As healthcare providers across the country seek to transition from fee-for-service to value-based care delivery and payment, many are trying to tackle the complexities involved in transforming from the traditional siloed care model into a network care model, which enables increased care coordination and effective population health management, both of which are foundational to value-based care. The majority of healthcare providers undertaking this work are facing monumental challenges related to combining clinical data from multiple health information systems with paid claims data, analyzing the data and then delivering actionable information back to clinicians at the point of care. It’s a capability that few provider organizations, thus far, have achieved, which makes the Cincinnati-based Mercy Health’s groundbreaking work in this area all the more impressive.
Clinical and IT executive leaders at Mercy Health are now successfully integrating population health analytics into the clinical workflow as part of an overall effort to achieve meaningful population health management. For their trailblazing work, the editors of Healthcare Informatics have named the Mercy Health team the co-second-place winning team in our Innovator Awards Program this year.
Essentially, this population health informatics project has been the result of a strategy to combine the technological capabilities of Mercy Health’s enterprise Epic electronic health record (EHR) and IBM Watson Health Explorys’s analytics platform, along with a generous amount of good old-fashioned elbow grease by the Mercy Health project team.
Mercy Health, the largest health system in Ohio and one of the largest health systems in the United States, operates about 450 health facilities, including 23 hospitals, eight senior living communities, five hospice programs and seven home health agencies in Ohio and Kentucky. J.D. Whitlock, vice president of enterprise intelligence, says the health system started its population health journey in 2011 when it’s clinically integrated network, Mercy Health Select, was selected to participate in the Centers for Medicare & Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP) accountable care organization (ACO) model. According to Mercy Health executive leaders, Mercy Health Select generated more than $15 million in savings in 2014. Today, Mercy Health’s value-based contracting programs include the MSSP ACO, which now covers close to 70,000 beneficiaries, as well as four Medicare Advantage programs and the employee health plan, for a total of 130,000 lives covered.
Essentially, as the result of the project team’s work to integrate its Epic EHR and Watson Health analytics, project leaders are using paid claims and clinical data to define populations, generate advanced risk scores and integrate them back into the Epic workflow. As a result, ambulatory care coordinators and primary care providers are able to leverage advanced and prospective risk scores within the EHR workflow, which significantly facilitates the work of identifying high-risk patients and improving care coordination.
An Evolving Technology Strategy
Whitlock credits the health system’s executive leadership, in particular CIO Becky Sykes, with making key, forward-leaning decisions back when Mercy Health began its ACO work that has helped to propel its population health management informatics work forward. As the executive sponsor for this project, Sykes drove the vision and execution of Mercy’s large single-instance Epic deployment with collaborative build and clinician-led optimization. Of the 650 primary care providers that participate in the Mercy Health Select MSSP ACO, 96 percent are on the health system’s single-instance of Epic, including both employed primary care providers as well as affiliate PCPs. “That makes all the difference in the world to be able to do these things efficiently,” Whitlock says.
Recognizing the need for a population health platform, Mercy Health also partnered with Cleveland-based Explorys back in 2011 to implement its population health strategy. [IBM acquired Explorys in 2015 and it is now a part of IBM’s Watson Health unit.] “When we kicked off our ACO work, back at the end of 2011, [Sykes] recognized some of [Explorys/Watson Health’s] capabilities very early. She also had resourced this work, so that everyone on the team had time to work on this project, understanding that it’s complex and it takes longer than you think it will,” Whitlock says.
According to Mark Binstock, M.D., associate medical information officer at Mercy Health, two years ago, when the health system really pushed forward into population health management, the capability to integrate paid claims data and clinical data was not a strength or functionality of the Epic platform. And so, Mercy Health physician and IT leaders saw an opportunity to leverage the strengths of Epic’s Healthy Planet platform—workflow integration, clinical decision support, the patient portal and patient outreach—with the strengths of Watson Health, namely, data aggregation from multiple EHRs and paid claims from multiple payers, as well as advanced risk scores and machine learning.
The project team was comprised of IT and clinical leaders, including Sykes, as the executive sponsor, Whitlock, as the solutions architect for the project, Binstock, Aaron Thomas, CarePATH team lead, population health, and Gary Grazak, population health IT senior director.