Project Development and Implementation Committee meets the Bronx Lebanon PPS IT Committee Robert H. Leviton MD MPH FACEP CMIO – Physician Advisor Bronx Lebanon Hospital Center Bronx, NY

What we’ve been up to… Reviewed the Bronx Lebanon PPS DSRIP application and detailed review of projects Completed BL PPS IT Review of 213 member partners Created, distributed, scored a Health Information Exchange Request for Information Reviewed HIE RFI, hosted Vendor Demonstration Day Evaluated Vendor Surveys by participants Created BL PPS IT Infrastructure Analysis Submitted budget suggestions for Capital Grant 2/20/20152

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OUR IT MATURITY Insights from Preliminary IT Assessment 2/20/20154

Surveys sent to 213 member partners Three s, 2-Robo calls 93 responded 2/20/20155

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VENDOR SELECTION Identifying our technology partners for HIE, Data Analytics and Care Coordination platforms 2/20/201511

Vendor Selection Process and Overview A comprehensive RFI was developed based on our IT requirements 6 vendors were selected to complete an RFI The 3 highest scoring vendors & BronxRHIO were invited to present to a community provider stakeholder group Results from the community provider evaluations will inform further vendor selection by the IT and Steering committee 2/20/201512

Vendor RFI Grading Tool 2/20/201513

Vendor RFI Scores 2/20/201514

UNDERSTANDING DSRIP IT REQUIREMENTS AND BRONX LEBANON PROPOSED CENTRALIZED IT SERVICES 2/20/201515

IT and DSRIP What is the IT expectation for DSRIP on an organizational level? – Incremental adoption of IT capabilities – not just for meaningful use eligible providers – DSRIP seeks to create a more integrated, coordinated care model that links providers across the continuum of care – Bridging gaps in communication, handoffs, timeliness of information sharing and enabling real-time decision support 2/20/201516

Functional IT Objectives ▶ Deliver functionality to support transitions of care ▶ Provide comprehensive population and patient level analytics ▶ Enhance IT interoperability ▶ Support the capture and management of DSRIP project goals and partner performance ▶ Increase patient and caregiver activation ▶ Support care coordination and management 2/20/201517

Critical Areas of Focus ▶ Bidirectional data sharing ▶ Analytics ▶ Data Warehousing ▶ HIE connectivity ▶ Automated alerts and secure messaging ▶ PCMH and MU ▶ Provider performance management ▶ Patient reconciliation and tracking 2/20/201518

Core Capabilities for Partners The participants in the PPS require the following capabilities for the PPS to accomplish objectives (Domain 1 metrics & milestones): Clinical Organizations (PCPs, specialists, BH, SNF, hospitals) – EMRs to document – Bi-Directional Interoperability – Ability to send/receive/manage referrals – Access to common care management data and care plans, etc. Community Based Organizations – Access to information (portal) – Ability to send and receive referrals – Document social services and behavioral health support – Access to common care management/portal (core data elements and alerts) 2/20/201519

Centralized Services – DSRIP Enablers PPS centralized IT services will increase PPS DSRIP performance, minimizing partner risk associated with IT requirements Proposed centralized services provide the platform for partners to engage on a level-footing and diminish variability in execution and performance Centralized services will leverage state-managed solutions and technology (e.g. SHIN-NY, DSRIP reporting, analytics), RHIO infrastructure, while selectively supplementing these solutions to bridge gaps and increase confidence in DSRIP performance Centralized services fulfill the DSRIP requirements for 2.a.i and the upfront investment increases our ability to ensure timely completion of metrics & milestones defined within scale and speed 2/20/201520

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Centralized Population Health Management Services (BL will deploy and centrally manage) RHIO Integration/HIE and Bi-Directional Services Data Warehouse with predictive analytic & modeling capabilities Care Management, Care Coordination Platform & Secure Messaging Quality Dashboards & DSRIP Reporting (in alignment with State/SHIN-NY proposed capabilities) Customer Relation Management Service Call Center and Warm-line (?) BL PPS User & Member Portal (?) 2/20/201522

RHIO /HIE Integration and Bi-Directional Communication Information sharing and data harmonization amongst the partners via RHIO/other connecting technology Common guidelines, checklists, alerts integrated into EMRs Transition planning checklists Evidence based practice guidelines and alerts (i.e. antibiotic prescribing) Care gap alerts Bi-directional communication between all BL PPS providers and CBOs with the HIE 2/20/201523

RHIO / HIE Integration – Provider Value Single online resource for patient information from multiple sources consolidated into a longitudinal record for each patient Makes critical information available so providers can more effectively care for their patients Saves time chasing down reports, faxing, and manually logging into multiple portals Reduces unnecessary procedures and tests; reduces time spent gathering history from patients 2/20/201524

