Outcomes and Lessons Learned From 5010 Testing Project Collaboration

Transcription

1 Outcomes and Lessons Learned From 5010 Testing Project Collaboration Elliot Sloane, PhD, CCE Villanova University Co-Chair, IHE International Bob Bowman CORE Manager CAQH Paul Decrosta Manager, IPP Regulatory BCBSA April 5, :45 10:45 am

2 IHE Agenda Proven Standards Adoption Process Encourage adoption of existing standards/private-public collaboration Complementary Paths: Streamlining Data Exchange CORE Clinical (IHE s focus) and Administrative (CORE s focus) Overview: Mission, Vision and Rules Goal of HIMSS/IHE-CORE-BCBSA Demonstration Support for existing standards: 5010 testing crossover Public-private involvement HITSP cross-over Outcomes and Lessons Learned BCBSA BCBSA Overview CAQH / CORE Coordination Role in public private collaboration in national and local HIT efforts Blues 5010 work to date HIPAA Mandates and HIT Implementation 2

3 A Synergistic Collaboration for the 5010 Testing Project The Players Centers for Medicare & Medicaid Services (CMS) provided (non-financial) support 3

4 Integrating the Healthcare Enterprise 4

5 What is Integrating the Healthcare Enterprise? A 11-year public-private initiative Driven by end-users, IHE improves patient care by harmonizing electronic health information exchange Enables approved standards to seamlessly pass health information among care providers on a local, regional and national level IHE products are freely available to all 5

6 Users Who s involved in IHE? Clinicians, Staff, Administrators, CIOs, Gov t agencies (e.g. NIST, VA, DoD, CDC, CMS) Professional Societies representing 270,000 individual members HIMSS, RSNA, ACC, ACP, AAO, ACCE, ASTRO, etc Standards Development Orgs (SDOs) HL7, DICOM, ISO, CDISC, ASTM, W3C, IEEE, IETF, etc Vendors & Consultants e.g., imaging, EHRs, cardiology, medical devices 6

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8 Proven Standards Adoption Process Develop technical specifications Testing at Connectathons IHE Demonstrations Identify available standards ( standards (e.g. HL7, DICOM, IETF, OASIS) Products with IHE Document Use Case Requirements Timely access to information Easy to integrate products 8

9 The IHE Development Domains 11 Years of Steady Evolution Radiology since 1998 Pharmacy NEW 2009 Laying the Groundwork 1998 Cardiology since 2004 Pathology since 2006 Eye Care since 2006 (Healthcare) IT Infrastructure since 2003 Quality Research & Public Health since 2006 Patient Care Devices since 2005 Laboratory since 2004 Radiation Oncology since 2004 Patient Care Coordination since 2004

10 The IHE Deployment Initiative Worldwide International Adoption Europe North America Asia Oceania

11 CORE and IHE: Complementary Paths Both IHE and CORE serve as a process and a forum for encouraging uniform implementations of existing standards, respectively achieving clinical and administrative information exchange goals Each has a testing process to demonstrate entity-specific implementations of milestone-driven requirements key to achieving the goal of interoperability IHE and CORE also share the common HITSP thread: CORE rules and IHE profiles are both incorporated in HITSP s efforts, thereby allowing HITSP to more quickly achieve its goals and ensure industry efforts are complementary, and not duplicative Collectively, CORE and IHE testing demonstrates existing industry testing tools are guiding stakeholders towards standards-based real world implementations 11

12 Committee on Operating Rules for Information Exchange (CORE) 12

13 CORE CORE is composed of more than 100 industry stakeholders health plans, providers, vendors, government agencies, associations, regional entities, standard-setting organizations and other healthcare entities Working in collaboration, CORE is building consensus on a set of operating rules that will: Enhance interoperability between providers and payers Streamline the exchange of administrative data transactions (e.g., eligibility, claim status) Reduce the amount of time and resources providers, payers, and other stakeholders spend on administrative functions Allow for administrative-clinical compatibility 13

14 Administrative and Clinical Integration IHE, CORE, HITSP efforts Industry initiatives through phased approaches Interoperable solutions Administrative and clinical data integration CORE Admin/Clinical Integration IHE HITSP 14

