Good afternoon. Welcome to the today's presentation on igniting HIE to data standardization edition -- Data Standardization.

Transcription

1 Event ID: Event Started: 4/12/2017 2:51:04 PM ET Please stand by for real time captions. Good afternoon. Welcome to the today's presentation on igniting HIE to data standardization edition -- Data Standardization. If you have a question, please type it into the chat function on your WebEx. My name is Katy Brown. I am the clinical pharmacy specialist in medication safety task later for the quality improvement organization of Colorado, Iowa and Illinois. I'm also the program manager lead for our company. This gives you information about the QIO. We encourage you, anyone interested to join the network. With connections of the local, regional and national level. We believe we can all come together to better serve our community. I will introduce our speaker. He's a pharmacy management consultant. In his role with the pharmacy HRT -- he serves as a chair. The collaborative is a coalition of pharmacy stakeholders working to ensure pharmacist s role of providing direct patient care is integrated into the national HRT framework. His work is developed on facilitating implementation of clinical documentation for health information exchange and quality reporting. He has been active in several professional associations including the American Society of Health Pharmacists, Academy of Managed Care Pharmacy and Pharmacy Quality Alliance. He grew up in Charles City, Iowa and graduated with distinction from the University of Iowa College of Pharmacy. He completed postgraduate training and a Masters degree program specializing health system pharmacy administration at the University of Kansas. After working in hospital pharmacy management at an academic medical center, he transitioned into a consultant role focused on healthcare technology. I will pass the ball to Samm. We are lucky to have him today. The floor is yours. Thank you. I appreciate the introduction. Can anyone hear me? Yes. Let's get started. We have some learning objectives listed. My main goal is to introduce the idea of data standardization and what it means for practice, moving forward and what are the next steps that we can build and do a plan to achieve the

2 ultimate goal. The ultimate goal would be to exchange patient information to and from different vendors systems, regardless of our practice setting you are in. So we can coordinate care better and achieve better outcomes for the patient. I will describe what it means to document using standard terminology and how it applies to exchange. Exchange focusing on HL7 standard. The collaborative is a pharmacy coalition representing 250,000 members. It was founded by the nine major Pharmacists Associations. We also have associate members of the collaborative and one that's not listed is up docs -- we are always looking for additional stakeholders. You can work with us intimately and join our orderly meetings. Most of the CEO members are there and if you have questions you can contact me after the session. Our goals are to do three major things: to ensure pharmacists have access to information, patient information; #2 - Make sure we can connect via health information exchanges. When we are caring for these folks, we want to share our care plans, interventions and recommendations with other members of the team; #3 - To achieve optimal outcomes and that leads into quality. We want to support national quality initiatives enabled by health IT involving reporting quality measures to participate in programs that are tied into macro and several others. This is a bold statement, I believe. The key to all of healthcare is through structuring data, discrete data within our documentation practices. It is huge implications for reporting data consistently, meaning no matter what software you use, if you report the data it can be aggravated -- aggregated, we can identify trends and no which can be used for optimal outcomes. The pay for value equation, if you're providing great care, you should achieve great reimbursement for it. When you think about clinical documentation or coding, most people think about billing, CPT codes, ICD 10 codes and that's recording got its start. We needed a mechanism to submit claims and get paid for services. When I talk about clinical coding, I am really talking about documenting the care. Regardless of whether you are billing for it or not. Tracking your productivity and linking it to outcomes, measuring quality. Communicating between different systems, exchanging standard data points over health information exchanges. That's the interoperability peace. There are various ways to do that and we are limited by the software systems available today. I will go into more detail. To explain standardizing data, I ll give a simple example. You may be familiar, think about filling out forms at the position. They ask questions, take a history and physical. They make a plan. All of that information is entered into electronic health information as free text. It lives in the software systems in that form. You can't do anything with that form, you can't report on it. You can only read it. We want to move towards

