1. University of Minnesota Information Technology in Healthcare Medical Industry Leadership Institute Course: MILI/PUBH 6562 Fall Semester B, 2014 Stephen T. Parente, Ph.D. Carlson School of Management Department of Finance sparente@umn.edu

2. Class # 3 Health IT Data Structure The Insurer Basic data structures Units of analysis Health data over time Health insurance data architecture Small group exercise

3. Data Structure Fundamentals Simple text/column data Pre-packaged data Relational databases

4. Simple Column Text Data PatientDOSProcedureAllowed Joe02/03/14MD Visit$100 Joe06/05/14Lab test$60 Joe02/03/14Lab test$60 Joe06/05/14MD Visit$100 Mary01/06/14MD Visit$100 Penny11/11/14Eye Exam$80

5. Pre-packaged databases MS-Access databases SQL databases SAS databases SPSS databases STATA databases Excel spreadsheets

6. Relational Databases The database stores data in individual files or tables with data items arranged in rows and columns. AT LEAST one data item (the key) is common to each table and is used to LINK two or more tables for ad hoc queries. Common method to use relational databases is through SQL (structured query language).

7. Units of Analysis Health Data Display by Different Units of Analysis By provider By person By episode/incident By transactions Over fixed units of time

8. By Person

9. By Episode

12. By Transaction

13. Health Data Representation: Over Time? Mental Health Jan AprJulyOctDec =Pysch consult Cumulative Cost Well Sick Normal $50K $0

14. Insurers’ Role in Health IT They are the ‘links’ that connect to everything about a patient in an electronic form. – Employers – Providers – Patients – Government agencies – Researchers

15. Insurer’s IT Paradox They are being held accountable for an insured patient’s total care. Best breadth of data – Most all places of service – ‘Standardized’ data Worst detail – No clinical info on patient health status and outcomes.

16. IS Management Structure CEO CIO Claims CFOCOO SystemsMISActuarialAccountingURMCO Working Group Backbone

17. HEALTH INSURANCE CLAIM FORM

18. The Health MIS Pyramid Hardware Decision Support Software Life Support Software Clinical & Financial Data

19. Insurer Hardware - Mainframe

20. Insurance Database Architecture Claims Membership Provider files Case management Utilization review / Demand Management Decision-support databases Analytic / Financial data

21. Claims Data Entered manually (10%), submitted electronically (90%) - on average. Key items: – Claim ID and date or service – Member / Subscriber ID – Provider of service – Diagnosis & procedure – Charges, reimbursements & copays – Administrative information

22. Claims Data Example

24. Membership / Subscriber Data Member / Subscriber ID (sometimes not person specific!) If managed care, assigned gatekeeper Dates of enrollment Age, gender, case-mix, health risks Address Type of policy, employer Status of benefits used during enrollment

25. Subscriber Data Example

26. Provider Files Used to pay bills and identify providers to be included in ‘Panels’ for new products. Key Data Items: – Provider ID – Specialty, Board Certification, Education – Malpractice history & insurance – Address – Profiling summary

27. Provider File Example

28. Case Management Patient tracking systems Check to see if recommended ‘process of care’ is occurring as part of good quality care. Patient reminder systems (mail) Provider reminder systems (phone, mail & electronic) Outcomes and cost assessment

29. Utilization Review / Disease Management Either run directly or contracted to 4th party acting as Insurer’s agent. Have decision-support systems based on clinical algorithms (and possibly patient’s claims) to manage a patient’s care. Common conditions reviewed/managed: – Schizophrenia, depression – Heart disease – Diabetes, Asthma, Glaucoma – AIDS

30. Support Databases Procedure fee schedules Diagnosis codes Institutional arrangements for managed care payment Pharmacy fee schedules and formularies ‘Grouper’ algorithms – DRGs, MDCs, – Case-mix and severity

31. Life Support Systems Accounts Receivable – Employers – Consumers – Government Claims payment – Error checking – Provider payment – Fee schedules & payment algorithms Benefits/eligibility

32. Analytic / Financial Data ‘Cleaned’ versions of claim, provider and membership files designed to: – Generate premium estimates – Adjust provider fee schedules – Profiling of: population (e.g., all patients with diabetes) practices employer groups patients

33. Small Group Exercises (Part 1 of a 2 Part Exercise) What ‘information’ can health insurance data provide? Name 2 major strengths and weaknesses of claims data as a management tool. Poof: You’re a Blue Cross Blue Shield CIO. – You have $50M to spend to upgrade your claims system. – It costs $1M per text/character to enhance your data. – What data fields would you add? – Are there any data fields you would consider deleting or optimizing?

