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Community Care of North Carolina with NC HIE
Overview Presentation for NCNA Council on Nursing Informatics
May 16, 2014
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 About
Overview
NC HIE
 Population
 Q&A
Health Solutions
+ About NC HIE
+ One Connection, Many Data Sources
One connection to NC HIE means access to provider electronic health record
systems, State systems, pharmacies, labs, behavioral health and long-term
care entities, disease registries and other sources of patient data.
VA, DOD, SSA, etc.
Health System, Community
Vendor, Technology, Strategic
Government, Regulatory, Advocacy
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NC HIE’s Growing Network of Partners
+ Current Footprint
Currently, more than 700 sites are participants of NC HIE. We build connected communities
that include clinics, local health departments and long-term care and behavioral health
providers. A complete list can be accessed on our website: http://nchie.org/providers/ourproviders/
Legend:
Hospitals
Physician Practice – Primary Care
Physician Practice – Specialist
Long-Term Care
+ Current Hospital Participation
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Ashe Memorial Hospital
Blowing Rock Rehabilitation &
Davant Extended Care Center
Cannon Memorial Hospital
CaroMont Medical Center
Carteret General Hospital
Hugh Chatham Hospital
Davie Medical Center
Granville Medical Center
Halifax Regional Medical Center
High Point Regional Medical Center
Hugh Chatham Memorial Hospital
Johnston Medical Center
Lenoir Memorial Hospital
Lexington Medical Center
Maria Parham Medical Center
Morehead Memorial Hospital
Nash General Hospital
Our Community Hospital
Person Memorial Hospital
Rex Hospital
UNC Caldwell
UNC Chatham
UNC Hospitals
UNC Pardee
UNC Wakebrook
Wake Forest Baptist Medical Center
Watauga Medical Center
Wilson Medical Center
+ Current Ambulatory Participation
NC HIE ambulatory participation includes more than 700 sites
encompassing a variety of provider types:
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Primary Care Practices
Specialist Practices
FQHCs
Free Clinics
Long-Term Care
Home Health
+ Enabling Meaningful Use and State
Reporting
Objective/Measure
Submission of electronic data to an immunization
Immunization
Registry Reporting registry
Electronic Lab
Reporting (ELR)
Submission of electronic reportable laboratory results
to the State public health agency
Transitions of Care For 50% a Summary of Care document must be
provided, 10% of which must be electronically
provided
Electronic Clinical
Quality Measures
(CQMs)
Electronic Clinical Quality Measures (CQMs) reporting
(NC HIE enables for Medicaid Eligible Professionals)
Identify and report specific disease cases to a
Specialized
Registry Reporting specialized registry (other than a cancer registry)
Cancer Registry
Reporting
Identify and report cancer cases to a public health
cancer registry
Core or Menu Core or Menu
Stage 1
Stage 2
Menu for EPs
and EHs
Core for EPs and
EHs
Menu for EHs
Core for EHs
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Core for EPs and
EHs
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Required for EPs
and EHs
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Menu for EPs
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Menu for EPs
EPs- Eligible Professionals
EHs- Eligible Hospitals
+ Improving Care and Population Health
NC HIE with its partner, Community Care of North Carolina (CCNC), is building value-added
applications to enhance patient care. Current projects include:
Complete Medication Management
Population Health Analytics
Incorporation of multi-sourced information, both clinical and claims
data, into comprehensive view of evidence-based population
health dashboards/utilities to facilitate systematic approaches to
improve care.
PHARMACeHOME
Chronic Disease Registries
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Development of chronic disease registries:
 Diabetes
 Asthma
 Heart Failure
 Hypertension
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Reporting of Clinical Quality Measures
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Development of aggregated reports, currently exploring:
 PQRS*
 HEDIS*
 UDS*
 Ad-hoc to allow user to generate and save frequently used
reports*
*At an additional cost
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NC HIE and State Reporting
Wake Forest Baptist
Health System is
piloting the connection
to submit immunization
data to NCIR. Expected
pilot completion is Q2
2014.
NC HIE and NC Medicaid
are building connectivity
to enable electronic
clinical quality measure
reporting directly to NC
Medicaid. Service
availability is scheduled
for Spring 2014.
CaroMont Health is
piloting the connection
to submit reportable lab
results to NC EDSS and
NC LEAD. Other
hospitals have begun
the onboarding process.
In 2014, to comply with the NC
Health Care Cost Reduction and
Transparency Act, hospitals will
begin reporting Medicaid
demographic and clinical data to NC
Health and Human Services
via NC HIE.
About Population Health
+ Solutions
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Data Phases
1Q ‘14
2Q ’14
3Q ’14
4Q ‘14
Infrastructure Build
Initial Clinical Database Build
Administrative / Claims Data Build
QRDA & Additional Clinical Data
Additional Data Sets
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Demographics
Diagnosis
Procedures
Labs
Medications
Vitals
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Claims
Enrollment
Scheduling
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Social History
Asthma
Management Data
Screenings
Meaningful Use
Quality Specific
Data
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Prenatal
Foster Children
Special Population
Files
Vital Records
Referrals
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Population Health Solutions
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Clinical Quality Measure Reporting
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Chronic Disease Registries
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Diabetes
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Hypertension
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Asthma
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Heart Failure
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Physician Quality Reporting System
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ACO Quality Measures
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The Process
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Data Extraction
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Assignment of EMPI
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Review and Normalization of Targeted Data Sets
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Labs, allergies, race and ethnicity, medications
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Load into data repository and HIE (if applicable)
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Process through rules engine
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Present data in population health solutions
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Data Normalization
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In order for applications to recognize, store and process data
elements, data must be in a discrete format with a standard
codes
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Procedure Codes (CPT)
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Diagnosis (ICD 9)
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Labs (LOINC)
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Medications (RxNorm, Multum or NDC)
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Med Allergies (RxNorm)
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Vitals (SNOMED)
As we are extracting the data, we are finding the data quality
varies by practices and by measure set.
