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
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 1
Abstract





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.
But when is an HIE not an HIE?
When one is a Health Information Exchange
and one is a Health Insurance Exchange.
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.
Evaluating the effectiveness of each, separately, offers a significant
research challenge.
Creating and monitoring effective relationships between the two
may be the future of risk management in healthcare.
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 2
Outline of This Presentation
1.
2.
Healthcare and Health Insurance
are Information Intensive Industries
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.
4.
Experience To Date
Measuring Success of HIEs
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 3
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
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 4
Healthcare & Health Insurance Information
Pathways
Equip.
Mfrs.
Hospitals
Suppliers
Drug
Mfrs.
*Us! =
Federal
& State
Gov’t.
Data
Services
PHOs
Physicians
Pharm.
Benefit
Mgrs.
Peer
Review
Orgs.
Fiscal
Intermediaries
Employers,
Unions,
& Assns.
IPAs
Patients, Employees,
Citizens, Enrollees,
Members, Covered Lives,
Consumers, Marginal Units,
Populations
*
ASO
TPAs
Network
& Care
Mgrs.
Insurers
Us!
Financial
Services
Credit
Bureaus
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Claims
Assistance
Slide 5
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.”
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 6
Color Key:
Clinical (specific)
Clinical (summary)
Financial
Administrative
Equip.
Mfrs.
Healthcare Information:
Order from Chaos?
Peer
Review
Orgs.
Fiscal
Intermediaries
Suppliers
Federal
& State
Gov’t.
Data
Services
Hospitals
Employers,
Unions,
& Assns.
Physicians
Patients
Drug
Mfrs.
Claims
Assistance
Pharm.
Benefit
Mgrs.
Network
& Care
Mgrs.
Insurers
ASO
TPAs
Financial
Services
Credit
Bureaus
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 7
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?)
???
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 8
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 9
Health Information Exchange



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.
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).
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-bystate basis and mandated interconnection of these through the
application of Nationwide Health Information Network (NwHIN)
standards for inter-HIE exchange.
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 10
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 11
Health Information Exchange (sources)

DHHS ONCHIT (created in 2004)
Office of the National Coordinator for Health Information Technology (ONCHIT)
Federal Health IT Strategic Plan, updated for 2011-2015 – 80pp.
(http://healthit.hhs.gov/portal/server.pt/community/fed_health_it_strategic_plan/1211/home/15583)

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)

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)

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.)
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 12
Health Insurance Exchange



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.”
Health Insurance Exchanges are intended to serve as fully online
health insurance marketplaces where individuals and small
businesses may select and purchase health insurance.
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 http://www.hhs.gov/healthcare/rights/law/index.html),
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.”
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 13
Health Insurance Exchange (continued)

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).
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 14
Health Insurance Exchange Functions
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 15
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 16
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 17
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 18
Health Insurance Exchange (sources)

PPACA (2010)
Patient Protection and Affordable Care Act (PPACA) (“Obamacare”)
(http://www.ncsl.org/documents/health/ppaca-consolidated.pdf) – 974pp.
Louisiana Department of Insurance
 Louisiana Healthcare Reform Resource Center
-- for Consumers
-- for Producers

