CRISP Provider Data Services

Transcription

1 CRISP Provider Data Services Chesapeake Regional Information System for Our Patients MESC Conference September,

2 CRISP Mission and Vision CRISP is a 501(c)3 non-profit established by healthcare organizations in the state Mission To advance the health and wellness of Marylanders by deploying health information technology solutions adopted through cooperation and collaboration. Vision We will enable and support the Maryland healthcare community to appropriately and securely share data in order to facilitate care, reduce costs, and improve health outcomes. 2

3 Governance Structure 3

4 Current HIE Focus Areas Query Portal Growth Prescription Drug Monitoring Program Encounter Notification System (ENS) Encounter Reporting System (ERS) Health Benefits Exchange (HBE) 4

5 CRISP serves as Maryland s Health Information Exchange 5

6 Do HIEs need a broad comprehensive Provider Directory? Do Provider Directories Matter? Starting point question (and this really applies far more broadly than PD): Is there a real demand in the HIO s market for a broad-based provider directory solution, and if so, is the HIO is the best position to offer that solution? Has the likes of Meaningful Use/other skewed priorities? Uncomfortable reality: value-based demand (as opposed to short-term incentive-based demand) for service may fall outside of the primary requirements for clinical health information exchange. Few have connected the dots for Provider Directory value? The broader opportunity of offering a provider directory as a shared service may be a best practice and commonly cited conceptually, but in reality not pursued because of the perceived risks of putting the fate of one program into the hands of a third party. Title? Local relationships, shared vision (primarily among key decision-makers), and a strong vendor partner (or in house execution capability) are key factors bring a solution to market in time to capitalize on short-term funding streams and closing procurement windows. 6

7 Health Benefits Exchange Services CRISP has partnered with the Maryland HBE to support 3 specific services: 1.Provider Information Management Partnering with Optum, CRISP will offer a verified provider demographics source to enable HBE customers to search for plans by providers in the network 2.Master Patient Indexing Services for the All Payer Claims Database Relying on the Initiate MPI, CRISP can enable insights into member churn between QHPs and Medicaid plans as member eligibility status changes over time 3.Clinical Summary Care Coordination Service Based on a triggering event, CRISP will compile a time-banded summary of data (starting with just encounter data) to forward to care coordinators 7

8 Optum PIM Provider Data Services Carriers send provider and product/plan affiliation data files to CRISP/Optum bi-weekly Optum validates, cleans, standardizes, and matches provider data against existing PIM data sources Optum creates a bi-weekly PIM directory file of all provider data and sends to HBE to enable provider search

9 Optum PIM Provider Data Services Health IT HIEs: Clinical Information Transport and Aggregation EMRs: Provider Directories, and Contract Management HISPs: Direct Support Cloud: Optum Healthcare Cloud: Users Operational Support Health Plans: Credentialing, Quali8ty and Cost Reporting, Fraud Risk Screening Medicaid: Provider Screening, Provider Enrollment Fraud Risk Detection, Analysis APCDs: Quality & Cost Reporting, Care Pattern Analysis, Practice Improvement, Fin Analysis HBEs: Provider Selection, Network Analysis, Quality Reporting Provider Information Management ILPD Relationships ELPD PIM Enables a host of Applications Admin User Portal Custom APIs Standard APIs PIM Access Methods Publishing Sources Cleansing Employers Public Sources Providers Government Matching Payers

10 Current Use for PIM in Maryland HBE Leveraging multiple data sources to create a consolidated clean provider file Enabling consumers to search on provider to select a Health Benefit Plan 10

11 Future PIM Values Beyond the Current HBE Plan Future Optum PIM opportunities for CRISP: Primary source verification or medical credentials Coordination with HIE provider directories Physician portal to maintain / enhance information Storage of electronic address information (digital identification) for providers (i.e. Direct address and EMR endpoint data) External APIs to Payers and Provider Entities (including ILPD to ELPD relationships data) 11

12 PIM Service An Extension of Optum P360 Database CRISP is using P360 to verify and match provider demographic information against existing PIM data sources using existing cleansing and updating processes Ø Ø Database of over one million US physicians Over 2.5 million total providers Ø Approximately 65,000 providers in Maryland (30,000 licensed physicians) Ø Roughly 14,000 practicing physicians in Maryland Provider Data As of 1/25/2013 Personal Medical Education & Specialty Medical Licenses & Numbers Practice Data Data Element Physicians Filled Dentists Filled Other P rofes s ional Filled # % # % # % Name 32, % 5, % 34, % Gender 31, % 5, % 34, % Birth Date 22, % 2, % 11, % Language* 9, % 1, % 3, % Degree 32, % 5, % 31, % Medic al S c hool 18, % 2, % 9, % Residency 16, % % 3, % Specialty 27, % 4, % 21, % Provider Type 32, % 5, % 34, % License 29, % 5, % 30, % NPI 28, % 4, % 32, % UPIN 17, % % 6, % DEA Number 23, % 4, % 9, % Address 32, % 5, % 34, % Phone 29, % 5, % 32, % Fax 21, % 3, % 20, % Practice Affiliation 17, % 2, % 16, % Hos pital Affiliation 18, % % 5, % Tax ID 21, % 2, % 14, % Sanction % % % Other Medic are Enrollment 20, % % 9, % Medic are Opt- Out % % %

13 Existing P360 Data Source and Processing Model 13

14 P360 Databases 14

15 P360 Data Sources Over 200 Proprietary Sources (UnitedHealthcare & OPTUM Businesses) Sources Key Data Elements Update Frequency Provider Data Stores Primary Source Verified Data Provider-Attested Data Provider demographics, medical education, and practice affiliation data Weekly/ Monthly Over 400 Primary Sources (Government Issuing Sources) Source Key Data Elements Update Frequency CMS National Plan and Provider Enumeration System (NPPES) NPIs and Taxonomy Codes Monthly CMS Provider Enrollment, Chain and Ownership System (PECOS) Medicare Enrollment Monthly National Technical Information Services (NTIS) DEA Numbers Weekly State Licensure Boards State License Data Monthly/Quarterly Sanction Data Monthly Federal Office of Inspector General (OIG) Sanction Data Monthly Federal General Services Administration (GSA) Sanction Data Monthly Social Security Administration (SSA) Death Master File Deceased Providers Monthly UPIN Registry UPINs Grandfathered Medicare Administrative Contractors (MACs) Medicare Opt-Out Quarterly US Postal Service Licensee Experian-QAS Delivery Point Validated Addresses Weekly US Postal Service Licensee AccuZip National Change of Address Bi-Weekly American Board of Medical Specialties (OPTIONAL BY CLIENT) Board Certification Data As Needed Commercial Sources Source Key Data Elements Update Frequency Various Hospital Data Monthly-Annually ID Insight Address Watch Fraud Origination Locations Monthly 15

16 Thank you Scott Afzal, Program Director, CRISP Sagran Moodley, VP Product Optum Government Solutions 16