3 discrete data, codifying the clinical information, in a standard way. I will show you an example. Here is a typical progress that you might see, chief complaint, history of present illness, plan, and all of this is typed out in free text and means nothing. If we think about some things that we do when we care for patients, as pharmacists, that could be codified. We do medication reviews, a bad rap -- we might create in medication action plan. Medication synchronization is another hot topic, intervention that we need -- no leads to better interference. They can be easily codified. Let's say you click the checkbox to say that you did each one of these. We report on this. You might think of it as an Excel spreadsheet. Each line item would be a separate encounter for unique patient. We may have different information associated with that. In the first column, we know the patient identifier, we know what clinic they were seen in, we know what medical services it was associated with. Columns on the right of the interventions. If I click a check box for that visit, that signifies that I performed that service. When I report, I get different Excel spreadsheet cells that show I clicked the check box. If you look at these 10 encounters, we see that we are performing a medical review medication action plan and med sync -- this is a small sample size. What gets into identifying trends is when we aggregate the data and trend it. Each column represents a different quarter and shows our performance. We calculate that on the last spreadsheet. My eyes go to the right, we are great on med rec, CMR is doing well but we need to work on a medication action plan and med sync. We can then add color and identify more trends. Red is below threshold of what we are trying to achieve, yellow intermediate, greenness we are meeting goals. We can see med rec we were doing poorly, last year. We increased that overtime. We had a targeted initiative, we were going to reconcile all of our patients medication. Improving on that and the med review, we were still doing poor in the other category. Color brings this to life. This is where the rubber meets the road. We can trend this data and try to draw conclusions on outcomes. If you take the black lines and think of that as interventions or med rec's, as they go up we see readmissions go down. It allows us to draw conclusions as to, what services are we providing and how is it impacting the care of the patient. We can then assign dollar values, to say how much money are we saving. Using this data and comparing it to outcomes helps us improve quality. It gives us a way to quantify. We will step back and look at the landscape and how that impacts us, moving forward. I know everyone is familiar with meaningful use. It was a program to incentivize the adoption of electronic health records. The second phase is to build on that. What it does, it outlines different capabilities of functions of software, that they must do. If they do that, there is incentive payments tied to that. Meaningful use or no

4 it's been incorporated into macro require systems to report quality measures, using data and exchange information over a [Indeiscernible] HIE -- progressing towards the same capabilities and referencing a certain standard. Everyone can report the same data. [ Indiscernible ] is becoming a buzzword in that health IT community. It's one of the requirements of meaningful use to help us get to our goals and accomplish them. There is the EHR coordination program outlines specifications that the software vendors need to meet to achieve the goals. I will focus on interoperability in this presentation. Interoperability is an initiative to connect different software systems together and exchange that data freely. The problem in our community, in the pharmacy profession, is pharmacists aren't providers. It has implications in health IT, we weren't included in the meaningful use program. As a result, there was no business incentive for pharmacy software vendors to adopt technical requirements to exchange information. There is no financial incentive for pharmacists to adopt complaints to do this. We were left on the side. That's where the pharmacy HIE -- HRT collaborative comes into play. We need to be lined up with them and exchange information. Our goals moving forward: align pharmacy systems functionality with that of EHR systems. I like to say leverage interoperability to gain accountability. In the pharmacy world, we know we are good at managing medications and we are good at maintaining data. If we want to make sure the medication list is accurate and up-todate in the EHR systems, we need to pull that information from the doctor s record, maintain it, updated, talk with the patient and make sure it is accurate. We then share that with them, when they go to the next appointment the information is accurate and up-to-date. We can take full accountability if we can freely exchange information. The same with allergy information. Managing treatment is critical. Support the exchange of standardized data between all providers and software vendors. The regulatory environment, the standard environment is all very convoluted. It takes quite a bit of effort and communication between these different stakeholders, to coordinate these efforts moving forward. There are many different standards organizations, HL7, NC PDP can be thought of as the HL7 version of pharmacy claims. What are the standards for submitting claims for pharmaceuticals, to pharmacy benefit managers? In the health information exchange world, they are standards that are mentioned. There are different clinical vocabularies. [ Indiscernible ] is federally recognized standard or clinical nomenclature, coding standard for documentation. It's very detailed. If you think about ICD 10 in the order of magnitude. It can be thought of as more detailed than ICD 10. There are over 300,000 concepts in the SNOMED library. Meaningful use is the problem, the diagnosis, EHR's have to

