L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM

Louisiana Center for Health Informatics at The University of Louisiana at Lafayette Slide 1

WRIA 2014 Meeting, Napa CA

Evaluating Information Exchangefor Effective Risk Management

in Healthcare

L. Philip Caillouet PhD FHIMSSWilliam L. Ferguson PhD CLU CPCU ARM

The University of Louisiana at LafayetteJanuary, 2014


Abstract The healthcare delivery sector and the health insurance industry

seem destined to collide once again as voluntary HIEs are launching and as mandated HIEs are coming on-stream.

But when is an HIE not an HIE? When one is a Health Information Exchange and one is a Health Insurance Exchange.

One is vital in maintaining health and critical to managing clinical risk in the delivery of healthcare services, while the other is hoped to aid individuals and small businesses in managing economic risks in daily life.

Evaluating the effectiveness of each, separately, offers a significant research challenge.

Creating and monitoring effective relationships between the two may be the future of risk management in healthcare.


Outline of This Presentation1. Healthcare and Health Insurance

are Information Intensive Industries2. Information Technology Applications

(especially HIEs) are Essential Enablers for Implementation of Health Insurance Reforms– HIE = Health Information Exchange (ARRA/HITECH 2009)

– HIE = Health Insurance Exchange [HIX, HIEx]; [HIM = Health Insurance Marketplace (Marketplace)] [AHBE = American Health Benefit Exchange (PPACA 2010)]

3. Experience To Date4. Measuring Success of HIEs


1.“Healthcare and Health Insurance Are Information

Intensive Industries”Healthcare has two underlying processes:

a. provision of careb. gathering of information to facilitate provision of care in the future

Health Insurance has two underlying processes:a. mitigation of risk for the insuredb. gathering of information to facilitate mitigation of risk in the future


Equip.Mfrs.

Suppliers

DrugMfrs. Physicians

Pharm.BenefitMgrs.

Network& CareMgrs.

Us!

PeerReviewOrgs.

Federal& StateGov’t.

FiscalInter-

mediaries

Employers,Unions,

& Assns.

Insurers FinancialServices

CreditBureaus

ClaimsAssistance

ASOTPAs

DataServices

Healthcare & Health Insurance Information Pathways

PHOs

IPAs

Hospitals

*Us! = Patients, Employees, Citizens, Enrollees, Members, Covered Lives, Consumers, Marginal Units, Populations

*


2.“Information Technology Applications (especially HIEs)

are Essential Enablers for Implementation of Health

Insurance Reforms”The U. S. federal “plan is to propose Health Information Exchange and interoperability requirements … so that patient information follows patients to the point of care and informs critical health decisions.”


Equip.Mfrs.

Hospitals

Suppliers

DrugMfrs.

Physicians

Pharm.BenefitMgrs.

Network& CareMgrs.

Patients

PeerReviewOrgs.

Federal& StateGov’t.

FiscalInter-

mediaries

Employers,Unions,

& Assns.

Insurers FinancialServices

CreditBureaus

ClaimsAssistance

ASOTPAs

DataServices

Color Key:Clinical (specific)Clinical (summary)FinancialAdministrative

Healthcare Information:Order from Chaos?


The Future’s Just Not the Same Anymore!attributed to Yogi Berra

Meaningful Use?Healthcare Reform?

Health Insurance Reform?Coordinated Care Networks?

Accountable Care Organizations?National Health Information Infrastructure?

HIPAA? / ARRA? / HITECH?PPACA? / (repeal?)

???



Health Information Exchange A “Health Information Exchange” is an online mechanism whereby

clinical, financial, and administrative information can be securely exchanged among patients, physicians, hospitals, other professional and institutional healthcare providers, public health agencies, regulators, and payors.

In the United States, the electronic transactions are well documented in the Administration Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and have been refined in the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH).

HITECH, an embedded component of the American Recovery and Reinvestment Act of 2009 (ARRA, or “”The Stimulus Bill”), funded the creation of State Health Information Exchanges on a state-by-state basis and mandated interconnection of these through the application of Nationwide Health Information Network (NwHIN) standards for inter-HIE exchange.



