Optimizing Technology to Achieve Population Health Shannon Nielson, MHSA, PCMH-CCE Centerprise, Inc May 5 th, 2015 Indiana PCA Annual Conference

Patient Information Technology/EMR PI QI Care Coordina tion Whole Person Access Interdiscipli nary Population Data Community Population Stratification Measurement Payment Population Health MANAGEMENT Decreased Cost Improved Outcomes Improved Pt. Experience Primary Care Access Team Based Care Care Manage ment Populati on Health Manage ment Outreach Population Health Data

The Buzz Words Population Health: Population Health MANAGEMENT: Outcomes of a group of individuals, including the distribution of such outcomes within the group Set of interventions designed to maintain and improve people’s health across the full continuum of care-from low-risk, healthy individuals to high-risk individuals with one or more chronic conditions

EMRPHM Visit DataX\ Population DataX Coordinated CareX TrackingXX DataXX Information\X AnalyticsX Pre visit summariesXX Clinical summariesXX Data ValidationX Risk StratificationX Patient Engagement\X Clinical vs. Claims DataSeparateCollaborative

Technology makes PHM Sustainable Institute for Health Technology Transformation- A Roadmap for Provider Based Automation in a New Era of Healthcare

10 Technology PHM Tools EHR Patient Registries Health Information Exchange Risk Stratification Automated Outreach Referral Tracking Patient Portals Telehealth/telemedicine Remote Patient Monitoring Advanced Population Analytics

Patient Registries What? List of visits at a given time Who? Identification and grouping of patients Why? Population How? evidence based guidelines When? At execution or patients to perform an action Practice specific and continuously by information or immediate and ongoing

Risk Stratification Who? Patients at risk What? Patients in need of care management to avoid a negative financial, clinical or satisfaction experience When? At the time of visit Why? Visit alerts for missed opportunities and visit needs How? Visit alerts and chart prep, pre-visit and post visit and Proactive care management to improve clinical outcomes between visits and promote patient engagement Evidence based decision support on an entire population using clinical and financial data

Outreach Who? Patients defined by practice What? List of patients requiring communication from practice When? At time of execution Why? Identified need at time of execution How? User defined report to identify all current patients Automated or as scheduled for automatic generation or patient falls into eligibility criteria automatic report triggered by definition and schedule

Analytics Who? Patients as defined and encounter based What? Numerator When? On demand How? Report building with static criteria Why? A number Advanced Population or population data– as a percentage of additionally defined population-today and now and denominator for utilization in information based decision making and PI or real time or variation in definition Or information to analyze pt. population and use for decision making, PI and planning

Referral Tracking Care Management Automated Outreach Data Validation Reporting ANALYTICS Benchmarking Risk stratification External population measurement Customization of structured data Patient Engagement tools and information Population data Visit data Proactive population alerts Influence: Data Visit data Structured data Reporting Outreach Referral Tracking Point of Service Electronic Encounter Alerts Minimal paper Patient engagement documentation Unstructured data Referral Tracking Data Validation High paper use Risk Stratification Care Management External Population Measurement Benchmarking Population alerts Patie nt LOW HIGH Population LOW HIGH

The (HIGH) Performance Equation Goals Influence Execution Performance Goals Execution Level of Performance

How do we get there? Defined goals and objectives – Organizational Strategy – Organizational Structure Tools of Influence Execution – Skilled Staff – Involved Staff – Engaged Patients

PHM as Influence

PHM as Influence

PHM as Influence

The Triple Aim Equation EMRPHM Encounter Based One Pt. at a Time Rule Based Provider Led Pay for Encounter Patient Based Multiple Populations Outcome Based Data led Pay for Value

PHM in our Reality Pt. Calls when sick or in need Pt. is scheduled as capacity allows Pt. receives communication identifying need- Outreach. is scheduled as capacity is defined by patient data- includes same day Pt. schedules electronically Pt. checks in- update information Pt. waits for intake Pt. checks in- update Pt. reviews medication Pt. reviews health history Pt. waits for intake Pt is roomed Vitals taken Reason for visit documented Pt. is roomed Reconcile meds and health history Vitals documented Self management goals reviewed Barriers addressed Needed interventions addressed Review of RFV Dx Referrals Clinical treatment Rx Clinical summary Clinical Huddle Pre-visit identification of visit needs RFV reviewed Identified interventions addressed Treatment goals set Pt. Engagement Treatment plan Barriers addressed “what matters to the patient” Pt. leaves with CLINICAL summary Pt. returns to normal activity Pt. goes to referrals? Pt. identifies need for visit Pt. leaves with clinical summary and self management plan Pt. works toward goal Pt. navigated to external needs (referrals, community, lab) Outreach Track referrals etc… F/U on care plans Missed opportunities Care Coordinator contact Analytics- INFORMATION

Your PHM Solution-Day to Day Patient care opportunities Access analysis Utilization monitoring Clinical performance Data validation Care coordination Patient engagement

Your PHM Solution-Strategy Information based strategy Information based decision making Influence Scope of Services Growth Needs Assessment Access Quality Plan

Organizational Population Health Assessment What is our population health goal/strategy? What information do we want? – What information do we have? – Where is the gap? – Can we get this information? – What is needed in order to get this information? – Who has this information? – Who has access to this information What do we do with this information? – Where in the workflow is information important? – Who is accountable AND responsible for the execution? – Do we have access to this information in workflow? – Will the information help us to execute on the overall strategy? – What does this information mean to the patient?

Pop Health IT Assessment Interpret the information Implement in workflow Visualize the information Communicate the information What is the process Who is executing What is the outcome How does outcome align with goal ANALYTICS What do we have What is the current state What does this impact What do we need Why do we need it What are you we going to do with it Clinical Operational Financial Patient Centered Sustainable StrategyInformation InfluenceExecute

Successful Pop Health IT IS High Performance PERFORMANCEPERFORMANCE