Episode Treatment Groups - Tri-State Regional Extension Center

Report
An Overview of
HealthBridge’s
Shared Data Analytics
Infrastructure
HealthBridge is one of the nation’s
largest and most successful health
information exchange organizations.
Randy Woodward
Director, Business Intelligence Systems
March 16, 2012
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“Best of Breed” Partners
 Enterprise Master Patient Index (eMPI)
 IBM’s Initiate™
 Clinical & Claims Data Repository & Clinical Analytics
 PluralSoft’s CareQuotient™
 Semantic Data Normalization
 Clinical Architecture’s Symedical™
 Claims Data Grouping Engines
 OPTUMInsight’s Symmetry™
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Initiate™
by
IBM
Overview
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IBM - Initiate
 Proven Patient and Provider data models
 Configurable identity matching algorithms and matching
thresholds, by data source
 Efficient data stewardship, governance, and data quality
resolution tools
 Enables collaborative data stewardship
 Alerts for data quality issues
 Custom business rules
 Tools to locate and correct duplicates
 Tools to identify and resolve potential duplicates and links
 Tools to identify and resolve patient data quality issues via
pre-configured analytics
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IBM - Initiate
 Proven standards-based integration
 Integration toolkit for loading patient data
 HL7 v2 and HL7 v3 support
 Web Services in support of SOA environments
 Support for Integrating the Healthcare Enterprise (IHE) HL7
v2 & v3 Profiles:
o Patient Identifier eXchange (PIX)
o Patient Demographic Query (PDQ)
o Audit Trail and Node Authentication (ATNA)
o Patient Admission Management (PAM)
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Symedical™
by
Clinical Architecture
Overview
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Clinical Architecture - Symedical
 Free-standing semantic normalization tool
 Critical capability to improve interoperability, and enable
aggregation of disparate data sources – operates across
all data structures
 “Out-of-the-box” mapping includes LOINC, RxNORM,
CPT, ICD-9/10, NDC
 Supports namespace and site specific terminologies
 Maps in advance when terminologies are known
 Maps terms dynamically at run-time when they're not
known
 Monitors and manages multiple maps remotely with
powerful workflow tools
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Clinical Architecture - Symedical
 Mapping algorithms that learn
 Recognition of new and changed terms and workflow tools to
manage
 Leverage configurable algorithms to fine tune results
 Role / Site based user security
 Fully audited environment
 “Rosetta Stone” – Enables terms to be mapped to/from
standard and non-standard lexicons
 Application: EPIC to EPIC translations (e.g., Hospital A lab
test catalogue to or from Hospital B lab test catalogue
utilizing LOINC coding as the common link)
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CareQuotient™
by
PluralSoft
Overview
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PluralSoft - CareQuotient
 Highly flexible DIMENSIONAL model for storing
conformed/normalized data
 Can store non-coded data and later transform that data
when translation maps are available
 Optimized data structure for reporting and aggregation
 Extensible data model, supports the addition of future data
requirements and related reporting
 Platform for data marts & OLAP cubes
 Data model supports clinical & claims data
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Information Domains
Encounters
People &
Organizations
Lab Orders & Results
Patient
Referrals & Authorizations
Appointments
Revenues (Charges, Grants ..)
Medications & Prescription Information
Provider
Expenses (Payroll, Supplies,
Infrastructure, …)
Immunization
Payer
Products
Radiology & Documents
Staff
Master Data (ICD, CPT, DRG, HCPCS,
CCS, CRG …), Geography
Facility
Medical Conditions (Allergies, Familysocial-medical history)
Clinical Observations & Vital Signs (EHR
Template/Flow Sheets )
Legend:
Provider
Member Enrollment
Medical & Rx Claims
Revenue (Ins. Billing)
Utilization
Payer
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PluralSoft - CareQuotient
 14 chronic disease conditions and preventative care
measures:
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Diabetes
Asthma
Hypertension
Ischemic Vascular Disease (IVD)
Coronary Artery Disease
Congestive Heart Failure
Chronic Pain
Depression
Tobacco Use Cessation Counseling and Advice
Breast Cancer Prevention
Cervical Cancer Prevention
Colon Cancer Prevention
Childhood Immunizations
Preventive Care and Screening
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PluralSoft - CareQuotient
 264 clinical measures including HEDIS, NQF, and PQRI
 Clinical measures can be customized
 360 standard reports & dashboards
 Standard reports & dashboards can be customized
 Leverages existing investments in hardware and
software infrastructure
 Built on the Microsoft Business Intelligence stack
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Diabetes Measures – Sample
Chronic Disease - Physical health
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Diabetes Measure Drill Through - Sample
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Patient Scorecard – Sample
Managing Comorbidity (physical & mental) + Preventive Care
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Provider Scorecard – Sample
Performance across physical & mental health, Chronic & Preventive Care
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Symmetry™
by
OPTUMInsight
(formerly Ingenix)
Overview