5 connect to SNOMED. The easiest way to explain it is it's a common language that allows a different software systems to talk to each other. As an example, for pharmacy, we did an analysis of what we document when we care for patients and if there's a SNOMED CT code available. These are examples of things he came up with who the patient was referred by, different medication therapy problems, the dose is too low. Whether we performed education and looking at outcomes also. [ Indiscernible ] is less than seven, different codes are tied to each one. We have worked to develop them from scratch. The next question, if we know we need to use SNOMED, how do we implement them into our software systems? That's where value sets common. Value sets are sets of codes that are to be documented in certain areas of the electronic record. It pairs down and guides implementers which codes the use and where to place them in the software system. If you think about the entire SNOMED library with 300,000 codes, we know which ones are pharmacy-related and that takes it down to 400 or approaching 500. We can package them in these value sets. They are sets of anywhere from 1 to 40 key codes and it allows us to know which codes should be used where. Think about the problem is in the allergy list. The allergy list is a list of all different types of medications, environmental substances, food substances that he patient may be allergic to. We have a list of codes that would fit in the allergy field. If we think about documenting the problem list, that's a set of diagnoses and different problems the patient may have. I would not want to use the allergy value set in the problem list field. I would want to use the diagnosis value set in the problem list field. That is a simple example of the way to categorize these codes, in a way where we know they should be in the system. Another example would be, different cards and your wallet. There are different types of cards and your wallet. Value sets can be thought of as a way to organize those. If you have ever been to DC and you know the Metro, your Metro card fits into the Metro card reader. That's the only place it fits in the only place it works. Your ATM card is a separate category and it works in ATM machines. I would not use my Metro card for an ATM machine or vice versa. That's another simple way to think about it. An example of a value set, collecting codes that tell us who the patient was referred by they can be organized into the referral source value set in the codes are attached. Someone building software or implementing data points knows which value set to pull from and what that list should look like, when the clinician is trying to select the code describing where the patient was referred from. Looking at health information exchange mechanisms, if we have this infrastructure within our software systems in the city tendered iced -- standardized codes, all

6 vendors are referencing. It needs to be exchanged over a network to flow from one clinician to the next. I'm familiar with different national vendors who are trying to accomplish this. Collaboratives like Commonwealth, Sure Scripts is involved in a prescription and they provide the pipes to and from different EHRs to the pharmacy and vice versa. Care quality is another alliance forming that's getting different vendors on board to move this process forward. Then you have the state level exchanges, I'm sure you are familiar. Exchanging information on more of a regional or local level, you might have [ Indiscernible ] forming and they all use different vendor systems but they all want to pull from the same data and share data to coordinate care. Different mechanisms for exchanging information. They are all using HL7 standards or [ Indiscernible ] to exchange this data over the network's. How does the exchange of information take place? We go back to our standards organizations and look to them to leave those efforts. HL7 has developed electronic standard documents. They use consolidated PDA as the architecture, to build these documents. It's the framework that allows you to pull the standardized data points and populate them in certain parts of an electronic form. Everyone can recognize them and read them to facilitate health information exchange. There are different templates and they are all actually mimicking some of the templates we have in our typical electronic health record system. History and physical, a procedure known or progress note, discharge summary and one that we are working on more closely is the pharmacist E care plan. I will talk about that at the end and let you know what's going on in that arena. These documents are templates, so to speak. They are structured documents they describe the patient, what clinician is caring for them and they have different bodies in sections. Think about the allergy list, the allergy list would be a section within the template. There would be space to populate that section of the template with different allergy codes. Penicillin, amoxicillin, and pollen might be three different SNOMED CT codes that populate the allergy section, in a certain way. That document, once populated, is shot over health information exchange to a different vendor with a different system. Since this vendor recognizes the standard document they know exactly where those allergies are located. They can take that information out and populated into their vendor system. When it's received it looks like the information was documented at that site using that vendor system. It's the holy grail. It's a way to exchange information freely. You must start with baby steps. Allergy lists, problem lists, and build on that moving forward to make it more complex. We are making progress in the area. Moving forward, the best way to think of this is, how do I implement these codes in this to achieve this outcome. You should map out your patient care process. What are

