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April 15, 2024: In this episode of This Week Health, Bill Russell interviews Samira Singh, Director of Informatics for Providence, at HIMSS 2024. They delve into the intricacies of value-based care contracts, data exchange frameworks like FHIR, and the evolving landscape of healthcare interoperability. With discussions ranging from the challenges of closing care gaps to the future potential of standardized data sets, listeners are invited to ponder the role of regulation in driving healthcare standards, the impact of FHIR on bidirectional data exchange, and the necessity of financial data inclusion in interoperability efforts. How can professionals navigate the complexities of value-based care while ensuring data accuracy and accessibility for providers and payers alike? Can standardized frameworks like TEFCA pave the way for a more streamlined and efficient healthcare ecosystem? And how might the integration of financial performance reporting reshape the provider-payer relationship in the era of value-based care contracts?

Transcript

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

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  📍 📍 Welcome to This Week Health. My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health, where we are dedicated to transforming healthcare, one connection at a time. 📍 Today , we have an interview in action from the 2024 conferences, the spring conferences, VIVE in LA, HIMSS in Orlando.

📍 Special thanks to our sponsors, Quantum Health, Gordian, Dr. First, CDW, Gozeo Health, Artisite, and Zscaler. You can check them out on our website, thisweekhealth. com. Now, onto our interview

(Interview 1)   📍 All right, here we are from HIMSS 2024 in beautiful Orlando. We're joined by Samira Singh, Director of Informatics for Providence.

Director of Informatics, you should know that the source data is so important. So I'll make note of that.

Yeah, I want to talk to you about let's start with your role. Because people, Director of Informatics might need something at different health systems. What are you working on?

Yeah, absolutely. I lead a product team focused on bidirectional data exchange for value based care. Our focus areas are on data acquisition, as it pertains to our pair of partnerships.

Both just value based care, risk adjustment in general. And we also focus on outbound data, so clinical data, risk adjustment. And the exciting part is we do all this, or a good chunk of this, through FHIR, which stands for Fast Healthcare Interoperability Resources, and we leverage the national data standards that we have available to

And that's fascinating. Value based care. Yes. you've just taken me back to 2013, 2014. I'm sitting across from Kevin Manaman and he's saying, Hey, we have this clinically integrated network. We've got to bring all this information together. And I look at him and I go, That's 75 different EHRs.

And he goes, Yeah, and we have to do all these quality metrics, all these standards, all these things across all these EHRs. And it was virtually impossible back in 2014. So we've made a lot of progress on that? Yeah. What does it look like? A value based care contract covers a lot of different entities.

How are we doing that?

Yeah, so value based care contracts, as you've mentioned. You may have pay for performance contracts, quality based contracts, where you are submitting clinical data to close quality gaps. Risk focused contracts where if you have a sicker population, your reimbursement is tied to that and so forth.

And as it pertains to Data is a lot more liquid now than it was a few years ago, right? There are national supported by the government that are available to a lot of payers and providers. G10 APIs, for example. It's not just

that it's more liquid. The discrete data elements are more liquid.

That was part of the problem back then. We could move data, but then we'd have to extract the data somehow from that. And what FHIR enables.

It does, yeah, through the use of APIs. I agree. Right think you had a really good point. The data is more discreet now, right?

That is in part due to EMR certification as well. It is also in part due to things like data standards around the US core data interoperability data set, right? All of our EMRs vendors and so forth that are engaged in this healthcare information state or. Healthcare Information Exchange process are very aware of those data elements.

And so we're all speaking the same language now.

think about that, a value based care contract. Providence has consolidated onto a single platform. Maybe not a single platform, but you're all on Epic now. Yes. It used to be, it used to be a little bit

Meditech, Star, lots of, yeah.

But you're now consolidated. And somebody might look at it and go, that's what made all that possible, but the value based care contract is reaching outside of Providence in a lot of cases.

And it's not heavily provider focused as it pertains to your relationship. Yes, providers are on the hook for performance, quality care, keeping costs really low, right?

That's what value based care is, the intersection of high quality, low cost. But really you have a relationship with your payer partners, and we know they're not on Epic, not as a standard. Data aggregation tool.

If you talk to people about it, not yet.

Yeah and if we look to the future of data exchange, I think we have to talk about QHINs, right?

Qualified Health Information Networks and TEFCA and what the Office of the National Coordinator is pushing for. And creating this Nationally scalable, essentially HIE framework that will support FHIR. And it's so much more than that. It's like an HIE on steroids to begin with, but will scale out to be so much more.

