Innovator Semi-Finalist Team: CHOC Children’s Improves Asthma Outcomes through Population Health | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

Innovator Semi-Finalist Team: CHOC Children’s Improves Asthma Outcomes through Population Health

February 14, 2017
by Heather Landi
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For children with asthma, and their families, a trip to the emergency room due to a severe asthmatic flare-up can be a traumatic and frightening experience and can often lead to a hospital stay. For a pediatric healthcare system, effective management of the pediatric asthma population improves the wellbeing of the patients and their families, reduces emergency department visits and improves overall health outcomes.

With this goal in mind, physician and IT leaders and care management teams at Children’s Hospital of Orange County (CHOC Children’s), based in Orange, California, leveraged health IT tools to improve the health of pediatric asthma patients through a population health approach in the health system’s primary care clinics. CHOC Children’s is a regional pediatric healthcare network that includes a 279-bed main hospital facility in the City of Orange and a hospital-within-a-hospital in Mission Viejo. CHOC also operates many primary and specialty care clinics, more than 100 additional programs and services and four centers of excellence – The CHOC Children’s Heart, Neuroscience, Orthopaedic and Hyundai Cancer Institutes. CHOC Health Alliance, an IPA comprised of Children’s Hospital of Orange County and CHOC Physician Network, manages approximately 160,000 fully capitated Medicaid pediatric patients through a contract with the Orange County-affiliated health plan, CalOptima.

Alexandra Roche, M.D., pediatrician at CHOC Children's

The pediatric asthma population health initiative, which entailed the implementation of health IT-supported care model redesign, has produced impressive results so far, with emergency department visits reduced 18 percent year-over-year, with asthma-related issues driving many of those ED visits. Further, this reduction in ED visits has resulted in $1 million in avoided emergency room costs. For their use of health IT to improve health outcomes and patient care, the editors of Healthcare Informatics have named CHOC Children’s as a semi-finalist winner in the 2017 Healthcare Informatics Innovator Awards Program.


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Health IT-Supported Care Model Re-Design

Four years ago, CHOC Children’s developed a strategic plan, the “CHOC 2020,” and a major pillar of the strategic plan was the development of the CHOC Pediatric System of Care to better manage pediatric lives in the communities that the healthcare system serves.

“As part of that, we built in physician alignment, we built in care model redesign, we built in the information technology pieces that need to support that, and with all those being successful, we built in the ability to take on innovative payment models,” Mike Weiss, D.O., vice president of CHOC Health Alliance, CHOC’s Children’s health insurance plan. “As part of that foundation, we quickly realized that we could look at small segments of our population where we had an opportunity to use data to effect change. So we incorporated some tools, specifically disease registries, to approach a very common clinical condition that leads to a lot of morbidity and mortality and high cost, which is pediatric asthma.”

Three years ago, clinician, care management and IT leaders at CHOC Children’s working collaboratively on the Pediatric System of Care began looking at analytics tools to support population health programs. For this particular initiative, the collaborative team includes Bill Feaster, M.D., CHOC Children’s chief medical information officer; Weiss, who also works with the population health division; Bonnie Wolf, IT program manager at CHOC Children’s and Christina Grapentine, informatics specialist. Also instrumental in this effort were Cathy Nesselroad, R.N., care manager at the CHOC Primary Care Clinic and Carmen Namenek, manager of clinical operations for the CHOC primary care clinic, who implemented the technology tools within the primary care practices.

The team decided to focus on pediatric asthma patients in four CHOC primary care clinics in order to develop care models that could then be rolled out to other primary care practices, and they implemented Cerner’s HealtheIntent population health management platform in those four primary care clinics. Approximately 27,000 pediatrics in the CHOC Health Alliance are seen in the health system’s primary care clinics, and of this, 6,000 are registered in the asthma registry, Wolf says.

 “Two of the diseases we decided to focus on were asthma and seizures, based on the fact that those are two of the highest utilizers within the hospital for ED and hospitalization services,” Feaster says. “So asthma was our first registry that we really developed. It was a multi-disciplinary group of primary care and specialty physicians, Dr. Weiss, myself, and Bonnie, we had a very broad-based approach to defining the measures of the asthma registry. We have been a development partner with Cerner, so that asthma registry, and the other registries we developed, are now the pediatric registries for Cerner.”

As part of this registry, the CHOC Children’s team worked together to research and define measures that were appropriate for the care of pediatric asthma patients. Ten measures were defined and built into the HealtheIntent asthma registry. Of these, two were selected for a focus on improvement—patients with an asthma control test completed in the past year and patients with an asthma action plan completed in the past year.

Once the database was built and the measures mapped to the database, a key factor for effectively using the measures and the patient registry was making the status of those measures available in real time in the clinical workflow and in the electronic medical record (EMR). For example, if a child who has asthma has a visit with a physician at a primary care clinic and that patient has not had an asthma control test in the past year, the project leaders wanted to ensure that information would be front-facing to the providers and the care teams. In addition, to track improvement, a dashboard was built and baseline data was documented and the dashboards are now used to provide information on the completion of measures.

“The key there is taking that technology that we had and operationalizing it and really putting in front of the caregivers, in real time, up front when the patient is walking in the door. And that’s where Cathy and Carmen’s team really took the technology and took it to the team,” Wolf says.

