External Data Acquisition

©️ 2024 Kaiser Foundation Health Plan, Inc.

This resource is part of the Data Quality & Reporting Implementation Guide, offering steps and activities to ensure your practice is capable of reporting valid and reliable data for selected population health measures. It is the first in the “Building the Foundation” series of implementation guides.

PHMI/HEDIS measures often rely on external data or data that reflects care or services received outside of the community health center (CHC). This may include:

• Outside laboratory tests.
• Screenings.
• Follow-up visits from a specialist (e.g., OB-GYN, endocrinologist, or behavioral health).
• Hospital data (e.g., admission, discharge, and transfer data).
• Primary care rendered in other settings (e.g., urgent care center or at a different primary care provider’s office).
• Race and ethnicity data from the managed care plan (MCP).

To accurately report core HEDIS measures for PHMI, CHCs will need access to these types of data and processes to ensure the data are properly stored within the electronic health record (EHR) and accessible to data analytic platforms. This could include coordinating with external clinicians to ensure ongoing communication and feedback or connecting to the data via a third party, such as health information exchange (HIE) or managed care plan (MCP).

This document identifies potential external clinical data sources needed for accurate PHMI/HEDIS measurement and provides resources to inform processes for connecting with and utilizing external data.

Assessing the current state of data connection and identifying gaps will assist CHCs in determining data needed. CHCs will establish a process for obtaining and analyzing data in ways that can be utilized for PHMI/HEDIS measurement and monitoring patient care.

Working with their practice coaches and subject matter experts (SMEs), CHCs should follow a process to identify relevant data related to patient care received outside of the clinic. This process can be tailored for each CHC based on their specific circumstances such as relationships with regional area consortia (RACs), HIE use, and MCP connections.

Step 1: Review metrics and identify where external data are needed.

CHCs should review the data components needed for each metric (as provided in Figure 6.2: Components of Core HEDIS Measures for PHMI Potentially Obtained from External Sources) and assess whether they have consistent and ongoing access to data from external sources. Figure 6.2 includes external data that may be relevant for patients seen in the clinic but who have been referred out for specialty care, or for labs or pharmacy, as well as data related to patients who have not been seen in the clinic but are attributed to the clinic by the MCP.

The CHC should ensure they have access to all types of external data and that the data are stored in the EHR in ways that are accessible to data analytic platforms used for reporting. For example, if screening results are received from a specialist, but these results are attached via a PDF document and not incorporated into standard data fields, the CHC will struggle to easily report its measures without significant manual work and/ or the data will be a false representation of actual measure performance.

The process for assessing access to data for Step 1 includes: 

• Align with work conducted under Data Quality and Reporting Resource 4: Standard Data Fields for HEDIS Measures to better understand access to standard data in the EHR and to help identify where there may be gaps in external data or its storage.
• Assess access to lab, pharmacy and specialist data. CHCs should assess whether it has processes for the receipt and ingestion of lab, pharmacy and specialist data when patients are referred to outside care or services.
• Assess access to rosters for patients attributed to the health center. CHCs should also consider whether they have processes to analyze MCP attribution rosters to identify patients who are attributed but may not be accessing care within the health center. The CHC should assess whether it is using these rosters for processes including:
  • Initiating outreach and engagement to these patients.
  • Initiating patient reassignment to other health centers as needed.
• Assess access to care data for attributed patients not seen in the health center. Attributed patients who have not been seen in the health center may be receiving services in other locations. CHCs should consider whether they have processes to access care data for this patient population, including whether or where they are receiving care. These data will help inform needed outreach to and engagement with the patient, as well as whether reassignment may be warranted.
• Assess access to race and ethnicity data. MCPs are valuable sources of patient data, including race and ethnicity. CHCs should assess whether they have significant gaps in race and ethnicity data for patients in the EHR and if they are capturing and ingesting this information from MCPs. These data will be critical to calculating measures by sub-population to identify and address disparities in care.
• Assess access to aggregate sources of external data. CHCs should consider whether they are connected to and can access external platforms with aggregated care information (e.g., MCPs, HIEs), which limit the need for connections with individual sources of data (e.g., needing connections in place with each specialist to which the CHC refers).

Step 2: Where gaps in external data are identified, determine external data to acquire.

