By Mary Butler
At AHIMA20, Tom Mason, MD, chief medical officer at the Office of the National Coordinator for Health IT (ONC), will join Chantal Worzala, PhD, of Alazro Consulting, and Jennifer E. Mueller, MBA, RHIA, FACHE, FAHIMA, vice president and privacy officer, Wisconsin Hospital Association Information Center, on a panel discussion, “Bringing Together Clinical and Administrative Data,” on Wednesday, October 14.
AHIMA20 spoke with Dr. Mason about the ONC’s role in the initiative, standardization, and the challenges of data integration. This interview was edited for length and clarity.
AHIMA20: What is ONC’s role in the initiative to facilitate and standardize the integration of clinical and administrative data?
Tom Mason: The 21st Cures Act, which was signed into law December 2016, has a section focused on reducing clinician burden, which requires the Secretary of the Health and Human Services (HHS) to create a report for Congress.
The secretary delegated the authority to create the report to ONC in close partnership with Centers for Medicare and Medicaid Services (CMS). So we partnered with CMS to host a series of national listening sessions to get broad input on the current landscape of burdens related to the use of electronic health records (EHRs).
AHIMA20: What did you uncover during your listening sessions?
Tom Mason: One of the key areas of concern was prior authorization. We heard loud and clear that it was a significant burden to clinicians in terms of time and cost, because the majority of prior auths were completed using fax, phone, or paper-based mail.
Most physician offices had EHRs, but we investigated the underlying challenges related to prior auth from a standards-based perspective. One of the root causes of many prior auth challenges was a lack of clinical and administrative data integration.
We found that this lack of harmonized clinical and administrative data and standards leads to burdens like inefficient workflow. We discovered time- consuming, payer-specific requirements that providers need in order to deliver efficient care. There were technical barriers related to the different platforms that healthcare providers were using in terms of capturing clinical data, versus the platforms they were using for their practice management system. We were hearing about significant impacts on the quality of healthcare delivery and also a significant impact on patient safety.
I would say one of the most important things we found is that the clinical data needed for prior authorization, and the administrative data that’s needed run in two different data streams have different electronic standards for processing, transmitting, and storing the information.
We found that integrating clinical and administrative data something we should look into.
“We see the opportunity to leverage the existing technology infrastructure and overlay modern standards and technology to merge the clinical and administrative burden to improve efficiency, ultimately improving outcomes and decreasing these negative clinical outcomes that we’ve heard can happen as a result of prior authorization.”
—Tom Mason, MD
AHIMA20: What’s an example of the patient safety issues that can come up?
Mason: The American Medical Association an annual survey of 1,000 practicing physicians. Their most recent survey asked about the impact of prior authorization on patients.
One of the key findings was that 28 percent of respondents said prior auth had led to a serious adverse event with one of their patients. Prior auths also can lead to delays in care or treatment abandonment because the process can take so long and be so convoluted.
AHIMA20: What are the primary challenges of clinical and administrative integration?
Mason: A key part of HIPAA was the administrative simplification provisions. Those provisions were designed at the time to make healthcare delivery more effective by adopting administrative data standards for healthcare transactions between payers and providers.
HIPAA had a section focused on how to make the process of interacting between the doctor’s office and the payer electronic. There were considerable successes as a result of these electronic transactions, such as the basic claim, payment, and eligibility information.
Fast forward to 2009 and the HITECH Act. A key part of that law was to improve the efficiency and effectiveness of healthcare by adopting technology and standards for clinical data. That law really focused on clinical data and establishing a regulatory mechanism for certifying health information technology, such as EHRs, and support standards for digitizing clinical data.
What happened is these two data flows are currently uncoupled, clinical and administrative data, and it’s been a result of the way that healthcare has gone about digitizing.
An interesting point that we’ve found from a federal perspective is that two federal advisory committees [the National Committee on Vital and Health Statistics (NCVHS) and ONC’s Health Information Technical Advisory Committee (HITAC)] have come together to help solve this problem and established a new taskforce that’s specifically focused on how we bring these two siloed data and information workflows together to help reduce burden.
Prior auth is one example of the burdens that can be addressed by having a better process of merging clinical and administrative data.
AHIMA20: What standardization work still needs to be done?
Mason: There’s a lot of work and momentum going on in this space. HL7 is the standards development organization that’s really been at the forefront of setting standards for clinical data, and it’s been at the forefront in a private sector initiative to convene stakeholders to tackle the issue of integrating clinical and administrative data.
They’ve established the DaVinci Project, which is designed to help address the needs of the value-based care community by leveraging the FHIR standard.
So medical service prior authorization is one of their priority use-cases and we see a lot of promise in the work that’s coming out of that initiative. And in terms of the standardization work that needs to be done, that’s what we’re expecting to get better insight into from our joint NCVHS and HITAC task force. This new task force really has a vision of supporting the convergence of administrative data to improve data interoperability, to support clinical care, to reduce burden, and improve efficiency.
At the same time we really think there’s a great opportunity with HL7’s FHIR-based standard and to explore potentially grafting FHIR data onto X12 transactions for the process to be more streamlined, more seamless and have a significant reduction in burden to providers.
The industry is in the early stages of being able to merge these standards and we hope that the work that the task force develops will help to clarify and provide direction since there’s so much work being done in this space from different entities.
AHIMA20: Much has been written about the advantages for payers and providers, but how does clinical and administrative data integration help patients?
Mason: Addressing clinical and administrative data integration and making it a more streamlined, transparent, standardized process, will put the patient at the center of care.
If the clinician knows at the point of care what requirements are needed, they can immediately send that information and get an approval so there aren’t delays in care, treatment, medication, services, or referrals. I think a lot of this work is going to help improve the patient experience and eliminate delays in care by leveraging technology that’s in most healthcare settings.
We see the opportunity to leverage the existing technology infrastructure and overlay modern standards and technology to merge the clinical and administrative burden to improve efficiency, ultimately improving outcomes and decreasing these negative clinical outcomes that we’ve heard can happen as a result of prior authorization.
Journal of AHIMA: A Pathway to Clinical and Administrative Data Integration
Mary Butler (firstname.lastname@example.org) is Senior Editor of the Journal of AHIMA.