Ecosystem a member of the ECHAlliance International Ecosystem Network
Using data to support better healthcare outcomes Flavia Rovis, PhD Director Cerner Population Health Europe Deployment
Our strategy: shifting from reactive care to proactive health Know identify and predict what will happen within your population Engage people, their family and care providers to take action Manage outcomes to improve health and care
Our approach Connect the continuum Clinic Hospital Home Empower people, care teams and organizations Employer Person Fitness Center Facilitate knowledge-driven care and continuous learning to move from reactive care to proactive health. School Retail Pharmacy Long-Term Care
Single source of truth While EHRs have successfully digitized some health care information, convenient and personalized care will only be achieved through the integration of data from sources within and outside the EHR platforms. Alistair Erskine, MD Chief Informatics Officer
HealtheIntent: a peek inside the engine
Create a unified person view
We are using [HealtheEDW] to give visibility to information and provide transparency into what s really happening. Data analysis Amanda Hammel Vice President IT Operations and Population Health
HealtheAnalytics & HealtheEDW: strategic analytics Aggregates and normalizes disparate data Utilizes industry-leading analytic visualization tools (SAP BusinessObjects and Tableau) Provides pre-built, visually organized data models and content with drilldown capabilities Incorporates alerts, trends and targets Need resources? We offer analytics and reporting services.
HealtheAnalytics & HealtheEDW: drillable insights Displays new level of detail by clicking on data elements Conveys various attributes of a population Conducts advanced analyses to isolate specific groups Shows trends, aggregates population measures and drills down to specific lists Filters by demographic, clinical, in/out of network and geographic information
Actionable insights within the workflow One provider and nurse have adapted the workflow in their office to incorporate the HealtheRegistries measures. The nurse in the past was spending her lunch hour pulling the same information for the next day s appointments. Cindy Schaefer Director of Clinical Transformation
HealtheRegistries: chronic condition & wellness management Identifies a population for registries and appropriate measures Provides visibility to the quality measures for the provider s population and performance Produces client-defined, performance scorecards at specific or rollup levels Provides executive dashboards with drill-down capabilities
HealtheRegistries: standard content Cerner registries Chronic disease Atrial fibrillation Asthma Chronic kidney disease COPD Depression Diabetes Heart failure Hepatitis C Hypertension IVD/CAD Lipid management Rheumatoid arthritis Pediatric chronic disease Asthma Cardiomyopathy Children w/ medical complexity Cystic fibrosis Diabetes Down s syndrome Epilepsy Inflammatory bowel disease Neonatal follow up Sickle cell Cancer Breast cancer Colon cancer Leukemia Prostate Myelodysplastic syndrome Acute conditions Ambulatory urgent care Back pain Zika Wellness Adult wellness Adolescent wellness Childhood wellness Childhood & adolescent immunizations Comprehensive adult wellness Maternity health Pediatric wellness Senior wellness Regulatory registries ACO AHRQ HEDIS MIPS MA STAR
Behind the scenes: infer new knowledge Allergies Conditions Medications Procedures 5 10 210 lbs. 129/85 mm Hg 3,200 steps / day Immunizations Visits Pre-hypertension? Un-diagnosed individual Lab results Vitals Hyperlipidemia registry
Predictive models: Transitions of Care and Readmissions Deliver proactive recommendations and decision support into the workflow Use clinical and financial intelligence data from internal and external sources
Transfer of Care study Cerner-Advocate Health Care (Chicago) partnership (8 hospitals and various post acute care services) Relative risk of hospital readmission for patients receiving post-acute care (PAC) at different care settings Improved PAC coordination reduces costs and improves quality of health Home, Home Health Agency (HHA), Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Long Term Care Hospital (LTCH) Methods: Matched patients on clinical needs Propensity Score Matching Method Discharge to different PACs Examine 30 days readmission rate Stat significance p<0.05 SNF and HHA patients had a higher risk of hospital readmission than PAC patients receiving home care Concerns on infections and delayed return to independence https://www.omicsonline.org/open-access/hospital-readmission-after-postacute-care-at-different-settings-estimationusingthe-propensity-score-matching-method-2161-0711-1000408.php?aid=71975
Reducing avoidable readmissions
Open development
Extend and expand capabilities into existing applications
Client collaboration
145+ HealtheIntent signed clients and counting *Information is current as of Feb. 2018
Together, we can make a difference.