Health Information Exchange (sources) DHHS ONCHIT (created in 2004)

Office of the National Coordinator for Health Information Technology (ONCHIT) Federal Health IT Strategic Plan, updated for 2011-2015 – 80pp. (http://healthit.hhs.gov/portal/server.pt/community/fed_health_it_strategic_plan/1211/home/15583)

ARRA / HITECH (2009) American Recovery and Reinvestment Act (ARRA) (“the Stimulus Act”) incorporated the $20B Health Information Technology for Economic and Clinical Health (HITECH) Act, seeking “to improve American health care delivery and patient care through an unprecedented investment in health information technology.” (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1487&mode=2)

HITECH and HIE HITECH authorized State Health Information Exchange Cooperative Agreements (http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true)

LDHH / LHCQF Louisiana Department of Health and Hospitals & Louisiana Health Care Quality Form (LHCQF) – LaHIE Strategic & Operational Plans published in 2010 – 164pp. (http://lhcqf.org/images/stories/LaHIE%20State%20Plan.pdf.)

http://healthit.hhs.gov/portal/server.pt/community/fed_health_it_strategic_plan/1211/home/15583

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1487&mode=2

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true

http://healthit.hhs.gov/portal/server.pt?open=512&objID=1488&parentname=CommunityPage&parentid=58&mode=2&in_hi_userid=11113&cached=true

http://lhcqf.org/images/stories/LaHIE%20State%20Plan.pdf


Health Insurance Exchange In the United States, the Patient Protection and Affordable Care Act

of 2010 (PPACA) entered into a new phase of its implementation on October 1, 2013, with the launch of “Health Insurance Exchanges.”

Health Insurance Exchanges are intended to serve as fully online health insurance marketplaces where individuals and small businesses may select and purchase health insurance.

HIEs will be operated on a state-by-state basis, either by each state independently or by the federal government if a state should chose to opt out of the costs of managing its HIE. In the 974-page text of PPACA (available at http://www.hhs.gov/healthcare/rights/law/index.html), references to the “exchange” concept appear 333 times, and the concept is alternatively termed “Health Insurance Exchange,” “Health Benefit Exchange,” “American Health Benefit Exchange,” “Small Business Health Options Program (SHOP) Exchange,” “Data Exchange,” or simply “State Exchange.”

http://www.hhs.gov/healthcare/rights/law/index.html


Health Insurance Exchange (continued) More formally, PPACA amended Section 2791(d) of the Public

Health Service Act (42 U.S.C. 300gg–91(d)) to add the following definition: “The term ‘Exchange’ means an American Health Benefit Exchange established under section 1311 of the Patient Protection and Affordable Care Act.” In 12 pages, Section 1311 details requirements and functions of a State Exchange, including 11 specific functions to be performed by the online system. Such exchanges were originally dubbed with the acronym “HIE,” but more recently “HIX” has been used to avoid confusion with “Health Information Exchange” (another federally promoted concept).


Health Insurance Exchange Functions





Health Insurance Exchange (sources)

PPACA (2010) Patient Protection and Affordable Care Act (PPACA) (“Obamacare”) (

http://www.ncsl.org/documents/health/ppaca-consolidated.pdf) – 974pp.

Louisiana Department of Insurance (http://www.ldi.louisiana.gov/)

Louisiana Healthcare Reform Resource Center -- for Consumers (http://www.ldi.state.la.us/HealthCareReform.html

-- for Producers (http://www.ldi.state.la.us/MarketplaceTraining.html)

http://www.ncsl.org/documents/health/ppaca-consolidated.pdf

http://www.ldi.louisiana.gov/

http://www.ldi.state.la.us/HealthCareReform.html

http://www.ldi.state.la.us/MarketplaceTraining.html


HIE-HIE Connections?

Eligibility Co-Pay Collection Coverage Levels Prior-Authorization Changes Enrollment

Enrollment


HIE-HIE Communications

HealthcareProviders

Patientsand

Families

PayorsInsurers

Healthplans


What an Applicant-Patient wants to know(how does PPACA affect me and my choices of Providers)

1. What is the monthly cost of the Healthplan’s premiums?2. How long has the Healthplan been in business? How viable is the

company? How stable will my premiums be over time?3. Can I still see my regular doctors? Will it cost more to see my regular

doctors?4. Are my current medications in the formulary? Will it cost more to get my

current medications?5. Must I have prior approval to see a specialist? approval from my regular

doctor? approval from the healthplan?6. Must I file my own claims? Will I get statements showing total costs and

total out-of-pocket expenses?7. Is there a co-pay required for routine visits? an annual deductible to meet?8. Is there an annual or lifetime maximum benefit? [PPACA prohibits maxima

for “essential health benefits” renewals after 12-31-2013]


What a Provider wants to know (how does PPACA affect me and what compliance issues loom)

1. How will I know which Patient is eligible under which Healthplan?2. May a Patient be rejected on the basis of their choice of Healthplan? [e.g.,

a Healthplan in which I do not participate]3. How will I know which services are covered by a particular Patient’s

Healthplan?4. How will I know which medications are including in a Healthplan’s

formulary?5. Must I seek approval from the Healthplan prior to ordering tests,

performing procedures, prescribing medications, or referring the Patient out to other Providers? How do I go about seeking such approvals?