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Symmetry Suite
 Universal language and business standard for health care analytics
in the marketplace
 Only product suite in the market providing comprehensive health
care analytic solutions through “component” engines on an
integrated platform
Provider Measurement & Engagement
PCQ Connect
ETG
PEG
ERG
EBM
Connect
Clinical Resource
Measurement
Risk Assessment and
Predictive Modeling
Quality
Measurement
A complete toolkit for health care management and analytics
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Symmetry Suite
Episode Treatment Groups
Episode Risk Groups
Procedure Episode Groups
EBM Connect
PCQ Connect
 Symmetry Suite – common
analytics platform for:
 Care quality improvement
 Care cost management
 Physician performance
ratings
 Minimized total cost of
ownership
 Industry recognized common
methods and analytics
 8 of top 10 health plans
 20 of top 25 health plans
 24 BCBS plans
 Transparent, not a Black Box
 Flexible for your needs
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Episode Treatment Groups (ETGs)
Claims data
• Diagnosis codes
• Drug codes
• Procedure codes
Episode Treatment Groups
Claims data,
grouped by
episode
 Episode Treatment Groups
 Foundation for clinical resource
use and efficiency analyses
analysis by episode to support:
 Transparency
 Health care measurement
 Incentives for increased value and
high quality care
 Organize health care data
(experience) into episodes of care
related to the treatment of a
medical condition for a given
patient
 The market leading episode of
care grouper
 Over 200 health plans and other
health care organizations
covering over 160 million
individuals
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Episode Risk Groups (ERGs)
Claims data
• Diagnosis codes
• Drug codes
• Procedure codes
Episode Treatment Groups
Claims data,
grouped by
episode
 Episode Risk Groups
 Population-based health risk
assessment
 Predict current and future health
care usage for individuals and
groups
 Predicts a member's current
(retrospective) and future
(prospective) need for health care
services and associated costs
Episode Risk Groups
 Clinically-relevant – robustly
prioritize multiple conditions and
co-morbidities
Administrative
• Age, gender
Risk score for
each individual
 Adoption
 Over 100 health plans and other
health care organizations covering
over 115 million individuals
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Evidence Based Medicine (EBM Connect)
Claims data
• Diagnosis codes
• Drug codes
• Procedure codes
Administrative
• Enrollment records
• Laboratory results
• Disease registry
EBM Connect
 EBM Connect
 Foundation for quality measurement:
assesses compliance of delivered care with
evidence-based medicine and care
guidelines
Members who
qualify for EBM
conditions and
their compliance
 Identifies gaps between clinical evidence and
health care practice
 Unnecessary or potentially harmful
diagnostic tests or treatments
 Patients with indications of poor disease
control
 Potentially harmful drug-to-drug or drugto-disease interactions
 Identifies both high-performing
physicians and areas to recommend
improved physician compliance with
prescribed care
 Adoption
 30 Health plans and other health care
organizations covering over 100 million
individuals
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Procedure Episode Groups (PEGs)
Claims data
• Diagnosis codes
• Drug codes
• Procedure codes
Procedure codes
• CPT
• HCPCS
• NUBC
Episode Treatment Groups
Claims data,
grouped by
episode
Procedure Episode Groups
 Procedure Episode Groups
 Industry-first foundation for
enhanced analysis by procedure
to support
 Transparency
 Provider measurement
 Incentives for increased value
and high quality care
 Analyze the cost and quality of
surgical providers, procedures,
and related services
Risk score for
each individual
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Provider Cost & Quality (PCQ Connect)
Claims data
• Diagnosis codes
• Drug codes
• Procedure codes
Episode Treatment Groups
Claims data,
grouped by
episode
PCQ Connect
Peer Groups
• Attributed episodes of care,
by severity group
• Attributed quality measures
– EBM conditions and
compliance
EBM Connect
Administrative
• Enrollment records
• Laboratory results
• Disease Registry
Members who
qualify for EBM
conditions and
their compliance
 PCQ Connect
 Foundation analysis for physician
measurement
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Network management
Transparency
Tiering
P4P
Centers of excellence
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Advantages of PCQs
 Adjust for Severity
 Provides multiple methods to reflect underlying differences
in the types of cases addressed and the severity of a
patient’s condition
 Manage outliers
 Provides different methods to identify outliers, and the
ability to include, exclude, or set the cost to the threshold
value to account for and treat outlier episodes appropriately
 Define peer groups
 Provides standard methodology for creating peer groups
within the same region and specialty
 Attribute properly
 PCQ Connect correctly attributes the right cost and quality
measures to the right provide
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Symmetry Applications
Business
Application
ETG PEG ERG EBM
PCQ
Connect
Connect
Provider Performance
Measurement
Disease / Care
Management
Member / Population
Risk Assessment
Financial Performance
and Trends
Providers, Employer
Groups, and Consumer
Information Sharing
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Thank You!
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