(http://www.ldi.louisiana.gov/)
(http://www.ldi.state.la.us/HealthCareReform.html
(http://www.ldi.state.la.us/MarketplaceTraining.html)
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 19
HIE-HIE
Connections?
Eligibility
Co-Pay Collection
Coverage Levels
Prior-Authorization
Changes
Enrollment
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 20
HIE-HIE Communications
Payors
Insurers
Healthplans
Healthcare
Providers
Patients
and
Families
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 21
What an Applicant-Patient wants to know
(how does PPACA affect me and my choices of Providers)
1.
2.
3.
4.
5.
6.
7.
8.
What is the monthly cost of the Healthplan’s premiums?
How long has the Healthplan been in business? How viable is the
company? How stable will my premiums be over time?
Can I still see my regular doctors? Will it cost more to see my regular
doctors?
Are my current medications in the formulary? Will it cost more to get my
current medications?
Must I have prior approval to see a specialist? approval from my regular
doctor? approval from the healthplan?
Must I file my own claims? Will I get statements showing total costs and
total out-of-pocket expenses?
Is there a co-pay required for routine visits? an annual deductible to meet?
Is there an annual or lifetime maximum benefit? [PPACA prohibits maxima
for “essential health benefits” renewals after 12-31-2013]
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 22
What a Provider wants to know
(how does PPACA affect me and what compliance issues loom)
1.
2.
3.
4.
5.
6.
7.
How will I know which Patient is eligible under which Healthplan?
May a Patient be rejected on the basis of their choice of Healthplan? [e.g.,
a Healthplan in which I do not participate]
How will I know which services are covered by a particular Patient’s
Healthplan?
How will I know which medications are including in a Healthplan’s
formulary?
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?
What must I collect as a co-pay from any particular Patient?
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?
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 23
What a Healthplan wants to know
(who are the Applicants and what underwriting options still exist)
1.
2.
3.
4.
5.
6.
7.
Does the Applicant have pre-existing medical conditions that might
disqualify them for coverage? [PPACA prohibits!]
Does the Applicant have behavioral risk factors that might alter their
premium? [PPACA allows (e.g., smoking)]
May an Applicant be rejected on certain specific criteria other than a preexisting condition or a risk factor?
[e.g., Healthplan lacks certain services that Applicant-Patient may need]
Does the Applicant agree to all terms associated with the healthplan?
Has the Applicant prepaid the required initial premium?
Will the Applicant’s premium be supported by federal grants or aids?
What Provider(s) will Applicant choose?
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 24
What the Regulators want to know
1.
2.
3.
4.
5.
6.
7.
8.
(Exchange effectiveness and PPACA compliance metrics)
How many Applicants have visited the Health Insurance Exchange? nonduplicated individuals?
How many Applicants have applied for coverage with each specific
Healthplan? non-duplicated applications?
How many Applicants have been approved for coverage with each specific
Healthplan? Applicants and individual persons to be covered?
How many Small Businesses have visited/applied/been/approved? Small
Businesses and individual persons?
What fraction of previously uninsured individuals will now have coverage?
How many dollars in initial premiums committed/paid by Applicants?
How many dollars in initial premiums committed by federal grants or aids?
What complaints, misrepresentation, violations, etc. have occurred as a
result of the Health Insurance Exchange?
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 25
3. 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!
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 26
The HIE & the HIE in Louisiana

The Louisiana Health Care Quality Forum (LHCQF), the StateDesignated 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.


