University of MinnesotaInformation Technology in

Healthcare Medical Industry Leadership Institute

Course: MILI/PUBH 6562Fall Semester B, 2014Stephen T. Parente, Ph.D.

Carlson School of ManagementDepartment of Finance

sparente@umn.edu

Class # 3 Health IT Data Structure

The Insurer• Basic data structures• Units of analysis• Health data over time• Health insurance data architecture• Small group exercise

Data Structure Fundamentals

• Simple text/column data • Pre-packaged data• Relational databases

Simple Column Text Data

Patient DOS ProcedureAllowed

Joe 02/03/14 MD Visit $100

Joe 06/05/14 Lab test$60

Joe 02/03/14 Lab test$60

Joe 06/05/14 MD Visit $100

Mary 01/06/14 MD Visit $100

Penny 11/11/14 Eye Exam $80

Pre-packaged databases

• MS-Access databases• SQL databases• SAS databases• SPSS databases• STATA databases• Excel spreadsheets

Relational Databases

• The database stores data in individual files or tables with data items arranged in rows and columns.

• AT LEAST one data item (the key) is common to each table and is used to LINK two or more tables for ad hoc queries.

• Common method to use relational databases is through SQL (structured query language).

Health Data Display by Different Units of Analysis

• By provider • By person• By episode/incident• By transactions• Over fixed units of time

By Person

By Episode

By Transaction

Health Data Representation: Over Time?

Mental Health

Jan Apr July Oct Dec

=Pysch consult

Cumulative CostWell

Sick

Normal

$50K

$0

Insurers’ Role in Health IT

• They are the ‘links’ that connect to everything about a patient in an electronic form.– Employers– Providers– Patients– Government agencies– Researchers

Insurer’s IT Paradox

• They are being held accountable for an insured patient’s total care.

• Best breadth of data–Most all places of service– ‘Standardized’ data

• Worst detail– No clinical info on patient health status and

outcomes.

IS Management Structure

CEO

CIO

Claims

CFOCOO

SystemsMIS Actuarial AccountingUR MCO

Working Group Backbone

HEALTH INSURANCE CLAIM FORM

The Health MIS Pyramid

Hardware

Decision Support Software

Life Support Software

Clinical & Financial Data

Insurer Hardware - Mainframe

Insurance Database Architecture

• Claims• Membership• Provider files• Case management• Utilization review / Demand Management• Decision-support databases• Analytic / Financial data

Claims Data

• Entered manually (10%), submitted electronically (90%) - on average.

• Key items:– Claim ID and date or service– Member / Subscriber ID– Provider of service– Diagnosis & procedure– Charges, reimbursements & copays– Administrative information

Claims Data Example

Claims Data Example

Membership / Subscriber Data

• Member / Subscriber ID (sometimes not person specific!)

• If managed care, assigned gatekeeper• Dates of enrollment• Age, gender, case-mix, health risks• Address• Type of policy, employer• Status of benefits used during enrollment

Subscriber Data Example

Provider Files

• Used to pay bills and identify providers to be included in ‘Panels’ for new products.

• Key Data Items:– Provider ID– Specialty, Board Certification, Education–Malpractice history & insurance– Address– Profiling summary

Provider File Example

Case Management

• Patient tracking systems• Check to see if recommended ‘process of care’

is occurring as part of good quality care.• Patient reminder systems (mail)• Provider reminder systems (phone, mail &

electronic)• Outcomes and cost assessment

Utilization Review / Disease Management

• Either run directly or contracted to 4th party acting as Insurer’s agent.

• Have decision-support systems based on clinical algorithms (and possibly patient’s claims) to manage a patient’s care.

• Common conditions reviewed/managed:– Schizophrenia, depression– Heart disease– Diabetes, Asthma, Glaucoma– AIDS

Support Databases

• Procedure fee schedules• Diagnosis codes• Institutional arrangements for managed care

payment• Pharmacy fee schedules and formularies• ‘Grouper’ algorithms– DRGs, MDCs,– Case-mix and severity

Life Support Systems

• Accounts Receivable– Employers– Consumers– Government

• Claims payment– Error checking– Provider payment– Fee schedules & payment algorithms

• Benefits/eligibility

Analytic / Financial Data

• ‘Cleaned’ versions of claim, provider and membership files designed to:– Generate premium estimates– Adjust provider fee schedules– Profiling of:• population (e.g., all patients with diabetes)• practices• employer groups• patients

Small Group Exercises(Part 1 of a 2 Part Exercise)

• What ‘information’ can health insurance data provide?

