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Hello,
everyone. This is Jacob Emerson with the Becker's
Payer Issues podcast.
Thrilled today to be joined by a special
guest. Piyush Khanna is the vice president of
clinical services at CareFirst Blue Cross Blue Shield.
Piyush, thank you so much for taking the
time to be with me on the podcast
today.
Thank you, Jacob. Thank you for the opportunity.
Excited to be here.
Yeah. And we're excited to have you, and
we have a lot we wanna talk with
you about. So before we dive into all
of that, can you talk to us a
little bit more about yourself, your background in
health care, and what it is that you're
doing today at CareFirst?
Absolutely, Jacob.
So I've been in the health care industry
for a little bit, spent the last, 20
plus years in health care, working on provider
systems,
working in start ups, working at large companies.
And at CareFirst, my role,
is focused on the clinical services element.
So supporting the medical management function, the value
based stuff,
within the company,
supporting our
nurses, supporting our care management staff, supporting our
appeals and grievance teams. So I have a
team of resources that
are working
and supporting the quality area, the risk adjustment
area, the value based care area, and the
medical management function.
Fantastic.
So, Piyush, we're here to talk with you
a little bit about receiving timely data from
provider networks to meet quality reporting requirements. So
for our listeners who might not be as
familiar as you are, can you give us
a general overview of what the quality reporting
requirements are today in terms of current challenges
you're seeing and how you and CareFirst are
preparing for any upcoming shifts in in regulations
or reporting standards?
Absolutely, Jacob.
I think it's very important for the listeners
to understand that
the quality requirements is just not another reporting
ex expectation, but it has some value for
all parties involved.
From a business value perspective, we look for,
you know, if there is a quality expectation
or requirement, how does that clinical quality
improvement in the care delivery system lead to,
medically necessary care, for example, being delivered.
And these quality reporting metrics
are basically a parameter
for
all of us to assess
the current operating system, how the care has
been delivered to our members, to our populations.
And and this provided data that we are
looking to gather also helps us in selecting
really,
you know, how are we performing, what is
happening within our health care ecosystem.
So that's a very important,
expectation.
Quality reporting is,
threefold.
You know, obviously, they're talking about the measures,
in the quality reporting are around
clinical quality
of how the care is being delivered.
But it also has a patient experience component
to us, which is becoming more and more
important for the consumer assessment of,
health care or our providers and systems that
we have. And also to look at our
processes internally from an operating model aspect. So
there are 3 components
that I look at from a quality reporting
perspective that we are focused in on.
Of course, some of the challenges,
as you know very well, health care ecosystem
is
extremely fragmented, the data sources.
Where this data lives is also spread out.
Right? So we have multiple
electronic health records
where our members
are interacting with clinicians. And how do we
get that data from disparate sources
into a central location for us to be
able to better understand
how the quality is being
affected,
and how do we understand as it's going
through the journey, where are the gaps
or the opportunity for care,
how do we coordinate care. You know, there's
data that comes in
comes in all kinds of format and structured
and unstructured,
format. How do we collect that data, and
how do we pull that data into a
single
data source so we can then report it
back out to,
from a HEDIS perspective, the NCK, for example,
for accreditation,
for us to better benchmark our operating processes,
or
the CMS are under stars for our our,
government program business. So,
these are very important elements for us to
consider. These are some challenges that we are
facing as well, and we are,
aggressively working towards addressing some of these,
these challenges. There are more regulatory,
compliance requirements that are in front of us.
For example, there is an initiative
for here in the state to do the
managed care organization that, say, provide Medicaid services
and MCO plan for
for in states have, you know, a quality
reporting system, a rating system that's being put
together,
for for members who are trying to
look at different products from health plans and
try to assess which one they should be
buying. So there is that quality rating system
that will be put together
for health plans.
There is more requirements on home based care
and
rehab services within the community. So see a
lot of movement and opportunity in the whole
quality reporting system.
Understood. So very clearly a complicated process, a
lot of different challenges involved. You mentioned the
the internal,
operations that have to occur at at CareFirst
to make sure this all happens. Can you
give us an on the ground example from
the company, in terms of the operational aspects
of quality reporting? How are you handling staffing,
timeliness,
workflow efficiencies,
to make sure the company meets these requirements?