CHCs should consider which source of external data would be most beneficial to capture needed data. For example, services received from a specialist could be obtained directly from the specialist, through claims received by the MCP or through an HIE. The CHC should assess the best sources to address its current gaps and consider factors such as the timeliness of data (e.g., real-time vs. claims lag) and ease of connection to and ingestion of data from the source.

Step 3: For each type of external data acquired, assess the process for data submission, mapping and storage in the patient’s medical record.

For each type of external data, consider the interoperability function from each outside source versus the manual effort needed to access the data. Interoperability requires multiple stages: sending, receiving, finding and eventually using the data. A successful process and data capture approach for each external data source will require timelines, specific metric extractions, standard data fields, and related policies and procedures. Key considerations include how often data are needed, in what format and how granular the data needs to be. The format in which data is received drives how it can be displayed, aggregated or reported. As a best practice, CHCs should map data elements to standard data fields to ensure their ability to report measures without relying on manual extraction. Data mapping requires an understanding of the EHR’s current and future capacity in order to map potential gaps and determine opportunities for additional efficiencies through technological interfaces.

Step 4: Identify gaps and plan data acquisition strategy.

Based on the gaps identified, CHCs will work with their practice coaches/SMEs to develop action plans to remediate gaps and establish ongoing processes. This action plan could include:

1. A process for reviewing and connecting to each selected external data source. The process will be dependent on the type of external data sought.
2. Timelines and sequencing of acquiring different sources of external data.
3. Developing policies, procedures and staff training related to the acquisition, ongoing ingestion and oversight of external data.
   1. Developing business associate agreements (BAAs), care compacts, memorandums of understanding (MOUs), etc. as needed.
4. Ensure ongoing sustainability with annual assessment and review of:
   1. Remaining external data gaps and plans to address.
   2. Quality assurance processes for obtained external data.

 

CHCs should consider a variety of external data sources that could provide information related to care for patients. Types of external data sources are listed in Figure 6.1.

FIGURE 6.1: TYPES OF EXTERNAL DATA SOURCES

Figure 6.2 below identifies components of each core HEDIS measure for PHMI and the types of external sources that may contain the data. As the table shows, aggregate sources of data provide a larger cross-section of needed data components. However, individual sources of data are also important and may be the most efficient way to connect to data that requires frequent and timely connection points (such as high-volume labs and specialists).

FIGURE 6.2: COMPONENTS OF CORE HEDIS MEASURES FOR PHMI POTENTIALLY OBTAINED FROM EXTERNAL SOURCES

Processes for connecting with and utilizing external data will vary depending on the source. In each case, the CHC should assess the current state of data connection and identify the gaps and develop a process for timely acquisition

CALIFORNIA’S DATA EXCHANGE FRAMEWORK

In developing processes, CHCs should consider the California Health & Human Services Data Exchange Framework and leverage the data exchange standards as applicable to ensure compliance with regulatory requirements that will begin in 2024.

The key data exchange framework principles to apply are:

• Establish clear and transparent terms and conditions for data collection, exchange and use.
• Adhere to federal, state and industry-recognized data exchange standards, policies, best practices and procedures.
• Ensure accountability of all entities participating in the collection, exchange and use of the data.

Below are considerations by data source to assist CHCs in determining data needed and to establish a process for obtaining and analyzing data to measure PHMI/HEDIS and monitor patient care.

Lab, Pharmacy and Diagnostic Imaging Data

Assessment of current state and identification of gaps: To assess and improve connections to laboratory, pharmacy or diagnostic imaging data, CHCs should focus on organizations that provide a high volume of services to their patient population and its current connections to these data. CHCs should assess policies that govern their connection to these organizations, including whether they include critical factors such as:

• Unique patient identifiers to ensure the data returned are accurate, timely secure, confidentially handled and accessible.
• Frequency of data batching.
• Processes to address data retrieval from the organization and integrity management.
• Storage in the EHR.
• Identified process owners.

Typical gaps in these data are caused by lack of compliance to the International Organization for Standardization (ISO) standards, including insufficient patient identifiers, transmission errors, computer systems and platform errors, or incomplete data that was not responded to in a timely manner.

Process for timely acquisition going forward: Working with high-volume organizations and ensuring cycles of data delivery are synchronized with PHMI reporting needs is a best practice. The development of policies, procedures and standard trainings should include the following:

• How the data are interfaced.
• Defined frequency of data delivery.
• Data accuracy and flow standards.
• Expected interface with the EHR.
• Location of data.
• Backup of interface systems.
• Transmission error mitigation strategies.

