By Chantal Worzala, PhD
Imagine a world where health information management teams know in advance the documentation a payer needs to authorize an admission or conduct a medical necessity review, their IT systems populate the needed data for them to verify, and the documentation is then sent electronically to the right place within the payer organization for a timely decision.
Increasingly, policymakers and industry experts are trying to tackle the burdensome processes currently in place when clinical and administrative data come together, with an initial focus on prior authorization. This includes work being done by the Centers for Medicare and Medicaid Services (CMS), the Office of the National Coordinator for Health IT (ONC), and the National Committee on Vital and Health Statistics (NCVHS) to evaluate clinical and administrative standards and policy levers, as well as private sector efforts to develop automated solutions.
For example, a joint task force of two federal advisory committees–NCVHS and the ONC Health IT Advisory Committee—is working to develop recommendations for the federal government on how to “support the convergence of clinical and administrative data to improve data interoperability to support clinical care, reduce burden and improve efficiency.” The joint task force plans to make recommendations in September and NCVHS will separately address the issue this year.
To ensure that the health information perspective is part of these conversations, the AHIMA board recently approved a policy statement on Integrating Clinical and Administrative Data. In doing so, the Board affirmed that “AHIMA supports the use of policy and other tools to realize the benefits of greater integration of clinical and administrative data, including improved patient experience, decreased administrative costs, reduced provider burden, and improved quality of care and outcomes. Health information (HI) professionals have considerable knowledge and relevant experience to contribute in developing policy.”
The statement identifies seven policy considerations to ensure the best outcome for individuals. Policy efforts in this area must:
- Improve processes for patients and providers. Policy approaches must be evaluated to ensure that they remove unnecessary steps and complications for patients, while decreasing administrative burdens for providers.
- Address factors beyond automation. Policy must take a holistic approach that looks at business processes, representation from stakeholders, and other factors that will create trust across providers and payers.
- Maintain stability of the revenue cycle. New approaches to administrative processes must be adopted in a way that supports all parties and does not disrupt or slow down the numerous steps from checking patient eligibility through claims processing and payment.
- Consider operations and the role of HI professionals. New standards and approaches must reflect how information flows through the healthcare system, the technical systems that are needed, and the crucial role HI professionals play in translating across clinical and administrative domains.
- Address coding accuracy. Integration will only be successful if it builds from a detailed understanding of how code sets are used for administrative and clinical purposes and addresses mapping issues, particularly when different codes sets are used for the same underlying concept (such as SNOMED/HL7 versus ICD/CPT/HCPCS for problems and diagnoses). Otherwise, data may not hold the same meaning for those who generate it and those who use it in other contexts (semantic interoperability).
- Account for workforce training needs, including shifts in needed capabilities, training on new standards, vocabularies, technologies and processes, and the potential for workforce realignment. Successful automation also will require greater collaboration across the range of professionals engaged in creating, curating, sharing, and using both clinical and administrative data.
- Prioritize privacy and security. Increased sharing of health information across payers and providers requires careful consideration of privacy issues, including ensuring that only the minimum necessary information is shared, and uses beyond the specific transaction are limited. One element of building privacy in by design is addressing the problem of patient matching. Addressing privacy and security successfully involves both technical and operational solutions that support clear policies that are consistent across all actors.
To develop these policy principles and ensure they were grounded in operational realities, AHIMA brought together a member Work Group on Integrating Clinical and Administrative Data to first paint the picture of how these transactions happen today, and then address policy considerations. The group affirmed that the challenges in sharing clinical data with payers are significant and pose financial and time burdens on patients as well as providers, and that everyone would benefit if they could be simplified and automated.
To help explain current processes, the group identified three types of “trigger events” for sharing clinical data with payers: prior authorization, concurrent review, and post-discharge processes(see chart below). For all of these events—whether it’s approval of DME at discharge, assessment of patient acuity, or medical necessity review—the group emphasized that each transfer of information must follow appropriate practices for privacy and security, documentation integrity, and appropriate disclosure.
Based on the group’s operational experience, many of the challenges in sharing clinical data for administrative processes come from variability and lack of clarity in the documentation needed by the payer, which can also vary by plan and change over time without notice. In addition, multiple formats may be needed to share information, from using a payer-specific portal to sending a CD or defaulting to phone and fax. Sometimes, multiple formats are needed for a single patient event.
The work group findings were highlighted when Alison Nicklas, MJ, RHIA, CHPC, CCS, regional director, HIM Services, Trinity Health of New England joined Lauren Riplinger, JD, vice president, Policy and Government Affairs at AHIMA and myself in presenting in front of the ONC-NCVHS joint task force on June 23. By sharing operational realities, AHIMA was able to help the task force understand that automation will bring significant benefits by integrating clinical and administrative data, but success in that endeavor will require addressing the many issues beyond automation that are addressed in the policy statement. We used the below chart in our presentation to the task force.
Work Group on Integrating Clinical and Administrative Data Members
- Jennifer Mueller, MBA, RHIA, FACHE, FAHIMA, vice president and privacy officer, Wisconsin Hospital Association (Board member)
- Ezenwa Dike, RHIA, health information exchange project manager, Missouri Health Connection
- Sarah Tonn, MPH, CHTS-PW, data scientist, IDaStat Healthcare Analytics Consulting
- Andrews Dean, CPHIMS, CHDA, CPHI, CPPM, CPM, population health, EHR & quality payment program healthcare compliance consultant
- Cindy Spann, MIS, RHIA, CHPS, CCS-P, FAHIMA, executive director health information, Community Health Network
- Alison Nicklas, MJ, RHIA, CHPC, CCS, regional director, health information management services, Trinity Health of New England
- Judy Kelly, RHIA, CPHI, CHDA, CCS-P, CCS, senior director, health information management, Rochester Regional Health
Chantal Worzala is principal at Alazro Consulting and is currently working as a consultant to the policy and government affairs team at AHIMA.