6. What must I collect as a co-pay from any particular Patient?7. How will I get paid by a Patients’ Healthplan for services rendered to that

Patient? on a prepaid per capita basis? on a fee-for-service basis, using a negotiated fee schedule?


What a Healthplan wants to know(who are the Applicants and what underwriting options still exist)

1. Does the Applicant have pre-existing medical conditions that might disqualify them for coverage? [PPACA prohibits!]

2. Does the Applicant have behavioral risk factors that might alter their premium? [PPACA allows (e.g., smoking)]

3. May an Applicant be rejected on certain specific criteria other than a pre-existing condition or a risk factor?[e.g., Healthplan lacks certain services that Applicant-Patient may need]

4. Does the Applicant agree to all terms associated with the healthplan?5. Has the Applicant prepaid the required initial premium?6. Will the Applicant’s premium be supported by federal grants or aids?7. What Provider(s) will Applicant choose?


What the Regulators want to know(Exchange effectiveness and PPACA compliance metrics)

1. How many Applicants have visited the Health Insurance Exchange? non-duplicated individuals?

2. How many Applicants have applied for coverage with each specific Healthplan? non-duplicated applications?

3. How many Applicants have been approved for coverage with each specific Healthplan? Applicants and individual persons to be covered?

4. How many Small Businesses have visited/applied/been/approved? Small Businesses and individual persons?

5. What fraction of previously uninsured individuals will now have coverage?6. How many dollars in initial premiums committed/paid by Applicants?7. How many dollars in initial premiums committed by federal grants or aids?8. What complaints, misrepresentation, violations, etc. have occurred as a

result of the Health Insurance Exchange?


3. Experience To DateDonabedian’s Indicators:

Structure – Result of Federal (primarily) and State FundingProcess – If you built it, will they come?Outcomes – Too soon to tell!


The HIE & the HIE in Louisiana The Louisiana Health Care Quality Forum (LHCQF), the State-

Designated Entity in Louisiana, has used HITECH funding to create the Louisiana Health Information Exchange (LaHIE), which has just passed the second anniversary of its launch.

LaHIE Now Includes More Than 500K Unique Patient Records> The Louisiana Health Information Exchange (LaHIE) now features more than 560,000 unique patient records.> “For those patients, it means their physicians have greater, more timely access to their health records. As we continue our efforts to onboard more hospitals and practices to LaHIE, that number will grow exponentially in the coming months.” Cindy Munn, LHCQF Executive Director> To date, 33 hospitals and clinics are live with LaHIE, and 68 are actively onboarding. The exchange has participation agreements with more than 170 hospitals, providers, clinics, school-based health centers, home health agencies and other health care companies across the state.

The State of Louisiana has opted out of managing its ownHealth Insurance Exchange at least for now, which under the terms of PPACA requires the federal government to operate the online marketplace in Louisiana.

It is too early to judge the effectivenesseither of the HIE or of the HIE (HIX, HIeX, HIM, ABHE)in Louisiana, but it is not too late to create an evaluation plan!


Only 16 States Run Their Own Insurance Exchanges


Official Skepticism in Louisiana






Apologies & Apologists


New Action Plan


On the Mend?



https://www.healthcare.gov/families/

https://www.healthcare.gov/families/










Louisiana Plan Comparison – Single, 50 or older


Tricks no Treats?


Period*


https://www.healthcare.gov/small-businesses/

https://www.healthcare.gov/small-businesses/


EmployerPenalties


Downstream Implementation Timeline


4. Measuring Success of HIEsHealth Information Exchanges

Providers, Payors, Patients, Regulators, Public Health Agencies

Health Insurance ExchangesConsumers, Sponsors, Carriers, Networks, Providers, Regulators


Defining “Success”for Each

Health Information Exchange Functionality


Table 1. “Pre-Arrival”Uses of Information Exchanged in an HIE

HIE FUNCTIONALITYand Transactions Transaction Type Sender Receiver

Primary Beneficiary

CLASS

REFERRALS (INBOUND) PROVIDERS

Request to Accept Referred Patient Unsolicited Request Provider A Provider B Provider A

