# Presentation: 243821

## Data Infrastructure for Quality Improvement

**Carol Wilhoit, MD, MS**
**May 3, 2007**

**Notes:**
With health care costs continuing to rise, the management of care becomes increasingly important. We strive to collaborate with network providers to deliver broad access and cost-effective quality care for our HMO members. 

## Blue Cross Blue Shield of Illinois

- BCBSIL is a division of Health Care Service Corporation, which operates the Blue plans in Illinois, New Mexico, Oklahoma and Texas.
- Mission:
- To promote accessible, cost effective and quality health care for our customers
- BCBSIL quality improvement data are organized around three areas of focus:
- HMO medical groups and IPAs
- Physicians in the PPO and Blue*Choice* networks
- Hospitals
- Because of contractual differences and the fundamental distinctions between these three provider types, the quality improvement initiatives, data needs, data infrastructure and challenges in reporting vary for each of these focus areas.

## BCBSIL Data Sources for Quality Improvement

**BCBSIL claims data**
**Medical claims data**
- Utilization rates (by product, by procedure, by provider)
- Complication rates (by hospital)
- Episodes of care (by employer, by physician/physician group)
- HEDIS reporting for HMO (numerators and denominators)
- Quality indicators based on claims data (HEDIS reporting for HMO, assessment of physician/physician group performance for PPO, use in assessment of IPA performance for HMO)
- Electronic claims submission rates
**Pharmacy data**
- Utilization rates
- Formulary compliance/generic utilization rates
- HEDIS reporting for HMO (numerators and denominators)
- Assessment of physician/physician group clinical quality indicators for PPO (numerators and denominators)
- Identification of members for inclusion in disease management programs

## BCBSIL Data Sources for Quality Improvement

**IPA encounter data **(Claims data submitted by capitated HMO medical groups and IPAs [collectively referred to as IPAs])
- 2007 QI uses include HEDIS reporting, identification of members for inclusion in disease management programs, reporting quality indicators for individual IPAs.
- Future uses will include identifying members in need of preventive services for outreach efforts.
**Medicare data**
- Publicly available Medicare claims data are combined with BCBSIL claims for assessment of hospital-specific complication rates using AHRQ Inpatient Quality Indicators and Patient Safety Indicators.
**Clinical data submitted by HMO IPAs**
- BCBSIL identifies members with specific conditions and members eligible for specific preventive services.  IPAs abstract their own data from their claims and/or medical records and submit the data on scannable forms for assessment of performance at the IPA level.
- IPA-submitted data is used to create condition-specific registries.
- HMO IPAs abstract and submit data for HEDIS reporting.

## BCBSIL Data Sources for Quality Improvement

**Member survey data**
- CAHPS survey
- HCSC Continuous Tracking Survey (telephone survey)
- BCBSIL HMO Member Survey (mailed to a random sample of members from each IPA)
- BCBSIL Hospital Member Survey (mailed to BCBSIL members with a hospital admission)
**Provider-reported data**
- Hospitals self-report regarding patient safety practices, physician board certification, and participation in state / national quality improvement initiatives.
**Publicly available data**
- Leapfrog, Hospital Quality Alliance, Accreditation
**Inquiry and Complaint data**
- BCBSIL inquiry tracking database

## BCBSIL QI Data Procedures

- All BCBSIL claims data and pharmacy data are aggregated into EDW, an internally developed electronic data warehouse. Claims data needed for quality improvement purposes are obtained from EDW.
- Files from EDW are loaded into other applications for quality improvement initiatives and reporting.  Examples include:
- BCBSIL staff use EDW files to create lists of members for outreach purposes.
- EDW files are loaded into vendor software that creates episodes of care.
- EDW files are loaded into vendor software that will also accept registry and medical record data for HEDIS reporting.
- Since all-payor data are not currently available for Illinois, a BCBSIL vendor combines BCBSIL admission data from EDW with publicly available Medicare admission data to create a database used in reporting AHRQ IQIs and PSIs.
- EDW files are sent to a vendor for reporting quality indicators at the PPO physician/physician group level.

## BCBSIL QI Data Procedures

- Clinical data and HEDIS data abstracted and submitted by HMO IPAs:
- The IPAs are required to submit supporting documentation.  BCBSIL nurses review the submissions and verify their accuracy.
- These data are maintained in project-specific databases that are used to report IPA performance.
- IPA encounter data are separately maintained by a vendor and must be separately accessed.  In the future, the data will be incorporated into EDW.
- Other types of quality improvement data are analyzed, reported and stored in separate databases.  Examples include:
- Survey data
- Inquiry and complaint data
- Provider-reported data
- Publicly available data