15 CORE Rules Phased Approach Phase I Phase II Infrastructure rules Infrastructure rules Acknowledgements Connectivity: HTTPS with SOAP WSDL and Connectivity: HTTPS and authentication authentication Last Name Normalization Companion Guide format AAA Error Code Reporting Response Time for patient identification System availability Data Content Data Content Additional 270/ /271 Eligibility, e.g. Eligibility Patient financials, e.g. Additional service co-pay, deductibles types In/out of network More financials, e.g. variances YTD deductibles Service type 276/277 Claim Status coverage Application of Phase I infrastructure rules 15

16 HIPAA Mandated Version Latest iteration of implementation guide for administrative transactions mandated by HIPAA federally mandated compliance by January 2012 Replaces current version Examples of X12 standard transactions under HIPAA - used by providers and health plans: : Eligibility inquiry and response An inquiry from a provider and the response from a health plan regarding a patient s eligibility for coverage, or the benefits for which a patient may be eligible : Claim status inquiry and response An inquiry from a provider and the response from a health plan about the processing status of a submitted claim or encounter 278: Prior authorization and referral An inquiry from a provider and the response from the health plan about a patient s prior authorization or referral for services 837: Claims or equivalent encounter information Healthcare service information provided to a health plan for reimbursement Note: For each transaction, only part of the standard is required 16

17 Goals of HIMSS/IHE-CORE-BCBSA Demonstration Goals Learn about the proactive approaches and work among the healthcare stakeholders that is building momentum for the implementation of the 5010 HIPAA transaction requirements CORE rules and testing - key input by Blues HITSP and CORE convergence Annual CORE participation at IHE See how trading partners are demonstrating industry capabilities for HIPAA-compliant administrative data exchange testing via CORE 17

18 Proactive, Voluntary, Implementation of Standards and Business Rules CORE demonstrates that: Public and private healthcare stakeholders can work to implement change Building on HIPAA and other standards, CORE rules are written through a consensus-based process, agreed upon by its participants and implemented by stakeholders; Medicare and CMS Office of e-health Standards and Services are at the table as are other parts of government like Department of Veterans Affairs A voluntary industry effort can be used to quickly achieve milestones CORE uses an incremental approach in order to achieve maximum adoption Take advantage of early adopters and industry leaders Stakeholders can implement and test new standards/specifications in the real world before a federal mandate or directive is sought The CORE rules were defined with 5010 in mind HITSP includes the CORE Rules connectivity and content rules 18

19 CORE/5010 Crossover: Response to Generic Eligibility Inquiry from Provider CORE: Required by Phase I effective 4/ : Federal Mandate for Jan Name of health plan (if available) Health plan coverage begin date In/out of network coverage variance Status of coverage (active, inactive) Status of following service types such as*: 1 Medical Care 33 Chiropractic 35 Dental Care 86 Emergency Services 88 Pharmacy 98 Prof. Office Visit AL Vision Name of health plan (if available) Health plan coverage begin date Status of coverage (active, inactive) Status of following service types: * 41 other service types required in CORE Phase II 1 Medical Care 33 Chiropractic 35 Dental Care 86 Emergency Services 88 Pharmacy 98 Prof. Office Visit AL Vision 47 Hospital MH Mental Health UC Urgent Care NOTE: Red italicized font indicates service type variance between CORE Phase I and

20 CORE/5010 Crossover: Eligibility Inquiry- Patient Financials CORE certification for Health Plans responding to an eligibility query from Provider includes testing for the return of patient financials The return of patient financials has been included in CORE requirements using the HIPAA standards - since Apr 06 well ahead of the recommendations in 5010 to return such information Patient Financial Required by CORE Phase I 4/06 or CORE Phase II since 7/08 (either 6 or 4 yrs prior to 5010) Recommended by 5010 (not mandated) Co-pay X X Coinsurance X X Deductible (static) X X YTD Deductible (remaining) X (Phase II) No In/out of network variances X No 20

