Population Management David Dorr, MD, MS, FACMI Professor and Vice Chair, Informatics and Internal Medicine, OHSU

The Mission of Care Management Plus is to better understand how data, information, and knowledge can assist in transforming health for our most vulnerable patient populations. Identifying vulnerable people Risk stratification and segmentation Tailoring care to these needs Improving outcomes

Major topics … What is population health and its relationship to informatics? What are initiatives for population health? From a policy perspective, one entirely primary care focused : Comprehensive Primary Care Plus; others include Accountable Care Organizations, payment reforms away from volume to value What are transformation needs ? And What are informatics needs?

Population health Determined by Environment > Lifestyle / behaviors > Genetics ~ Medical care Public health – all of society, vs. a defined population Management – how can health care assist in maximizing the health of a population Payment changes Quality improvement Data-driven elements

CPC+ Overview National advanced primary care medical home model Aim: strengthen primary care through regionally-based multi-payer payment reform, and care delivery transformation 2 tracks 14 regions, 2688 practices 5 years

Policy: Significant payment changes Dave (PBPM) (PBPM)

Medicare SSP* Participation Organizational Structure CPC+ Oregon Region Payer Partners AllCare Health, Inc. ATRIO Health Plans CareOregon Eastern Oregon Coordinated Care Organization (EOCCO) FamilyCare Health Oregon Health Authority (Medicaid) Moda Health Plan PacificSource PrimaryHealth of Josephine County Providence Health Plan (PHP); Providence Health Assurance (PHA) Tuality Health Alliance (THA) Umpqua Health Western Oregon Advanced Health, LLC Willamette Valley Community Health Yamhill Community Care Organization, Inc. 156 Practices 15% 46 independent practices 30 rural practices 23 small practices 100,549 Medicare FFS beneficiaries served Total Number of Practices Starting in 2017 Medicare SSP* Participation 23 practices in existing Medicare SSP ACOs** Organizational Structure Track Breakdown 234 applied *Shared Savings Program (SSP) **Accountable Care Organizations (ACOs) Practice information current as of January 2017. Subject to change.

CPC+ HIT needs Risk stratification Segmentation Tailoring care Care Plans Incorporating social needs / determinants Quality metrics Alternative visits (e-Visits) Population health

Prediction of at risk, vulnerable populations Definition (e.g.) Highest Multiple Social, Behavioral, Mental, and Chronic issues High Severe/ uncontrolled illness or multiple controlled issues Moderate Controlled, stable issues Low Preventive needs or limited chronic issues 1-5% 5-10% 25-40% >50%

Risk prediction and scoring Hierarchical Condition Categories (HCC; CMS); DxCG; ACG; Charlson Comorbidity Score; etc. Algorithmic risk score Adjudicated risk score Targeted services by risk category Pure clinical intuition “Of your patients, who would you not be surprised if they ended up in the hospital / had a major health issue / died in the next year?”

Adjudication or Human Review is important for successful risk stratification at the point of care Figure 3a. Composite risk stratification perception by algorithm type From Ross et al, under review. Survey of 99 persons from 37 clinics engaged in risk stratification.

Identification of vulnerable people

Data and information sources: social and behavioral issues

Ideas for HIT enhancements / workflow for risk stratification The High Risk Patient List Report provides a means to track and enroll high risk patients. It also stores multiple risk calculations and what approaches have been used to address needs.

Population-based reminders Make reports interactive Prioritized Population Reminders As a task list Centralized reminder list of tasks & communications proactively planned but incomplete, allows population-based tasks to be merged with individual encounter tasks.

Care planning / summarization Goals: What brings you joy? What matters in life? or Increase walking 5 times per week or A1c < 8.0% Edited flowchart. When working with persons with multiple illnesses or complex illness, a clinical summary that captures a core set of information improves patient outcomes (1). Care coordination and behavioral modification (goal setting) elements often require special effort ,and the quality summary requires more advanced monitoring and implementation than most standard EHRs provide. Generate summarized clinical information; Facilitate structured conversations Wilcox et al, Proc AMIA, 2009; Edwards, Dorr, Landon JAMA, 2017 Goals: What brings you joy? What matters in life? Increase walking 5 times per week

CPC+ Clinical Quality Tracking and Reporting Prioritize measures Start with one measure Identify documentation workflow Implement workflow Conduct data analysis and validation Provide data for clinical staff Data Analysis and Validation Audit patient detail list Chart exploration Identifying errors in reporting Giving specific patient examples to vendor Mapping SNOMED and LOINC codes

3. Data from EHR reports are not credible and trustworthy Challenges with using Electronic Health Records for Quality Measurement and Improvement Inability to produce clinical quality reports that align with quality improvement needs 2. Inability to produce clinical quality reports at practice, clinical team, clinician, and patient levels 3. Data from EHR reports are not credible and trustworthy 4. Delays in modifying specifications when guidelines or measures change

Informatics and Health IT Challenges Lack of perceived usefulness, lack of computer skill, system design flaws, lack of system interoperability, and incompatibility with clinical workflows are primary deterrents to the use of Health IT systems(1,2) Exchanging health information effectively can provide significant care coordination and care management benefit, but is still a struggle at many sites (3) Use of Health IT alone is not sufficient to improve quality but engaging organizational management can influence the effect health IT has on quality improvement initiatives (4) Implementing a new system or changing an existing system will be met with resistance

Steps to grow Health IT expertise Your Vendor’s Training Certification, often for a variety of roles Champions Regular online and in-person training (see left – networking, informal communications) Experiential + Asking Questions CPC+ Connect Affinity groups HIT/EHR user groups HIT/EHR technical support HIT/EHR online repositories Local informatics folks (hospitals, academic centers) Try! Get Unstuck! General Informatics Training ONC HIT curricula : Free online courses and materials 10x10 courses (single online courses) : AMIA Formal programs (e.g., certificates -> PhDs) :

Future state FHIR / APIs to build better functionalities (later today!) Reduced lag times Patient entered data – especially for outcomes Analytics capabilities in the hands of users

dorrd@ohsu.edu www.ohsu.edu/cmp Thank you! dorrd@ohsu.edu www.ohsu.edu/cmp Oregon Health & Science University Bhavaya Sachdeva Karri Garaventa Melanie Marzullo Jesse Wagner Raja Cholan Nicholas Colin Colleagues and Mentors Cherie Brunker, MD Adam Wilcox, PhD Bill Hersh, MD Paul Clayton, PhD Family Introduction to our team