HealthVisions. Delmarva. improved health, healthcare quality and experience, lower healthcare costs and improved provider experience

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1 HealthVisions Delmarva improved health, healthcare quality and experience, lower healthcare costs and improved provider experience 1

2 Randy Farmer, MS, M Ed Mr. Farmer joined the DHIN in September of 2011 and currently serves in the role of Chief Operating Officer. As the DHIN s COO, Mr. Farmer is responsible for all customer facing aspects of the organization, specifically in the areas of new business strategies, marketing, product development, operational support and customer service. Mr. Farmer joined the DHIN after a decade at JP Morgan Chase in Wilmington, where he served most recently as senior segment manager of strategic partnerships. He also served as senior communication and public affairs manager during his 10 years at Chase. Prior to working in financial services, Mr. Farmer served as the Director of Student Development at Villanova University. He earned a Master of Science in Human Organization Science at Villanova, as well as a Master of Education in Higher Education Administration, and a Bachelor s degree in communication from the University of Delaware. Lakeisha Moore, MBA Ms. Moore joined the DHIN in September of 2011 as a Provider Relationship Manager and was promoted to the role of Director of Provider Relations in Reporting directly to the DHIN s Chief Operations Officer, Moore focuses on strengthening the relationships and strategic partnerships with DHIN s Healthcare Provider Community. Ms. Moore joined the DHIN after six years with Merck and Co., where she covered the Eastern North Carolina Territory as a Pharmaceutical Sales Representative. During her time with Merck, Ms. Moore was promoted to a Territory Manager where she continued to work with various healthcare providers and mentored new representatives in her sales region. Before joining Merck, Ms. Moore worked as a TV technical news director and in TV news promotions. Moore earned a Masters of Business Administration in Pharmaceutical Chemical Studies from Fairleigh Dickinson University and holds a Bachelor s degree in Communications/Broadcast Production from North Carolina A&T State University.

3 Randy Farmer and Lakeisha Moore have both indicated that they have no financial conflicts of interest relevant to this presentation.

4 Describe how DHIN products and services align with the DE SIM, PTN & ACO practice transformation metrics Identify ways to leverage DHIN products and services to achieve Practice Transformation and improve patient outcomes

5 SIM/PTN Learning Session DHIN Presentation Randy Farmer Chief Operating Officer Delaware Health Information Network Lakeisha Moore Director of Provider Relations Delaware Health Information Network November 15, 2016

6 Introductions About the Delaware Health Information Network (DHIN) DHIN Community Health Record Demo Overview of DHIN Resources DHIN ONC Grant Next steps

7 The MS Outlook & Google of Health IT DHIN Delivers Medical Results 14MM Deliveries Per Year DHIN Provides Previous Medical Results On-Demand 11,000 Users 2.2 MM Patients 100% DE Hospitals Public Health Approaching 100% of doctors who make orders Catalogs of patients from all 50 states 3 from Maryland 99% Labs 95% Rads Syn. Surveillance Immunization Registry Cancer Registry Dep t of Corrections

8 Current Participation in DHIN (as of April 2016) Data Senders Hospitals 100% All DE acute care hospitals, + 3 border hospitals in MD Laboratories ~100% All major reference labs, + Public Health lab + several smaller independent labs, including 2 NJ based Imaging Centers -- ~ 95% All hospital based imaging centers, + majority of freestanding Neighboring State HIE 1 DHIN exchanges hospital and ED discharge information with Maryland s HIE Pharmacies (IZ Update) -- ~62% Ambulatory Practices (CCD) -~9% Data Receivers/Users Providers ~ 98% Plus providers in bordering states with affiliations in DE FQHCs 100% School Based Clinics 100% Urgent Care/Walk-In Facilities 82% Skilled Nursing Facilities 100% Assisted Living 90% Home Health 59% Hospice 50% Behavioral Health 40% State Agencies State epidemiologists Immunization registry Cancer registry Department of Corrections Health Plans 49% of DE residents covered by payers/plans supporting DHIN financially