CCR/CCD Request Decision-triggered Response Provider B Provider A

CCR/CCD Delivery CCR/CCD Transmission Provider A Provider B

Response (Accept/Decline) Decision-triggered Response Provider B Provider A Provider B

APPOINTMENTS PATIENTS, PROVIDERS

Request for Appointment Unsolicited Request Patient Provider Provider

Response (Accept/Decline) Decision-triggered Response Provider Patient Patient


Table 2. “Point-of-Arrival”Uses of Information Exchanged in an HIE


Primary Beneficiary

CLASS

ELIGIBILITY CHECKING PROVIDERS

Inquiry Unsolicited Inquiry Provider Payor

Response Decision-triggered Response Payor Provider Provider


Table 3. “Point-of-Care”Uses of Information Exchanged in an HIE

HIE FUNCTIONALITYand Transactions Transaction Type Sender Receiver Primary Beneficiary

CLASSPATIENT RECORD REQUESTS PROVIDERS CCR/CCD Request Unsolicited Request Provider B Provider C CCR/CCD Delivery CCR/CCD Transmission Provider C Provider B Provider B LABORATORY TESTS PROVIDERS Order Unsolicited Order Provider Laboratory Laboratory Interim Status Inquiry Unsolicited Inquiry Provider Laboratory Interim Status Report Decision-triggered Response Laboratory Provider Provider Result Decision-triggered Response Laboratory Provider Provider, Patient RADIOLOGY WORKUPS PROVIDERS Order Unsolicited Order Provider Radiology Radiology Interim Status Inquiry Unsolicited Inquiry Provider Radiology Interim Status Report Decision-triggered Response Radiology Provider Provider Report Decision-triggered Response Radiology Provider Provider, Patient PRESCRIPTIONS PROVIDERS ePrescribing of Rx Unsolicited Order Provider Pharmacy Pharmacy Rx Fill/Pickup Report Event-triggered Response Pharmacy Provider Provider, Patient PRIOR AUTHORIZATIONS PAYORS, PROVIDERS Request Unsolicited Request Provider Payor Payor Interim Status Inquiry Unsolicited Inquiry Provider Payor Interim Status Report Status Report Payor Provider Provider Determination (Approval/Disapproval) Decision-triggered Response Payor Provider Provider, Patient REFERRALS (OUTBOUND) PROVIDERS Request to Accept Referred Patient Unsolicited Request Provider B Provider D Provider B CCR/CCD Request Decision-triggered Response Provider D Provider B Forwarding of Patient Record CCR/CCD Transmission Provider B Provider D Response (Accept/Decline) Decision-triggered Response Provider D Provider B Provider D


Table 4. “Point-of-Departure”Uses of Information Exchanged in an HIE


Primary Beneficiary

CLASS

REIMBURSEMENT CLAIMS PROVIDERS

Claim Submission Unsolicited Transmission Provider Payor Payor

Claim Status Inquiry Unsolicited Transmission Provider Payor

Claim Status Report Event-triggered Response Payor Provider Provider

Remittance Advice Event-triggered Response Payor Provider Provider

Electronic Funds Transfer Event-triggered Response Payor Prov. Bank Provider

PERSONAL HEALTH RECORD PATIENTS

ePHR Update Unsolicited Transmission ProviderePHR Custodian

Patient


Table 5. “Post-Departure”Uses of Information Exchanged in an HIE


Primary Beneficiary

CLASS

IMMUNIZATION REGISTRY PUBLIC HEALTH AGENCIES

Registry Update Unsolicited ProviderRegistry Agency

Registry Agency

Registry Update Acknowledgement Event-triggered ResponseRegistry Agency Provider

DISEASE/TUMOR REGISTRY PUBLIC HEALTH AGENCIES

Registry Update Unsolicited ProviderRegistry Agency Registry Agency

Registry Update Acknowledgement Event-triggered Response Registry Agency

Provider

QUALITY REPORTING REGULATORS

Quality Reporting Unsolicited ProviderQuality Agency Quality Agency

Qual. Reptg. Acknowledgement Event-triggered Response Quality Agency

Provider


HIE: Measuring SuccessFUNCTIONALITY Primary Beneficiary Type of Benefit Benefit Measure

Quantitative Qualitative

REFERRALS (INBOUND) PROVIDERS Source of new patients # of new patients Provider satisfaction

APPOINTMENTS PATIENTS Convenience Time saved Patient satisfactionPROVIDERS Staff time/cost savings $ saved in FTE staff costs Staff satisfaction