• Name 2 major strengths and weaknesses of claims data as a management tool.

• Poof: You’re a Blue Cross Blue Shield CIO.– You have $50M to spend to upgrade your claims system.– It costs $1M per text/character to enhance your data.– What data fields would you add?– Are there any data fields you would consider deleting or

optimizing?

Intermission

Medical Provider Data

• Patient Diagnosis Information• Treatment plan• Referrals• Outcomes• Explanations for treatment

The Operation• The Hospital submits lots of bills

– Lab work– Blood– Anesthesia– ER room time– Supplies

• Surgeon John submits a claim for surgery.• Dr. Bob submits a claim for IP consultation.• Internal hospital systems affected:

– Inventory– Payroll– Accounts receivable– Medical records

• PPO reimburses hospital.• PPO reimburses Dr. Bob• PPO reimburses Dr. John

Medical Center Data Systems

LifeSupport

Data

Hardware

Medical Data Collection - 1

• Operational data: Transaction-oriented– Hospital pharmacies– Laboratories– Radiology departments– Critical care units– Order-processing units

Medical Data Collection - 2

• Analytic data– Carry all variables of interest– Single record– Data is stored horizontally

Code Systems Standards - 1

• HL7 - American National Standards Institute Health Level – Patient registration data– Patient orders– Clinical information (e.g., vital signs)– Referral information– Clinical trial data– Other operational transactions

Code Systems Standards - 2

• X12 - Data Interchange Standards Association’s Accredited Standards Committee– Insurance enrollment & payment– Administrative messages

Code Systems Standards - 3

• Diagnoses: International Classification of Diseases, Version 9 (ICD9)

• Procedures: Current Procedural Terminology, Version 4 (CPT4)

• Drugs: Food and Drug Administration’s Nation Drug Code (NDC) directory

Code Systems Standards - 4

• LOINC - Logical Observations Identifier Names and Codes (LOINC) database: The Missing Link– Codes, names and synonyms for more than 12,000

observations:• laboratory tests• vital signs• electrocardiograph measurement• input & output measures• clinical impressions• discharge summary

Code Systems Standards Examples

Integrated Delivery SystemIT Network

LifeSupport

Data

Hardware

DecisionSupport

Insurer Only Data

1/31/14

2/6/14

PCP visit

Specialist visit

Laboratory test

Biopsy

Surgery

Sub-Acute Care

Medical Data Available to a U.S. Fee-for-Service Insurer

LifeSupport

Data

Hardware

DecisionSupport

Medical Data Available to a U.S. Staff Model HMO

LifeSupport

Data

Hardware

DecisionSupport

Provider Only Data

1/31/14

2/6/14

White blood cell count high

Cancer metastasized

Referral to specialist

Malignant cancer remains

E/CPR Model A

E/CPR Model B

What are the Pros & Cons of these Models?

Are they out of date as useful data management models?

Data Available to the Average Medical Provider About a Patient’s Care

15% ofCare

25% ofCare

15% ofCare

10% ofCare

35% ofCare

Merging Insurer & Provider Data

1/31/14

2/6/14

PCP visit

Specialist visit

Laboratory test

White blood cell count highBiopsy

Cancer metastasizedSurgery

Referral to specialist

Malignant cancer remains

Sub-Acute Care

Small Group Exercises(Part 1 of a 2 Part Exercise)

• What ‘information’ can health insurance data provide?

• Name 2 major strengths and weaknesses of claims data as a management tool.

• Poof: You’re a Blue Cross Blue Shield CIO.– You have $50M to spend to upgrade your claims system.– It costs $1M per text/character to enhance your data.– What data fields would you add?– Are there any data fields you would consider deleting or

optimizing?

Small Group Exercises(Part 2 of a 2 Part Exercise)

• What ‘information’ can medical data provide?• If you are an insurance company CEO, how vital are

clinical medical records to your business?• If you are hospital administrator, name one pro and

one con to having access to health insurance data? What share of your profit/surplus are you willing to invest for such a link?