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1 Disclosure Statement: The content and/or presentation of the information will promote quality or improvements in healthcare and will not promote commercial interests

2 UTILIZING POPULATION HEALTH DATA John Studebaker, MD, MS

3 OBJECTIVES Describe the concept of population health management and why its all the rage. Describe the technology of population health management. Identify approaches for implementing population health management.

4 SET THE STAGE

5

6

7 EVOLUTION Current growth rate in health care spending is not sustainable. Current system rewards treating illness much more so than preventing it. Payers (including CMS) are motivated to try different approaches.

8

9 TRANSFORMATION How health care is paid for Shared Risk Models - ACO Value-Based Care How health care is delivered Patient Centered Medical Homes Integrated Delivery Networks Medical Neighborhoods

10 POPULATION HEALTH: Front and Center Focus Shift from one patient at a time to all patients at a time How to manage a group of patients Clinical Goals Financial Goals How to know what is working (and what is not) Measurement Rapid Improvement Cycles

11 WHAT IS POPULATION HEALTH? The health outcomes of a group of individuals, including the distribution of such outcomes within the group. --Kindig, DA, Stoddart G. (2003). What is population health? American Journal of Public Health, 93,

12 INDIVIDUAL HEALTH

13

14 PANEL

15 CLINIC OR SYSTEM

16 PUBLIC HEALTH

17 THE SPACE BETWEEN INDIVIDUAL HEALTH and PUBLIC HEALTH Responsibility for a group of patients. NOT restricted by a disease, nor by a demographic, nor by geography.

18 POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions,

19 POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions, implemented for populations defined by a healthcare need or condition,

20 POPULATION HEALTH MANAGEMENT A collection of physician-supervised interventions, implemented for populations defined by a healthcare need or condition, that help patients and caregivers optimize care, prevent future complications and maximize opportunities for wellness.

21 POPULATION HEALTH POPULARITY

22 TECHNOLOGY OF POPULATION HEALTH MANAGEMENT

23 Data Sources

24 Data Sources EHR / EMR Practice Management

25 Data Sources EHR / EMR HIE Practice Management Registry Outside Clinics

26 Data Sources EHR / EMR HIE Legacy Systems Practice Management Registry Lab Outside Clinics Pharmacy

27 Data Sources EHR / EMR HIE Legacy Systems Claims Practice Management Registry Lab Outside Clinics Pharmacy

28 Data Sources EHR / EMR HIE Legacy Systems Claims Practice Management Registry Lab Home Monitoring Outside Clinics Pharmacy Personal Devices

29 Health System Perspective EHR / EMR Practice Management

30 Health System Perspective EHR / EMR Practice Management Data Warehouse

31 Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab

32 Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab Registry

33 Health System Perspective EHR / EMR Practice Management Data Warehouse Legacy Systems Lab EHR / EMR Registry

34 Person Perspective

35 Person Perspective My Cardiologist My Dermatologist My Doctor

36 Person Perspective My Chiropractor My Cardiologist My Dentist My Dermatologist My Doctor My Care Coordinator My Kids Pediatrician

37 Person Perspective Urgent Care My Pharmacy My Chiropractor My Cardiologist My Dentist My Dermatologist My Doctor My Care Coordinator My Kids Pediatrician

38 Person Perspective Lab from Urgent Care Urgent Care My Pharmacy My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My Care Coordinator My Kids Pediatrician

39 Person Perspective Lab from Urgent Care Urgent Care My Insurance Plan My Employer My Pharmacy My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My FitBit My Care Coordinator My Kids Pediatrician

40 Person Perspective Lab from Urgent Care Urgent Care My Insurance Plan My Employer My Pharmacy??? My Chiropractor My Cardiologist Lab from My Cardiologist My Dentist My Dermatologist My Pathology Report My Doctor Lab from My Doctor My FitBit My Care Coordinator My Kids Pediatrician