+ Clinical Quality Measures EP
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Hypertension Measures
Reference
Name
PQRS 236
Controlling High Blood Pressure
PQRS 295
Aspirin or antithrombotic Use
PQRS 296
PQRS 297
Complete Lipid Profile
Urine Protein Screening
PQRS 298
Annual serum creatinine testing
PQRS 299
Diabetes Mellitis annual screening
PQRS 302
NQF 0421
Dietary and Physical Activity Modifications Appropriately Prescribed
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
NQF 0021
Preventive Care and Screening: Influenza Immunization
NQF 043
Pneumonia Vaccination Status for Older Adults
NQF 0028
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
NQF 0075
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
NQF 0068
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
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Hypertension Registry
Goshen #1
Goshen #2
Goshen #3
Goshen #4
Goshen #5
Goshen #6
Goshen #7
Goshen #8
Goshen #9
Goshen #10
Goshen #11
Goshen #12
Goshen #13
Goshen #14
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Hypertension Registry – Site View
Ability to select different
measures or dimensions
Compare
performance across
providers
Provider #1
Provider #2
Provider #3
Provider #4
Provider #5
Provider #6
Provide #X
Hypertension Registry – Patient
Level Listing
Site #1
Provider
Name
Provider #1
Serum Creatinine Test
Performed
Tobacco Use
Screening(HTN)
N
Y
Y
N
Y
N
N
xxx/xx 5/1/2014
6/24/1958 Provider Name
N
N
N
N
Y
N
N
Y
N
N
xxx/xx 5/2/2014
Patient Name #3 M
3/16/1948 Provider Name
N
N
N
N
Y
N
N
N
N
Y
xxx/xx 5/3/2014
123459
Patient Name #4 F
9/6/1958 Provider Name
N
N
N
N
N
Y
N
Y
Y
N
N
xxx/xx 5/4/2014
123460
Patient Name #5 F
3/4/1977
Provider Name
N
N
N
N
N
Y
N
Y
N
N
N
xxx/xx 5/5/2014
123461
Patient Name #6 M
8/20/1941 Provider Name
N
N
N
N
Y
Y
N
Y
N
N
xxx/xx 5/6/2014
123462
Patient Name #7 F
N
N
N
N
Y
Y
N
Y
N
Y
xxx/xx 5/7/2014
123463
Patient Name #8 F
N
N
N
N
Y
Y
N
N
N
N
xxx/xx 5/8/2014
123464
Patient Name #9 F
10/10/196 Provider Name
4
11/14/195 Provider Name
5
11/1/1941 Provider Name
N
N
N
N
N
Y
Y
Y
Y
N
Y
xxx/xx 5/9/2014
123465
Patient Name
#10
Patient Name
#11
Patient Name
#12
F
4/30/1958 Provider Name
N
N
N
N
N
Y
N
Y
Y
N
N
F
6/28/1920 Provider Name
Y
N
N
M
11/12/196 Provider Name
0
Y
N
N
xxx/xx 5/10/201
4
xxx/xx 5/11/201
4
xxx/xx 5/12/201
4
123457
Patient Name #2 M
123458
123466
123467
N
N
N
N
N
N
N
N
Y
N
Y
BP Date
Ischemic Vascular
Disease (IVD): Aspirin or
Antithrombotic
Another
Vascular
Ischemic
Use(HTN)
Disease (IVD): Complete
N
Urine Protein Screening
Influenza
Immunization(HTN)
N
Date Of
Patient Name
Gender Birth
Provider Name
Patient Name #1 F
7/10/1959 Provider Name
Lipid Panel and LDL
Control(HTN)
Pneumonia Vaccine for
Older Adults(HTN)
Dietary and Physical
Activity Modifications
Appropriately Prescribed
N
Patient ID
123456
BMI screening and
followup(HTN)
Diabetes Mellitis Screen
Measure Name
Complete Lipid Profile
Performed
Ability to download patient
listing to MS Excel for care
management and outreach
Y - Performance Met
N - Performance Not
Met
E - Exclusion
Blood Pressure Reading
Facility
Name
Aspirin or Another
Antithrombotic Use
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Mobile
Number
919-5551212
919-5551213
919-5551214
919-5551215
919-5551216
919-5551217
919-5551218
919-5551219
919-5551220
919-5551221
919-5551222
919-5551223
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Diabetes Measures
Reference
NQF 0059
Name
HbA1c Poor Control (>9.0)
HbA1c A1c Test
HbA1c control (<8.0)
NQF 0064
Low Density Lipoprotein (LDL) Management and Control
LDL-C screening
Blood Pressure In Control (<140/90)
NQF 0055
Eye Exam
NQF 0056
Foot Exam
NQF 0062
Urine Protein Screening
NQF 0068
Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
NQF 0075
Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control
NQF 0421
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
NQF 0021
Preventive Care and Screening: Influenza Immunization
NQF 043
Pneumonia Vaccination Status for Older Adults
NQF 0028
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
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Questions?
Contact:
Marya Upchurch, VP, Solution Development
mupchurch@n3cn.org / 919.882.0328