The Department of Health Care Services (DHCS) is working to advance the ability of program areas to exchange health information with trading partners throughout the state.
As the largest health care purchaser in the state, DHCS primarily collects administrative data on claims and encounters, Member eligibility, and providers – all of which is used for payment and Medi-Cal operations. This data provides a point-in-time reference but has limited clinical value and does not support a modular, integrated system. Clinical data, on the other hand, provides a more complete view of a Member’s medical history and fills in the gaps left by administrative data. With the health care delivery system shifting from one based on volume of services to one based on value, Medicaid programs across the country are leveraging clinical data to develop new reimbursement strategies and outcome-based assessments.
The use of clinical data by the Department is a critical component for improving the quality, efficiency, and cost-effectiveness of care delivered to Medi-Cal members. Merging clinical data with administrative data will allow DHCS to do the following:
Meet federal goals for program improvement and delivery system redesign (e.g., Medicaid Information Technology Architecture [MITA] and the Medi-Cal 2020 Waiver).
Improve care for members through care coordination, case management, and quality monitoring.
Help advance interoperability and health information exchange (HIE) across the health care ecosystem
Since 2013 the Department has been developing a strategy to incorporate clinical data into the Medi-Cal enterprise and participate in the electronic exchange of health information. This strategy, which aligns with California Health and Human Services Agency (CHHS) goals, includes sending and receiving data from electronic health records (EHRs) and HIE organizations, providing data to Members, and exchanging data with state and county departments to support Members.
The Superior Systems Waiver (SSW) allows the Clinical Assurance and Administrative Support Division (CAASD) to provide oversight of the utilization of Medi-Cal services in a post-payment setting that does not require a Treatment Authorization Request (TAR) for specific types of service. These TAR-Free programs rely on Program staff being granted virtual access into a hospital EHR system to review medical records for specific cases. There are currently over 75 hospitals participating in one of the TAR-Free programs, but there are more than 300 hospitals in California. To further expand the TAR-Free programs, CAASD must find an alternate means of obtaining hospital clinical data.
The DHCS Office of HIPAA Compliance (OHC) is working with CAASD to implement a more viable clinical data access solution. The proposed solution includes a system that receives data electronically from hospitals, validates and stores the data, and makes it available for Program staff to perform case reviews. The primary benefit to hospitals will be less manual intervention to send data and a reduction in Medi-Cal billing cycle time. For the Department, the benefit is a secure, scalable solution to support expanding the TAR-Free programs and improved case review productivity.
By having access to and using clinical data, DHCS will also able to advance its MITA maturity by increasing the efficiency and effectiveness of decision-making.
The proposed approach is to utilize national standards for data structure and exchange, while also leveraging the existing HIE infrastructure and minimizing the impact to participating providers. California follows a community-oriented, decentralized approach to data sharing based on existing organizations and networks. Many hospitals, health systems, and providers are already connected to a local or regional HIE organization, which support community-based data sharing throughout California. These organizations are in turn connected via the California Trusted Exchange Network (CTEN) to form a statewide HIE network.
To facilitate data collection, the Department will leverage the CTEN to connect with the various community HIEs and large hospital systems. Trust and governance of exchange will be managed through the California Data Use and Reciprocal Support Agreement (CalDURSA), the entry point for participation on CTEN. Clinical data will be pulled from hospital EHR systems using query-based exchange specifications and standard Consolidated Clinical Data Architecture (C-CDA) documents.
More information will be provided on the transition to this new method of clinical data collection as details become available. In the meantime, hospitals are encouraged to begin working with their community HIE, or to join a community HIE, in advance of any future transition. The California Association of Health Information Exchanges (CAHIE) has up-to-date information about HIE in California.
The availability and use of clinical and post-adjudicated claims data is necessary to support the Triple Aim of improved patient care and population health at a lower cost. In the future, clinical data can be used by DHCS in the following ways:
Following successful implementation of a solution to support the TAR-Free Programs, the Department will evaluate additional projects to leverage the investment to support other uses of clinical data throughout the department. Possible future phases include the following: