The Bronx RHIO and FQHCs: Population Management and Analytic Tools
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1 The Bronx RHIO and FQHCs: Population Management and Analytic Tools 1
2 What I ll Cover Bronx RHIO Basics Some Key RHIO Functions for FQHCs Subscriptions for Registration Alerts Referral Routing Data Availability Flags Single Sign-On Analytics Health Home Support 2
3 BRONX RHIO Vision Improving the health of the residents of the Bronx, and helping to eliminate healthcare disparities through health information exchange. 3
4 Current RHIO Data Feeds Demographics Encounter Level Data Procedures Consent Laboratory Text Reports Inpatient Meds Outpatient Scripts Diagnoses Comments Acacia P P P P P Includes BCHN Sites Boom!Health (BAS) P P P P P Bronx Lebanon Hospital Center (w MLK) P P P P P P P P Send problem list Children of Zion Pediatrics P P FEGS - Case Management P P P P Anil Gupta, MD P P Sindhu Gupta, MD P P Hebrew Home -CHHA P P P P Hebrew Home -Home Care P P P P Hebrew Home -LHCSA P P P P Housing Works P P P Institute for Family Health P P P P P P Jewish Home Lifecare P P P P Medalliance P P P MJHS - Hospice P P P P MJHS - Palliative Care P P P P P Montefiore Medical Center P P P P P P P P Includes BCHN Sites Montefiore Behavioral Health (SVTN) P P P P P Morris Heights Health Center P P P P P New York Associates in Gastro P P NY GI Center P P P Optimum Family Medicine P P Olive Osborne, MD P P Perry Ave. Family Medicine P P Riverdale Family Practice P P Salud Medical P P SBH Health System P P P P P P Union Community Health Center P P P P P Urban Health Plan P P Visiting Nurse Service of NY P P P P P P P P FQHCs are highlighted in Yellow As of: September 24,
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6 Bronx RHIO Patient Consent Process Each facility collects facility-specific consent from patient Facilities with Registration/EMR and Data Feed to RHIO: Enter consent value of E, N, or Y into designated consent field in site system Consent message is sent to RHIO automatically and updates RHIO immediately upon receipt Facilities without data feed to RHIO: Enter consent into front end of RHIO system Virtual Health Record, OR Send RHIO a flat file with demographic, MRN and other matching information with consent value. RHIO feeds this into the system via an internally created HL7 message 6
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8 Some Key RHIO Functions for FQHCs Subscriptions for Registration Alerts Referral Routing Data Availability Flags Single Sign-On Analytics Health Home Support 8
9 Registration Alerts 9
10 Subscriptions- An immediate benefit from the HIE A subscription proactively establishes a relationship between a provider and patient and automatically triggers notification to the provider based on specific healthcare related events. A Subscription for Registration Alerts notifies the subscription holder whenever the patient is admitted to or discharged from an ED or Inpatient setting. Consent is not required to establish a subscription, but is required to receive the notification alert. 10
11 Ways to turn ON/OFF a subscription Front end RHIO portal Manual, one by one Provider/User requires appropriate credentials Admit transaction (A04) Covers entire patient population Allows only 1 subscription type for all patients, although can use differentiator like location to set multiple subscriptions Order Message (ORM) Order a subscription Provides Flexibility (trigger, multiple subscription settings) 11
12 Receiving Notifications: RHIO portal Requires appropriate user credentials- out of workflow This option will be replaced by Direct Messaging in the near future Local EMR Requires ability of local system to receive HL7 messages RHIO can provide local MRN when known 12
13 Subscription Data Flow RHIO Provider sets subscription on a Patient Electronic Message sets subscription 13
14 Referral Routing and Reporting 14
15 Electronic Referral Loop Request for Referral Ordered in local EMR system B R O N X Received by Intake team Appointment Scheduled Referring Provider Documented Completed note, or tickler of note availability sent to provider based on Referring provider field* R H I O Appointment Occurs Provider writes note and signs/locks it Referring Provider/Organization Consulting Provider/Organization * Note all reports with referring provider listed are routed 15
16 Data Availability Flags 16
17 Data Availability Flags Patient is registered Does patient have data from other sources? No Yes Display flag in local EMR Create Negative Data Availability Flag Create Positive Data Availability Flag Local EMR BxRHIO 17
18 Single Sign-on 18
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24 Analytics 24
25 RHIO: User with Individual Patient Focus RHIO VHR Views Alerts Subscriptions RHIO VHR DATABASE RHIO Members Patient Care Users and Data Sources: Hospital Inpatient Emergency Hospital Outpatient Community OP Community MD Nursing Home Home Care Community Agency Health Home Other Future Data Sources: Pharmacy Dispensing Data Insurance Claims Other TBD Data DATA BRIC Users with Focus on Groups of Patients BRIC Analysts CLINICAL LOOKING GLASS BRAD DATABASE 25