21 HITSP Standards Harmonization HITSP process for Standard Development: Identify a pool of standards for a general breakthrough area Identify gaps and overlaps for specific context Make recommendations for resolution of gaps and overlaps Develop Interoperability Specifications for using the selected standard(s) for a specific context Test the instruction for using the standard 21

22 HITSP and CORE HITSP includes CORE Rules within its constructs HITSP Number HITSP Name IS03 Consumer Empowerment IS05 Consumer Empowerment and Access to Clinical Information via Media IS07 Medication Management CORE Rules Inclusion C32 Summary Document Using HL7 CCD includes CORE Phase I Data Content Rule as informative text in insurance module T40 Patient Generic Health Plan Eligibility Verification Transaction -includes complete CORE Phase I Rule Set T85 Administrative Transport to Health Plan includes CORE Phase II Connectivity Rule, e.g. SOAP with WSDL and digital certificates or user/passwords IS08 Personalized Healthcare IS09 Consultations and Transfers of Care IS77 Remote Monitoring T40 and T85 is included in all of these. 22

23 CORE-Certified Trading Partners CORE-certified trading partners are exchanging eligibility 5010-level HIPAA administrative data today Edifecs is the Phase II CORE Testing and Certification Vendor Over 40 CORE-certified organizations/products Clearinghouses, health plans, providers and vendors have all gone through the testing process Complete list can be found at CORE-certified trading partners attest to compliance with HIPAA (currently mandated versions) 23

24 Lessons Learned Implementing change is not easy Eligibility/data content is a challenge Multiple databases, legacy systems Multiple systems may need enhancement Gap analysis is important Test environment set up for CORE can also assist with trading partner testing Infrastructure established be CORE also matters it helps data flow (e.g., response time, connectivity) CAQH submitted comments to HHS on 5010 based on implementation experience from CORE 24

25 Outcomes CORE rules are having an impact Reducing administrative costs Increasing real-time eligibility verification (e.g., BCBSNC) More efficient process for providing eligibility and benefits information to providers Have begun goal to improve other transactions/processes (e.g., claim status in Phase II) Momentum toward a national approach that can be implemented on a state/regional level Merging clinical/admin (e.g., CORE Connectivity Rule is payload agnostic can use X12 or HL7) Better communication among industry stakeholders 25

26 Blue Cross Blue Shield Association 26

27 BlueCross BlueShield Association Who we are: Mission Statement: We are an association of BlueCross and BlueShield Plans dedicated to protecting and strengthening the BlueCross and Blue Shield Brands, supporting the Plans individually and collectively in their pursuit of Blue business and preserving the private healthcare market BCBSA is made up of 39 individual community based Plans We represent more than 101 million members throughout the country 27

28 BCBSA Statement of Support BCBSA is pleased to participate in CAQH CORE's efforts to streamline electronic eligibility. Simplifying provider access to patient insurance coverage information is critical and the Blues believe that CORE is a key initiative to bring the industry together for collaboration and consensus building. 28

29 HIPAA Mandated Version BCBSA work effort to date We have partnered with a vendor to conduct a gap analysis of existing formats We are working with BCBS Plans to establish implementation timelines and an education strategy BCBS Plan calls best practices sharing and issues resolution Create Provider outreach toolkits and education sessions Partnering with CMS and other industry groups on national education and outreach efforts We will continue to work with our Plans and the industry to look at best practices on implementation strategies 29

30 Blue Industry Engagement Currently have active, leadership roles in numerous industry organizations that work to advance HIPAA and HIT X12 HL7 WEDI HITSP CCHIT NCVHS NeHC CAQH CORE Local BCBS Plans engaged with implementing local HIE s (e.g., AHIN) Partnered with AHIP to establish Payer-to-Payer transfer of PHR data Operating Rules Partnered with ASC X12 and HL7 to develop Payer-to-Payer transfer of PHR data technical standards Local BCBS Plans (e.g., BCBS of MA) are conducting pilots or providing incentives or hardware to advance provider HIT adoption 30

31 5010 Industry Collaboration: Leveraging Coordinated Testing Efforts to Help Prepare for Uptake and Adoption of National IT Standards CAQH/CORE Presentation April 7, :15-11:45 am IHE Theater B Exhibit Floor Booth # 7750

32 Q and A