But I would break down the quality reporting,
stuff into 3,
3 major stages. Right? So first stage for
me is actually collecting the data. Right? The
the ability for us to go and collect
the data so we can then
put it into a quality engine and really
try to understand how well or how poorly
or how, you know, why are we regressing
forward or progressing,
or progressing forward or regressing backwards, if you
will? How do we get that,
that viewpoint into a system so we can,
you know, from a staffing perspective, you know,
if we are not doing well in a
particular measure, do we
invest more in the community? So for example,
if if, you know, we in a diabetes
management looking at hemoglobin
a 1 c levels,
getting that data timely is very, very critical
for us. And then if we are seeing
trends that are not covered, how do we
engage the provider network to be able to
help us in closing these gaps in care?
How do we interact with them? So in
my mind,
as I said, these are kind of events
that we are constantly looking and tracking,
not waiting till the end of the year
to say what has how do we know
as it is happening in the
in the environment, in the health care delivery
ecosystem for our members? How do we make
sure we are ready,
to be able to,
first,
have timely action so we can make some
changes and make sure that the the clinical
quality aspects are addressed.
How do we constantly look for ways in
which we can automate some of these data
gathering
slash gaps in care, creating feedback
loops. We are investing
into into practice transformations,
to actually engage our practices, reaching out to
them, sharing these gaps,
and making sure that they are working towards
closing them.
And also,
of course,
most important aspect is to make sure
the members
care delivery and quality of care is never
compromised.
So as I said, diabetes is a good
example
where we were looking at,
you know, how do we look at
the the lab dataset to be able to
better predict whether diabetes is progressing?
Can we hold some of our members into
a type 1 diabetes situation versus all of
them transition to type 2 or many of
them transition to type 2? How do we
how do we look at the data, look
at the clinical quality, and help the providers,
target some of the members that we believe
are not progressing forward or regressing backwards. So,
we we look at this as an example
and constantly try to tweak our operational capability,
whether it's looking for automation, looking for discrete
data,
and making sure, more data we can get
timely so we can
attack some of the problems.
And then, again,
we are constantly shifting where are we seeing
the trends, which measure is falling behind, what
are what is that measure trying to tell
us. And then we staff whether it's, as
I said, working in the community aspect,
working internally with the care management teams.
Depending on the problem at hand, we will
basically come up with a game plan to
address that particular gap.
Sure. And I think a keyword in what
you just said, Piyush, is is timely data.
What what happens if there's delays
or or gaps in the data that you
receive?
Can you can you
explain to us how important it is,
to to make sure that this data is
timely from your provider network?
I think it's it's absolutely critical. Right? I
mean, getting access to that information so we
can create a game plan.
I mean, an example comes like, for example,
in high-tech imaging. Right? So
we are going through,
so
a member goes through an MRI.
And if we are looking at that MRI,
are we seeing a trend? Is there too
many imaging studies being done on a particular
member? Is there an opportunity for us to
look at home care
and see the clinical quality of the data
coming back and saying, is the member progressing
or regressing?
The timeliness is critical because we want to
interject ourselves
to make sure that the transition of care
as they move from a home care setting
into a,
to another setting or they went from an
inpatient setting to a home health setting.
How do we make sure that we are
able to support these these kinds of,
elements?
And, again, as I said, timeliness is critical
because you want to interject yourself.
You want to share that data with the
clinician
early and often so they can make a
plan that can
alleviate some of the problems. Right? Within 48
hours of a transition of care from a
care setting is when most of the readmissions
occur. Right? Within 48 hours. So how can
we timeliness of getting that information, what was
the discharge summary about? What was the medication
reconciliation
around?
How quickly are we addressing those gaps
is is is paramount important
for us to have a good clinical outcome
for our members?
Absolutely. That makes sense. And it sounds like
health outcomes are are literally on the line
when it comes to receiving this this timely
data.
Let's let's switch gears here for a sec,
Piyush, and talk a little bit about CareFirst
current data exchange program.
What is it? How does it work? And
can you talk about some of the key
successes you you've seen so far?
So as I've said, you know, data in
disparate formats and getting access to that data
in a timely manner is absolutely critical.
So what we have started with about three
and a half, 4 years ago, we started
in a program
to really create a clinical data repository
and work with our providers,
community, and actually get access directly from their
EHRs,
being able to pull that information.
So we can create a single longitudinal
record of the member. And, you know, a
typical member of ours would see about 5
to 6 physicians. And we would be able
to collect all of that information and put
it into a single longitudinal record.
So now we can see on a daily
basis as the member is interacting with the
candidate every ecosystem,
what is happening? What what are we doing?
So
that, data exchange program and that clinical data
repository becomes a huge value add. And I
said it's been a journey, and I did
happen overnight.
