Actionable Data at Point of Care. Kris Gates, JD. Health Endeavors. Contact

Transcription

1 Actionable Data at Point of Care P a g e 1 Actionable Data at Point of Care Kris Gates, JD Health Endeavors Contact Kris Gates, JD is CEO of Health Endeavors located in Scottsdale, Arizona, 8955 E. Pinnacle Peak Rd, Suite 103, Scottsdale, AZ Contact: gates@healthendeavors.com Abstract Recently, health care has seen a substantial rise in claims, clinical and patient-generated information shared with providers and payers. We found most of this data is presented at a board or committee meeting to learn about trends in populations and then filed away. It rarely makes it way to the point of care much less in an actionable format. The two groups that can act on the data are often left out of the data sharing flow the provider team and the consumer. Often, the provider team is left out by choice as they won t take an excel list of care gaps as it doesn t fit in their clinical work flow. In summary, our data study found data must be at the point of care where the provider and consumer have a face-to-face encounter and it needs to be actionable data such as a list of the patient s current care gaps.

2 Actionable Data at Point of Care P a g e 2 Problem Statement Accountable Care Organizations (ACOs), Clinically Integrated Networks (CINs) and payers have lots of data, but very little actionable data is put in front of the provider team and consumer which results in lack of engagement and goal achievement. It is very difficult for an ACO, CIN or payer to achieve the below goals under the current mountain of data structure: Improve Consumer Health Outcomes Lower Costs Provider Team Buy-In of Initiatives o Awareness of Initiatives o Engagement with Initiatives Consumer o Network Alignment o Care Engagement

3 Actionable Data at Point of Care P a g e 3 Solution 1. Data-driven intelligent data delivered to provider team s Electronic Health Record (EHR) systems via Application Program Interface (API). As more EHRs offer vendor stores to accelerate population health offerings, the logical place for actionable data is in the EHR. A prime example for generating actionable data is the Medicare Blue Button FHIR EOB as it is everywhere a patient has been treated for the last 4 years. 2. Data-driven intelligent data delivered to consumers via text alerts that push the consumer to resolve care caps at a face-to-face encounter with the provider team. Background The background for this topic is our data study of 40 accountable care organizations (ACOs) with chronic care management programs from 2015 to The common theme with ACOs and CCM staff was how to best utilize the data to lower costs and improve health outcomes. From 2015 to 2017, the ACO group we tracked focused on trending analytics. Reports such as aggregate expenditure and utilization, re-admissions, emergency department visits, hospitalizations, imaging and post-acute care provider performance. While trending resulted in identifying problem areas, 78 percent of the ACOs in our group, did not significantly lower costs or improve health care outcomes. 22 percent did significantly lower costs and improve health care outcomes. Health care outcomes were defined as the ACO Group Practice Reporting Option (GPRO) quality metrics and expanded to performance changes as compared to the Medicare

4 Actionable Data at Point of Care P a g e 4 national average aggregate expenditure and utilization such as readmissions, post-discharge follow-up visits and episode of care complications and emergency visits. Costs were defined as the ACOs historical and updated benchmarks. In summary, our findings were data outside the point of care may be good for data trends, but it didn t significantly solve the problems of rising costs and poor health outcomes. From 2017 to 2018, a subset of the 40 ACOs shifted focus from trending data to actionable data at the point of care. The results were 66 percent of the ACOs in our group, did not significantly lower costs or improve health care outcomes. 34 percent did significantly lower costs and improve health care outcomes. A 12 percent improvement in 2 years. The actionable data was brought to the point of care by (i) the patient who received text alerts with a list of care gaps to coordinate with the primary care provider; and (ii) by the provider team at the point of care in their electronic health systems using patient match technology. Based on the improvement over 2 years, our 2019 to 2020 study will be how to improve the data at the point of care and the delivery mechanisms to process the data. Data utilized from 2017 to 2018 at the point of care: Benchmark/Spend Risk Score Cost & Utilization Quality Metrics Care Gaps HCC Coding Out-of-Network

5 Actionable Data at Point of Care P a g e 5 Provider Performance Enroll Patient in Text Alerts Care Gap Data-sharing formats utilized from 2017 to 2018: CDA FHIR EOB Claims Conclusion Our data study brought us to the HIMSS Interoperability Showcase to learn and share with other vendors. Showcase Use Case Clinical and financial data are made available at every point of care through HL7 FHIR and other standards. FHIR questionnaire, FHIR EOB and SMART on FHIR applications enable a retired patient with chronic knee pain to take control of his healthcare journey as data is passed from a referral management platform directly to payer benefits validation to streamline care. Mark pulls his care plan and uses Blue Button 2.0 to determine next steps on his continuum. Scenario Vendor Products Standards Netsmart Referral Management Platform to serve post acute skilled nursing market Receives referral from the hospital system to skilled nursing for 30 days as knee replacement pt is discharged to home. Notify Virence of the discharge. Send care information to Orion HIE and Cerner HIE Payer benefits validation Cerner HIE - Payer Portal XDS CCDA

6 Actionable Data at Point of Care P a g e 6 Payer validates history of healthcare to ensure 30- day stay is warranted. Reviews record to ensure course of care is appropriate for patient history. Mobile Patient App: Patient syncing Medicare Blue Button 2.0 health information of 4 years of health history with weekly updates. Data-driven intelligence auto-generates a text alert to the patient that his annual wellness visit is due to complete. Patient schedules annual wellness visit with primary care provider. Health Endeavors Get your Health Record Mobile App EHR Connector FHIR EOB FHIR Direct Message CCDA Button appears on EHR interface with API/SSO handshake to show Health Endeavors screen (EHR Connector) PCP: During primary care provider visit, patient complains of knee pain. Assign Physical Therapy and pain tracking Virence Ambulatory EHR Payer sends message to PCP ADT notification of discharge to HIE Orion Clinical Visit Summary to Orion HIE and Allscripts One month later - Home Pt Questionnaire goes to patient and trigger the pt follow up view telehealth visit Pt Reminder App finds that under the new Medicare billing codes to chat with his primary care provider about his continuing knee pain Allscripts Follow My Health Sends care plan to the patient Would like to receive the CCDA and then create the care plan and send it to the HIE query the HIE for

7 Actionable Data at Point of Care P a g e 7 Patient Engagement Solution: Pre-& post-acute ambulatory Virence and Orion to determine what data they can exchange Orion HIE Data will be pushed into HIE from multiple systems in the use case. Orthopedic office NextGen queries the Orion HIE to retrieve any C- CDA R2.1 document available Documents from the HIE have their discrete data pulled into the patient's chart in order to be available for the CDS pull from Mitre CDS application using to show pain management summary in an outpatient setting NextGen Enterprise EHR XDS C-CDA R2.1 Mitre Smart on FHIR Dashboard for providers to review chronic pain and pain hx from NextGen EHR