34. Intermission

35. Medical Provider Data Patient Diagnosis Information Treatment plan Referrals Outcomes Explanations for treatment

36. The Operation The Hospital submits lots of bills –Lab work –Blood –Anesthesia –ER room time –Supplies Surgeon John submits a claim for surgery. Dr. Bob submits a claim for IP consultation. Internal hospital systems affected: –Inventory –Payroll –Accounts receivable –Medical records PPO reimburses hospital. PPO reimburses Dr. Bob PPO reimburses Dr. John

37. Medical Center Data Systems Life Support Data Hardware

38. Medical Data Collection - 1 Operational data: Transaction-oriented – Hospital pharmacies – Laboratories – Radiology departments – Critical care units – Order-processing units

39. Medical Data Collection - 2 Analytic data – Carry all variables of interest – Single record – Data is stored horizontally

40. Code Systems Standards - 1 HL7 - American National Standards Institute Health Level – Patient registration data – Patient orders – Clinical information (e.g., vital signs) – Referral information – Clinical trial data – Other operational transactions

41. Code Systems Standards - 2 X12 - Data Interchange Standards Association’s Accredited Standards Committee – Insurance enrollment & payment – Administrative messages

42. Code Systems Standards - 3 Diagnoses: International Classification of Diseases, Version 9 (ICD9) Procedures: Current Procedural Terminology, Version 4 (CPT4) Drugs: Food and Drug Administration’s Nation Drug Code (NDC) directory

43. Code Systems Standards - 4 LOINC - Logical Observations Identifier Names and Codes (LOINC) database: The Missing Link – Codes, names and synonyms for more than 12,000 observations: laboratory tests vital signs electrocardiograph measurement input & output measures clinical impressions discharge summary

44. Code Systems Standards Examples

46. Integrated Delivery System IT Network Life Support Data Hardware Decision Support

47. Insurer Only Data 1/31/14 2/6/14 PCP visit Specialist visit Laboratory test Biopsy Surgery Sub-Acute Care

48. Medical Data Available to a U.S. Fee-for-Service Insurer Life Support Data Hardware Decision Support

49. Medical Data Available to a U.S. Staff Model HMO Life Support Data Hardware Decision Support

50. Provider Only Data 1/31/14 2/6/14 White blood cell count high Cancer metastasized Referral to specialist Malignant cancer remains

51. E/CPR Model A

52. E/CPR Model B

53. What are the Pros & Cons of these Models? Are they out of date as useful data management models?

54. Data Available to the Average Medical Provider About a Patient’s Care 15% of Care 25% of Care 15% of Care 10% of Care 35% of Care

55. Merging Insurer & Provider Data 1/31/14 2/6/14 PCP visit Specialist visit Laboratory test White blood cell count high Biopsy Cancer metastasized Surgery Referral to specialist Malignant cancer remains Sub-Acute Care

56. Small Group Exercises (Part 1 of a 2 Part Exercise) What ‘information’ can health insurance data provide? Name 2 major strengths and weaknesses of claims data as a management tool. Poof: You’re a Blue Cross Blue Shield CIO. – You have $50M to spend to upgrade your claims system. – It costs $1M per text/character to enhance your data. – What data fields would you add? – Are there any data fields you would consider deleting or optimizing?

57. Small Group Exercises (Part 2 of a 2 Part Exercise) What ‘information’ can medical data provide? If you are an insurance company CEO, how vital are clinical medical records to your business? If you are hospital administrator, name one pro and one con to having access to health insurance data? What share of your profit/surplus are you willing to invest for such a link?