1. Meeting 6 Brownsville Regional Campus

2. Agenda Brownsville Regional Campus School of Public Health 1. Members and Architecture Overview 2. RGVRegistry Project and RGVHIE Update 3. Wellcentive Use Cases and Data Needs 4. Su Clinica: Technical Implementation Lessons Learned 5. Su Clinica: How Su Clinica will use Wellcentive 6. Salud y Vida: Technical Implementation Lessons Learned 7. Salud y Vida: How Salud y Vida will use Wellcentive

3. 1. Members and Architecture Overview Brownsville Regional Campus School of Public Health

4. NameOrganizationContact Susan Fisher-HochUTHealthsusan.p.fisher-hoch@uth.tmc.edu Anaelle MoalUTHealthanaelle.moal@uth.tmc.edu Kristina VatchevaUTHealthkristina.p.vatcheva@uth.tmc.edu Belinda ReiningerUTHealth (Salud y Vida)belinda.m.reininger@uth.tmc.edu Lisa Mitchell-BennettUTHealth (Salud y Vida)lisa.mitchell-bennett@uth.tmc.edu Jennifer SpragueWellcentivejennifer.sprague@wellcentive.com Henry PresasSu Clinicayepresas@suclinica.org Emily AlpertBrownsville Community Health Centerealpert.bchc@tachc.org Justin RockValley Baptist Health Systemjustin.rock@valleybaptist.net Michael PaezValley Baptist Health Systemmichael.paez@valleybaptist.net Sheila MagoonBuena Vida y Saluddrmagoon@bizrgv.rr.com NameOrganizationContact Andrew LombardoRGVHIEandrew@rgvhie.org Janie MartinezRGVHIEjanie@rgvhie.org Peggy LeeRGVHIEpeggy@rgvhie.org Johnny BenderUTHealthjohn.p.bender@uth.tmc.edu Christina LawsonWellcentivechristina.lawson@wellcentive.com Brownsville Regional Campus School of Public Health Advisory Team Action Team

5. The Registry Review Architecture Brownsville Regional Campus School of Public Health Summary: Action Team works with Workgroups Per need basis: every week to every three weeks Progress presented to Advisory Team Advisory Team provides feedback Advisory Team provides advice UTHealth Workgroup analyzes data Data quality suggestions Complete architecture document located on The Registry Review wiki (https://theregistryreview.wikispaces.com/file/detail/The-Registry-Review_Architecture_3-31-2015.pdf)

6. The Registry Review Presentations Brownsville Regional Campus School of Public Health Complete architecture document located on The Registry Review wiki (https://theregistryreview.wikispaces.com/file/detail/The-Registry-Review_Architecture_3-31-2015.pdf)

7. The Registry Review Presentation Goals Brownsville Regional Campus School of Public Health Complete architecture document located on The Registry Review wiki (https://theregistryreview.wikispaces.com/file/detail/The-Registry-Review_Architecture_3-31-2015.pdf)

8. The Registry Review Wiki Brownsville Regional Campus School of Public Health Wiki Page: URL: http://theregistryreview.wikispaces.com/http://theregistryreview.wikispaces.com/ Content: Currently: Support Documentation Meeting Documentation Education Page Discussion Page

9. 2. RGVRegistry Project and RGVHIE Update Brownsville Regional Campus School of Public Health

10. Technical Connection Status Brownsville Regional Campus School of Public Health 100% complete 90% complete 95% complete 50% complete Initiating

11. Chronic Disease Registry DSRIP Needs and Strategy 1.Identify disease status and risk of uncontrolled status Disease status: Controlled, Marginal, Not Controlled Risk of uncontrolled status: (High → Low) UTHealth revising list of alerts and reports The Registry Review & Short-Term Provider Panel to review 2.Use registry to assist providers in diabetes management Identify follow-up need Referral to management resources UTHealth revising list of alerts and reports The Registry Review & Short-Term Provider Panel to review 3.Track patient admission and discharge across facilities Identify high-utilizers UTHealth, Valley Baptist, STHS: Strategies for using/displaying hospital data Criteria for identifying patients that need intervention Brownsville Regional Campus School of Public Health

12. Training Plan 1.User Access Wellcentive user access, initiatives, and HIPAA overview 2.Secure Messaging How to send messages in Wellcentive Sending patient charts identified and de-identified 3.Referral Workflow Hands-on referral workflow for external facilities, like TTBH and RGSC 4.Creating and Using Alerts Process of creating and using alerts in Wellcentive 5.Creating and Using Reports Process of creating and using reports in Wellcentive Training for Advisory Team? Brownsville Regional Campus School of Public Health

13. Presentation in D.C. on June 4 th Brownsville Regional Campus School of Public Health Office of the National Coordinator for Health IT Meaningful Use; forefront of administration’s health IT efforts Association of State and Territorial Health Officials National nonprofit organization representing public health agencies in the U.S. National Association of City and County Health Officials Represents 2,700 local health departments across the United States. Present the disease registry project and other programs in the RGV Advertise the health efforts and positive impact of efforts in the RGV to national agencies and organizations for future growth.

