Bronx Health Access: IT Requirements Gathering IT REQUIREMENTS GATHERING 1

Electronic Medical Record (EMR) An EMR is a digital version of a paper chart in a clinician's office. It contains the medical and treatment history of the patients in one practice. Health Information Exchange (HIE) Health information exchange (HIE) is the movement of healthcare information across a number of organizations electronically. Centralized Analytics Centralized Analytics involves the collection of data from disparate sources, which is used to discover meaningful patterns in patient populations. Care Coordination Platform A Care Coordination platform contains a centralized care plan shared amongst all members of the care team. Overview of IT Platforms 2

Electronic Medical Record (EMR) DSRIP Goal Participating providers will meet Meaningful Use and PCMH Level 3 standards by the end of DY 3. Participating providers include PCPs, Specialists, BH, SNF, and Hospitals. IT Committee Create a menu of EMR recommendations for PPS members that are selecting an EMR. Note: In order to achieve MU and PCMH, organizations must use an EMR. Project Workgroup Requirements for IT Ability to capture ‘structured’ data Ability to ‘talk’ to other EMR’s Clinical Reporting and Registries capabilities Patient Portal Meaningful Use Eligible EMR Other Functionality? 3

Health Information Exchange Labs Medication Direct Messaging Health Information Exchange 4

Health Information Exchange (HIE) DSRIP Goal PPS members will exchange data between organizations to meet DSRIP clinical outcomes. This will enable disparate EMR’s and other systems to ‘talk’ to each other. IT Committee Determine which interfaces and data feeds the HIE must develop between organizations within the PPS. Project Workgroup Requirements for IT Encounter Level Data Procedures Consent Demographics (ADT) Laboratory Text Reports Medications Diagnoses Messages between providers (Direct) Referral tracking and automated alerts CCD Summary of Care Care Coordination Data 5

Health Information Exchange HIE Data PPS Reports Claims Data CAHPS Data Central Database/ Data Warehouse Centralized Analytics for DSRIP* 6 *Note: This does not include reporting or analytics contained in an EMR or Care Coordination Platform. It’s strictly for centralized reporting (i.e. a system that is outside of a clinicians typical workflow)

Centralized Analytics DSRIP Goal PPS members will have the ability to report on all required data sources. Note: A data source can be from a computer program, website, or spreadsheet. IT Committee What sources of data are needed by the Clinical Projects for reporting? Project Workgroup Requirements for IT Claims Data Immunizations CAHPS Data HMO data All data exchanged through the HIE (See slide 5 for list of data) Other Sources? 7

Centralized Analytics DSRIP Goal PPS members will have the ability to run reports from the analytics platform. IT Committee Create reports needed for the PPS. Project Workgroup Requirements for IT Clinical Performance Metrics outlined in Attachment J Risk Stratification and patient registry reports Project specific requirements? 8

Immediate Data Needs ACTIVELY ENGAGED PATIENTS 9

Immediate Data Needs: Collecting Actively Engaged Patient Data ProjectActively Engaged Criteria 2.a.i Patients residing in counties served by the PPS having completed a RHIO Consent Form (including agreeing or denying consent). 2.a.iiiNumber of participating patients who completed a comprehensive care management plan. 2.b.iNumber of participating patients who had two or more distinct services at an Ambulatory ICU in a year. 2.b.iv Number of participating patients with a care transition plan developed prior to discharge who are not readmitted within that 30-day period. 3.a.i Total number of patients engaged per each of the three models in this project, including: Model 1: PCMH Service Site: Number of patients screened (PHQ-9 / SBIRT) Model 3: IMPACT: Number of patients screened (PHQ-9 / SBIRT) 3.c.iNumber of participating patients with at least one hemoglobin A1c test within previous Demonstration Year (DY). 3.d.iiNumber of participating patients based on home assessment log, patient registry, or other IT platform. 3.f.iNumber of expecting mothers and mothers participating in this program. 10

Example- Actively Engaged Criteria: 2.a.iii Actively Engaged Criteria: Number of participating patients who completed a comprehensive care management plan. Considerations: 1.What is a comprehensive care management plan? ◦Which fields are needed to complete a care management plan? 2.What is a participating patient? ◦What is the threshold assessment score to enroll the patients into the program? 3.What fields are needed to audit? ◦The creation date of the comprehensive care management plan to ensure it was created in a certain timeframe. 4.What system are these fields stored in? ◦EMR, Care Coordination Platform, etc. End Goal- Example template: Medicaid ID Number Patient NameDOB Assessment Score (Over 7) Self- Management Goal (Y/N) Link to community resources? (Y/N) Encounter method (i.e. Phone, Face to Face, etc.) Medication Reconciliation Nutritional Needs met 11

Next Steps for Project Workgroups 1.Determine if there are additional IT Requirements for: 1.Electronic Medical Records: ◦Review the information and functionality the project workgroup needs in an EMR. ◦Reference the list of EMR functionality on slide 3. If you are unsure the functionality is already listed, follow-up Harbage. 2.Health Information Exchange: ◦Review the fields and data the project needs to exchange from clinician to clinician ◦Reference the list of data in slide 5. If you are unsure if a specific field will be exchanged, follow-up Harbage. 3.Centralized Analytics*: ◦Review the sources of data and reports the project workgroup needs to exchange. ◦Reference the sources of data and reports in slides 7 and 8. If there are additions, follow-up Harbage. 2.Immediate Data Needs: “Actively Engaged” Patients 1.Define specific criteria for an “Actively Engaged” patient 2.Create template with necessary fields need to assess if a patient is “Actively Engaged” for the project 3.Note: This are not the projects reporting requirements. This will only be used to meet DY1Q2 DOH Implementation Plan reporting requirements 12 *This does not include reporting or analytics contained in an EMR or Care Coordination Platform. It’s strictly for centralized reporting (i.e. a system that is outside of a clinicians typical workflow)

Questions and Follow-up? Steve Maggio ◦Phone: ◦ Gerardo Escalera ◦Phone: ◦ 13