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.
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!
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 27
Only 16 States Run Their Own Insurance Exchanges
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 28
Official Skepticism in Louisiana
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 29
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 30
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 31
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 32
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 33
Apologies & Apologists
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 34
New Action Plan
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 35
On the Mend?
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 36
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 37
https://www.healthcare.gov/families/
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 38
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 39
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 40
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 41
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 42
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 43
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 44
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 45
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 46
Louisiana Plan Comparison – Single, 50 or older
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 47
Tricks no Treats?
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 48
Period*
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 49
https://www.healthcare.gov/small-businesses/
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 50
Employer
Penalties
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 51
Downstream Implementation Timeline
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 52
4. Measuring Success of HIEs
Health Information Exchanges
Providers, Payors, Patients, Regulators, Public Health Agencies
Health Insurance Exchanges
Consumers, Sponsors, Carriers, Networks, Providers, Regulators
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 53
Defining “Success”
for Each
Health Information Exchange
Functionality
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 54
Table 1. “Pre-Arrival”
Uses of Information Exchanged in an HIE
HIE FUNCTIONALITY
and Transactions
Transaction Type
Sender
Primary
Beneficiary
CLASS
Receiver
REFERRALS (INBOUND)
PROVIDERS
Request to Accept Referred Patient
Unsolicited Request
Provider A
Provider B
CCR/CCD Request
Decision-triggered Response
Provider B
Provider A
CCR/CCD Delivery
CCR/CCD Transmission
Provider A
Provider B
Response (Accept/Decline)
Decision-triggered Response
Provider B
Provider A
Provider A
Provider B
PATIENTS,
PROVIDERS
APPOINTMENTS
Request for Appointment
Unsolicited Request
Patient
Provider
Provider
Response (Accept/Decline)
Decision-triggered Response
Provider
Patient
Patient
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 55
Table 2. “Point-of-Arrival”
Uses of Information Exchanged in an HIE
HIE FUNCTIONALITY
and Transactions
Transaction Type
Sender
Receiver
ELIGIBILITY CHECKING
Primary
Beneficiary
CLASS
PROVIDERS
Inquiry
Unsolicited Inquiry
Provider
Payor
Response
Decision-triggered
Response
Payor
Provider
Provider
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 56
Table 3. “Point-of-Care”
Uses of Information Exchanged in an HIE
HIE FUNCTIONALITY
and Transactions
PATIENT RECORD REQUESTS
CCR/CCD Request
CCR/CCD Delivery
Transaction Type
Unsolicited Request
CCR/CCD Transmission
Sender
Provider B
Provider C
Receiver
Provider C
Provider B
LABORATORY TESTS
Order
Interim Status Inquiry
Interim Status Report
Result
Unsolicited Order
Unsolicited Inquiry
Decision-triggered Response
Decision-triggered Response
Provider
Provider
Laboratory
Laboratory
Laboratory
Laboratory
Provider
Provider
RADIOLOGY WORKUPS
Order
Interim Status Inquiry
Interim Status Report
Report
Unsolicited Order
Unsolicited Inquiry
Decision-triggered Response
Decision-triggered Response
Provider
Provider
Radiology
Radiology
Radiology
Radiology
Provider
Provider
PRESCRIPTIONS
ePrescribing of Rx
Rx Fill/Pickup Report
Unsolicited Order
Event-triggered Response
Provider
Pharmacy
Pharmacy
Provider
PRIOR AUTHORIZATIONS
Request