7 the things that you do when a patient comes in and sits down with you, what are the questions that you asked, how do you assess them, do perform any evaluations are test? How do you collect that data, basically. How do you formulate the plan, what are the things you need to document to determine the patient goals and concerns are. Which medications they should be on, which they should start or stop, what type of education are you providing. Building that plan and intimate -- implementing that plan. Everyone should work on a standard care process. That allows you to build a workflow within your software system. It can incorporate these codified data points. You can pull information from the value sets that we have published. You can pull them in so you know which ones to select to document the encounter or the care you are providing. It's important to point out, a lot of the frustration in healthcare is coming from different healthcare professionals, it takes too much time to use an electronic health record. We are spending so much time documenting things, after the fact, I don't have time to take care of my patients. Usability and navigation within these systems is critically important. That has to be incorporated into this entire process. We hear a lot from the field in folks who are using different software systems that say my system cannot do this. And I cannot get traction or customize my software so I can incorporating these things. I encourage you, don't feel like you are stuck with the current capabilities of your system. We need to push our vendors to incorporate some of this. We need to do what we do to take care of patients and incorporate the information, so it can be shared. There is a struggle one provider or practice site, at a national vendor with multiple customers. We notice what works, when the community of users come together and pushes the vendor to adopt new ways of doing things. I encourage you not to feel like you are stuck, and together an advocate. When you do start engaging, have the conversation about do you know what SNOMED is to know what [ Indiscernible ] is. Are you incorporating them into your system? Do you know what consolidated clinical architecture is? Having resources to point these vendors to, to start educating them about the process that you want to achieve and how to go about doing that. For example, we are working on a pilot sponsored by CMS and it's called the pharmacist E care plan. It's trying to build out that standard consolidated clinical document architecture, clinical document that we call the pharmacist E care plan and building that document, to exchange information across health information networks. We have engaged six pharmacy management system vendors and we will add another six soon. All of them say, we are willing to test in this pilot because this is what our customers are advocating for. We have the vendors at the table, we have a peer at the table that says we want this information because we want to know the services the clinicians are providing, so we can compare it to our claims and study what interventions are reducing utilization and saving money. The ultimate goal is to set up these risk-based contract agreements, if you achieve certain quality measures

