1. Danielle Oryn DO MPH Chief Medical Informatics Officer Redwood Community Care Organization RCCO 2 nd Quarter Summit 1 RCCO – DATA & ANALYTICS UPDATE: CUTTING THE CAKE

2. CCMR = The Swiss Army Knife of the ACO

3. CCMR General Features Accessibility Usability

4. CCMR CCMR Connector Data Visualization eHUB Claims Data LIS/RIS EHR Vendor 2 EHR Vendor1 Nursing Home eCW EMR Hospital Connector L V Portal Other EMRs eMPI Interoperabilit y Referrals JTN – Join the Network

5. eHX = Care Coordinator Connector Patient Stories 72 yo Medi-Medi COPD (on O2), DM, CHF, HTN, CKD … 23 Medications 2 Medication allergies Caregiver and Case Manager 7 ED visits and 3 hospitalizations Complications of lack of information: Given medication she had previous reaction to. Repeat studies already done as outpatient Unnecessary hospitalization PCP does not know if patient is d/c for f/u and medication reconciliation

6. eHX Features Physician portal Longitudinal patient record Ability to import (eCW) structured records from other organizations Admit, Transfer, Discharge feed

7. eHX Consenting All ACO patients will be automatically in the system. All other patients need to be given the opportunity to opt out at the next appointment.

8. Care Planning Case Managers Inability to manage a caseload within the system Difficult to track interventions No risk scoring or acuity scoring Keeping of non-HIPAA compliant spreadsheets Silo of information Lack of information to PCP Missed opportunities for intervention Lack of clear system for patient identification

9. Care Planning Features Longitudinal record Program enrollment Monitor case load Risk stratification (both ACG and custom)

10. Analytics Two current systems are difficult to program Only work with eCW No ability to see claims data Little ability to do risk stratification Getting data across the system is close to impossible Difficult to make large population health changes Disparities amongst health center capability

11. Analytics Features ACG Scoring – see resources on RCCO website Data by organization>site>provider>PATIENT Ability to see claims and clinical data side by side

12. Demo Analytics

13. CCMR Implementation Timeline 5/1 – (1:30pm – 3:00pm) Fist CCMR Care Coordination Module training for Health Center Key Contacts 5/6 to 6/9 – Dashboard Training for RCCO – CCMR Team June through August - Work with eCW CCIS consultant to map, plan, train teams on Dashboard. Eight weeks of time have been purchased that may be used in intervals of two to four weeks July – Go live for first RCCO Health Center July through September – Training and Go live for Health Centers

14. CCMR – Implementation update April 22 – RCCO obtained Medicare Claims Files and upload to CCMR May 7 – eCW and RCCO begin work to customize views available within CCMR for initial analysis of ACO data. May 12 – Preliminary data available to share with ACO participating health centers. April and ongoing – ACO participants connect EMRs to CCMR through eHX tool. Once connected the health center will be able to view clinical data together with claims data.

15. eBO Reports available Medicare Patient List – eBO report that generates a full list of the organization’s Medicare beneficiaries with demographics and PCP. Note that this list includes all patients with Medicare rather than only those who are attributed to the ACO. ACO – Model for risk – This report generates a list of Medicare beneficiaries, number of current medications, and high risk conditions (COPD, CHF, CAD, DM). Data Sharing Preference – This report is used to track informing patients of the option to opt-out of data sharing.

16. Analysis of five eCW health centers

17. Other Medicare data available Beneficiary Lists – Provided quarterly to RCCO. These will be made available to each participating organization. The next one will be available mid-May. Benchmarking data – Provided to RCCO on an annual basis in March-April Patient experience measurement.

18. eCW New Structured Data New structured data to meet the ACO 33 measure requirements: Guidebook / documentation is available on RCCO website Training on data capture is coming very soon Build for SRCHC, PHC, CHA and CHCO is complete. WCHC is pending.

19. Obtaining Access to CCMR 3-5 individuals from each RCCO provider organization to start Request form will be available online for more staff after that

20. THANK YOU! RCCO Petaluma Santa Rosa RCH John Canova, MD Alliance Alexander Valley West County Clinic OleCoastal Contact Information: Danielle Oryn DO MPH doryn@rchc.net 20