9 DHIN Data Senders * * * mercy diagnostics Coming Soon * These data senders make radiology images available in the CHR

10 PTN/SIM/ACO Measures PTN PC Measure Description 1 Improvement Sustainability SIM Measures Description 2 Reducing Unnecessary Tests 3 Reducing Unnecessary Hospitalizations Milestone 1 Panel Management 4 Patient and Family Engagement - Collaboration in Care 5 Patient and Family Engagement - Feedback 6 Team-Based Relationships - Functions & Responsibilities Milestone 2 Access Improvement 7 Team-Based Relationships - Continuity 8 Population Management - Empanelment Milestone 3 Care Transitions & Follow-Up 9 Population Management - Risk Stratification 10 Population Management - Care Management for High Risk Milestone 4 24/7 Access to Panel Members 11 Community Partner 12 Coordinated Care Delivery - Medical Neighborhood 13 Coordinated Care Delivery - F/U After Discharge Milestone 5 Prep for High Risk Care Plans 14 Coordinated Care Delivery - Care Coordination Integration Milestone 6 Reduce ED Overutilization 17 Enhanced Access 18 Engaged & Committed Leadership Milestone 7 Preventative Care 19 QI Strategy - Organized, Identified Approach 20 QI Strategy - QI Mindset Integration Milestone 8 Implement High Risk Care Plans 21 Transparent Measurement & Monitoring 22 Optimal Use of HIT Milestone 9 Plan for BHI 23 Strategic Use of Practice Revenue 24 Staff Vitality & Joy in Work 25 Capability to Analyze & Document Value: Business Acumen 26 Capability to Analyze & Document Value: Readiness for VBPM 27 Efficiency of Operation 15 Organized EB Care - Holistic Care 16 Organized EB Care - Reports & Registries ACO Measures ACO-1 ACO-2 ACO-3 ACO-4 ACO-5 ACO-6 ACO-7 ACO-34 ACO-8 ACO-35 ACO-36 ACO-37 ACO-38 ACO-9 ACO-10 ACO-11 ACO-39 (CARE-3) ACO-13 (CARE-2) ACO-14 (PREV-7) ACO-15 (PREV-8) ACO-16 (PREV-9) ACO-17 (PREV-10) ACO-18 (PREV-12) ACO-19 (PREV-6) ACO-20 (PREV-5) ACO-21 (PREV-11) ACO-42 (PREV-13) ACO-40 (MH-1) ACO-27 (DM-2) ACO-41 (DM-7) ACO-28 (HTN-2) ACO-30 (IVD-2) ACO-31 (HF-6) ACO-33 (CAD-7) Description Access to Care Provider Communication Patient Satisfaction Access to Specialists Health Education Shared Decision Making Health Status Stewardship of Patient Resources Risk Standardization Skilled Nursing Facility Unplanned Diabetes Admissions Unplanned Heart Failure Admissions Unplanned MCC Admissions ACSC: COPD or Asthma ACSC: Heart Failure Meet Meaningful Use Medications in Medical Record Fall Risk Screening Influenza Immunization Pneumonia Vaccination BMI Screening & Follow-Up Tobacco Screening & Cessation Depression Screening & Follow-Up Colorectal Cancer Screening Breast Cancer Screening HBP Screening & Follow-Up CVD Prevention & Treatment Depression Remission (12 Months) Diabetes Poor A1C Control Diabetes Eye Exam Controlling HBP IVD: Treatment w/antithrombotic Heart Failure: Beta Blockers CAD: Treatment

11 PTN/SIM/ACO Measures PTN PC Measure SIM Measures Milestone 1 Milestone 2 Milestone 3 Milestone 4 Milestone 5 Milestone 6 Milestone 7 Milestone 8 Milestone 9 ACO ACO-1 ACO-2 ACO-3 ACO-4 ACO-5 ACO-6 ACO-7 ACO-34 ACO-8 ACO-35 ACO-36 ACO-37 ACO-38 ACO-9 ACO-10 ACO-11 ACO-39 (CARE-3) ACO-13 (CARE-2) ACO-14 (PREV-7) ACO-15 (PREV-8) ACO-16 (PREV-9) ACO-17 (PREV-10) ACO-18 (PREV-12) ACO-19 (PREV-6) ACO-20 (PREV-5) ACO-21 (PREV-11) ACO-42 (PREV-13) ACO-40 (MH-1) ACO-27 (DM-2) ACO-41 (DM-7) ACO-28 (HTN-2) ACO-30 (IVD-2) ACO-31 (HF-6) ACO-33 (CAD-7)

12 Milestone #1: Identify the 5% of panel at the highest risk and highest priority for care coordination. Milestone #2: Provide same-day appointments and/or extended access to care. Milestone #3: Implement a process of following up after patient hospital discharge. Milestone #4: Supply voice-to-voice coverage to panel members 24/7 (e.g., patient can speak with a licensed health professional at any time). Milestone #5: Document sourcing and implementation plan for launching a multidisciplinary team working with the highest-risk patients to develop a care plan.

13 Milestone #6: Document plan to reduce emergency room overutilization. Milestone #7: Implement the process of contacting patients who did not receive appropriate preventive care. Milestone #8: Implement a multi-disciplinary team working with highest-risk patients to develop care plans. Milestone #9: Document a plan for patients with behavioral health care needs.

