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

2. 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

3. 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?

4. 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

5. 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

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

7. 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 Subject to change.

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

9. 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%

10. 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?”

11. 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.

12. Identification of vulnerable people

13. Data and information sources: social and behavioral issues

14. 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.

15. 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.

16. 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

17. 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

18. 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

19. 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

20. 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) :

21. 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

22. dorrd@ohsu.edu www.ohsu.edu/cmp
Thank you!
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