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Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 1 WRIA 2014 Meeting, Napa CA Evaluating Information Exchange for.

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Presentation on theme: "Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 1 WRIA 2014 Meeting, Napa CA Evaluating Information Exchange for."— Presentation transcript:

1 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 1 WRIA 2014 Meeting, Napa CA Evaluating Information Exchange for Effective Risk Management in Healthcare L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM The University of Louisiana at Lafayette January, 2014

2 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 2Abstract n The healthcare delivery sector and the health insurance industry seem destined to collide once again as voluntary HIEs are launching and as mandated HIEs are coming on-stream. n But when is an HIE not an HIE? When one is a Health Information Exchange and one is a Health Insurance Exchange. n One is vital in maintaining health and critical to managing clinical risk in the delivery of healthcare services, while the other is hoped to aid individuals and small businesses in managing economic risks in daily life. n Evaluating the effectiveness of each, separately, offers a significant research challenge. n Creating and monitoring effective relationships between the two may be the future of risk management in healthcare.

3 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 3 Outline of This Presentation 1. Healthcare and Health Insurance are Information Intensive Industries 2. Information Technology Applications (especially HIEs) are Essential Enablers for Implementation of Health Insurance Reforms –HIE = Health Information Exchange (ARRA/HITECH 2009) –HIE = Health Insurance Exchange [HIX, HIEx]; [HIM = Health Insurance Marketplace (Marketplace)] [AHBE = American Health Benefit Exchange (PPACA 2010) ] 3. Experience To Date 4. Measuring Success of HIEs

4 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 4 1.“Healthcare and Health Insurance Are Information Intensive Industries” Healthcare has two underlying processes: a. provision of care b. gathering of information to facilitate provision of care in the future Health Insurance has two underlying processes: a. mitigation of risk for the insured b. gathering of information to facilitate mitigation of risk in the future

5 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 5 Equip. Mfrs. Suppliers Drug Mfrs. Physicians Pharm. Benefit Mgrs. Network & Care Mgrs. Us! Peer Review Orgs. Federal & State Gov’t. Fiscal Inter- mediaries Employers, Unions, & Assns. Insurers Financial Services Credit Bureaus Claims Assistance ASO TPAs Data Services Healthcare & Health Insurance Information Pathways PHOs IPAs Hospitals *Us! = Patients, Employees, Citizens, Enrollees, Members, Covered Lives, Consumers, Marginal Units, Populations *

6 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 6 2.“Information Technology Applications (especially HIEs) are Essential Enablers for Implementation of Health Insurance Reforms” The U. S. federal “plan is to propose Health Information Exchange and interoperability requirements … so that patient information follows patients to the point of care and informs critical health decisions.”

7 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 7 Equip. Mfrs. HospitalsSuppliers Drug Mfrs. Physicians Pharm. Benefit Mgrs. Network & Care Mgrs. Patients Peer Review Orgs. Federal & State Gov’t. Fiscal Inter- mediaries Employers, Unions, & Assns. Insurers Financial Services Credit Bureaus Claims Assistance ASO TPAs Data Services Color Key: Clinical (specific) Clinical (summary) Financial Administrative Healthcare Information: Order from Chaos?

8 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 8 The Future’s Just Not the Same Anymore! attributed to Yogi Berra Meaningful Use? Healthcare Reform? Health Insurance Reform? Coordinated Care Networks? Accountable Care Organizations? National Health Information Infrastructure? HIPAA? / ARRA? / HITECH? PPACA? / (repeal?) ???

9 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 9

10 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 10 Health Information Exchange n A “Health Information Exchange” is an online mechanism whereby clinical, financial, and administrative information can be securely exchanged among patients, physicians, hospitals, other professional and institutional healthcare providers, public health agencies, regulators, and payors. n In the United States, the electronic transactions are well documented in the Administration Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and have been refined in the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH). n HITECH, an embedded component of the American Recovery and Reinvestment Act of 2009 (ARRA, or “”The Stimulus Bill”), funded the creation of State Health Information Exchanges on a state-by- state basis and mandated interconnection of these through the application of Nationwide Health Information Network (NwHIN) standards for inter-HIE exchange.