Further, in the primary care clinics, new workflows were rolled out to include a morning huddle with the entire care team where important information about the patients to be seen that day are reviewed including any outstanding measures for the asthma patients. Clinical staff were also provided with additional training on completing and documenting the asthma control test.

At the registration level, medical assistants within the primary care practices chart prep for the visits, with the status of the measures feeding into the physicians’ notes. “This ensures that there’s no missed opportunities at the time of the visit. So if that asthma control test is due, it’s handed out to the family at the start of the visit, prior to the provider seeing them, so we could get the score into the EHRs. That enables the provider to document it and talk to the family at the time of the visit about the outcomes of the control test, and also augmenting that the asthma action plan has been completed,” Nesselroad says.

“That information has always been in the chart, but it wasn’t forward facing, and now it identifies that there is an asthma patient, and it looks at these measures and identifies whether it’s on-time or behind and puts it forward facing on the summary screen so clinicians aren’t looking all over for it,” Namenek adds.

Making that information available in real time in the clinical workflow helps physicians to maximize the effectiveness of his or her patient visits, Nesselroad says, “Which is important when thinking about providers and how busy their schedules are. For our PCPs, their visits are precious, and only have so many in a day. If the care team can identify gaps in the service and be proactive about getting some of those gaps met prior to the visit or in between a visit without taking up another visit, that maximizes our ability to see our other patients who really need to be seen as well.” She adds that this new process also facilitates better monitoring of the patients to ensure that follow-up appointments are scheduled.

The population health management initiative went live in four primary care clinics in September 2015, and year-over-year results have been impressive. “Looking at the process outcomes, which were the completion of the asthma control test and completion of asthma action plan, for the most part, we were fairly abysmal to start with. About 15 percent of the time, overall, we were completing those two tasks, which we know are very important to reducing ED visits and inpatient stays,” Weiss says. Year-over-year, the percentage of pediatric asthma patients with those two measures completed rose to about 45 percent. “More importantly, as an outcome measure, for that population of patients, the 27,000 patients in our CHOC clinics, we reduced ED visits for nine-month period, year over year, by 18 percent, which translates to a savings of over $1 million based upon our cost of care, and all we did was implement this care team model and use the registries and the data.”

Feaster contends that one lesson learned from this initiative is that technology or workflow, alone, can’t improve care as much as when developed and implemented together. “Technology should not drive clinical care, it should support clinical care. I think this is a good example of how we have used that to our best advantage where the technology was developed to support the care model and the care model was developed around the technology, so they were done in tandem,” he says.

Weiss agrees, adding, “What we really did here, and I’m a doctor at heart, is that we didn’t allow the technology to drive what we did. We developed a care model and then presented that care model to our technology colleagues and created a solution to solve our clinical problems, which to me is what was really exciting about this and continues to be exciting.”

Wolf also notes that being a Cerner development partner enabled IT leaders to develop a solution that would work for the organization, rather than buying something off the shelf. “I think that gave us a great opportunity to partner with the technology, and say, ‘wouldn’t it be great if it could this, because this is what we would do with that’ and really have both sides of the clinical operations and technology people all together working toward making a system that not only is great technology but really supported how we practice and operate.”

High-level leadership buy-in also was critical to the success of the initiative, Weiss says. Feaster and Weiss both say that is represents a change in paradigm to focus on managing populations rather than hospital visits and revenue. “That’s a big step for a hospital-based system to take. We’re very privileged that our leadership sees that, and that transitioning is occurring,” Weiss says.

Further, that leadership buy-in goes all the way to the individual clinic level. “It’s the physicians and nurse managers, at a given location, because if they don’t believe in this and are not stakeholders, it won’t be successful,” Weiss says. “And, it’s important to really involve the front line workers as you design the operation. So Cathy and Carmen, to their credit, spent hours with those medical assistants and nurse managers and people at the front lines who do the work, answer the phones, all of that, to get their feedback and input as we developed the process.”

Next Steps and Future Work

In September 2015, CHOC Children’s was one of 29 healthcare collaborative networks selected for the Transforming Clinical Practice Initiative through the Centers for Medicare & Medicaid Innovation (CMMI). The health system received a $17.7 million grant, starting with $4.8 million in 2016, to fund quality improvement strategies in clinician practices, with asthma being one of CHOC Children’s target conditions for that initiative.

“Part of the grant is building guidelines into the EMR to help to build order sets that implement guidelines. And, so, one of the first ones we put into place, that is now available to primary care practitioners, is the ambulatory asthma guidelines implementation, which is very complicated to build but also very useful for practitioners. And that is now available to them, in addition to the data on their patients in the form of registries. So we present them the upfront data at the point of care, and then give them tools to more easily manage those patients, and that is based on national guidelines of care,” Feaster says.

Moving forward, CHOC Children’s plans to continue its population health initiatives with a focus on implementing an already developed well child registry, which, Weiss contends, will be more challenging, and a “game changer.” “We will actually be able to track children proactively for their immunizations and all their preventive care,” he says. “We’re also working with four or five other disease-specific registries, including rolling out this care model into our GI clinic to do this with the inflammatory bowel disease population. We’re focusing on areas where we know we have solid data to drive the care model re-design.”


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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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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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