From a strictly technical standpoint, establishing a data-sharing connection between Paramount, a health insurance company and its primary care physician practices could have been executed in a short period of time. The real challenge of interoperability, however, was determining the right data to share—an arduous task that required not just technical expertise but considerable input from subject matter experts. In this case, investing the time to get it right was the difference between generating yet another unused data report and designing a game-changing population health strategy.

The Project Parameters

Paramount’s data-sharing initiative was undertaken as part of its participation in the Ohio Medicaid Comprehensive Primary Care (CPC) program.¹ This new program requires bi-directional data sharing in order to ensure that primary care physicians can serve as the gatekeepers of a member’s care. In that role, the program asserts, physicians should know everything about a member’s medical circumstances—from the results of tests ordered by other providers to changes in status due to social determinants of health.

On their own, primary care physicians may not know what happens in a patient’s medical world until they self-report the information at the next office visit. The health plan, however, may have a more holistic view, paying claims for multiple providers and collecting additional interview data. Together, these two ends of the healthcare continuum can form a more complete picture of each member.

Paramount set a goal to share “timely, meaningful and actionable data” between the health plan and its providers via the real-time generation of auto-triggered UCMDs (Universal Care Management Documents) and CCDs (Continuity of Care Documents). “Auto-triggered” was also a significant component; it was critical that the new system not involve any manual effort on either side. And, recognizing the project’s potential to improve outcomes, the team also broadened the scope to include sharing data for all members, not just those covered by the Medicaid plan.

The integration team employed the TruCare Linx integration engine to manage and translate the data as it moved between TruCare, Paramount’s Care Management platform and the various systems utilized by the primary care practices and hospital systems. In doing so, a critical question loomed increasingly larger: Exactly which data is “timely, meaningful and actionable”?  

“It had to be the data that would make people want to use it,” recalls Tammi McCormick, the project manager at Paramount. “We want them to say, ‘I’ve got to go get the UCMD because it has exactly what I’m looking for every single time.’ We didn’t want it to be in some folder in the EHR they never looked at.”

Key Accomplishments

Over the course of the implementation, the technical team and the subject matter experts collaborated to design an effective UCMD and populate it with the most relevant data. The following are some of their key strategic accomplishments:

Member/Patient ID—With no universal identifier in existence for healthcare, the integration first had to reconcile Paramount’s Member ID with the providers’ EMPIs, MRNs or practice-specific ID numbers. To accomplish this, the team leveraged a Master Data Management solution that allows the system to discretely validate the identity of each member, matching the two disparate ID numbers to the same patient.  The ability to apply member matching logic was determined a needed component provided by TruCare Linx for the target solution to work overall.

Auto-Updating—Significantly, the ID system was also designed to map incoming data from the providers to all instances of a patient’s record within TruCare, Paramount’s Care Management platform—a major concern for members with more than one plan. Members with both a commercial plan and a Medicaid plan, for example, were at risk for knowledge gaps because Medicaid is always secondary. If the commercial plan covered a recent service, a care manager viewing the Medicaid plan may not have had access to the member’s full history.

“We wanted to ensure that it didn’t matter where a care manager was working with that particular member—whether they were pulling up one plan or another plan, they would have the latest data from the EHR available to them right there and they wouldn’t have to go looking for it,” notes Stephen Hollifield, the implementation lead for the TruCare Linx product.

Determining the Data Triggers—On the provider side, ProMedica’s Epic EMR triggers a data exchange to Paramount automatically 13 hours after discharge from the ED or Inpatient hospital stay or, in the case of an office visit, after the physician signs off to complete the patient encounter. Determining the cadence for generating documentation for Paramount required understanding what data the providers would need and when they would need it.  All without overloading them with too much data rendering the integration useless.  Given Case Managers are taking in volumes of data that may or may not be useful to a physician providing real-time care, Paramount SMEs helped to focus in on the most relevant data, such as:

• Changes in Risk Stratification—Anytime a member’s risk level changes, up or down, the physicians are notified. A member might have recently become homeless, for example, and the provider may have had no way of knowing this.
• Changes in Medication—A new medication prescribed by other physicians will auto-trigger a report to the primary care physician, who can now assist in safeguarding against interactions or contraindications.
• A Hospitalization—When alerted to a hospitalization, primary care physicians can be proactive with follow-up care.

Notably, much of this information simply wasn’t practical to share before the integration—care managers and practice managers had no scalable method for contacting each other with updates on a member’s social determinants of health. The auto-triggered reporting now provides a structured format through which to organize and communicate with the care team.

Condensing the Data—While a care manager’s assessment may contain dozens of questions, a provider only needs the answers to certain ones. Sending irrelevant data, or data that providers had to work hard to weed through, would virtually ensure that providers wouldn’t use the reports. SMEs painstakingly determined which data would be most relevant for transfer, then the technical team pulled it and mapped it to the correct fields in the UCMD.

With the integration in place, Paramount and its primary care partners will soon be able to measure the project’s success in keeping patients healthier. I look forward to sharing those results here in the near future.

http://medicaid.ohio.gov/provider/PaymentInnovation/CPC#1657107-cpc-enrollment