11 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 11

12 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 12 Health Information Exchange (sources) n DHHS ONCHIT (created in 2004) Office of the National Coordinator for Health Information Technology (ONCHIT) Federal Health IT Strategic Plan, updated for – 80pp. (http://healthit.hhs.gov/portal/server.pt/community/fed_health_it_strategic_plan/1211/home/15583) n ARRA / HITECH (2009) American Recovery and Reinvestment Act (ARRA) (“the Stimulus Act”) incorporated the $20B Health Information Technology for Economic and Clinical Health (HITECH) Act, seeking “to improve American health care delivery and patient care through an unprecedented investment in health information technology.” (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1487&mode=2) n HITECH and HIE HITECH authorized State Health Information Exchange Cooperative Agreements (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=1111 3&cached=true) 3&cached=truehttp://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=1111 3&cached=true n LDHH / LHCQF Louisiana Department of Health and Hospitals & Louisiana Health Care Quality Form (LHCQF) – LaHIE Strategic & Operational Plans published in 2010 – 164pp. (http://lhcqf.org/images/stories/LaHIE%20State%20Plan.pdf.)

13 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 13 Health Insurance Exchange n In the United States, the Patient Protection and Affordable Care Act of 2010 (PPACA) entered into a new phase of its implementation on October 1, 2013, with the launch of “Health Insurance Exchanges.” n Health Insurance Exchanges are intended to serve as fully online health insurance marketplaces where individuals and small businesses may select and purchase health insurance. n HIEs will be operated on a state-by-state basis, either by each state independently or by the federal government if a state should chose to opt out of the costs of managing its HIE. In the 974-page text of PPACA (available at ), references to the “exchange” concept appear 333 times, and the concept is alternatively termed “Health Insurance Exchange,” “Health Benefit Exchange,” “American Health Benefit Exchange,” “Small Business Health Options Program (SHOP) Exchange,” “Data Exchange,” or simply “State Exchange.”

14 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 14 Health Insurance Exchange (continued) n More formally, PPACA amended Section 2791(d) of the Public Health Service Act (42 U.S.C. 300gg–91(d)) to add the following definition: “The term ‘Exchange’ means an American Health Benefit Exchange established under section 1311 of the Patient Protection and Affordable Care Act.” In 12 pages, Section 1311 details requirements and functions of a State Exchange, including 11 specific functions to be performed by the online system. Such exchanges were originally dubbed with the acronym “HIE,” but more recently “HIX” has been used to avoid confusion with “Health Information Exchange” (another federally promoted concept).

15 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 15 Health Insurance Exchange Functions

16 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 16

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19 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 19 Health Insurance Exchange (sources) n PPACA (2010) Patient Protection and Affordable Care Act (PPACA) (“Obamacare”) (http://www.ncsl.org/documents/health/ppaca-consolidated.pdf) – 974pp. n Louisiana Department of Insurance (http://www.ldi.louisiana.gov/) n Louisiana Healthcare Reform Resource Center -- for Consumers (http://www.ldi.state.la.us/HealthCareReform.html -- for Producers (http://www.ldi.state.la.us/MarketplaceTraining.html)

20 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 20 HIE-HIE Connections? Eligibility Co-Pay Collection Coverage Levels Prior-Authorization Changes Enrollment Enrollment

21 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 21 HIE-HIE Communications Healthcare Providers Patients and Families Payors Insurers Healthplans

22 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 22 What an Applicant-Patient wants to know (how does PPACA affect me and my choices of Providers) 1. What is the monthly cost of the Healthplan’s premiums? 2. How long has the Healthplan been in business? How viable is the company? How stable will my premiums be over time? 3. Can I still see my regular doctors? Will it cost more to see my regular doctors? 4. Are my current medications in the formulary? Will it cost more to get my current medications? 5. Must I have prior approval to see a specialist? approval from my regular doctor? approval from the healthplan? 6. Must I file my own claims? Will I get statements showing total costs and total out-of-pocket expenses? 7. Is there a co-pay required for routine visits? an annual deductible to meet? 8. Is there an annual or lifetime maximum benefit? [PPACA prohibits maxima for “essential health benefits” renewals after ]

23 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 23 What a Provider wants to know (how does PPACA affect me and what compliance issues loom) 1. How will I know which Patient is eligible under which Healthplan? 2. May a Patient be rejected on the basis of their choice of Healthplan? [e.g., a Healthplan in which I do not participate] 3. How will I know which services are covered by a particular Patient’s Healthplan? 4. How will I know which medications are including in a Healthplan’s formulary? 5. Must I seek approval from the Healthplan prior to ordering tests, performing procedures, prescribing medications, or referring the Patient out to other Providers? How do I go about seeking such approvals? 6. What must I collect as a co-pay from any particular Patient? 7. How will I get paid by a Patients’ Healthplan for services rendered to that Patient? on a prepaid per capita basis? on a fee-for-service basis, using a negotiated fee schedule?

