CUSTOMER: 1.9 million member NY-based health plan
CHALLENGE: Tracking quality performance primarily through measures required by State and Federal programs such as
NCQA’s HEDIS and CMS’ Medicare STARS program
OUTCOME: A private HIE based on InterSystems HealthShare®, for timely access of data from the provider network to drive care coordination processes
When everything is measured and aligned, things work better – with less effort and greater efficiency. That’s especially true in healthcare when process improvements save time and money, and measures of care quality correlate with better outcomes. In the greater New York City area, a regional health plan and pioneer in value-based care, recognized early on the need for alignment and collaboration with providers through quality measurement and data sharing. The health plan insures 1.9 million members.
The Accountability and Measurement Challenge
The health plan tracks 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. “We are sponsored by 15 hospital systems, and we have value-based payment agreements in place with them to care for our members,” said the Director of Health Information Exchange. The health plan members receive care from the health plan’s providers, who “share accountability for the value-based quality measures,” they said. “So, we all benefit when we closely manage care for our members.”
Claims Data Can be Too Little, and Sometimes Too Late
Given this complex matrix of care delivery and accountability, the health plan needed a way to get a complete and timely picture of its members’ health data to improve care decisions and calculate associated quality measures. Some measures, for example, require follow-up action within seven or thirty days of a discharge to be considered “closed.” The health plan found that relying on claims data alone to understand member activity wasn’t timely enough to effectively coordinate care. With notification from clinical systems soon after an event occurs, the health plan could inform providers that a follow-up is needed to close the gap in care to count toward the measure numerator.
A Private HIE to Access and Share Member Data
In 2015, the health plan developed and deployed a private health information exchange (HIE), based on InterSystems HealthShare®, to access timely data from their provider network to drive care coordination processes. HealthShare components used include Unified Care Record and Clinical Viewer to access, normalize, and view member health records; Patient Index to support a single patient identity across information systems; and Health Insight for analytics and data feeds to third-party analytics systems.
The health plan’s HIE accesses data from roughly 450 facilities, including hospitals, community practices, laboratories, radiology, post-acute facilities, home healthcare, Federally Qualified Health Centers, and regional HIEs. Member data is updated in near real time through these connections, and the health plan’s HIE shares critical, curated reports with different departments within the organization. They use the information to coordinate care among providers or directly with members.
Hitting the Mark on Time-Sensitive Quality Measures
The health plan also uses the HIE as a supplemental data source for HEDIS to show measure adherence and close care gaps. HIE data informs 20 priority measures and consistently contributes to the health plan’s quality measure rates. Examples include Follow-Up After Emergency Department Visit for Mental Illness (FUM) and Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC).
Follow up After Emergency Department Visit for Mental Illness
This HEDIS measure 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 the health plan’s 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 provider 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. “We’re also starting to alert providers in the ED to the seven-day follow up requirement, so everyone is working to get the members back in for follow up care,” added the Vice President.
Follow up After Emergency Department Visit for People with Multiple Chronic Conditions
For this measure, the health plan tracks and reports on a seven-day follow up window. “This one was a trickier ask for the HIE team,” the Vice President noted. Members land in the denominator by having two or more chronic conditions and an ED visit. “So, we were asking the HIE team to basically recreate the measure’s denominator and identify members who had these chronic conditions in advance, and then use that to bump against the ED visits. Our Enterprise Analytics team came through by identifying members with chronic conditions to assist us in alerting providers of members in this measure.”
Other Measures, More Success
Similar processes are in place for Follow-Up After Emergency Department Visit for Substance Use (FUA) and Medication Reconciliation Post-Discharge (MRP) measures. In measure year 2021, a simple and timely email reminder to the primary care provider resulted in a 5% boost in compliance for MRP and a 9% for FUA.
“These measures really spotlight the value of health information exchange for health plans,” the Director of Health Information Exchange said. “The real-time nature of the clinical data we have is key to dealing with time-sensitive needs of our members,” they continued. “With claims data only, 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 health plan’s HIE provides awareness of events and the ability to align care delivery and follow up, providing the best outcomes for the health plans’ members. It also helps the health plan distinguish itself from other payers in its region as more of a partner in care. “This data isn’t just for addressing quality measures,” the Director of Health Information Exchange 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.”