CHALLENGE: Tracking quality performance primarily through measures required by State and Federal programs such as NCQA’s HEDIS and CMS’ Medicare STARS program
OUTCOME: Timely access to data from the provider network to drive care coordination processes
In the greater New York City area, Healthfirst, a not-for-profit, hospital-sponsored health plan and pioneer in value-based care, recognized the need for collaborative data exchange with providers for quality and improved member outcomes.
A Private HIE to Access and Share Member Data
Leveraging the relationship with its sponsors, Healthfirst created a private health information exchange (HIE) in 2015 to access timely data from its provider network and drive care coordination processes. The HIE was built using:
- InterSystems HealthShare® Unified Care Record to access, normalize, and view member health records
- InterSystems HealthShare Patient Index to support a single patient identity across information systems
- InterSystems HealthShare Health Insight for analytics and data feeds to third-party analytics systems
Today, the Healthfirst HIE accesses data from roughly 700 facilities, including hospitals, community practices, post-acute facilities, Federally Qualified Health Centers, public health departments, and public HIEs. Member data is updated in near real-time through these connections, and shared with internal care managers, providers, and members to help coordinate care and close measures.
The Healthfirst HIE also leverages its connections with network providers to share claims and identify gaps in care. With this type of bi-directional exchange, the health plan and providers share an understanding about what services have been provided to the member and which services are still needed.
The Accountability and Measurement Challenge
Healthfirst tracks health plan quality performance primarily through measures required by State and Federal programs such as NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS) and CMS’ Medicare STARS program.
“Healthfirst is sponsored by 15 hospital systems, and we have value-based payment agreements in place with them to care for our members,” said Kate Beck, Healthfirst AVP of Health Information Exchange. Healthfirst members receive care from the health plan’s providers, who “share accountability for the value-based quality measures,” Beck said. “So, we all benefit when we closely manage care for our members.”
HIE as a Supplemental Data Source
A few years ago, Healthfirst qualified its HIE as a supplemental data source for HEDIS and began providing data to show measure adherence and close care gaps. Today, its HIE data informs 20 priority measures and consistently contributes to Healthfirst’s quality measure ratings. Supported measures include Controlling High Blood Pressure (CBP), Hemoglobin A1c Control for Patients with Diabetes (HBD) and Cancer Screening measures.
Healthfirst AVP of Health Information Exchange
Claims Data Can be Too Little, and Sometimes Too Late
Healthfirst saw another opportunity for HIE data to impact some of the time-sensitive measures that require follow-up action within seven or thirty days of a qualifying event to be considered adherent. Claims data with its traditional 30+ day lag wasn’t timely enough to effectively coordinate care, but the real-time nature of HIE data allowed Healthfirst to identify activity that would likely add the member to the denominator of a measure, and then share timely and actionable data with providers to support the closure of these care gaps.
Transitions of Care (TRC) Medication Reconciliation Post-Discharge Sub-measure
TRC Medication Reconciliation was the first measure Healthfirst tackled with its proactive provider notifications. Using a simple and timely email reminder to the primary care provider following an in-patient discharge, Healthfirst saw a 5% increase in overall compliance for events where the email was shared vs. where it was not.
Follow up After Emergency Department Visit for Mental Illness (FUM)
Following the success with TRC, Healthfirst expanded the service to include the FUM measure which targets 7-day and thirty-day follow up rates.
“The 7-day measure is obviously more time-bound, and is incentivized in our provider performance programs,” said Autumn Kerr, Assistant Vice President, Clinical Quality.
When the HIE receives the discharge message from the emergency department, it identifies the visit for mental illness and then alerts the member’s Primary Care Provider, the ED provider, as well as internal care managers of the seven-day follow up requirement. The goal is to get the member back into care within 7 days to avoid any further emergency visits or inpatient hospitalizations.
“By alerting the member’s care team in such a timely manner, we’re able to increase the chance we can engage with the member and get them back in for follow up care,” added Kerr. Preliminary results show a 6% overall increase in compliance for events where the email was shared vs. where it was not.
Healthfirst AVP of Health Information Exchange
Other Measures, More Success
Similar processes are in place for Follow-Up After Emergency Department Visit for Substance Use (FUA), Follow-Up After Emergency Department Visit for People with High-Risk Multiple Chronic Conditions (FMC) measures and Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET).
The targeted and timely sharing of the data demonstrates that this kind of coordination with a provider network can have a significant impact on member outcomes and quality rates. Building upon its early success, Healthfirst has plans to iterate, improve, and expand this program to include better identification of measure specific events, improved delivery of notifications, and additional time sensitive measures.
“These measures really spotlight the value of health information exchange for health plans,” Beck said. “The real-time nature of the clinical data we have is key to dealing with time-sensitive needs of our members,” Beck continued. “Relying solely on claims data, we’d likely miss the window of opportunity to reach out to primary care and emergency physicians to encourage the necessary follow up care for our members.”
Supporting Members When They Need it the Most
The data flowing through the Healthfirst HIE provides awareness of events and the ability to align care delivery and follow up, providing the best outcomes for Healthfirst members. It also helps Healthfirst distinguish itself from other payers in its region as a collaborative partner in care.
“This data isn’t just for addressing quality measures,” Beck said. “The real time data from our HIE enables us to reach out to our members when it matters the most, in the ED or inpatient setting or during transitions of care. It’s a very personal interaction we can have that wouldn’t be possible otherwise. It certainly builds stronger bonds between us and our members.”