24 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 24 What a Healthplan wants to know ( who are the Applicants and what underwriting options still exist ) 1. Does the Applicant have pre-existing medical conditions that might disqualify them for coverage? [PPACA prohibits!] 2. Does the Applicant have behavioral risk factors that might alter their premium? [PPACA allows (e.g., smoking)] 3. May an Applicant be rejected on certain specific criteria other than a pre- existing condition or a risk factor? [e.g., Healthplan lacks certain services that Applicant-Patient may need] 4. Does the Applicant agree to all terms associated with the healthplan? 5. Has the Applicant prepaid the required initial premium? 6. Will the Applicant’s premium be supported by federal grants or aids? 7. What Provider(s) will Applicant choose?

25 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 25 What the Regulators want to know ( Exchange effectiveness and PPACA compliance metrics ) 1. How many Applicants have visited the Health Insurance Exchange? non- duplicated individuals? 2. How many Applicants have applied for coverage with each specific Healthplan? non-duplicated applications? 3. How many Applicants have been approved for coverage with each specific Healthplan? Applicants and individual persons to be covered? 4. How many Small Businesses have visited/applied/been/approved? Small Businesses and individual persons? 5. What fraction of previously uninsured individuals will now have coverage? 6. How many dollars in initial premiums committed/paid by Applicants? 7. How many dollars in initial premiums committed by federal grants or aids? 8. What complaints, misrepresentation, violations, etc. have occurred as a result of the Health Insurance Exchange?

26 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide Experience To Date Donabedian’s Indicators: Structure – Result of Federal (primarily) and State Funding Process – If you built it, will they come? Outcomes – Too soon to tell!

27 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 27 The HIE & the HIE in Louisiana n The Louisiana Health Care Quality Forum (LHCQF), the State- Designated Entity in Louisiana, has used HITECH funding to create the Louisiana Health Information Exchange (LaHIE), which has just passed the second anniversary of its launch. LaHIE Now Includes More Than 500K Unique Patient Records > The Louisiana Health Information Exchange (LaHIE) now features more than 560,000 unique patient records. > “For those patients, it means their physicians have greater, more timely access to their health records. As we continue our efforts to onboard more hospitals and practices to LaHIE, that number will grow exponentially in the coming months.” Cindy Munn, LHCQF Executive Director > To date, 33 hospitals and clinics are live with LaHIE, and 68 are actively onboarding. The exchange has participation agreements with more than 170 hospitals, providers, clinics, school-based health centers, home health agencies and other health care companies across the state. n The State of Louisiana has opted out of managing its own Health Insurance Exchange at least for now, which under the terms of PPACA requires the federal government to operate the online marketplace in Louisiana. n It is too early to judge the effectiveness either of the HIE or of the HIE (HIX, HIeX, HIM, ABHE) in Louisiana, but it is not too late to create an evaluation plan!

28 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 28 Only 16 States Run Their Own Insurance Exchanges

29 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 29 Official Skepticism in Louisiana

30 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 30

31 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 31

32 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 32

33 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 33

34 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 34 Apologies & Apologists

35 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 35 New Action Plan

36 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 36 On the Mend?

37 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 37

38 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 38 https://www.healthcare.gov/families/

39 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 39

40 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 40

41 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 41

42 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 42

43 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 43

44 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 44

45 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 45

46 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 46

47 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 47 Louisiana Plan Comparison – Single, 50 or older

48 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 48 Tricks no Treats?

49 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 49Period*

50 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 50 https://www.healthcare.gov/small-businesses/

51 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 51 Employer Penalties

52 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 52 Downstream Implementation Timeline

53 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide Measuring Success of HIEs Health Information Exchanges Providers, Payors, Patients, Regulators, Public Health Agencies Health Insurance Exchanges Consumers, Sponsors, Carriers, Networks, Providers, Regulators

54 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 54 Defining “Success” for Each Health Information Exchange Functionality

