It will take some time before physicians and hospitals have comprehensive medical records for their patients in their newly acquired Electronic Medical Record (EMR) software. EMR systems that are already deployed by providers don't typically contain clinical data about the care delivered by other providers. In contrast to EMRs, EHRs contain a longitudinal view of a patient's medical history across providers and can be populated from other sources including lab companies, at-home medical devices, health plans, and patient self-reported data (for example, data about over-the-counter drug that could potentially generate an adverse drug reaction).
Discussions on Meaningful Use don't usually mention health plans since the incentives are only directed at eligible professionals and hospitals. However, health plans can play a very important role in jumpstarting EHR adoption by extracting health records from the vast amount of clinical data in claim transaction repositories and by making that data available to members and providers as well.
Quality and Care Coordination with Claim-Based Health Records
The following examples demonstrate how health records extracted from claim data, when made available to providers, can significantly improve the quality and coordination of care :
- Pharmacy claim data can enable medication reconciliation during transitions of care.
- Lab and radiology claim data help avoid redundant and potentially costly orders.
- Diagnosis codes in medical claims can provide a view of a patient's problem list for care coordination purposes.
When delivered in standard compliant data format, these claim-based data can be fed into clinical decision support systems for the automated execution of clinical guidelines and for generating alerts and reminders.
Data Integration and the Importance of Data Standards
Maintaining an up-to-date and truly longitudinal view of a patient's medical history requires merging and reconciling data from heterogeneous sources including providers' EMR systems, lab companies, medical devices, and payers' claim transaction repositories. This data integration will only be possible if all stakeholders adhere to common data exchange standards such as the ASTM Continuity of Care Records (CCR) and the HL7 Continuity of Care Documents (CCD) standards.
Both the CCR and the CCD specify an XML Schema for constraining and validating EHR data. Therefore XML tools based on XSLT or XQuery/XQuery Update can be used to automate the merging of data from multiple sources.
To ensure data portability when members switch jobs or health plans, the HL7 standard development organization published a Plan-to-Plan Personal Health Records Implementation Guide of the CCD specification with active participation by America's Health Insurance Plans (AHIP) and the Blue Cross and Blue Shield Association (BCBSA).
Health Plans and HIEs
Collaboration between all stakeholders in the healthcare industry requires an IT infrastructure to ensure effective data exchange orchestration and security. This infrastructure can take the form of a Health Information Exchange (HIE) network at the regional, state, or even federal level. A HIE provides capabilities such as a document registry and repository, an authorization policy engine, a consumer preferences manager, a HIPAA-compliant audit log, and a master patient index (MPI) to reliably aggregate patient's data across payers, providers, and other data sources. Such exchange networks can be built with open source software such as NHIN Connect and the emerging NHIN Direct.
The Value of Claim-Based Health Records for Health Plans
Claim-based health records can help providers meet health plans' pay-for-performance incentives and quality measures initiatives. Electronic Health records will also be an important component of health plans' Population Health Management programs.
Some Accountable Care Organizations (ACOs) will be led by health plans. Data integration will be essential to the success of those ACOs.
Health Plans vs. Google Health and Microsoft Health Vault
Health Plans have a huge competitive advantage compared to online personal health records (PHRs) services such as Google Health and Microsoft Health Vault: they can pre-populate the PHRs of their members with health records extracted from claim transactions and those PHRs are likely to be more useful and reliable to providers than patient self-reported data.
A Roadmap for Health Plans
Health plans can position themselves for their new role as enablers of EHR adoption by doing the following:
- Create an EHR view of the health records in claim transaction repositories
- Map the data to industry exchange standards such as the ASTM CCR or the HL7 CCD
- Make the data available to their members (through a web portal for example) and partners (subject to patient's consent)
- Get ready to contribute data to HIEs by adopting other necessary standards such as Integrating the Health Enterprise (IHE) profiles for cross-enterprise document exchange (XDS.b), security, and patient consent
- Embrace and participate in open source projects such as NwHIN Connect and Direct
- Actively participate in the health IT standards development process
- Prepare their infrastructure to send and receive health records from providers.