8 you can get paid to do that. It flips the incentive from [ Indiscernible ] to value base. The fact that we engage with the vendor, we told them what we are doing calmly said it's important for the future and important for the business strategy, the came and were willing to participate. That's one example of how this can move forward in progress. Another thing I want to highlight is the Medicaid incentive program. This was in 2016, there is funding tied to the information technical -- technology act. Allows 90% federal matching funds for administrative costs related to HIE, promotion like Medicaid eligible providers. State Medicaid programs can work with the office of the national coordinator and CMS to apply for funds, to hook up pharmacy in the state to their state HIE. That can pay for the administrative costs related to performing that. This is just an opportunity for states who feel like they are at a good point, to engage in this initiative so we can share information not only to and from different physicians but also to share that with pharmacies across the state and long-term care providers also and mental health providers. That is something to look into, if you have not heard about it. The collaborative has online resource centers. Just an introductory presentation but I want you to know where you can go for more information. WWW. pharmacy HIT It goes into what this means, what the standards are, how they apply to what we are currently doing, where we will go with these, what are ultimate goal is and what our next steps that I can do as a person in my position, to advance forward. And recommend checking out the resource center at www. pharmacyhit.org www. This gives a broad overview and next steps to take moving forward. The value sets, the standardized codes are grouped into packages that help me know where to implement them in my software system. Those are all publicly housed on the value set authority center. I've provided a link and it's free to access, you just have to sign up for a license and it's usually approved within one day. This lists all the different value sets that several people are creating. I believe there are close to 1000 out there now. We have 83 developed. There are probably more now. You can search for those by searching [ Indiscernible ]. If you have questions or inquiries, we have gotten a lot of requests for new SNOMED CT codes to be added. Just general questions about how this works. There is a portal. There will just be one button that you need to click on that prompts you to fill out the form and that notifies us that you have requested information or something about SNOMED CT codes are values. We have a committee that manages which codes are added to value sets, which are retired and if we need to add a new value set coming forward. It get your name in the queue and we work from that. If you have any questions feel free to contact me directly.

9 Some takeaways, introduce the collaborative and we want everyone to know we are a resource. If you have questions, we understand it's complicated. Speaking to different clinicians and why it's important, it's tough to bridge that gap. We want to be an advocate for you and an information resource for you. These feel free to reach out to us. We want to make sure that you know about the terminologies like SNOMED CT and consolidated [ Indiscernible ] that make health information exchange impossible - - possible. We have a mechanism to get us there. We just need to get all of our stakeholders on board to achieve this. By stakeholders, I mean information system vendors. It's possible, we just have to get together and commit to making this work for our patients. Standard data sets, value sets are the vehicle for the software vendors, once gauged, to populate their systems with standard data points so we are able to exchange this data over health information exchange networks. That concludes the content that I had appeared. I would like to add or clarify or expand on anything that was covered in the presentation. Thank you. That's a lot of great information. I will start with questions. I want to remind everyone, if you have a question enter them into chat and we would direct that. If there was one action that people listening could do, after the presentation, how would you prioritize those? What's the one thing they could do? To move this forward? Where you can make the most impact, contact your other friends in your community if you are clinician and maybe you are all using the same vendor systems and say what capability do we have to document this information in our systems? Function more like a provider then in [ Indiscernible ] in the pharmacy. Once you find similar folks that are using one vendor, you can come together and engage with that vendor and have the conversation about whether this is possible or not. That's the first step. Do an assessment and ask about the capabilities with the current system and evaluate ways to move forward and start documenting the information and exchanging it between providers to coordinate care. That would be step number one. Great. Thank you. We also run into the lack of business case for pharmacy software vendors and health information exchanges, to build this out, if you well. What are some key language or key points that pharmacists can use with software and HIE vendors in the business case? I would incorporate the business case as part of it. There is a case to make. You have to think about everything in terms of dollars. That's what makes people act. In terms