55 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 55 Table 1. “Pre-Arrival” Uses of Information Exchanged in an HIE HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS REFERRALS (INBOUND) PROVIDERS Request to Accept Referred PatientUnsolicited RequestProvider AProvider B Provider A CCR/CCD RequestDecision-triggered ResponseProvider BProvider A CCR/CCD DeliveryCCR/CCD TransmissionProvider AProvider B Response (Accept/Decline)Decision-triggered ResponseProvider BProvider A Provider B APPOINTMENTS PATIENTS, PROVIDERS Request for AppointmentUnsolicited RequestPatientProvider Response (Accept/Decline)Decision-triggered ResponseProviderPatient

56 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 56 Table 2. “Point-of-Arrival” Uses of Information Exchanged in an HIE HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS ELIGIBILITY CHECKING PROVIDERS InquiryUnsolicited InquiryProviderPayor Response Decision-triggered Response PayorProvider

57 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 57 Table 3. “Point-of-Care” Uses of Information Exchanged in an HIE HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS PATIENT RECORD REQUESTS PROVIDERS CCR/CCD RequestUnsolicited RequestProvider BProvider C CCR/CCD DeliveryCCR/CCD TransmissionProvider CProvider B LABORATORY TESTS PROVIDERS OrderUnsolicited OrderProviderLaboratory Interim Status InquiryUnsolicited InquiryProviderLaboratory Interim Status ReportDecision-triggered ResponseLaboratoryProvider ResultDecision-triggered ResponseLaboratoryProvider Provider, Patient RADIOLOGY WORKUPS PROVIDERS OrderUnsolicited OrderProviderRadiology Interim Status InquiryUnsolicited InquiryProviderRadiology Interim Status ReportDecision-triggered ResponseRadiologyProvider ReportDecision-triggered ResponseRadiologyProvider Provider, Patient PRESCRIPTIONS PROVIDERS ePrescribing of R x Unsolicited OrderProviderPharmacy R x Fill/Pickup ReportEvent-triggered ResponsePharmacyProvider Provider, Patient PRIOR AUTHORIZATIONS PAYORS, PROVIDERS RequestUnsolicited RequestProviderPayor Interim Status InquiryUnsolicited InquiryProviderPayor Interim Status ReportStatus ReportPayorProvider Determination (Approval/Disapproval)Decision-triggered ResponsePayorProvider Provider, Patient REFERRALS (OUTBOUND) PROVIDERS Request to Accept Referred PatientUnsolicited RequestProvider BProvider D Provider B CCR/CCD RequestDecision-triggered ResponseProvider DProvider B Forwarding of Patient RecordCCR/CCD TransmissionProvider BProvider D Response (Accept/Decline)Decision-triggered ResponseProvider DProvider B Provider D

58 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 58 Table 4. “Point-of-Departure” Uses of Information Exchanged in an HIE HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS REIMBURSEMENT CLAIMS PROVIDERS Claim SubmissionUnsolicited TransmissionProviderPayor Claim Status InquiryUnsolicited TransmissionProviderPayor Claim Status ReportEvent-triggered ResponsePayorProvider Remittance AdviceEvent-triggered ResponsePayorProvider Electronic Funds TransferEvent-triggered ResponsePayorProv. Bank Provider PERSONAL HEALTH RECORD PATIENTS ePHR UpdateUnsolicited TransmissionProvider ePHR Custodian Patient

59 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 59 Table 5. “Post-Departure” Uses of Information Exchanged in an HIE HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS IMMUNIZATION REGISTRY PUBLIC HEALTH AGENCIES Registry UpdateUnsolicitedProvider Registry Agency Registry Update AcknowledgementEvent-triggered Response Registry Agency Provider DISEASE/TUMOR REGISTRY PUBLIC HEALTH AGENCIES Registry UpdateUnsolicitedProvider Registry Agency Registry Update AcknowledgementEvent-triggered Response Registry Agency Provider QUALITY REPORTING REGULATORS Quality ReportingUnsolicitedProvider Quality Agency Qual. Reptg. AcknowledgementEvent-triggered Response Quality Agency Provider

