Population Health and Care Coordination

Vision Mission Guiding Principles Our Vision To advance health and wellness by deploying health information technology solutions adopted through cooperation and collaboration. Our Mission We will enable and support the healthcare community of Maryland and our region to appropriately and securely share data in order to facilitate care, reduce costs, and improve health outcomes. Our Guiding Principles 1. Begin with a manageable scope and remain incremental. 2. Create opportunities to cooperate even while participating healthcare organizations still compete in other ways. 3. Affirm that competition and market-mechanisms spur innovation and improvement. 4. Promote and enable consumers control over their own health information. 5. Use best practices and standards. 6. Serve our region s entire healthcare community.

Care Coordination Support CRISP is developing infrastructure to support the Integrated Care Network and population health programs Continuing efforts from the HSCRC s Care Coordination Workgroup Alignment with HSCRC and waiver initiatives Resources to support hospital, regional, and other provider-based collaborations Data connectivity and sharing Population-based reporting, reporting across facilities Other needs to support partnerships

Clinical Query Portal The clinical query portal allows credentialed users to search the HIE for clinical data. All 47 acute care hospitals in Maryland and 6 of 8 DC hospitals share clinical data. Currently over 100,000 queries per month Types of data available: Patient demographics Lab results Radiology reports PDMP Meds Data Discharge summaries History and physicals Operative notes Consult notes

Clinical Query Portal Enhancements Care Alert Available! (Click to View) Click to View Full Care Profile ENS Subscribers to this Patient Johnson Family Medicine 410-555-7676 Readmission Risk: 76

Encounter Notification Service Current Capabilities CRISP currently receives Admission Discharge Transfer messages in real-time from: All Maryland Acute Care Hospitals 6 of 8 D.C. Hospitals All Delaware Hospitals Through ENS, CRISP generates real - time hospitalization notifications to PCPs, care coordinators, and others responsible for patient care. Full Continuity of Care Documents (CCDs) are also routed through ENS to subscribing providers, who elect to receive them to support transitions of care. 10 Hospitals currently send CCDs to CRISP Hospitals can auto-subscribe so they can be alerted when one of their past discharges is being readmitted within 30 days. 34 hospitals currently auto-subscribe to receive readmission notifications

Near-term Additional Approaches for ENS CRISP will also offer an ENS user interface rather than simple spreadsheet via secure email. Users will still have the ability to download the spreadsheet.

CRISP Reporting Services (CRS) Reports generated from a collection of data sources to support quality improvement, strategic planning, financial modeling, and other activities Originally focused on hospitals, but expanding to public health departments, regional partnerships, and ambulatory providers Allowable data use varies based on the amount of detail included Example: Patient-level detail in new Patient Total Hospitalization (PaTH) Dashboard is only permitted to be used for care coordination activities

CRISP Methods for Reporting CRS Portal Internet-based Distributes static reports, includes archived reports Evolved from emailing users In use for over 2 years Patient-level data Target audience: Hospitals Tableau Internet-based Separate entry point from Portal, shared credentialing Mostly aggregated data; patient level data piloting Portals for Hospitals, Ambulatory Providers, and Populations

CRS Portal

CRS Portal Folders with reports Each folder is separately credentialed Patient level details are separately credentialed from the aggregate reports

Tableau Portal Some hospitals already using Tableau to view reports Additional hospitals will pilot Tableau with access to the PaTH dashboards Access limited to care coordination activities (per data policy and EUA) CRISP and the pilot hospitals partner for continued feedback and development

CRS Favorites with Added Value Filters

CRS Favorites with Added Value Filters Filtering for Medicare

New Content Based on Portal Reports

New Reporting and Analytics Tools The CRS team is enhancing the care network infrastructure for reporting and analytics Developing tools and information to support: 1. High-Risk Patient Identification 2. Regional Coordination and Planning 3. Performance Measurement

Population-Based Patient Identification

High-Risk Patient Identification

Standardized Risk Stratification Tools Risk Stratification Methodology Statewide Hospital Visits Data (CRS Database) Standardized and shared risk stratification and predictive modeling tools Supporting common understanding high risk patients Data feeds to provider care management systems Risk scores available through broader set of CRISP tools Note: Over time, additional data, such as Medicare claims data, can supplement the currently available hospital case mix data.

Regional Coordination and Planning

Population-Based Coordination

Hospital Services Coordination

Panel-Based Information

Performance Measurement

Privacy and Security All CRISP services are fully compliant with State and Federal Regulations, and HIPAA. CRISP adheres to industry best practices, such as: Passwords must be 8 characters, contain 3 character types, and change every 90 days All PHI is encrypted in transit; all PHI will be encrypted at rest in January Client-side rendering is limited or removed from Tableau reports, and users are encouraged to clear their web browser cache after viewing reports All participating organizations must distribute opt-out information to patients. CRISP is working to enhance patient information shared by providers, as well as developing more granular consent policies.

Cross-Facility Report Credentialing Patient-level, cross-facility reports additional user requirements: Individual execution of End User Agreement User verification through photo ID (drivers license or hospital) Hospital point of contact approval CRS Operations procedures: Document/verify all user forms Add user to Tableau server and set all related permissions Separate Ops team member provide quality assurance Contact user for access and any required training Disable accounts that are inactive for 60 days

CRS Table of Contents As of November 9, 2015 Portal Content Available Credentialed Users Utilization of CRISP Services Currently Portal Summary Maryland Hospital Acquired Conditions Currently Portal Summary, Portal Patient-Level Potentially Avoidable Utilization Currently Portal Summary, Portal Patient-Level Readmission Summary Report Currently Portal Summary Readmission by Discharge Service Line Currently Portal Summary Readmission Trends Currently Portal Summary Readmission Reduction Program Currently Portal Summary Readmission Patient-Level Details Currently Portal Patient-Level Transfers Currently Portal Summary, Portal Patient-Level Quality-Based Reimbursement Q1 2016 Portal Patient-Level

CRS Table of Contents As of November 9, 2015 Tableau Content Available Credentialed Users All Hospital Readmission Report Currently Tableau Summary (Hospital Only) Inpatient Readmissions by Region Currently Tableau Summary (Hospital Only) Readmissions by Clinical Service Line Currently Tableau Summary (Hospital Only) Readmission Trends and Locations Currently Tableau Summary (Hospital Only) Service Line Readmission Analysis Currently Tableau Summary (Hospital Only) Medicare Chronic Conditions Maps Currently Tableau Summary Emergency Department High Utilizers Currently Tableau Summary Inpatient Hospitalization High Utilizers Currently Tableau Summary Patient Total Hospitalizations Summary Currently Tableau Summary (Hospital Only) Patient Total Hospitalizations Details Q4 2015 Tableau Patient-Level

Upcoming Products Patient Identification Risk stratification tools/methodologies applied Enhancements to Patient Total Hospitalizations reports Admission and discharge analysis Services Coordination Regional and cross-hospital patient utilization mapping Population-based Preventive Quality Indicator dashboards Panel-based trends and utilization reports Performance Measurement Core metrics dashboard Benchmarking for regions and providers

Next Steps to Utilize CRS Identify users to CRISP for credentialing CRS Portal Tableau Dashboards Share feedback on CRISP Reporting Services Additional filters, dashboards, data elements to support care coordination and alignment programs Participate in regular conversations about the CRS offerings Contact CRISP with questions

Contact: Craig Behm, Director of Reporting and Analytics Office: 410.872.0823 Cell: 410.207.7192 Email: craig.behm@crisphealth.org