Leveraging Network-Wide Opportunities to Manage Population Health

Transcription

1 Leveraging Network-Wide Opportunities to Manage Population Health Session 286, February 14, 2019 Richard T. Shirey, SVP and CIO, Hartford HealthCare Isabella Veillette, Application Manager, Hartford HealthCare 1

2 Conflict of Interest Employees of Hartford HealthCare Hartford HealthCare is a client of Innovaccer Innovaccer has sole ownership and rights to their healthcare data platform 2

3 Agenda About us Problem statement Our solution illustrated Key outcomes Insights and lessons learned Critical success factors Q&A 3

4 Learning Objectives Describe the importance of integrating physicians in a network spread across various geographies on multiple data systems Explain the importance of clinical data quality and its business impact Illustrate a framework for connecting ambulatory sites on different data systems and leveraging that connection to close gaps in care, report on quality performance, and improve overall outcomes 4

5 Hartford HealthCare Background 6 hospitals 1,941 beds 80,536 inpatient transitions 381,630 ED visits Behavioral health network Home care network Rehabilitation network Senior care network Integrated Care Partners (ICP) clinically integrated network 128 clinics 14 surgical and diagnostic centers 27 imaging locations 126 cities and towns in service area 15,000+ lives touched daily 5

6 Hartford HealthCare Background 6 hospitals 1,941 beds 80,536 inpatient transitions 381,630 ED visits Behavioral health network Home care network Rehabilitation network Senior care network Integrated Care Partners (ICP) clinically integrated network 128 clinics 14 surgical and diagnostic centers 27 imaging locations 126 cities and towns in service area 1,800 providers throughout eastern, central, and northwestern Connecticut 300 primary care providers 1,100 specialty physicians 400 advanced practice clinicians 30 community care managers who assist primary care providers in managing complex and/or chronically ill patients 2 pharmacists who assist providers with complex medication challenges 11 primary care behavioral health clinicians embedded in 13 primary care locations 15,000+ lives touched daily 6

7 ICP Strategic Priorities Create Value Manage Risk Coordinate Care Culture & Capabilities Quality Performance Manage Alternative Payment Models Integrated Care Management Change Provider Decisions Manage the Total Cost of Care Clinical Data at Point of Care Growth of Attributed Lives & In-Network Utilization 7

8 Barriers to Achieving Strategic Goals: Data from Multiple Sources Problem: Managing risk contracts and quality with limited clinical information and no ability to measure or track performance on quality measures across all ambulatory sites Members of our clinically integrated network (CIN) were utilizing 36 unique ambulatory EHRs across 102 practice locations Additionally, CIN members on the same EHR were utilizing different versions with unique configurations for their practice 8

9 Data Integration: The Need of the Hour Solution: Integrating clinical and claims data into a single database using standard data formats for analysis in a centralized performance platform C-CDAs for clinical data Pre-adjudicated claims (837s) for claims data 9

10 Illustrating the Solution: A Centralized Performance Platform Provider / Organization Dashboards CIN Members ONC-certified EHRs Epic Athena NextGen Export Transmit Extract Normalized Database Centralized performance platform Allscripts 30+ Others 10

11 A Three-Pronged Approach to Effective Population Health Creating an Integrated Data Platform Comprehensive data platform with regular data extraction and ingestion from ambulatory practices Obtaining and Constantly Improving Quality Data Top quality data to create actionable insights for care managers, providers, and leadership Pushing All Data into Epic to Create a Single Source of Truth Regular push into Epic s data warehouse and utilization of Healthy Planet tools to power analytics and dashboards 11

12 Transforming Data into Insights Clinical and Financial Data 837 Integration File Generation Healthy Planet Quality Metrics Ingestion QA Delivery Analytics 12

13 Genesis of an Intelligent Data Ecosystem Claims Data Patient Attribution Provider Contract Association FTP Healthy Planet Dashboards 13

14 Quality Data is the Foundation 14

15 Effectively Managing Data Gaps to Improve Quality Measure Performance CPT Code Description Number of Missed/Blank Codes Physical Medicine & Rehabilitation 1958 times Influenza Vaccine 1931 times PT (Hot/Cold Packs) 1550 times Pneumococcal conjugates vaccine 490 times ICD-10 Codes Description Number of Missed/Blank Codes E 78.0 Hyper Cholestrolemia 778 times E 78.1 Hypertriglyceridemia 358 times F 41.9 Anxiety Order 278 times E 78.5 Hyperlipidemia, Unspecified 147 times LOIN-C Codes Description Number of Missed/Blank Codes Pain Severity Score 777 times Systolic Blood Pressure 754 times Diastolic Blood Pressure 754 times 15

16 Additional Use Case for Data: Tracking Referral Patterns and Trends Centralized performance platform 16

17 Key Outcomes 15 ambulatory EHRs across 34 ambulatory practices integrated since October 2017 Over 1,000,000 C-CDAs delivered since February 2018 Over 90, s delivered since 2017 Data Quality Reports generated in Innovaccer s InData platform highlighting invalid codes and data gaps Achieved interoperability with Epic s Healthy Planet Deployed population health dashboards to MSSP practices through Healthy Planet Link 17

18 Insights and Lessons Learned Differences between what practices reported and what their data reflected in regards to quality measure performance Preparing for transition from audits via manual abstraction to electronic attestation Creating a culture of defensible data Physician resistance as a barrier to data integration Emphasizing the importance of data integration to physician alliance Shifting thinking from self-attestation to reporting as part of a larger group to realize benefits 18

19 Critical Success Factors Leveraging information from all practices across the network to identify key opportunities Integrating all existing systems so that all information is readily available, ideally in an intuitive format in a single location Getting every provider on same page regarding the outcomes of their patient population Engaging care teams by providing them with real-time insights on their patients 19

20 Questions? Contact information Richard Shirey: Isabella Veillette: Organization information Hartford HealthCare: hartfordhealthcare.org Integrated Care Partners: integratedcarepartners.org Remember to complete the on-line session evaluation! 20