14. Next Steps 1.Duplicate Patient Management Near patient-matches merging process 2.Alert/Report Excel list with descriptions PCMH, MU, NQF, disease registry, etc. 3.Data Quality Reports Recommendations to facilities 4.Comprehensive Data Availability Report Listing of all reportable data being captured in Wellcentive by facility 5.Patient intervention by participating facilities Quantifiable patient impact: Need 500 diabetic patient interventions (outreach, management, referral) by September 30, 2015 Brownsville Regional Campus School of Public Health

15. Brownsville Regional Campus School of Public Health 3. Wellcentive Use Cases and Data Needs

16. Brownsville Regional Campus School of Public Health User Access Venn Diagram Su Clinica SYV: SPH Tropical Texas SYV: MHP Aggregate, De-Identified Population Reports Cameron County DHHS Brownsville City Health Department Community Statistics: Grants, Initiatives, etc.

17. Brownsville Regional Campus School of Public Health Wellcentive Use Cases and Data Needs 1. Undiagnosed Diabetes Mellitus Self-reported diabetes: 13.7% (CCHC) Objectively measured diabetes: 30.7% (CCHC) 2. Pre-Diabetes Mellitus 30% of the population (CCHC) 3. At-risk for Diabetes Mellitus Obesity, CHF, family history of diabetes 4. Complications of Diabetes Mellitus Uncontrolled diabetes At risk for uncontrolled diabetes “Frequent flyers” to hospitals For Providers & Care Managers (Identified Data):

18. Brownsville Regional Campus School of Public Health Wellcentive Use Cases and Data Needs 1. Salud y Vida (only participants enrolled) Chronic care management program 2. Project Echo (only participants enrolled) MD Anderson cervical cancer project with Su Clinica 3. Medication Therapy Management (only participants enrolled) Sí Texas: Starting with Salud y Vida, expanding to referrals from outside For Support Programs for Provision of Care (Identified Data): 1. Public Health Facilities Cameron County Health and Human Services Department Brownsville City Health Department 2. Population studies Needs assessments, grant proposals, initiative development & feedback For Research (De-identified, Aggregate Data):

19. Brownsville Regional Campus School of Public Health 4. Su Clinica: Technical Implementation Lessons Learned

20. Brownsville Regional Campus School of Public Health Su Clinica: Technical Implementation Lessons Learned 1.Long implementation: ~4.5 months 2.Sending all data for analytics Ended up using a custom CCDA The vendor had difficulties getting it started HIE opt-out workflow is in the process of being created The PCP field used in house differed from the one used by the CCD which created a workflow change. 3.Initial trigger for the CCD was the signed visit Labs were not initially included if the visit was signed before the electronic lab came in. 4.Historical data challenging to send Based on active patients Waiting for increase in bandwidth

21. Brownsville Regional Campus School of Public Health 5. Su Clinica: How Su Clinica will use Wellcentive

22. Brownsville Regional Campus School of Public Health Su Clinica: How Su Clinica will use Wellcentive Care Managers as main users May have physicians use tool eventually Diabetes Registry Diabetes status of all locations Controlled, Marginal, Not Controlled Patients that need follow-up Care manager test reminder Patients with high, medium, low risk of diabetes uncontrolled status

23. Brownsville Regional Campus School of Public Health Su Clinica: How Su Clinica will use Wellcentive Patient-Centered Medical Home Secure Messaging Salud y Vida Feedback Referrals to other organizations Alerts based on survey results Salud y Vida Engagement based on DSME

24. Brownsville Regional Campus School of Public Health 6. Salud y Vida: Technical Implementation Lessons Learned

25. Brownsville Regional Campus School of Public Health Salud y Vida: Technical Implementation Lessons Learned 1. Long implementation ~6 months 2. Custom interface Export from ScoreMD (Chronicle) to Wellcentive 3. Figuring out what was needed in Wellcentive Data needed from ScoreMD (Chronicle) 4. Difficult to enable users to only use one application Chronicle is useful for DSME class management Wellcentive is useful for aggregated information and alerts/reports based on aggregated information

26. Brownsville Regional Campus School of Public Health 7. Salud y Vida: How Salud y Vida will use Wellcentive

27. Brownsville Regional Campus School of Public Health Salud y Vida: How Salud y Vida will use Wellcentive Aggregate data on patients in Salud y Vida Will help to reduce unnecessary tests Alerts/Reports to manage patients Based on aggregate data Secure messaging with other organizations Can communicate securely, and de-identify patient charts, if necessary Referrals to external organizations Referrals auditable from a central, secure source

28. Questions/Follow up/Next Meeting Questions/comments: How can we make these meetings better? Format, members, topics, perspectives, etc. Follow-up: Compiled, condensed chronic disease status and control risk literature will be sent to Advisory Team for edits and comments with The Registry Review Meeting 6 minutes Johnny to follow up with Henry (Su Clinica), Emily (BCHC), Mary (RGSC), Dr. Magoon (BVYS), Maria (SYV), and Peggy (RGVHIE) for provider panel physicians and care managers Any other follow-up? Next Meeting: June 23 from 2:00 – 3:00 pm CST Method for identifying high-utilizers by UTHealth, STHS, Valley Baptist, RGVHIE UTHealth, RGVHIE, and Wellcentive to present data quality methods Any other proposed topics? Brownsville Regional Campus School of Public Health

29. Thank you! Brownsville Regional Campus School of Public Health PowerPoint and meeting items located on The Registry Review wiki: http://theregistryreview.wikispaces.com/The+Registry+Review+Meeting+Documentation