Interim Status Inquiry
Interim Status Report
Determination (Approval/Disapproval)
REFERRALS (OUTBOUND)
Request to Accept Referred Patient
CCR/CCD Request
Forwarding of Patient Record
Response (Accept/Decline)
Unsolicited Request
Unsolicited Inquiry
Status Report
Decision-triggered Response
Unsolicited Request
Decision-triggered Response
CCR/CCD Transmission
Decision-triggered Response
Provider
Provider
Payor
Payor
Provider B
Provider D
Provider B
Provider D
Payor
Payor
Provider
Provider
Provider D
Provider B
Provider D
Provider B
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Primary Beneficiary
CLASS
PROVIDERS
Provider B
PROVIDERS
Laboratory
Provider
Provider, Patient
PROVIDERS
Radiology
Provider
Provider, Patient
PROVIDERS
Pharmacy
Provider, Patient
PAYORS, PROVIDERS
Payor
Provider
Provider, Patient
PROVIDERS
Provider B
Provider D
Slide 57
Table 4. “Point-of-Departure”
Uses of Information Exchanged in an HIE
HIE FUNCTIONALITY
and Transactions
Transaction Type
Sender
Primary
Beneficiary
CLASS
Receiver
REIMBURSEMENT CLAIMS
PROVIDERS
Claim Submission
Unsolicited Transmission
Provider
Payor
Claim Status Inquiry
Unsolicited Transmission
Provider
Payor
Claim Status Report
Event-triggered Response
Payor
Provider
Provider
Remittance Advice
Event-triggered Response
Payor
Provider
Provider
Electronic Funds Transfer
Event-triggered Response
Payor
Prov. Bank
Provider
PERSONAL HEALTH RECORD
ePHR Update
Payor
PATIENTS
Unsolicited Transmission
Provider
ePHR
Custodian
Patient
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 58
Table 5. “Post-Departure”
Uses of Information Exchanged in an HIE
HIE FUNCTIONALITY
and Transactions
Transaction Type
Sender
Primary
Beneficiary
CLASS
Receiver
PUBLIC HEALTH
AGENCIES
IMMUNIZATION REGISTRY
Registry Update
Unsolicited
Provider
Registry
Agency
Registry Update Acknowledgement
Event-triggered Response
Registry
Agency
Provider
Registry Agency
PUBLIC HEALTH
AGENCIES
DISEASE/TUMOR REGISTRY
Registry Update
Unsolicited
Provider
Registry
Agency
Registry Update Acknowledgement
Event-triggered Response
Registry
Agency
Provider
QUALITY REPORTING
Registry Agency
REGULATORS
Quality Reporting
Unsolicited
Provider
Quality
Agency
Qual. Reptg. Acknowledgement
Event-triggered Response
Quality
Agency
Provider
Quality Agency
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 59
HIE: Measuring Success
FUNCTIONALITY
Primary Beneficiary
Type of Benefit
Benefit Measure
Quantitative
Qualitative
REFERRALS (INBOUND)
PROVIDERS
Source of new patients
# of new patients
Provider satisfaction
APPOINTMENTS
PATIENTS
PROVIDERS
Time saved
$ saved in FTE staff costs
Patient satisfaction
Staff satisfaction
ELIGIBILITY CHECKING
PROVIDERS
% of booked revenue collected
Provider and staff satisfaction
PATIENT RECORD
REQUESTS
PROVIDERS
Time saved
Provider and staff satisfaction
LABORATORY TESTS
PROVIDERS
RADIOLOGY WORKUPS
PROVIDERS
Convenience
Staff time/cost savings
Avoidance of uncollectable
revenue
Elimination of duplicative
workups
Automatic EHR update of
results
Automatic EHR update of
reports
PRESCRIPTIONS
PROVIDERS
Automatic EHR update of
compliance
% of prescriptions filled and
picked up
PAYORS
PRIOR AUTHORIZATIONS
PROVIDERS
Enforcement of coverage
limitations
Avoidance of uncollectable
revenues
Time saved by avoiding delays
and manual filing
Time saved by avoiding delays
and manual filing
$ saved in medical payments
Accessibility of information
Accessibility of information
Provider satisfaction related to
this information not being
previously available
Utilization management goals
met
% of $ collected
Staff satisfaction
Time saved
Accessibility of information
REFERRALS (OUTBOUND) PROVIDERS
Expedited consultation
REIMBURSEMENT
CLAIMS
PROVIDERS
# claims submitted;
Expedited collection of revenue % 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 REPORTING
QUALITY AGENCIES
Enhanced compliance & data
integrity
#, timeliness, and completeness
of updates received
Better information upon which to
base health promotion policies
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 60
Defining “Success”
for Each
Health Insurance Exchange
Functionality
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 61
Health Insurance Exchange
HIE, HIeX, HIX,
AHBE, Marketplace
CONSUMERS
Adults
(+Students)
Seniors
Indigent
Children
REGULATORS
SPONSORS
Sponsors
Self
Employers
Small
Employers