41 Regional Perspective

42 Regional Perspective Health Systems Hospitals

43 Regional Perspective Health Systems Hospitals Primary Care Clinics Specialty Clinics Urgent Care

44 Regional Perspective Health Systems Hospitals Primary Care Clinics Specialty Clinics Urgent Care Safety Net Health Department Dental Clinics

45 Regional Perspective Health Systems Hospitals Primary Care Clinics Ancillary Care Specialty Clinics Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers

46 Regional Perspective Health Systems Hospitals Payors Primary Care Clinics Ancillary Care Specialty Clinics Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers

47 Regional Perspective Health Systems Patients Hospitals Payors Primary Care Clinics Specialty Clinics HIE Ancillary Care Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers

48 Regional Perspective Health Systems Patients Hospitals Payors Primary Care Clinics Specialty Clinics HIE Ancillary Care Lab Urgent Care Pharmacies Safety Net Health Department Dental Clinics Radiology Centers

49 Data Aggregation

50 Data Aggregation EDW

51 Data Aggregation EDW Interfaces Mapping

52 Data Aggregation EDW Interfaces empi Mapping

53 John Smith Who is Who? - empi

54 Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht

55 Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht 01/23/58 Jan 23 rd 1958 January 23,

56 Who is Who? - empi John Smith Jon Smith J. Smith John Q Smith J Q Smith John Smiht 01/23/58 Jan 23 rd 1958 January 23, Main Street

57 Lasix What is What? Mapping

58 What is What? Mapping Lasix Furosemide

59 What is What? Mapping Lasix Furosemide IV Tablet

60 What is What? Mapping Lasix Furosemide IV Tablet 20mg 40mg 80mg

61 What is What? Mapping Lasix Furosemide IV Tablet Coding Systems: RxNorm NDC GPI 20mg 40mg 80mg

62 What is What? Mapping Past Medical History Physical Exam BP Allergies

63 Analytics

64 Analytics Queries Filtering / Sorting

65 Analytics Queries Rules Engine Filtering / Sorting Standards

66 Analytics Queries Rules Engine Clinical Risk Filtering / Sorting Standards Financial Risk

67 Analytics Queries Rules Engine Clinical Risk Predictive Modeling Filtering / Sorting Standards Financial Risk Contract Modeling

68 PHM Tools and Applications

69 PHM Tools and Applications Care Management Addressing Care Gaps Patient-Centered Care

70 Patient Engagement PHM Tools and Applications Patient Self Management Care Management Addressing Care Gaps Patient-Centered Care

71 Patient Engagement PHM Tools and Applications Patient Self Management Care Management Addressing Care Gaps Patient-Centered Care Quality Improvement

72 Patient Engagement PHM Tools and Applications Patient Self Management Care Management Reporting Benchmarking Addressing Care Gaps Quality Metrics Patient-Centered Care Quality Improvement

73 Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Care Management Addressing Care Gaps Benchmarking Quality Metrics Resource Allocation Workflow Optimization Patient-Centered Care Quality Improvement

74 Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Risk Management Care Management Benchmarking Resource Allocation Addressing Care Gaps Quality Metrics Workflow Optimization Patient-Centered Care Quality Improvement

75 Patient Engagement PHM Tools and Applications Patient Self Management Reporting Performance Management Risk Management Care Management Benchmarking Resource Allocation Network Leakage Addressing Care Gaps Quality Metrics Workflow Optimization Contract Performance Patient-Centered Care Quality Improvement

76 COMMON MISCONCEPTION: I have an EHR, therefore I have all the PHM tools I need. AKA: I bought an EHR, it does this stuff right out of the box.

77 EMR / EHR EHRs are tools for data entry and workflow support. They are powerful transaction machines built to create a billable document. They are an important part of the equation, but not the only piece.

78 EHR AS THE ANSWER Data Sources Data Aggregation Analytics PHM Tools and Applications

79

80 SO WHAT IS THE ANSWER!? Understand what you re trying to accomplish. What tools will you need to meet your goals? Which pieces do you already have, and which will you need to find?

81 QUESTIONS?

82 CONTACT INFORMATION John Studebaker, MD, MS

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