But we've been able to get majority of
our our our,
membership
onto this particular platform with the support of
our providers
and actually get more real time access to
that information.
And again, it's been a game changer for
us.
I can imagine. And and I also am
curious about some of the challenges you've encountered
over the last 3 or 4 years. I
imagine with all the different technology,
different systems that providers are on, what have
what have you encountered in terms of challenges
with this program, and and how have you
overcome them?
So I I think, as as you said,
right, we have, this clinical exchange program. We
are connecting it to 47 different
EHRs,
47 different technology
paradigms, 47 different data structures,
47 different kinds of data output. So,
choosing a a partner who can help, again,
we don't we didn't want to be in
the game of writing all these connect connectors
and adapters to exchange that data with the
within the provider ecosystem with their EHRs.
So we actually worked closely with our partner,
MRO, to actually pull all of that data
using their technology, their adapters, their connectors,
and being able to pull it into a
consistent format. So we are able to get
to a a CCDA, which is basically a
continued care document, which gives us that clinical
data exchange capability.
Also merging. Right? Think about the MPI logic.
Like, I've got my huge data sitting in
6 different EHRs. How do you pull that
data as it's being changed
and bring it into a single repository and
then creating a single longitudinal record?
So I think those are some of the
challenges that we saw. Right? How do we
connect into 47 different EHRs, bringing them all
into a single repository?
But also working with the provider community, right,
explaining to them why this data is important
for the benefit of all of us, right,
whether it's for risk adjustment, whether it is
for heaters, whether it's for stars, whether it
is for
just the payment structures that we are constructing.
I think it's critical and beneficial for everybody
that the patient outcomes are improved when we
have this data exchange availability.
But we had to it took us a
little bit while because we inserted ourselves as
as contracts. So these providers were coming up.
We inserted language to make sure everybody
was complying with getting that information into this
clinical data repository
following a clinical data exchange format with,
our our partner here,
so that the data and information could be
in a single repository.
Yeah. Absolutely. And 47 different EHRs. That sounds
amazingly complex.
How would you say then that that advancements
in data exchange through better technology, like you
mentioned, through better collaboration
with providers and other partners, How does that
how is that shaping the future of quality
reporting from your perspective, Piyush?
Yes, Piyush. As I said, we started two
and a half, four years ago. Right, Jacob?
And I feel,
that,
you know, there weren't a lot of standards.
So we had
to pull data in whatever output format was
accessible to us.
But whereas the industry is moving towards more
fire and interoperability standards,
that's very exciting for us to be able
to get access to that information in a
consistent manner, whether it is
EHR 1 or 2 or 3 or 4,
it doesn't really matter. Everybody is exchanging data
in a consistent way using FHIR standards.
Very excited about the work that's happening from
a DevCo perspective
where there is now conversations to include,
sorry, DEFCA stands for the Trusted Exchange Framework
and Common Agreement.
And basically, that is that is the abstraction
or a or a a framework that has
been put together
on how to exchange data in a trusted
way. Right? So if a provider sends information,
how do we get that information out without
having to create these point to point connections?
How can we exchange information without requiring to
know where the endpoint is and they don't
need to know about us? But we are
able to, in a trusted, secure manner exchange
that information around the quality,
quality measures that we need to exchange information
around. So very excited about it.
I think those are the kind of technology
partnership paradigms that we are excited to participate
in.
CareFirst, for example, Jacob has,
you know, about,
has a a large out of area population
as well that we manage.
And if we can get that clinical data
exchange through the TEFCA
and as more and more QHANs come into
being, I think that is something that will
be, very important and valuable for us.
Sure. Absolutely. And to bring it back to
the most important part here, how do these
technology partnerships
contribute to better patient outcomes and also
better operational efficiency, both for CareFirst and and
for your provider network?
Again,
you know, as as I said, think of
a provider. Right? Large, you know, number of
CareFirst departments are reaching out for accessing the
same information from these providers.
We are asking,
for example, for risk adjustment or for HEDIS
or for stars or for quality measures or
for other purposes as well.
Now the providers can exchange that, share that
information with us without having
to answer 5 different questions from within the
Help and ecosystem, and they can share that
information, send it out.