That will give us an opportunity to focus on specific use cases, right? With value based care, we mentioned that quality is a large component. Your quality measures are typically tied to the HEDIS framework if you're part of a commercial or Medicare Advantage, Medicaid contract. And having A process, a streamlined process as it pertains to data acquisition, calculations data exchange, sharing, all that stuff.

That is, as we mentioned, not only liquid but discrete, where we're all speaking the same language through FHIR. A data element is a data element. We all understand what resources are and what they're comprised of, right? Like the baseline FHIR resource specifications. It's just a total game changer.

When You bring up the QHINs, bring up TEFCA, and those kind of things. We're talking about value based care contracts, but now you're also talking about a framework for almost national standard. It is, yeah. That is going to enable that. In theory across first the provider network, and then eventually the payer as well.

How do you envision that changing the way we do things? It used to be very complicated as we sort of started out. It seems to me like it will become not only easier, we can start to focus on those solutions a lot more quickly than before. We used to have to worry about the plumbing, like we were

right.

I love that you said the plumbing because that's exactly what the QHINs take care of, right? They're going to focus on the plumbing. They're going to create that onboarding ramp where data exchange at a national scale is available, right? And I think just for perspective the way that most The way most bidirectional data exchange conversations go without FHIR is you have a provider and that provider says, I'm going to send you clinical data so we can close gaps.

I'm responsible for quality, I want to make sure that you have a true depiction of the effort that we've been putting into this process, right? You as a payer may come back and say, I can't take that data. I've already written all this code for ingestion. That will not fit with my process. Happens all the time.

We joke around and call them data standoffs, but the reality is it happens all the time. One to one, that's okay. One to sixty or one to two hundred, if you have a large health system like Providence that has a lot of value based care contracts, it's not doable. You may agree on how you're going to exchange data, but the reality is you're all speaking a different language.

You're sending me, perhaps, data elements that I cannot just ingest. I have to normalize. I have to build AI processes or whatever it may be to take that data and call it something that is common to me. That's not the case with FHIR. Whether you look at the QHIN perspective or the standardized APIs out of EMRs or even a point to point connection between the provider and payer.

Something that Providence worked on for the past few years and actually went live with was the Clinical Data Exchange Use Case from DaVinci, so CDEX. And what we were able to do is we acknowledged that clinical data for quality measure calculation is extremely important. Millions of dollars of impact every single year, right?

And so we worked with our payers, in this case, Primera, to start out with. And we said, how do we leverage this data standard and build this thing together so that You can have the data that you need that we are contractually obligated to present that represents the care that we've given our patients, right?

And it's in a way where we fully understand each other. We understand the modality of exchange through an API. We understand the security. We understand what every single data element means. And the magic of this is, when you scale out to your You're not having those conversations. You have a national specification that explains everything, how it should be done, and you can scale out quickly.

So you have millions of dollars on the line. You're not wasting time saying, what if I give you this data element and you give me that?

Yeah it takes me, in my head, it takes me in a couple different directions. One is the 21st Century Cures Act sort of drives certain standards and those kind of things.

Those definitions that you're talking about, is that policy based, law based? Like they have to adhere to those?

To a certain extent. So some things, right? TEFCA as a whole is driven by regulation, right? And then prior authorization. Recently CMS released the prior authorization interoperability final rule.

So reducing provider burden with the creation of an end to end FHIR authorization automated process, right? Almost automated. That is rule driven. Attachments, for example, rule driven. As it pertains to value based care, I honestly feel like there isn't enough emphasis on it, right? We're all talking about clinical data exchange.

What can HIEs do? This is a really good area to focus on as it pertains to burden reduction. This is a really good area to focus on in ensuring that providers have access to actionable data from their payer partners to be able to provide the best care possible, to be able to be financially healthy to be able to reinvest in their business and so forth, and make sure that patients are benefiting.

So there should be some regulation tied to this. And I think what we've seen, because CDEX is an implementation guide through DaVinci, through HL7, other implementation guides have been mentioned in rulemaking, and I think it'll just be CDEX has as well, but not specifically for this use case, so it'll be time.

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I want to hit on U. S. CDI. Has a certain set of data. Are there still data elements that you're hoping get into U. S. CDI as you move forward?

Yes, so that's a wonderful question.

I emphasize a lot on the financial aspect of value based care, right? We talked about how providers are hurting across the board, right? So there's this wonderful use case through DaVinci again, and there are a lot of wonderful national accelerators, but DaVinci has this use case that Providence helped put forth called Value Based Performance Reporting, VBPR.

VBPR? And essentially what that does is it creates a standardized way for payers to share financial performance data with their provider partners. We have no way to do that now. We have teams that are dedicated to extracting information and keying it into a UI so that we can normalize that in some way, right?