60 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 60 HIE: Measuring Success FUNCTIONALITYPrimary BeneficiaryType of Benefit Benefit Measure QuantitativeQualitative REFERRALS (INBOUND)PROVIDERSSource of new patients# of new patientsProvider satisfaction APPOINTMENTS PATIENTSConvenienceTime savedPatient satisfaction PROVIDERSStaff time/cost savings$ saved in FTE staff costsStaff satisfaction ELIGIBILITY CHECKINGPROVIDERS Avoidance of uncollectable revenue % of booked revenue collectedProvider and staff satisfaction PATIENT RECORD REQUESTS PROVIDERS Elimination of duplicative workups Time savedProvider and staff satisfaction LABORATORY TESTSPROVIDERS Automatic EHR update of results Time saved by avoiding delays and manual filing Accessibility of information RADIOLOGY WORKUPSPROVIDERS Automatic EHR update of reports Time saved by avoiding delays and manual filing Accessibility of information PRESCRIPTIONSPROVIDERS Automatic EHR update of compliance % of prescriptions filled and picked up Provider satisfaction related to this information not being previously available PRIOR AUTHORIZATIONS PAYORS Enforcement of coverage limitations $ saved in medical payments Utilization management goals met PROVIDERS Avoidance of uncollectable revenues % of $ collectedStaff satisfaction REFERRALS (OUTBOUND)PROVIDERSExpedited consultationTime savedAccessibility of information REIMBURSEMENT CLAIMS PROVIDERSExpedited collection of revenue # claims submitted; % and timeliness of revenue collected Provider and staff satisfaction PERSONAL HEALTH RECORD PATIENTS Record of problems & interventions Time saved communicating past medical history to new providers Better information upon which to base lifestyle decisions IMMUNIZATION REGISTRY REGISTRIES Enhanced compliance & data integrity #, timeliness, and completeness of updates received Better information upon which to base health promotion policies DISEASE/TUMOR REGISTRY REGISTRIES Enhanced compliance & data integrity #, timeliness, and completeness of updates received Better information upon which to base health promotion policies and clinical research priorities QUALITY REPORTINGQUALITY AGENCIES Enhanced compliance & data integrity #, timeliness, and completeness of updates received Better information upon which to base health promotion policies

61 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 61 Defining “Success” for Each Health Insurance Exchange Functionality

62 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 62 Individual SHOP Health Insurance Exchange Adults (+Students) Seniors Indigent Children Sponsors Self Employers Small Employers Large Unions Assocs Carriers Blues Commercials Co-ops Networks ACOs CCNs HCOs HMOs PPOs IPAs RHAs,IHSs, IDSs,IDNs Providers Hospitals ASCs PCPs PCMHs SpecPhys Pharmacies Laboratories RadCenters HmHealthAgcs TelemedProvs State Insurance Commissioners (http://www.naic.org/)http://www.naic.org/ Dept.of Labor – Emp.Ben.SecurityAdmin. (http://www.dol.gov/ebsa/)http://www.dol.gov/ebsa/ Centers for Medicare & Medicaid Services (https://www.cms.gov/ /)https://www.cms.gov/ / + IRS & Homeland Security Govt.Progs Medicare Part A Part B Part C Part D Medicaid S-CHIPs CONSUMERSSPONSORSCARRIERSNETWORKSPROVIDERS HIE, HIeX, HIX, AHBE, Marketplace REGULATORS

63 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 63 Redefining the Individual Market

64 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 64 Table 1. “Pre-Application” Uses of Information Exchanged in an HIE [HIeX, HIX, AHBE, Marketplace] HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS SEEKING GENERAL INFORMATION Unsolicited Inquiry Consumer, Sponsor (SHOP) HIX Query Module CONSUMERS, SPONSORS BROWSING FOR HEALTHPLANSUnsolicited Inquiry Consumer, Sponsor (SHOP) HIX Query Module CONSUMERS, SPONSORS BROWSING FOR PROVIDERS NETWORKS Unsolicited InquiryConsumer HIX Query Module CONSUMERS

65 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 65 Table 2. “Point-of-Application” Uses of Information Exchanged in an HIE [HIeX, HIX, AHBE, Marketplace] HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS CREATING A MARKETPLACE ACCOUNT Unsolicited Input Consumer, Sponsor (SHOP) HIX Registry Module, Regulator CONSUMERS, SPONSORS, REGULATORS IDENTIFYING HEALTHPLAN DETAILS Unsolicited Inquiry Consumer, Sponsor (SHOP) HIX Query Module CONSUMERS, SPONSORS COMPARING SIMILAR HEALTHPLANS Unsolicited Inquiry Consumer, Sponsor (SHOP) HIX Query Module CONSUMERS, SPONSORS APPLYING TO PURCHASE A HEALTHPLAN Unsolicited Input Consumer, Sponsor (SHOP) HIX Applicatio n Module, Carrier, Regulator CONSUMERS, SPONSORS, CARRIERS, REGULATORS