If a manual or paper system is used, the training should include processes associated with duplicate copies and define the storage of records. The training should also address how to evaluate occurrences or variations from the standard practice.^[1]

Specialist or Other Primary Care Data

Assessment of current state and identification of gaps: To assess and improve connections to other clinicians of care, CHCs should determine:

1. Current state of referral processes.
2. Existence of care agreements with high-volume referral clinicians.
3. Whether current policies define expectations for closed loop referral processes (e.g., timeliness expectations, cycle of data return).
4. Current policies for interfacing, storage instructions and location once data are returned.

Process for timely acquisition going forward: CHCs should focus first on high-volume referral partners. It is best practice to implement care compacts or MOUs that would include standards for:

• Timeliness of information.
• Data elements needed (e.g., referral date, referral specialty, specialist appointment date and completion status, care plan).
• Identified process owner.
• Interface protocol.
• Elements needed for HEDIS compliance such as:
  • Problem list.
  • Medication list.
  • Procedures.
  • Vital signs.
  • Vaccinations, if applicable.
  • Lab results.
  • Clinical tests.
  • Diagnostic imaging.
  • Care plan.
  • Referrals.
  • Appointments.

CDPH/CAIR Data

Assessment of current state and identification of gaps: To assess and improve access to the California Immunization Registry (CAIR), CHCs should begin by understanding the current connection with their systems, any related policies and procedures, and the CHC’s internal process owner. CHCs should consider the typical turnaround cycles to receive this information, ability to accurately match patients (e.g., when there are demographic discrepancies or missing middle initials), and any data transfer or missing data issues.

Process for timely acquisition going forward: CHCs who need to connect (or reconnect) to CAIR should access the website for complete information and tools for connecting, as well as access to the CAIR 2 secure file access request form.^[2] If data issues were identified, CHCs should consider developing an action plan to resolve them.

Best practice processes include:

• Checking CAIR during each preventive care visit to assess the need for immunization(s).
• Checking CAIR at episodic visits.
• Entering any CHC immunization data that are not in CAIR (i.e., reconciling and ensuring accuracy of CAIR).

MCP Data

Connection to MCP data will be one of the most critical external data sources to ensure a population health approach to care.

Assessment of current state and identification of gaps: To measure and monitor care for the entire attributed population, CHCs need to consistently access and ingest their attributed patient rosters from MCPs, including race and ethnicity data. Additionally, CHCs should use MCP pay-for-performance (P4P) reports and other quality oversight or gap reports to understand care received by patients who are, and are not, accessing care at the CHC.

CHCs should begin by understanding the following:

• Current access to and ingestion of attributed patient roster and care data, if any.
• Related policies and procedures.
• Identified process owner.
• Cycles for ingestion.
• Where data are stored.
• Oversight to ensure accurate ingestion.

CHCs should understand which tools and processes are available from each MCP to oversee and understand care provided/care gaps related to each core measure. For attributed patients who have not been seen at the CHC, any follow-up processes to obtain additional data on these patients from other sources (e.g., HIE data) should be considered, as well as whether the patient should be reattributed based on another known place of care. Process for timely acquisition going forward: In addition to ensuring accuracy, the CHC will need to utilize the data and MCP tools to identify gaps in care and develop outreach approaches that address those gaps. Best practices may include:

• Reviewing care gaps and ensuring data submission when a gap is closed for the patient.
• Requesting data from the MCP when a patient is identified as completing a care gap by the MCP, but the CHC does not have a record of that service being completed.

HIE Data

Assessment of current state and identification of gaps: CHCs should identify which, if any, HIE they are connected to, how that connection is accessed, whether it feeds into the EHR, and whether there are data quality issues with the HIE. CHCs should consider whether their current policies and procedures, if any, for accessing HIE data are capturing and ingesting in actionable ways the external data needed for reporting core HEDIS measures for PHMI.

Process for timely acquisition going forward: CHCs with HIE connections that do not meet the needs for external data acquisition for the PHMI core measures should work to address current gaps with the HIE and internally (e.g., through policies, procedures and staff training). For CHCs not connected to an HIE, the regional HIE landscape^[3] can be assessed to determine potential opportunities. CHCs should utilize Table 2: Components of PHMI Core Measures Potentially Obtained from External Sources to identify components of PHMI core measures that could be obtained from external sources. The CHC can assess whether HIE access would alleviate gaps with access to real-time, actionable data.