Large
Unions
Assocs
Individual
----------------SHOP
CARRIERS
NETWORKS
Carriers
Blues
Networks
ACOs
CCNs
HCOs
HMOs
PPOs
IPAs
-------------
Providers
Hospitals
ASCs
PCPs
PCMHs
SpecPhys
RHAs,IHSs,
IDSs,IDNs
RadCenters
Commercials
Co-ops
Govt.Progs
Medicare
Part A
Part B
Part C
Part D
Medicaid
S-CHIPs
PROVIDERS
Pharmacies
Laboratories
HmHealthAgcs
TelemedProvs
State Insurance Commissioners (http://www.naic.org/)
Dept.of Labor – Emp.Ben.SecurityAdmin. (http://www.dol.gov/ebsa/)
Centers for Medicare & Medicaid Services (https://www.cms.gov/ /)
+ IRS & Homeland Security
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 62
Redefining the Individual Market
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 63
Table 1. “Pre-Application”
Uses of Information Exchanged in an HIE
[HIeX, HIX, AHBE, Marketplace]
Sender
Receiver
Primary
Beneficiary
CLASS
Unsolicited Inquiry
Consumer,
Sponsor
(SHOP)
HIX Query
Module
CONSUMERS,
SPONSORS
BROWSING FOR HEALTHPLANS
Unsolicited Inquiry
Consumer,
Sponsor
(SHOP)
HIX Query
Module
CONSUMERS,
SPONSORS
BROWSING FOR PROVIDERS
NETWORKS
Unsolicited Inquiry
Consumer
HIX Query
Module
CONSUMERS
HIE FUNCTIONALITY
and Transactions
SEEKING GENERAL
INFORMATION
Transaction Type
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 64
Table 2. “Point-of-Application”
Uses of Information Exchanged in an HIE
[HIeX, HIX, AHBE, Marketplace]
HIE FUNCTIONALITY
and Transactions
CREATING A MARKETPLACE
ACCOUNT
IDENTIFYING HEALTHPLAN
DETAILS
COMPARING SIMILAR
HEALTHPLANS
APPLYING TO PURCHASE A
HEALTHPLAN
Receiver
Primary
Beneficiary
CLASS
Unsolicited Input
Consumer,
Sponsor
(SHOP)
HIX
Registry
Module,
Regulator
CONSUMERS,
SPONSORS,
REGULATORS
Unsolicited Inquiry
Consumer,
Sponsor
(SHOP)
HIX Query
Module
CONSUMERS,
SPONSORS
Unsolicited Inquiry
Consumer,
Sponsor
(SHOP)
HIX Query
Module
CONSUMERS,
SPONSORS
Consumer,
Sponsor
(SHOP)
HIX
Applicatio
n Module,
Carrier,
Regulator
CONSUMERS,
SPONSORS,
CARRIERS,
REGULATORS
Transaction Type
Unsolicited Input
Sender
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 65
Table 3. “Point-of-Enrollment”
Uses of Information Exchanged in an HIE
[HIeX, HIX, AHBE, Marketplace]
HIE FUNCTIONALITY
and Transactions
RECEIVING CONFIRMATION OF
ENROLLMENT
SELECTING AN ACO / CCN /
PCMH / PCP
RECEIVING CONFIRMATION OF
THE HEALTHPLAN BEING IN
EFFECT
Transaction Type
Decision-triggered
Response
Unsolicited Input
Decision-triggered
Response
Sender
Carrier
Consumer
Carrier
Receiver
Primary
Beneficiary
CLASS
Consumer
CONSUMERS,
REGULATORS
Carrier,
Network,
Provider
CONSUMERS,
CARRIERS,
NETWORKS,
PROVIDERS,
REGULATORS
Consumer
CONSUMERS,
NETWORKS,
PROVIDERS,
REGULATORS
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 66
HIE: Measuring Success
FUNCTIONALITY
Primary Beneficiary
Type of Benefit
Benefit Measure
Quantitative
Qualitative
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
CONSUMERS
Knowledge 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
CONSUMERS,
APPLYING TO PURCHASE SPONSORS,
A HEALTHPLAN
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
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 67
Conclusions
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 68
This study suggests that ...








Benefits may accrue in various distinct areas and in varying degrees to each of the
HIE’s diverse participants.
Certain participants may have no direct interest whatsoever in any but a very few
specific HIE functionalities.
Participants who receive HIE transmissions are the principal beneficiaries of the
exchange – receiver receives “value” only if they perceive utility.
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.
Some unsolicited transmissions may be requests for services – “orders” – and the
receiver has an opportunity to benefit by turning the order into collectible revenue.
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.
Under-contributing functionalities may still find a long-term niche, especially
when these co-exist with other functionalities that can subsidize their continuance.
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.
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 69
Questions, Comments,
or Suggestions?
caillouet@louisiana.edu
ferguson@louisiana.edu
Learn more at
http://lchi.louisiana.edu
Louisiana Center for Health Informatics at The University of Louisiana at Lafayette
Slide 70