Data Warehouse with Predictive Analytic & Modeling Capabilities Focus on Medicaid and uninsured clinical and claims/administrative data Risk stratification Modeling for eligibility for high risk, chronic care, other care management Pharmacy medication reconciliation/management Disease Registry Functionality and BL PPS required data reporting Targeted tracking and management of chronic conditions such as diabetes 2/20/201525

Warehouse / Analytics – Provider Value Enables provider organizations to analyze and track the health of the populations they serve, and to implement interventions on specific cohorts of patients Supports transition from fee-for-service approach to proactive, preventive care and value-based payment models Supports reductions in avoidable hospital admissions Dashboards to track progress toward DSRIP goals Reporting capability to support the requirements described by each project Clinical decision support 2/20/201526

Care Management and Care Coordination Platform Our goal seeks to focus on the coordination between clinical and care navigator Manage the same cohort of patients between the clinical and care coordinator in a manner to assure the continuity of care Bring the tools that are on the clinical side with the Care Coordinator to assure a better view of the patient’s condition By creating robust analytics, and metrics for reporting and improvement Provide the ability to create their own dashboards – Homeless patients with diabetes with behavioral health issue – Homeless patients in shelters, SRO’s, Transitional Bed, Coach Surfing – Homeless patients in hospitals or emergency departments The goal is to provide the best tools to assure the patient’s care coordination requirements are continuously met 2/20/201527

Care Management and Care Coordination Platform Provider messaging and alerts – Provider to provider secure messaging – Distribution of discharge plans to step-down level of care and PCP – ED to clinic/PCP messaging and alerts – Inpatient admission to clinic/PCP messaging and alerts Secure messaging and e-referral with standardized guidelines – Enable e-authorization Care Management and Care Navigation/Enrollment – Standardized care management processes, protocols, templates and tools specific to Medicaid members and uninsured – Chronic disease, high risk and mental health care management – Centralized outsourced navigation services, including and enrollment processes, protocols, templates, tools and training – Health Risk Assessments, Interventions, Goals, and Care Plan development Upon attaining Risk Contracting relationships – Provide cohort information – Report on payers and services within provider networks 2/20/201528

Care Management – Provider Value Coordinate care for high-risk patients / patients with chronic conditions Shared planning among care teams from multiple provider organizations and CBOs Improved clinical outcomes through proactive care approaches 2/20/201529

Call Center Centralized Call Center for Providers Centralized Warm-line for Patients – Links patient to the right care at the right time PPS Resource Directory & Navigation Assistance for CBO, community services, medical care referrals Health coverage and special programs, eligibility support, pre-authorization, and referrals 2/20/201530

VENDOR PRESENTATIONS & GRADING End user feedback – community provider vendor evaluation 2/20/201531

Vendor Presentation Objectives & Assessment Criteria Vendors have been asked to present and demonstrate functionality with end-users in mind. Today is not about solving technical and interoperability challenges. Seven areas of focus: 1.Analytics 2.Care Coordination and Management 3.Clinical Decision Support Tools 4.Data Capture and Access 5.Data Management and Governance 6.Measurement and Reporting Requirements 7.Patient Activation Additional Requested Information: 1.Be prepared to describe how you will integrate your solution with other vendors and the BronxRHIO 2.Provide a profile of your markets, clients, and population 3.Describe if you are affiliated with any DSRIP, and / or have implemented your solution in New York 4.Provide References that are aligned with our population and similar experiences 2/20/201532

Scorecard & Evaluation Rank vendor demonstrations and responses for each area of focus on a scale of 1-5 – 1 being inadequate or poor response – 5 being best-in-show or excellent response For eCW, Allscripts and Medicity – How does the response or service for any given area of focus compare to that of the BronxRHIO Vendor Evaluation – One of several components in the vendor selection process – End-user feedback will inform final selection process guided by IT and Steering committee 2/20/201533

Vendor Evaluation Scorecard 2/20/201534

Summary of Vendor Evaluations 2/20/201535

SAMPLE HIE AND ANALYTICS TOOLS 2/20/201536

Sample Tools Following samples provide examples of analytic and reporting tools Tools are designed to provide clinical perspectives at four levels: – PPS Governance – Provider Entity (organization) – Individual Provider or Practitioner – Patient 2/20/201537

Potential HIE Solutions Sample Portal 2/20/201538

Potential HIE Solution Care Coordination 2/20/201539

Potential Quality Dashboard Clinical Quality Performance Analysis 2/20/201540

Potential Quality Dashboard Detailed View (Drill down) 2/20/201541

Potential Patient Cohort Module (Quality Measures) 2/20/201542

Potential Quality Measures (Drill down: Readmissions Analysis) 2/20/201543

Further Drill Down (Sample) Readmissions 2/20/201544

Patient Level Details Readmissions 2/20/201545

Potential Patient Utilization Metrics (Spend analysis by patient) 2/20/201546

Spend Analyses by Key Services 2/20/201547

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