ELIGIBILITY CHECKING PROVIDERS Avoidance of uncollectable revenue

% of booked revenue collected Provider and staff satisfaction

PATIENT RECORD REQUESTS PROVIDERS Elimination of duplicative

workups Time saved Provider and staff satisfaction

LABORATORY TESTS PROVIDERS Automatic EHR update of results

Time saved by avoiding delays and manual filing Accessibility of information

RADIOLOGY WORKUPS PROVIDERS Automatic EHR update of reports

Time saved by avoiding delays and manual filing Accessibility of information

PRESCRIPTIONS PROVIDERS Automatic EHR update of compliance

% of prescriptions filled and picked up

Provider satisfaction related to this information not being previously available

PRIOR AUTHORIZATIONSPAYORS Enforcement of coverage

limitations$ saved in medical payments Utilization management goals

met

PROVIDERS Avoidance of uncollectable revenues % of $ collected Staff satisfaction

REFERRALS (OUTBOUND) PROVIDERS Expedited consultation Time saved Accessibility of information

REIMBURSEMENT CLAIMS PROVIDERS Expedited collection of revenue

# claims submitted;% and timeliness of revenue collected

Provider and staff satisfaction

PERSONAL HEALTH RECORD PATIENTS Record of problems &

interventionsTime saved communicating past medical history to new providers

Better information upon which to base lifestyle decisions

IMMUNIZATION REGISTRY REGISTRIES

Enhanced compliance & data integrity

#, timeliness, and completeness of updates received

Better information upon which to base health promotion policies

DISEASE/TUMOR REGISTRY REGISTRIES Enhanced compliance & data

integrity#, timeliness, and completeness of updates received

Better information upon which to base health promotion policies and clinical research priorities

QUALITY REPORTING QUALITY AGENCIES Enhanced compliance & data integrity

#, timeliness, and completeness of updates received

Better information upon which to base health promotion policies


Defining “Success”for Each

Health Insurance Exchange Functionality


Individual----------------- SHOP

Health Insurance Exchange

Adults (+Students)

SeniorsIndigentChildren

SponsorsSelfEmployers SmallEmployers LargeUnions Assocs

CarriersBluesCommercialsCo-ops

NetworksACOsCCNsHCOsHMOsPPOsIPAs-------------RHAs,IHSs, IDSs,IDNs

ProvidersHospitalsASCsPCPsPCMHsSpecPhysPharmaciesLaboratoriesRadCentersHmHealthAgcsTelemedProvs

State Insurance Commissioners (http://www.naic.org/)

Dept.of Labor – Emp.Ben.SecurityAdmin. (http://www.dol.gov/ebsa/)

Centers for Medicare & Medicaid Services (https://www.cms.gov/ /)

+ IRS & Homeland Security

Govt.ProgsMedicare Part A Part B Part C Part DMedicaidS-CHIPs

CONSUMERS SPONSORS CARRIERS NETWORKS PROVIDERS

HIE, HIeX, HIX,AHBE, Marketplace

REGULATORS

http://www.naic.org/

http://www.dol.gov/ebsa/

http://www.dol.gov/ebsa/


Redefining the Individual Market


Table 1. “Pre-Application”Uses of Information Exchanged in an HIE

[HIeX, HIX, AHBE, Marketplace]


Primary Beneficiary

CLASS

SEEKING GENERAL INFORMATION Unsolicited Inquiry

Consumer, Sponsor (SHOP)

HIX Query Module

CONSUMERS, SPONSORS

BROWSING FOR HEALTHPLANS Unsolicited InquiryConsumer, Sponsor (SHOP)

HIX Query Module

CONSUMERS, SPONSORS

BROWSING FOR PROVIDERS NETWORKS Unsolicited Inquiry Consumer

HIX Query Module

CONSUMERS


Table 2. “Point-of-Application”Uses of Information Exchanged in an HIE

[HIeX, HIX, AHBE, Marketplace]HIE FUNCTIONALITY

and Transactions Transaction Type Sender ReceiverPrimary

BeneficiaryCLASS

CREATING A MARKETPLACE ACCOUNT Unsolicited Input


HIX Registry Module, Regulator

CONSUMERS, SPONSORS, REGULATORS

IDENTIFYING HEALTHPLAN DETAILS Unsolicited Inquiry


HIX Query Module

CONSUMERS, SPONSORS

COMPARING SIMILAR HEALTHPLANS Unsolicited Inquiry


HIX Query Module

CONSUMERS, SPONSORS

APPLYING TO PURCHASE A HEALTHPLAN Unsolicited Input


HIX Application Module, Carrier, Regulator

CONSUMERS, SPONSORS, CARRIERS, REGULATORS


Table 3. “Point-of-Enrollment”Uses of Information Exchanged in an HIE

[HIeX, HIX, AHBE, Marketplace]