That's not ideal. That data changes. But the U. S. The U. S. CDI data set, or the National, Core Data Interoperability data set, does not touch on the financial aspects enough. Okay. And so we're thinking that over time, those will be included in our pathways for that, but in the meantime, we're able to account for things through extensions and so forth.

That could be really powerful. It is. Yeah, for risk adjustment, feedback loops, there's so many things that it can encompass. When you think about a typical value based care contract let's say that it runs from January through December, a lot of the times, unfortunately, providers do not get actionable data throughout the year.

They may get an interim report sometime towards the end, you know this, I'm sure, more than a lot of people.

It takes a lot of people, it takes a lot of work to get that done, and a lot of times you're not looking at that data when it's actionable.

Or you don't have it when it's actionable, and you don't have a mechanism to get that data in a timely way.

You may get it from a joint operating committee meeting once a quarter, once every other quarter. You may wait until you get it through an SFTP server or an email at the end of the performance period. And then what do you do if you're losing money at that point? Performance period ended three months ago.

Talk to me about closing care gaps. I'm hearing a lot of really good stories. around health systems closing care gaps. What are you seeing today?

Yeah, a move to FHIR. I think, I'm joking in part, but I think there's a few pathways, right? Data acquisition through other sources. Right now And can we take a step back a little bit and talk about why all care gaps are not closed through claims, right?

Because typically people think you submit a claim, you're reimbursed for it, payers have the data. There are specific quality measures within a value based care contract where you need outcomes. I'm thinking about like A1C testing or BP results. There's a ton of them. Or perhaps the patient joins a plan after they've already had specific services done and the look back period is four or five, six years, right?

So health insurance companies, payers, can you know, request charts through HIM departments. They can join HIEs. They can receive supplemental data like they do from Providence and many other providers. All of that is proprietary to some extent, right? And unfortunately what happens then is you have data that perhaps wasn't as old and so it hasn't been mapped accurately to be able to actually close the gap, right?

Or data that's really difficult to acquire. And data that is being shared in proprietary formats that is difficult to parse, right? And so when I say the future is FHIR as it pertains to gap closures, it's because that data will not only be more liquid, it'll be more accurate, more discreet, and payers will be able to access data that they need, right?

And providers, as well, will be more empowered to share information that is beneficial to their contracts. And then that feedback mechanism, as well. When we talk about gaps in care, we oftentimes forget that pairs are the arbiters, right? If they don't have the data, it doesn't matter if your dashboard says that you've done something.

You're no longer doing outreach to the patient, but if pairs don't have the results, then what? Then you see it on your bottom line, right? And that is so important if you have a contract that is quality gated so your financial performance, your, depends on a quality gate, meaning that you don't, you cannot access any benefit of, the contractual agreement unless you meet specific quality criteria.

And so creating that bi directional loop of something is done. It's part of the contract, it goes back to the payer accurately, the gap is closed, and then the provider receives the feedback. And they can continue to focus on what they do best which is providing the best possible care to patients.

That's fantastic. You don't look old enough to have this much knowledge. Talk about your career a little bit in healthcare. and how you got to where you're at.

Sure, yeah, absolutely. I started with Providence after I graduated high school. I was an undergrad. I was part of government programs, worked on meaningful use. And then MIPS, MACRA, all of that stuff, and then really got involved in interoperability in the last year. I want to say five years. And through that, we've been able to do a lot of great things. I know I've talked about clinical data exchange a little bit and value based performance reporting, which will absolutely change the way that we exchange financial data.

But we've also made a lot of strides with enrollment data, right? How do you identify who are the patients that are part of the contract and how do you do so in a way that is seamless, that you can integrate into your process, where you can make sure that all of your analytic feeds are met, all that stuff.

It's been a long journey, but a really good one. I love

that. This reminds me of the old, Bethlehem Steel back in the day, a long time ago, I grew up in Bethlehem, Pennsylvania, so just but they used to have this program where they would bring people, mostly guys unfortunately, but they brought people in from college and they would essentially put them on a career track and they would say, okay you're, a year or two years in manufacturing, you're two years in finance, you're two years in sales, you're two years, and they would get that training and they would be.

In about a 10 year time frame, they would have worked in all those different areas and they would be invaluable to the organization because they have seen so much. That's what you just described to me. It's I started in the call center. You've seen so many different aspects from so many different angles, that when they say, oh, this data, you go, Yeah, I have that lens.

I've seen it from that lens. I've seen it from this lens. And there's just so much value in that. So I really appreciate you sharing your experience and wisdom with the community. Thank you.

Absolutely. Thank you for having me.

  📍 📍 Thanks

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