department of Defense Department of Homeland Security Department of Justice Department of Veterans Affairs Food and Drug Administration Indian Health Service National Cancer Institute National Disaster Medical System Social Security Administration Orange County ER Connect Redwood MedNet Indiana State Department of Health Iowa Department of Public Health Iowa Health Systems MedVirginia New York State Department of Health Thayer County Health Services Washington State Department of Health Limited pilot production on NHIN Limited pilot production on NHIN Limited pilot production on NHIN Federal Agencies Limited pilot production on NHIN Moving into limited production in 2010 Moving into limited production in 2010 Limited pilot production on NHIN Moving into limited production in 2010 Moving into limited production in 2010 Other Partners Limited pilot production on the NHIN Moving into limited production in 2010 Moving into limited production in 2010 Moving into limited production in 2010

Examples of Applying CONNECT - ESMD • Electronic Submission of Medical Documentation (ESMD) • Proposed solution would leverage the existing CONNECT architecture designed (reusable solution within CMS): • Document submission adapter • Policy engine adapter • Audit/Logging adapter • New esMD development contract awarded with focus on Electronic Document Submission and Electronic Document Request in support of RAC contractors • Develop an esMD profile and implementation guide (coordinated with ONC) • Incremental esMD transactions can be added to the existing gateway or a stand-alone esMD gateway modeled after the C-HIEP design can be implemented

ECM Content Transport Services Example of using Direct AND CONNECT – esMD Architecture Documentation Request Letter www.cms.gov/esmd CERT RACs PERM MACs ? Medicare Private Network D I R E C T D I R E C T CMS CONNECTCompatible

Example of Using CONNECT - CHIEP

Exchange – Enabling Nationwide Exchange of Information Support the nationwide exchange of information among larger organizations AND…..Expected to support more complex interoperability requirements that require intermediary assistance

Example of Exchange – Electronic Transmission of Service Treatment Records (STRs) When a person leaves the military, VBA needs to review their entire medical record to make a disability determination. In many cases, the veteran’s records are stored in several locations including both military and private providers. Iraq Bethesda, MD Quantico, VA Richmond, VA Kingsport, TN Pinehurst, NC Cherokee, NC Albuquerque, NM HIMSS 2010

Audit Repository Record Locator / Document Registry Provider Directory Patient Identity Manager Gateway Document Repository Consent Manager Infrastructure Enables Nationwide Exchange Personal Health Record and Personal Health Devices Payers Enterprise and Departmental Systems Including Medical Devices EHR System Specialists Core Infrastructure

NIEM Integration into ONC interoperability efforts

Benefits of Interoperability for Payors • Standardized content to facilitate the exchange of eligibility and enrollment information among payers • Innovative solutions for transporting eligibility and enrollment data • Point to Point – small providers and organizations can reuse Direct backbone for simplified eligibility and enrollment transactions • Reuse of existing systems – modular approach to support vendors who want to add this as a feature through CONNECT • New systems and services to support growing eligibility and enrollment requirements that are available on Exchange • Increased access to care through expedited eligibility and enrollment by standardized and efficient information exchange • Providers rightfully fear providing care to someone who cannot pay • Real time access for providers to determine “can you pay?”

Business Benefits of Interoperability • What ONC wants to do for you by providing various interoperability options….. • Improved timeliness of benefits adjudication – quick transmission of information • Improved completeness of information available to payers for analysis – making information available nationally • Decreased fraud and waste costs due to more information available for detection – the holy grail of payer interoperability • Closer tie-in to elimination of healthcare disparities – opening up a wealth of information to a larger group within the population to improve their care

Additional Business Benefits of Interoperability • Benefits also include: • Improved Coordination of Benefits across all federal and private payers and citizens • Federal Agencies, Private Health/Dental Insurance, Accident Insurance • Primary and tertiary payers sharing information helps to maximize benefits to patients and payers • Medicaid reconciliation across state boundaries • Helping to meet Meaningful Use Stage 1 national priorities • Coordination of Care Referrals, Transfers • Check ‘eligibility’ status electronically/Submit claims electronically from/to public and private payers • Provider priority of billing • Eventual development of citizen-accessible eligibility and enrollment summary • Coordination of Care, Coordination of Benefits, Consumer Empowerment

Questions? • I would be happy to answer questions on: • The role of payer organizations in interoperability • How you can help ONC and its interoperability initiatives • What is the future of interoperability?

HIMSS11 Payer Program • HIMSS11: February 20-24, 2010 in Orlando, FL • 31,225 attendees; 1,000+ exhibitors; 400+ edu sessions • 266 payers: CIOs, CFOs, COOs, CMOs, Innovation and R&D, IT Strategy, Health Information Systems, • Pre-conference events • Symposia: Secondary Use of Data (106); 5010/ICD-10 (230) • Conference events • Payer Breakfast (80 attendees) • PCP Roundtable w Wes Richel, Gartner (50 attendees) • VIP tour of interoperability showcase • ACO conference: Leading From the Future • Clinical Integration: the foundation for ACOs • Strategic Directions of ACOs from the Provider Perspective • ACO Building Blocks: Why a High Quality Data Organization Matters • ACOs: IT from the Payer Perspective (Lewis Sandy, SVP, UnitedHealth Group) • The Payer Perspective: An Update from CMS (Don Berwick, CMS Administrator) • Building and Sustaining ACOs Through the Meaningful Use of HIT

Roundtable: Next Steps • Governance • New Groups • Thanks to those who volunteered at HIMSS11 • Reaching out soon • Leadership • Speakers Bureau • Website Workgroup • FY12 – planning

Housekeeping • The Call for Proposals for HIMS12: • open March 21 – May 23, 2011. • http://www.himss.org/asp/education_annualConf_callProposal.asp • The Call for Reviewers for HIMS12: • open March 21-May 23, 2011. • http://www.himss.org/asp/education_annualConf_reviewer.asp

Wrap-up • Web page • http://www.himss.org/advocacy/about_patientCenterPayer.asp • Next meeting • 3rd Thursday of the month from 4-5pm EST • Thursday, April 21, 2011

Chairperson: Paul Oates Senior Enterprise Architect CIGNA Healthcare Paul.Oates@cigna.com Vice Chairperson: Jeffrey Pankow Director, IT Excellus BCBS Jeffrey.Pankow@excellus.com HIMSS Staff Liaison: Shelley Price Director, Payer and Life Sciences Initiatives HIMSS sfichtner@himss.org Leadership and Contact Information

HIMSS Patient-Centered Payer Roundtable March 17, 2011