10 of the pharmacy management system vendors, or any vendors who may participate, domain argument -- the main argument is that we have a list of your current customers, who are asking you to adopt this functionality. It's all very important to us and there will be more people that will need this in the future. If you want to differentiate yourself in the market and be a competitor long-term, as the healthcare system continues to evolve into outcomes-based reimbursement, this is something we think you should get on board with now. There will be a time when we are looking for other vendors. That will perk up some years. When you are talking to health information exchange networks, I know there are a lot of discussion about how those are funded and who is actually paying for the service. On a local level, for example, you have to look at which entities are there that will get the most benefit from sharing information over and HIE. If you look at hospital system, hospital systems have a lot of quality metrics that they are tied to that impact their reimbursement. It's increasing, the percentage of reimbursement that that risk is increasing. Let's say they are having trouble with certain outcomes, we had -- readmissions for example, they might be losing millions of dollars on readmissions. They need to improve those. One way to do that is to engage other stakeholders in transitions of care projects. Every time a patient with heart failure is discharged for example, you work with community pharmacies to say there should be a follow-up appointment, we go through all of your medications with the pharmacist and make sure your prescription is covered by insurance and you are taking them right away and you know when to call the doctor back for a reevaluation. Having that type of transition of care program, definitely would help readmissions. How do you operationalize that Lex you have to --? You have to communicate to them from the hospital and with the community pharmacy and share a common care plan and build on that to make sure medications are reconciled. The only way to do that is through health information exchange. If they really want to start looking at how to save money and improve outcomes, that points back to health information exchange and partnering with different stakeholders in the community, both in the business sense and technology since to share information. That's one way to drive adoption and drive standardization through HIE. Great. Thank you. How does the enhanced [ Indiscernible ] pilot fit into this topic? Good question. The enhanced model is CMS innovation Center demonstration project. CMS says MTM is going on but we have no way to measure its impact. We will form a pilot program, we will get five pairs involved and lift all the restrictions that a typical MTM program has. You don't have to perform a comprehensive med review annually, or quarterly targeted reviews, you can design it however you would like. It could focus on a specific disease stage, you could do more frequency [ Indiscernible ] lifting those in allowing creativity and healthcare delivery -- care delivery is designed. Paired with that, is a requirement that these [ Indiscernible ] to CMS to receive this

11 payment, that's another incentive. It's requiring SNOMED to be used as you provide the care and document some examples. What they will do with that, they will look at what interventions are being done in the field and compare that with Medicare part a and part B claims to see if there are savings and how much savings there is. That's exactly what's going on in the Medicare space it's also going on across the country at a state level with commercial payers. It is all tied into these data standards. If you're reporting SNOMED CT, regardless of the plan or vendor, all that can be aggregated and used immediately, to correlate to utilization on the medical benefits side. That is how it plays in, it's in a controlled environment right now, within these plants. That model can be easily do located -- duplicated in any setting. Great. Thank you. I don't have any further questions in the chat. At this time, Sam thank you so much for sharing your expertise with us today. Do you have any final advice, before we conclude today's call? I will leave you with, building on what I mentioned about the intent -- enhanced [ Indiscernible ] programs, with QIO's on a state level you have a great environment or closed community within your state, to bring different stakeholders together. Those stakeholders being your state Medicaid programs, your commercial payers, large employers are corporations who may be self-insured, all of those folks want to reduce the amount of cost they spend on health care. What are the ways that you can do that Lex it's about engaging other providers who can help and in our world it's pharmacists. If you know you have a large provider network, that can start providing some of these new services, and you have these stakeholders engaged in testing the services the first thing you can do is come together and say let's pilot it out and try it to see if it works. Bringing those people together, on a state level, allows things to advance more quickly rather than waiting for a federal initiative to move forward. If you have all the players at the table, I can almost guarantee you, you will have your vendors come to the table as well. This is where everything is moving towards valuebased payment for services, outcomes-based quality metrics. I encourage you to bring me stakeholders together and have conversations, to see what level of engagement they are willing to bring to the table. See if you can start building something like this. What would a pilot program look like? There are several states currently doing it and if your state is not, you can reach out to us for contact information or search on your own. You can start to move forward. That is one thing I will leave you with. Thank you. Thank you. Could you please advance one more slide. Thank you. Thank you Sam and everyone and WebEx. On this last slide you will find my contact information. As always, if you have questions or need follow-up information, please shoot me or Sam and . All of Telligen's presentations are posted on our newly remodeled website.

12 You will find this one under the medication safety portion and we will post the recording with the slides within a week. I will let you know as soon as that happens. Thank you for being with us this afternoon. This concludes today's presentation. [ Event Concluded ]