14 Practice Milestones and DHIN Resources Event Notification System Continuity of Care Documents Analytics Platform Direct Secure Messaging Other DHIN Services Milestone #1 PHR Milestone #2 MD Live Milestone #3 Milestone #4 MD Live Milestone #5 mpulse/phr Milestone #6 MD Live Milestone #7 PHR Milestone #8 PHR Milestone #9 PHR

15 DHIN Community Health Record (CHR) Login Page Website: five.dhin.net Key points when using the DHIN Community Health Record (CHR) Do not share your username and password with anyone Do not use another person s username and password Everything in DHIN leaves a fingerprint and audits are run regularly Only use DHIN for clinical need to know purposes

16 Patient Search Patient Search

17 Patient Search Access Additional Records

18 Patient Summary Patient Summary

19 Encounters Encounters

20 Results Clinical Results

21 Medications Medication History

22 Continuity of Care Documents CCD and other Documents

23 Documents: CCD CCDS and other C-CDA Documents

24 Direct Secure Direct Secure

25 Direct Secure Direct Secure

26 What is the Event Notification System Event Notification System (ENS) delivers hospitalization alerts from Delaware Health Information Network (DHIN) participating acute care facilities to DHIN enrolled practices Event Notification System (ENS) promotes care coordination Event Notification System (ENS) can be a revenue-driving service

27 Event Notification System (ENS) Snapshot PRACTICE Practice generates a panel of their active patients(csv/tab delimited Excel), provides to DHIN DHIN DHIN loads the panel into ENS, and identities are created/updated in DHIN s IBM Initiate system Trigger type: Practice determines frequency & type of updates (Full or Change Only). How will Panels be managed? Consolidation? ENS As ADTs come into the DHIN ENS infrastructure, they are compared to the identities in ENS REPORT When there is a match, ENS delivers a notification based on the Practice s preferences Trigger type: ED or inpatient admit or discharge Frequency: Real time, daily batch, other Method: SFTP, DIRECT, HL7

28 Event Notification System Delivered via Secure File Transfer Process (SFTP)

29 Additional DHIN Services Common Provider Scorecard / Analytics Milestones 1,3, 5-8 First technology project for the State Innovation Model grant the foundation for a richer set of analytic capabilities. Consumer Engagement Milestones 1-2 & 4-9 Electronic tools to help patients connect directly with their medical information.

30 The Common Provider Scorecard

31 The Common Provider Scorecard Initially, measures will be sourced through claims, to include CPT II codes We will switch to clinical sources of data as quickly as possible Data feeds from the participating practices to DHIN will be needed Enrollment is open now at: hde.com/

32 Consumer Products MD Live Telehealth Service Milestones 2, 4 & 6 24/7 access to clinical professionals For non-emergency issues featuring DHIN enrolled Doctors Consumer Portal Personal Health Record (PHR) Milestones 1 &7-9 Access patient information in the DHIN Community Health Record Consumer Alerts Milestone 5 mpulse Smart phone alerts on activity in the CHR

33 ONC Grant Award One of 12 Orgs to receive part of $29MM Asked for $3M received $2.75M Help EP s Meet Meaningful Use Stage 2 and the proposed Rules for Stage 3. Also help Non-EP s (Eligible Providers) and segments left out from the last Cooperative Agreement

34 Summary of Grant Work Eligible Providers ADT- based alerts (ENS) CCD (Care Summary) exchange Analytics (scorecard and more) Behavioral Health and Long Term Post Acute Care (LTPAC) Promulgate use of Direct Develop Directory Services (Provider Directory) LTPAC care summaries into the DHIN Community Health Record (via Vorro Health) Consumers/Individuals State-wide patient portal (PHR)

35 Wrap Up and Next Steps SERVICE COST DATE AVAILABLE HOW TO ENROLL Encounter Notification Service (ENS) Free through July 2017 for Eligible Professionals NOW DHIN Relationship Manager or e- mail Continuity of Care Documents (CCD) Free through July 2017 for Eligible Professionals NOW DHIN Relationship Manager or e- mail Analytics Platform (IMAT) Free through July 2017 for Eligible Professionals NOW DHIN Relationship Manager or e- mail Direct Secure Messaging (DIRECT) Free through July 2018 NOW DHIN Relationship Manager or e- mail MD Live (Telehealth) Variable cost Winter 2016 mpulse (Consumer Alerts) TBD Winter 2016 Personal Heath Record (PHR) TBD Anticipated Q1 2017

36 Randy Farmer, DHIN COO (302) Lakeisha Moore Covering CCHS Campus Practices Jamie Rocke Covering Nemours, Saint Francis and Union Hospital Practices Michael MacDonald Covering Sussex County, Peninsula Regional Medical Center and Atlantic General Hospital Garrett Murawski (302) Covering All of Kent County, Middletown, New Castle, Bear, and Newark, DE Ed Seaton (302) Covering New Castle County (Wilmington)

37 A Health Information Ecosystem in which all participants both contribute and receive value

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