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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.

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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.

 

 


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All of Us Team Building Data Browser, Researcher Workbench

January 23, 2019
by David Raths, Contributing Editor
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Software tools to help researchers explore, analyze research data set

As the national All of Us research program begins collecting health data, its Research Hub, which will house an array of data collected in the program, is developing software tools to help researchers explore and analyze the All of Us Research Data Set.

The Data and Research Center (DRC) located at Vanderbilt University Medical Center houses the All of Us research database. In a newsletter, the Research Hub noted that in 2019 it expects to release information that participants provided via surveys, physical measurements, and electronic health records. Researchers will be able to access participant research data, with personal identifiers removed in order to explore how various factors contribute to individual health and disease.

The EHR information included depends on what kinds of healthcare has been received and what types of providers a patient has seen. The All of Us Research Program employs Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) Version 5 infrastructure to ensure feasibility and standardization across EHR data for researchers. EHR data will be accessed longitudinally throughout the life of the program. Within the context of the Research Hub tools, EHR data will be presented at the highest level of granularity, which is by EHR Domain. Domains include: Demographics, Conditions, Procedures, Drugs, Measurements, and Visits.

In the first half of 2019, the DRC plans to release a Data Browser that will allow anyone to view aggregate counts of participant research data. Counts will be available for survey data collected from participants, physical measures collected during exams, and medical concepts from electronic health records (EHR) data. This tool will be available to anyone, with no registration or login required.

A “Researcher Workbench” is slated for release by the end of 2019. The Workbench is an analysis platform designed for researchers to create cohorts of individual-level participant research data, review these cohorts, and analyze and visualize the data in a Jupyter notebook using Python or R.

The initial version of the Workbench provides three tools for working with data:

• Workspaces: Create a project workspace. Store cohorts and notebooks. Share with team members.

• Cohort Builder: Build and review a custom data set.

• Notebooks: Analyze your cohort. Create graphs or tables to showcase your work.

To ensure participant privacy, researchers will be required to register and verify their identity in order to use the Workbench.

The DRC noted that it has sought input from an array of potential users of the Research Hub, collated their feedback, and leveraged these insights to help guide iterative development of the tools. 

Currently, the Research Hub is in its first beta launch within the DRC. The purpose of this release is to open the Research Hub up to vigorous internal testing that includes quality control, quality assurance, data characterization, data validation, and user testing as well as security and functionality testing. 

 

 

 

 

 

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Pediatric Asthma Care Management Program Extends to 7K Schools Nationwide

January 21, 2019
by Rajiv Leventhal, Managing Editor
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A regionally-established pediatric asthma care management program, which includes leveraging a student health record platform, is extending its reach.

Children's Hospital Colorado, the University of Colorado School of Medicine at CU Anschutz Medical Campus, and New York City-based pediatric healthcare technology company CareDox recently announced a new collaboration to scale the reach of the hospital's in-school asthma management program.

CareDox modeled this collaboration after the hospital's "Building Bridges for Asthma Care Program," which began in 2012, and is now offering its new care management platform to the more than 7,100 K-12 schools where the company's student health record platform and wellness services are already deployed.

By combining proven clinical protocols with widely deployed technology and wellness services operations, the three organizations “are poised to dramatically improve outcomes for pediatric asthmatics across the country,” officials of this partnership have attested.

The Building Bridges for Asthma Care Program is now deployed in 28 public elementary schools in Denver, Colo. and Hartford, Conn. The school program in Colorado was developed by Stanley Szefler, M.D., director of the pediatric asthma research program at Children's Hospital Colorado and the CU School of Medicine. Throughout the school year, school nurses train their students on asthma management, inhaler technique and other clinical best practices, and the students' absenteeism, physical activity and asthma control levels are monitored by nurses and communicated to their parents and healthcare providers.

In a study of the impact of the program published in the Journal of Allergy and Clinical Immunology, participants in the program experienced a 22-percent decrease in school absenteeism. Officials have noted that currently, approximately six million children under the age of 18 have asthma. It’s the top reason for missed school, totaling nearly 14 million days each year. Socioeconomically disadvantaged children and minority children are disproportionately affected by asthma. In these two groups, asthma is more often left uncontrolled, leading not only to absenteeism, but also disrupted sleep.

CareDox’s asthma care management program is already in use in the Clay County district schools in Florida, where there are more than 3,700 students who are known to have asthma. In addition to those students, CareDox leveraged medical data that resides on their student records platform to identify 345 additional students who are eligible for the program that weren't already known to school nurses and health officials as asthmatic.

In just three months, CareDox has already implemented the proven Children's Hospital Colorado/CU School of Medicine protocols to qualify about 1,200 students with asthma into the company’s asthma management program, of which 349 are eligible for CareDox's expanded care program for severe uncontrolled asthma.

The expanded care program includes four key components to address uncontrolled asthma among student populations, according to officials. One of these elements is the technology-enabled identification of new enrollees, which CareDox will leverage its student health record platform and enrollment processes for wellness services (flu and other vaccines, annual wellness checks) to screen for eligible asthma students.