There's an opportunity that some of the provider
networks
are exploring
is to be able to if they have
already built a connector with,
MRO,
could they then use that data that they're
already sending to MRO to other health plans
as well beyond CareFirst? So I think there's
some opportunities for us to really look for
that operational efficiency, look for the workflow efficiency
within the provider community as well. For us,
again, as I said, I I mean, there
are 3 things we are after. Right? Timeliness
of data. We already discussed that accuracy of
that information as well. Because as,
as it goes through the the clinical data
exchange, we are also able to validate certain
information, put some checks and balances in place
as the data is in transit and at
rest to make sure the quality of the
data is something that we can look at.
You know, we are doing the audits in
the clinical data exchange, to really look at
the aggregator validation,
doing PSV work.
So there's a lot of opportunities that we
are introducing under this process. So other parts
within CareFirst don't have to go through the
same exercise
again. And also looking excited about the technology
paradigm of maybe the feedback loop. Right? So,
yes, we can collect the data and benefit
the benefit CareFirst, but also how can we
insert ourselves,
look at the future state where we are
able to push this information into the clinical
workflow at the provider themselves
so they can look at and find out,
hey. I'm gonna order an MRI. There's already
one existing. Or I can look at a
gap in care and say, hey. Piyush hasn't
come into the office, the primary care
in the last 2 years. How can I
put that information from? Because I think there's
an opportunity
for us to be able to, use this
data not just in one direction, but also
start pushing that information to clinical workflows or
to clinical
decisions decision support tools as well.
So clearly, a lot of, industry leading work
happening under your your leadership, Piyush, and in
that vein there's a lot of health plan
leaders listening in who are in different stages
of their clinical data exchange
journey. Like you mentioned, it is a journey
and it's a it's a long process.
Do you have any advice for those listening
in terms of,
how to how to build and,
how to improve their own data exchange programs?
I think I can share with our experiences.
We started 3, 4 years ago and sort
of in a hybrid model where we have
data coming to us in in multiple,
formats, PDF, and still we don't have everything
through the clinical data repository that we have
constructed.
So I would just advise that there are
4 stages for me, right, in a program.
One is just a digital introduction. Right? Let's
stop getting access to EHRs, people logging into
EHRs, trying to decipher that data.
How do we give that digital introduction to
be able to pull this information without any
manual processes of,
you know, getting, you know, paying vendors to
go out and collect that information on behalf,
getting PDF data, trying to synchronize that information.
Can we do an inventory of the clinical
data sources?
Can we also, as we are doing the
digital introduction, look at these data sources, see
if we can go to a more open
standard, more interoperable standard like FHIR as an
example I was giving earlier.
And then get familiar with some of the
second stage would be to start to digitally
enable some of this. So why do I
get,
you know, this unstructured
content? Why do I still have access to
EHR to be whoever to pull that manual
data?
So start digitizing a lot more of,
of of the dataset that you are getting,
whether it's through access,
through,
a QHIN in the future or through HIEs
or getting that information through
the the CDR that we have there for
clinical data exchange.
You've gotta start moving to the digital enablement
aspect. Then I would say the next stage
for us that we are trying to push
for is to
really go fully digital. Right? We have about,
1,500,000
member data today. We want to continue to
push that to 2,000,000 and beyond. So as
we are adding more and more member data
into the ecosystem, I think that's gonna help
us and really want to go fully digital
in sort of a phase 3.
And then
everything we discussed in in the phase 4
is looking at technologies like CQL, looking at
NLP.
You know, there is a clinical query language
which allows us some of the flexibility that
we've been looking for, not just looking at
a year long worth of quality measures. Can
we
can we query that data to look at
certain stages? Say, you know, we get a
lot of wellness data beginning of the year.
We how how can we look at it
for certain
demographic
data, for certain geographic data,
and being able to query that data digital
data set to understand how quality is progressing
throughout the year on in a particular
geography,
is is something of interest that I feel
would be sort of a stage for all
the benefits that you would accrue from this
investment that you're gonna make over the the
journey.
Fantastic. Well, Piyush, what else are we missing?
Any other final thoughts you wanna offer our
listeners?
I think exciting times for us in the
health care ecosystem, I'm very, excited, as I
said, for the changes that are coming,
around the TEFCA and the QN work,
around the FHIR and then probability
capabilities that we are being built. So,
as the
as the provider pair
divide is becoming smaller and smaller, I think
working and collaborating
to truly give that best experience for a
member patient,
is is sort of exciting. And I think
the quality area and this clinical data exchange
is going to be absolutely critical
for a accurate, timely, and quality data exchange.
Wonderful. Well, Piyush, thank you so much for
taking the time to be with us and
for sharing your insights with our listeners. We
truly appreciate it.
Thank you, Jacob.
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