26 Data for Analytics Data we have today: Unique individuals: almost 2,000,000 Inpatient admissions by facility: 517,965 Outpatient visits: 10,657,647 ER visits by facility: 1,953,465 Lab results by facility: 185,695,676 Medication orders: 11,436,853 Text reports: 7,664,311 Insurance data on most patients Health Home/ACO assignments Data pending: Claims files Nursing Home ADT Scheduling system data Vital Signs Care Management Plans CCDs & CCDAs 26
27 RHIO-Member Type Home Health Agency Hospital Nursing Home FQHC/Outpatient Clinic Care Management/ Health Home ACO Analytics Database Uses for Analytics See where ELSE your patients get care! Identify High Risk Patients: Key clinical indicators Applied to multi-facility data = More complete list of patients at risk Create & Manage Patient Registries: Identify patients Obtain key patient activity data Track clinical progress Obtain more complete data for QARR and HEDIS reporting! 27
28 Health Home and Population Management Program Support 28
29 Patient Identification RHIO can be sent lists of patients in data feed, or RHIO can be sent lists in Excel format through secure Lists must include: Patient demographics Patient consent indicator is YES Assigned care management site &/or care manager 29
30 Active Patient Sample Weekly Report to Site A: Patients with Activity in Report Period Facility A - CHF Patients- Weekly Report -06/09/2014 thru 06/15/2014 Intervention Address ER Utilization IP Utilization OP Utilization Labs Inactive Patient Facility MRN Last Name First Name Date of Birth Age Gender A1 Patient1 A1 07/25/ FEMALE A2 Patient2 A2 12/22/ MALE A3 Patient3 A3 03/27/ MALE A4 Patient4 A4 10/18/ MALE A5 Patient5 A5 11/25/ FEMALE A6 Patient6 A6 06/18/ MALE A7 Patient7 A7 12/22/ MALE A8 Patient8 A8 10/17/ MALE A9 Patient9 A9 02/20/ MALE A10 Patient10 A10 03/05/ MALE 30
31 Sample Report: ER Activity A Facility Intd A - CHF Patients- Weekly Report -06/09/2014 thru 06/15/2014 erd IP Active ER ver Utilizat OP Utilization Labs Inactive Patient Patient Utilization ntie ion MRN Last s NER Facilty ER Admit Date ER Discharge Date ER Admit Diagnosis ER Discharge Disposition on s Serial/ Multiple ER Use Prior ER Visit Date Days Since Last ER Visit >= 4 ER visits past year 00PaMMC 06/18/ /19/2014 NO Diagnosis founadmitted TO H Serial 04/29/ Yes 00Pa SBH 06/19/2014 HND NO FNGR ALUNKNOWN Multiple 05/06/ Yes 00PaMMC 06/16/ /16/2014 NO Diagnosis founadmitted TO H Serial 05/22/ Yes 00PaMMC 06/21/2014 NO Diagnosis foununknown Serial 12/20/ PaMMC 06/19/ /19/2014 OTHER MALAISE ADISCHARGED TO Serial 05/15/ Yes 31
32 Sample Report: Inpatient Activity E n R t e ti Facility UA - CHF Patients- Weekly Report -06/09/2014 thru 06/15/2014 r Active li v IP Utilization OP Utilization Labs Inactive Patient Patient z Facili e a ty Last n IP Facility IP Admit Date IP Discharge Date ti IP Length of Stay MRN ti o (Days) o n n 000Pat MMC 06/19/ Pat SBH 06/19/ Pat MMC 06/16/ Pat MMC 06/17/ Pat MMC 06/20/ Pat BXLEB 06/18/2014 IP Admit Diagnosis Prior IP Admission Date 06/19/ SYNCOPE AND COLLAPSE 04/30/2014 Not disch as CELLULITIS&ABSC of report HAND NO 05/06/2014 Not disch as OTH SPEC of report NONINFLAM 05/23/2014 ASTHMA 06/21/ W/EXACERBAT 06/04/2014 Not disch as of report No Diagnosis found 04/07/2014 Not disch as of report UNSPECIFIED ANEMIA 05/19/2014 Days between readmits 30 Days Readmit? IP Discharge Disposiotion Yes Yes Yes DISCHARGED TO HOME WITH HOME CARE/HHA UNKNOWN IP Discharge in Last 2 weeks UNKNOWN DISCHARGED TO HOME OR SELF CARE 2 UNKNOWN UNKNOWN 1 32
33 Sample Report: Outpatient Activity A Activ d Int IP e d erv Utili Patie r entzatio acility nt e Mst ion Nam n s s 00000tien 00000tien 00000tien 00000tien 00000tien 00000tien 00000tien Facility A - CHF Patients- Weekly Report -06/09/2014 thru 06/15/2014 OP Utilization Labs Inactive Patient Number of Chronic Conditions List of Chronic Conditions CHF, CAD, HTN Mental Health, Diabetes, CHF, CAD, HTN Mental Health, Asthma, Diabetes, CHF, CAD, HTN Diabetes, CHF, CAD, HTN Mental Health, Diabetes, Arthrisis, CHF, HTN CHF, HTN Mental Health, Asthma, Diabetes, CHF, CAD, HTN Number OP visits in last year Last OP Visit Date 21 04/28/ /25/ /21/ /23/ /09/ /28/ /06/
34 Sample Report: Laboratory Activity Inter venti Facility A - CHF Patients- Weekly Report -06/09/2014 thru 06/15/2014 Active Address ER Utilization IP Utilization OP Utilization Labs Inactive Patient Patient on ility MLast Name First Name Number of labs in last 30 days 0000 atient A atient A atient A9 251 Lab Test (Click on each cell below to activate drop down menu) 1-GLUCOSE-GLUCOSE 1-HEMATOCRIT- HEMATOCRIT 1-HEMATOCRIT- HEMATOCRIT Lab Numeric Value Abmormal/ Normal ABOVE HIGH NORMAL-H BELOW LOW NORMAL-L BELOW LOW NORMAL-L 34
35 Sample Report: Laboratory Activity 35
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