"Children's Hospital Colorado and CU School of Medicine providers created the Building Bridges for Asthma Care Program to address the risk of health disparities and asthma-related absenteeism, as well as its related impact on academic achievement for inner city students," Robin Deterding, M.D., director of the Breathing Institute at Children's Hospital Colorado,  medical director of the Hospital's Center for Innovation and professor of pulmonary medicine in the Department of Pediatrics at the CU School of Medicine, said in a statement. “Building Bridges has proven that a school-centered asthma management program can have a positive impact on pediatric health and ultimately reduce asthma-related absenteeism within a school's population. Now by partnering with CareDox, we have the ability to drastically expand the program's footprint and reduce asthma-related absenteeism on a massive scale,” he added.

Like CareDox's existing school vaccination and annual wellness check programs, the company’s asthma care management program will be offered to eligible students at no cost to the student, their parents or the school district. CareDox partners with public and private health insurance to support the program, officials stated.

 

Related Insights For: Population Health

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Kaiser Creating Evidence-Based Complex Care Models

January 17, 2019
by David Raths, Contributing Editor
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Work aligns with recently published ‘Blueprint for Complex Care’

The National Center for Complex Health and Social Needs recently published a “Blueprint for Complex Care” to develop a collective strategy for promoting evidence-based complex care models. Recognizing that many patient issues have root causes that go beyond the medical, the Blueprint seeks to identify best practices for breaking down silos between the social care delivery system and healthcare.

Perhaps no health system has devoted as many resources to complex care as Kaiser Permanente. Its Care Management Institute, a joint endeavor between the Permanente Medical Groups and Kaiser Foundation Health Plan, has established Complex Needs as one of its national quality initiatives. It has named regional complex care leaders, created common quality measures across regions and established a complex need research arm called CORAL. (Kaiser Permanente has eight Permanente Medical Groups and regions, more than 12.2 million members, more than 22,000 physicians and 216,000 employees.)

In a Jan. 16 webinar presentation, Wendolyn Gozansky, M.D., vice president and chief quality officer, Colorado Permanente Medical Group and national leader for complex needs at the Care Management Institute, described Kaiser Permanente’s efforts and used some personal anecdotes to explain their goals.

She said Kaiser Permanenteis working on the concept of developing core competencies and tools to support a longitiudinal plan of care for patients with complex needs. “These are the folks for whom the usual care is not meeting their needs,” she said. “How do you recognize them and make sure their needs are being met?”

Gozansky gave an example from a patient she had just seen the previous wekend. This women had fallen and broken her hip. She had several chronic conditions, including significant asthma, yet she was not on an inhaled steroid.

“One concept I love from the Blueprint is that this field is about doing whatever it takes to meet the needs of the person in front of you,” she said. In speaking to the woman, she came to understand that singing in a church choir was the most important thing in her life, and the inhaler medication was making her hoarse and unable to sing.  She was fairly isolated socially except for church. “My goal was to get her rehabbed and leverage the patient-defined family that is supportive. Her goals are to sing, so we need to do what is possible to get her back to that. We have to capture that information, put it into a long-term plan of care. The goal is not to get her out of rehab but to get her singing in choir.”

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The health system has to work on care that is preference-aligned. The woman is not on a steroid inhaler but her care is preference-aligned. How does the health system assure that everyone knows they are doing the right thing?

Gozansky said the beauty of Permanente Medicine is that its setup involves an employed medical group focused on value, not volume. They can interact with health plan partners in delivery of new systems of care. “It is a virtuous cycle about value and person-centered care. This is what our complex needs team is trying to understand.”

She described the journey so far: In 2015 there were pockets of work being done across the eight Kaiser Permanente regions. In 2016 they established complex care as a national qualitiy iniative. “We knew we were not meeting these patients’ needs. We had to figure out the right way to do that.” They also realized that most of the previous research on the topic involved examples that were not in integrated systems such as Kaiser Permanente. “We had to figure it out in an integrated system,” she said.

 In 2017 they started working on cross-regional learning — for instance, taking a program from Colorado and trying it in Southern California. Then they sought to align quality measures. In 2018 they got funding to create CORAL, the complex needs research arm.  

The Care Management Institute has created a “community of practice” on complex care to break down silos within the organization and bring together research, operational and administrative executives. They also want to work with external stakeholders to make sure what they are developing is scalable, Gozansky said.

Mark Humowiecki, senior director of the National Center for Complex Health and Social Needs, also spoke during the webinar. He said one of the goals of the Blueprint was to get a clearer definition. Some people get confused about terms such as “hotspotting” and complex care, he said. He said there is a recognition that these patients’ needs are crossing traditional silos, so “there is a need to connect care for the individual but also at the system level.”

The goal, he added, is to create a complex care ecosystem by developing in each community system-level connections between social care delivery and healthcare, which in the past have operated too independently.  The five principles are that complex care is person-centered, equitable, team-based, cross-sector and data-driven. One of the Blueprint’s recommendations is to enhance and promote integrated cross-sector data infrastructures.

 

 


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