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November Health Information Technology Architecture

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November Health Information Technology Architecture Powered By Docstoc
					University of Minnesota
  Information Technology in
         Healthcare
          Course: MILI/PUBH 6562
            Fall Semester B, 2011
           Stephen T. Parente, Ph.D.
 Professor, Finance, Carlson School of Management
  Director, Medical Industry Leadership Institute
            (www.medicalindustrymba.com)
                 sparente@umn.edu
                 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
    Data Structure Fundamentals
• Simple text/column data
• Pre-packaged data
• Relational databases
     Simple Column Text Data
Patient   DOS        Procedure   Allowed
Joe       02/03/11   MD Visit    $100
Joe       06/05/11   Lab test    $60
Joe       02/03/11   Lab test    $60
Joe       06/05/11   MD Visit    $100
Mary      01/06/11   MD Visit    $100
Penny     11/11/11   Eye Exam    $80
        Pre-packaged databases
•   MS-Access databases
•   SQL databases
•   SAS databases
•   SPSS databases
•   STATA databases
•   Excel spreadsheets
         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).
Health Data Display by Different Units
             of Analysis

•   By provider
•   By person
•   By episode/incident
•   By transactions
•   Over fixed units of time
By Person
By Episode
By Transaction
                 Health Data Representation:
                         Over Time?
       Jan               Apr          July       Oct   Dec

             =Pysch
              consult

         Mental Health         Cumulative Cost
                                                             Well
$50K


                                                             Normal



$0                                                            Sick
  Insurers’ Role in Health Information
              Technology
• They are the ‘links’ that connect to everything
  about a patient in an electronic form.
  – Employers
  – Providers
  – Patients
  – Government agencies
  – Researchers
           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.
       IS Management Structure

                      CEO

     COO              CIO                    CFO


UR    MCO   MIS    Claims    Systems   Actuarial   Accounting



            Working Group Backbone
HEALTH INSURANCE CLAIM FORM
The Health MIS Pyramid

             Decision
          Support Software

     Life Support Software



          Clinical & Financial Data


              Hardware
Insurer Hardware - Mainframe
    Insurance Database Architecture
•   Claims
•   Membership
•   Provider files
•   Case management
•   Utilization review / Demand Management
•   Decision-support databases
•   Analytic / Financial data
                  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
Claims Data Example
Claims Data Example
  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
Subscriber Data Example
                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
Provider File Example
         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
         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
         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
        Life Support Systems

• Accounts Receivable
   – Employers
   – Consumers
   – Government
• Claims payment
   – Error checking
   – Provider payment
   – Fee schedules & payment algorithms
• Benefits/eligibility
          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
             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?
Intermission
          Medical Provider Data
•   Patient Diagnosis Information
•   Treatment plan
•   Referrals
•   Outcomes
•   Explanations for treatment
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
Medical Center Data Systems

                         Life
                         Support



                         Data




                         Hardware
    Medical Data Collection - 1

• Operational data: Transaction-oriented
  – Hospital pharmacies
  – Laboratories
  – Radiology departments
  – Critical care units
  – Order-processing units
    Medical Data Collection - 2

• Analytic data
  – Carry all variables of interest
  – Single record
  – Data is stored horizontally
    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
  Code Systems Standards - 2
• X12 - Data Interchange Standards
  Association’s Accredited Standards
  Committee
  – Insurance enrollment & payment
  – Administrative messages
   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
    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
Code Systems Standards
       Examples
Integrated Delivery System
        IT Network
                             Decision
                             Support

                             Life
                             Support



                             Data


                             Hardware
Insurer Only Data
                   1/31/11


PCP visit

Laboratory test

Specialist visit

Biopsy

Surgery

Sub-Acute Care


                   2/6/11
Medical Data Available to a U.S. Fee-
         for-Service Insurer
                                 Decision
                                 Support


                                 Life
                                 Support



                                 Data


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

                                  Life
                                  Support



                                  Data


                                  Hardware
Provider Only Data
       1/31/11


               Referral to specialist



               White blood cell count high

               Cancer metastasized

               Malignant cancer remains




      2/6/11
E/CPR Model A
E/CPR Model B
What are the Pros & Cons of these
            Models?

Are they out of date as useful data
      management models?
Data Available to the Average Medical
   Provider About a Patient’s Care



  10% of
  Care                       25% of
                             Care

               15% of
               Care

                                      15% of
                                      Care
    35% of
    Care
Merging Insurer & Provider Data
                          1/31/11


       PCP visit
                                   Referral to specialist
       Laboratory test

       Specialist visit
                                   White blood cell count high
       Biopsy
                                   Cancer metastasized
       Surgery
                                   Malignant cancer remains
       Sub-Acute Care


                          2/6/11
             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?
           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?

				
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