Primary Beneficiary

CLASS

RECEIVING CONFIRMATION OF ENROLLMENT

Decision-triggered Response Carrier Consumer

CONSUMERS, REGULATORS

SELECTING AN ACO / CCN / PCMH / PCP Unsolicited Input Consumer

Carrier, Network, Provider

CONSUMERS, CARRIERS, NETWORKS, PROVIDERS, REGULATORS

RECEIVING CONFIRMATION OF THE HEALTHPLAN BEING IN EFFECT

Decision-triggered Response Carrier Consumer

CONSUMERS, NETWORKS, PROVIDERS, REGULATORS


HIE: Measuring SuccessFUNCTIONALITY Primary Beneficiary Type of Benefit

Benefit MeasureQuantitative Qualitative

SEEKING GENERAL INFORMATION

CONSUMERS, SPONSORS Knowledge of Plans Time saved shopping for

healthplansUnderstanding of healthplan offerings

BROWSING FOR HEALTHPLANS



BROWSING FOR PROVIDERS NETWORKS CONSUMERS Knowledge of Plans Time saved shopping for


CREATING A MARKETPLACE ACCOUNT

CONSUMERS, SPONSORS, REGULATORS

Prerequisite for Application Time saved by avoiding delays and repetitive manual filing

Acquisition of“consumer status”

IDENTIFYING HEALTHPLAN DETAILS


healthplansRuling out/in specific healthplan offerings

COMPARING SIMILAR HEALTHPLANS


healthplansFacilitation of decision-making in favor of preferred healthplan

APPLYING TO PURCHASE A HEALTHPLAN

CONSUMERS, SPONSORS, CARRIERS, REGULATORS

Application submitted, then automatically routed, and queued for consideration; statistics available

Time saved by all parties through online “reusable” application; Carrier time savings through online marketing

Application encompasses decision (“the hard part is over for the consumer”); recognition of movement toward coverage of targeted populations

RECEIVING CONFIRMATION OF ENROLLMENT

CONSUMERS, REGULATORS

Confirmation and further information about healthplan

Tracking of coverage for targeted populations for Regulators

Comfort of knowing coverage is in place

SELECTING AN ACO / CCN / PCMH / PCP

CONSUMERS, CARRIERS, NETWORKS, PROVIDERS, REGULATORS

Exercise of consumer choice Tracking of relationships with Network and Provider

Exercise of consumer “control” through choice of Network and Provider

RECEIVING CONFIRMATION OF THE HEALTHPLAN BEING IN EFFECT

CONSUMERS, NETWORKS, PROVIDERS, REGULATORS

Confirmation of Carrier, Network, and Provider relationships

Tracking of ongoing events in place for Regulators

Comfort of knowing relationships secure


Conclusions


This study suggests that ... Benefits may accrue in various distinct areas and in varying degrees to each of the

HIE’s diverse participants. Certain participants may have no direct interest whatsoever in any but a very few

specific HIE functionalities. Participants who receive HIE transmissions are the principal beneficiaries of the

exchange – receiver receives “value” only if they perceive utility. If an unsolicited request for information arrives, the receiving participant is

obliged to respond – a new burden or “cost-of-doing-business” in the electronic age.

Some unsolicited transmissions may be requests for services – “orders” – and the receiver has an opportunity to benefit by turning the order into collectible revenue.

An HIE “succeeds” when it offers the proper mix of functionalities that can strike a successful balance of “value” for “value” exchange among its participants.

Under-contributing functionalities may still find a long-term niche, especially when these co-exist with other functionalities that can subsidize their continuance.

With HITECH-funded HIEs just coming on-stream in 2012, and PPACA-funded HIEs just coming on-stream in 2013, there is a significant opportunity for researchers to further develop and test HIE evaluation techniques.


Questions, Comments,or Suggestions?

[email protected]@louisiana.edu

Learn more at http://lchi.louisiana.edu

mailto:[email protected]

mailto:[email protected]

http://lchi.louisiana.edu/

Documents

L. Philip Caillouet PhD FHIMSS William L. Ferguson PhD CLU CPCU ARM