DH Blog

Dispatch from the SHIEC Conference

09/14/2017

Tom W. Gaither
Vice President of Marketing, Diameter Health

I recently returned from the 2017 SHIEC (Strategic Health Information Exchange Collaborative) Conference, held this year in Indianapolis, IN from August 27-30th.  SHIEC membership grew almost 100% in the last year and its members now cover nearly 75% of the people in the United States.  The conference is always extremely well run, and this year was no exception.  The sessions were informative, and the networking valuable.  As a SHIEC business partner, at Diameter Health we feel like part of the SHIEC family, and not just a “source of funds.”

Following are my impressions of the conference gathered from sessions, in the exhibit hall, and dining rooms.

From Connectivity to Value Creation

A definite shift in the conversation this year, away from “connectivity” and toward creating value for members (value creation going by several different aliases, including “member need,” “use case,” “line of business,” “value stream,” and “business case”).  Some examples include:

  • Pre-authorization

Medical pre-authorization, of course, is the process of a physician getting approval from a payer to cover a service or medication prior to the service being performed or the medication dispensed.  Pre- authorization certainly qualifies as a process in need of improvement.  It’s time consuming, expensive, dissatisfying and of questionable value… and becoming more prevalent.  A Kaiser Family Foundation study[i] showed that 8% of medications covered under Medicare Part D required prior authorization in 2007.  By 2013, the percentage had increased to 21%.

In addition, a 2017 AMA study[ii] estimated that physician practices spend more than 16 hours a week on activities related to prior authorization, totaling 853 hours annually per practice.  Even at modest billing rates, prior authorization costs physician practices billions each year.

Payers do have a legitimate need for clinical data.  Claims data does not provide the level of detail often required to assess clinical indications.  And prior authorization is also an expense for payers.  A 2009 study from the Robert Wood Johnson Foundation[iii] found that 1.3% of each premium dollar goes to “provider and medical management.”

A better approach would be to use technology and current interoperability standards to provide the clinical data needed to enable prior authorization. This would require both normalized data as well as applications designed to fit into existing provider and payer workflows.  Interesting how many companies are beginning to attack this opportunity.  Entrepreneurism at its best, seeking to use data and technology to eliminate waste from the system.

  • Behavioral Health

The behavioral health market is “booming:”

  • 9 million Americans over age 12 are addicted to drugs and alcohol [iv]
  • Significant eating disorders affect 30 million men and women[v]
  • One in three seniors die with Alzheimer’s or some other dementia[vi]
  • 9% of the US population suffers from significant personality disorders such as depression, schizophrenia, and bipolar disorder[vii]

Traditionally, behavioral health and medical delivery have utilized separate technical systems.  This is changing as payers push to reduce re-admissions and emergency room visits, recognizing that 75% of hospital inpatient frequent flyers have behavioral health diagnoses.[viii]

Unfortunately, current interoperability standards do not completely support behavioral health data.  While there are examples of health centers and health systems beginning to exchange such data (see, for example, Behavioral Health Care Executive, “Continuity of care documents bridge gaps” January 4, 2016) information gaps remain.  A frequent omission from the CCD is the treatment plan, which is a behavioral health standard.  Other shortcomings may include insufficient detail on patient problems and prescribing physicians.  An additional challenge are the stricter privacy requirements for behavioral health information.

Health Information Exchanges (HIEs) have an important role to play in the effective exchange of behavioral health data.  Jody Denson, Director of Provider Solutions at the Kansas Health Information Network (KHIN) had this to say, “HIEs are having increased success in working through complex issues around behavioral health privacy requirements and standards. By working through the challenges of technology and being able to segment data or restricting access to certain types of data, HIEs are beginning to develop solid and compliant ways to exchange behavioral health data.”

While tweaking existing data standards may be required, it seems current standards could be utilized more effectively if the right feedback loops were in place.  See the “Feedback” section below.

  • Quality Reporting

Drs. David Kendrick and Matt Hoffman, as well as John D’Amore (full disclosure – John is a colleague at Diameter Health) participated in a panel discussion on Quality Reporting.

As John D’Amore pointed out, quality reporting is now a primary measure for value based care.  Consequently, there is increasing interest from payers in the use of clinical data as standard data to supplement HEDIS reporting.  Finally, ONC has announced their intention to harmonize their e-clinical quality measures with existing NCQA standards.

In Dr. Kendrick’s presentation, he demonstrated that the current process for quality reporting provides inconsistent and even random results.  However, with consistent attribution of patients to providers and payers within a time window, reporting results from the health information exchange’s (HIE) perspective can provide a more accurate picture of quality performance.  In turn, this may be another significant new business opportunity for HIEs to provide value to members.

  • Feedback and Crowdsourcing

In general, we continue to hear that HIEs struggle to measure the quality of the data they manage “at scale.”  As has been documented elsewhere, this leads to errors in syntax as well as semantic meaning.  Often one missing field can result in multiple points of failure (example: a missing encounter can disqualify multiple quality measures which are otherwise completely conformant).  Automated data quality assessment tools (full disclosure again: Diameter Health provides one such tool) scan for the critical “for the lack of a nail, the shoe was lost, for the lack of the shoe, the horse (and the war) was lost…” data types and provides the needed feedback to the source to correct the issue.  Jody Denson from KHIN commented, “HIEs can work with EHR vendors and mental health centers to explore workflow or development solutions to improve the content and amount of data being exchanged.”

Such feedback loops would enable HIEs and other stewards of multi-sourced clinical data to, in effect, “crowdsource” data solutions for the prior authorization, behavioral health and quality measurement use cases discussed here.  In a fraction of the time previously required, and without additional government regulation, the industry could focus on and build out the data required for applications needed to improve patient care, while improving operating results and reducing expense.

[i] http://www.kff.org/medicare/issue-brief/medicare-part-d-prescription-drug-plans-the-marketplace-in-2013-and-key-trends-2006-2013/
[ii] https://wire.ama-assn.org/practice-management/survey-quantifies-time-burdens-prior-authorization
[iii] “Simplifying Administration of Health Insurance” Robert Wood Johnson Foundation, January 2009
[iv] Federal Substance Abuse and Mental Health Services Administration (SAMHSA), 2013
[v] Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011). Epidemiology of eating disorders
[vi] Asha.org. ‘Dementia: Incidence And Prevalence’. Web. 27 Jan. 2015
[vii] National Institute for Mental Health
[viii] Chakravarty, Sujoy et al. Role Of Behavioral Health Conditions In Avoidable Hospital Use And Cost. New Brunswick: Rutgers Center for State Health Policy, 2014. Web. 27 Jan. 2015

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