## Aggregation of Data for Reporting

**Aggregation of data:  HMO**
- Results are separately reported to IPAs for each type of data (childhood immunization, breast cancer screening, asthma, diabetes, member survey, etc.)  For the clinical indicators, IPAs receive feedback at the member level as well as at the group level.  Results are used for IPA performance-based compensation.
- Results of the individual IPA reports are summarized for public reporting in the Blue Star Medical Group/IPA report (clinical programs) and the Blue Ribbon report (member satisfaction).
**Aggregation of data:  PPO physician/physician group**
- Results for clinical quality indicators, cost efficiency, and administrative efficiency are compiled into a single report with an overall score.
**Aggregation of data:  Hospitals**
- Results of multiple indicators (structure, process, outcome, member survey, efficiency) from multiple data sources (BCBSIL data, provider-reported data, member survey, publicly available data) are aggregated into hospital-specific Profiles with an overall score.
- Many hospitals have compensation tied to the annual BCBSIL Hospital Profile score or Profile-related indicators.
- BCBSIL Hospital Profile results are summarized for public reporting in the Blue Star Hospital report.

## Data Aggregation

**Business functions** supported by data aggregation include:
- Provider feedback
- Quality improvement
- Transparency / public reporting
- Pay-for-performance
- Network creation
- Disease management
- HEDIS reporting
**Financial model**
- The cost of data aggregation is an administrative expense for BCBSIL.
**Database hosting:  **
- Some databases are internally created and maintained.
- Some databases use vendor software, but are loaded and used by BCBSIL staff.
- Some databases are created and maintained by vendors but are queried by BCBSIL staff.
- Some databases are created and used by the vendor, with reporting to BCBSIL.

## Hybrid Reporting

**Current hybrid indicators**
- HEDIS indicators that permit hybrid reporting
- HMO IPA clinical indicators
- BCBSIL encourages IPAs to start with claims data and then review medical records for additional information if there is no numerator event in the administrative data.
- Reporting to PPO physicians/physician groups combines multiple types of data (quality indicators, costefficiency based upon episodes of care and administrative efficiency) although the data source for all indicators is claims data.
- BCBSIL Hospital Profile combines data from multiple data sources.
**Future hybrid indicators**
- BCBSIL is working with a vendor on a web-based application, targeted for implementation during 2007, that will allow PPO physicians to supplement claims data with medical record data.  The indicators will initially be run using claims data, then physicians will have the opportunity to review the preliminary member-specific results and enter additional details that are not available from claims for members who do not meet numerator criteria.  Examples include past medical history of hysterectomy (exclusion for cervical cancer screening), drug allergies (exclusion for use of first-line antibiotics for children with acute otitis media) and childhood immunizations given at a public health clinic or under the Vaccines for Children program (childhood immunization rate).

## Hybrid Reporting:  Issues

- When a data element is available from more than one source:
- The more authoritative source is used
- Example:  While hospitals self-report their accreditation status, JCAHO and HFAP websites are used as the authoritative data sources.  If there is a discrepancy between the self-report and the authoritative source, the accrediting entity is contacted for clarification.
- Once a numerator event or an exclusion has been documented, the record is considered to be closed, and no additional information is sought.  This approach favors the provider being assessed.
- Desired data not currently available
- Laboratory results
- Pharmacy data from some external pharmacy benefit managers

## Episodes of Care

- Episodes of care (MEGs) are reported using commercially available vendor software that also incorporates risk adjustment.
- The claims and pharmacy data in EDW is used as the data source for building episodes.
- Ambulatory pharmacy data is available and included in reporting for some applications, such as employer-specific reporting.  However, since pharmacy data are not available for all members, pharmacy claims are not included in the episodes of care for quality improvement applications such as physician profiling.
- Laboratory results and electronic health record data are not currently available for inclusion in reporting episodes of care.

## Barriers

- Data sources such as EDW, the data warehouse, are used for diverse internal functions.  The size and the complexity of the database mean that there is limited ability to add new data elements, such as laboratory results.
- For HMO, capitated IPAs pay their own professional claims.  Obtaining complete encounter data from approximately eighty groups and having it compiled into one consistent format to make it usable has been a challenging process.
- The breadth of claims data allow relatively easy assessment of quality indicators for an entire population of members and providers.  However, claims data cannot have the depth of information available in the medical record.
- While supplementing claims data with provider-reported medical records data has the potential to improve the completeness of data, it may be challenging to achieve accurate provider data entry.
- Preventive care poses a significant challenge in cost efficiency reporting for physicians.  For primary care physicians, preventive care is one of the highest volume episode types, making it desirable for inclusion in reporting.  However, those physicians providing recommended preventive services will tend to appear more expensive than physicians who fail to provide recommended services.

## Lessons Learned

- Allow time for verifying the accuracy of data and data aggregation.  Use both standard queries and tests of reasonableness (is the rate for this indicator believable, given prior results, national comparisons and the results of similar indicators?)
- Listen to provider feedback and use it to improve quality indicator reporting.  Many of the issues that providers raise are valid and their suggestions may improve the indicators and/or the reporting process.
- Several cycles of confidential reporting of quality indicator results prior to public reporting allows providers to address deficiencies and to raise valid concerns about the methodology.   This may reduce barriers to public reporting.