66 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 66 Table 3. “Point-of-Enrollment” Uses of Information Exchanged in an HIE [HIeX, HIX, AHBE, Marketplace] HIE FUNCTIONALITY and Transactions Transaction TypeSenderReceiver Primary Beneficiary CLASS RECEIVING CONFIRMATION OF ENROLLMENT Decision-triggered Response CarrierConsumer CONSUMERS, REGULATORS SELECTING AN ACO / CCN / PCMH / PCP Unsolicited InputConsumer Carrier, Network, Provider CONSUMERS, CARRIERS, NETWORKS, PROVIDERS, REGULATORS RECEIVING CONFIRMATION OF THE HEALTHPLAN BEING IN EFFECT Decision-triggered Response CarrierConsumer CONSUMERS, NETWORKS, PROVIDERS, REGULATORS

67 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 67 HIE: Measuring Success FUNCTIONALITYPrimary BeneficiaryType of Benefit Benefit Measure QuantitativeQualitative SEEKING GENERAL INFORMATION CONSUMERS, SPONSORS Knowledge of Plans Time saved shopping for healthplans Understanding of healthplan offerings BROWSING FOR HEALTHPLANS CONSUMERS, SPONSORS Knowledge of Plans Time saved shopping for healthplans Understanding of healthplan offerings BROWSING FOR PROVIDERS NETWORKS CONSUMERSKnowledge of Plans Time saved shopping for healthplans Understanding of healthplan offerings CREATING A MARKETPLACE ACCOUNT CONSUMERS, SPONSORS, REGULATORS Prerequisite for Application Time saved by avoiding delays and repetitive manual filing Acquisition of “consumer status” IDENTIFYING HEALTHPLAN DETAILS CONSUMERS, SPONSORS Knowledge of Plans Time saved shopping for healthplans Ruling out/in specific healthplan offerings COMPARING SIMILAR HEALTHPLANS CONSUMERS, SPONSORS Knowledge of Plans Time saved shopping for healthplans Facilitation of decision-making in favor of preferred healthplan APPLYING TO PURCHASE A HEALTHPLAN CONSUMERS, SPONSORS, CARRIERS, REGULATORS Application submitted, then automatically routed, and queued for consideration; statistics available Time saved by all parties through online “reusable” application; Carrier time savings through online marketing Application encompasses decision (“the hard part is over for the consumer”); recognition of movement toward coverage of targeted populations RECEIVING CONFIRMATION OF ENROLLMENT CONSUMERS, REGULATORS Confirmation and further information about healthplan Tracking of coverage for targeted populations for Regulators Comfort of knowing coverage is in place SELECTING AN ACO / CCN / PCMH / PCP CONSUMERS, CARRIERS, NETWORKS, PROVIDERS, REGULATORS Exercise of consumer choice Tracking of relationships with Network and Provider Exercise of consumer “control” through choice of Network and Provider RECEIVING CONFIRMATION OF THE HEALTHPLAN BEING IN EFFECT CONSUMERS, NETWORKS, PROVIDERS, REGULATORS Confirmation of Carrier, Network, and Provider relationships Tracking of ongoing events in place for Regulators Comfort of knowing relationships secure

68 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 68 Conclusions

69 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 69 This study suggests that... n n Benefits may accrue in various distinct areas and in varying degrees to each of the HIE’s diverse participants. n n Certain participants may have no direct interest whatsoever in any but a very few specific HIE functionalities. n n Participants who receive HIE transmissions are the principal beneficiaries of the exchange – receiver receives “value” only if they perceive utility. n n If an unsolicited request for information arrives, the receiving participant is obliged to respond – a new burden or “cost-of-doing-business” in the electronic age. n n Some unsolicited transmissions may be requests for services – “orders” – and the receiver has an opportunity to benefit by turning the order into collectible revenue. n n An HIE “succeeds” when it offers the proper mix of functionalities that can strike a successful balance of “value” for “value” exchange among its participants. n n Under-contributing functionalities may still find a long-term niche, especially when these co-exist with other functionalities that can subsidize their continuance. n n With HITECH-funded HIEs just coming on-stream in 2012, and PPACA-funded HIEs just coming on-stream in 2013, there is a significant opportunity for researchers to further develop and test HIE evaluation techniques.

70 Louisiana Center for Health Informatics at The University of Louisiana at LafayetteSlide 70 Questions, Comments, or Suggestions? Learn more at


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