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Predicting Patients’ Next Healthcare Moves: How HIT Stakeholders are Keying in on Advanced Population Health Management

July 28, 2017
by Rajiv Leventhal
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Population health is hardly a new term in health IT circles, but a recent report from Black Book Research has shed some light into how serious stakeholders are about being able to holistically under­stand patients as they move across the care continuum.

The report, which included responses from 140 chief information officers (CIOs), 159 chief financial officers (CFOs) and 448 hospital managers involved in planning and executing population health initiatives at their or­ganizations within the next year, revealed that in an ideal world, next-generation population health management systems will be able to identify a plethora of patient groups and predict where, when and how to best en­gage them. In addition, they should have the ability to coordinate care across the entire healthcare continuum, support care team collaboration and measure the ac­tivities, outcomes and overall performance of providers within the network, according to the report’s authors.

While many IT systems have long been developed with fee-for-service healthcare in mind, a shifting landscape (EHR) vendors to tap into new, non-fee-for-service teth­ered platforms for population health. According to the Black Book report, 90 percent of healthcare leaders said that future population health management systems will essentially be projected to perform as next-generation patient accounting systems. Said Doug Brown, manag­ing partner of Black Book Research in a statement that accompanied the report, “Some EHR systems have handled managed care for years, and those that have deep experience with capitation and managed care will be better able to translate that knowledge into value-based initiatives. Systems like Epic that were developed from the start as a single, longitudinal patient record spanning inpatient, outpatient, post-acute and billing will have the advantage.”

What might these “next-generation” systems look like and how will they be tailored to a value-based care environ­ment? Brown, who was also interviewed for this story, says, “We will have to start working on predicting all the coordi­nates of care where patients might end up and when and where they might engage.” He adds, “We have to support the collaboration from the differ­ent care teams. Did the activity happen? Was it ordered and not performed? What were the outcomes? How was the performance of the provider, be it a physician or an outpatient facility? All that data now has to be mea­sured, not for fee-for-service, but it now becomes all of these other data sources that need to be pulled in. So it becomes a patient accounting system.” Brown notes that Epic, Cerner and Allscripts, either via acquisition or through needs from other clients, “are putting funding into building what this appears to be.”



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In Great Neck, N.Y., Northwell Health (formerly North Shore-LIJ), is the largest integrated healthcare system in New York State with 22 hospitals, 6,675 hospital and long-term care beds, and more than 550 outpatient fa­cilities. Simita Mishra, Ph.D., director/service line lead­er at Northwell, oversees the organization’s strategic population health initiatives from within the office of the CIO. Mishra says her job is to work in partnership with whoever is providing care management operational ser­vices on a day-to-day basis within Northwell.

“We [are] their strategic and advisory partners. We look to understand what would be the best business case so we can provide them with an IT infrastruc­ture that will help them provide evidence-based care management to the population that they are serving,” Mishra says. She adds that it’s not just about technol­ogy; rather, her team sits at the leadership level with clients and has councils where they work with them to better understand their requirements. “At times they don’t even understand their own requirements since they are primarily on the clinical side and don’t have that [business expertise]. So we will help in that re­gard,” she says.

Simita Mishra, Ph.D.

Mishra, who doesn’t have a technology background but has worked in population health and consulting for 14 years, has two core population health groups roll up to her leadership within the office of the CIO: the first is the standard population health management team at Northwell; and the second is the team in charge of the Delivery System Reform Incentive Payment (DSRIP) pro­gram for Medicaid patients. These two groups are kept separate, notes Mishra, since the DSRIP grant from New York State mandates that resources not be co-mingled, but essentially DSRIP is a subset of the broader popula­tion health organization.

One of the biggest focuses of Mishra’s work right now is the development and roll-out of Northwell’s homegrown Care Tool software. The tool is developed by the service line team and then designed to meet the requirements and features that are based on what the user wants, Mishra notes. The Care Tool might ca­ter to multiple programs such as a bundled payment program, the New York State Health Home program, or DSRIP.

An example of the tool being put in use, explains Mishra, would be a Northwell patient navigator who is in charge of patient outreach, reaching out to people in the Home Health population. In this scenario, the Care Tool will show the patients linked to that program, and once the navigator sees that, he or she can then see who the outliers are (the non-compli­ant patients), who might need appointment remind­ers, or who has been discharged within the last seven days. Those patients will then be pursued to see their primary care physician (PCP) if necessary, or a similar action will be taken, Mishra says, adding that a clini­cal snapshot in the EHR also gets sent from the Care Tool to the PCP, who can take a quick look to see if vaccines or immunizations are missing. The real-time alerts and ability to risk stratify in order to identify high-risk patients are all triggered by what’s originally entered into the tool, Mishra notes.

Meanwhile, Northwell’s DSRIP work creates broader population health challenges, since the state mandates that every physician practice associated with the pro­gram has to have an EHR by 2018, something that some of the health system’s voluntary practices still lack. Also, the practices have to all be Level 3 PCMH (patient-cen­tered medical home), meaning having the ability to col­lect and use data for population health management, as designated by the NCQA (National Committee for Quality Assurance). Like with the EHR mandate, North­well is also currently short of this requirement. Says Mishra, “We are still working towards DSRIP’s goal of 25 percent reduced [avoidable hospital] readmissions over a period of five years. The grant, which I wrote along with other folks on my team, was [based on] proving to the state that your health system was already invested in doing population health management. So you show them that you would have used the health system’s money to invest in population health,” she says. “It’s a lot of contracting and negotiating. Plenty of work is still ahead of us.”


Most experts would agree that although efforts to im­prove healthcare in the U.S. have largely been focused on the clinical side, it would be unwise to ignore the many social, economic, and environmental factors that influence a person’s health.

At Humana, the Louisville, Ky.-based health insurer, a “Bold Goal” program was put into place two years ago with an overarching aim to make the communities it serves 20 percent healthier by 2020. For this goal to be achieved, it’s necessary to understand that social deter­minants of health are fundamentally important in terms of how to care for populations, says Roy Beveridge, M.D., chief medical officer at Humana. He notes an ex­ample of a diabetic patient being food insecure; the likelihood that this patient will have a prescribed diet and can control his or her sugar intake is quite small. “In the U.S., we have 5.4 million seniors who are food insecure, and if you don’t address that issue, treating someone’s diabetes—meaning also taking care of blind­ness, diabetic foot ulcers, and kidney disease—becomes very hard. But we do know that by working with grocery stores, hospitals, the local government and others in the community, you can begin to take care of food insecu­rity,” Beveridge says.

However, despite a growing recognition that looking at these social determinants of health is a critical com­ponent of improving one’s care, just four or five years ago, most physicians would have said that it’s a social worker’s problem rather than a clinical issue, says Bev­eridge. “This is why the move from fee-for-service to val­ue-based care has begun to focus in on [the notion] that treatment is more than giving someone a prescription. Fundamentally, how can I influence this person’s health as opposed to giving him or her a medication and then saying the patient is non-compliant?” he asks.

Drilling down deeper, Vipin Gopal, enterprise vice presi­dent, clinical analytics at Hu­mana, notes the importance of integrating the internal Hu­mana data that the payer has on its members with the data it has about its communities, and with the social determi­nant data. “That gives us a broader view about the health of a community that we didn’t have by just looking at primary claims from a payer perspective,” Gopal says. What’s more, he notes, understanding the given population in detail is also critical. “What would lead a person to progress from their diabetes condition into getting ad­ditional complexities, be it congestive heart failure or something else?” he asks. “It helps us move things from a population perspective and enables us to be more personalized in the solutions we offer to our members.”

Vipin Gopal

To this end, one of the biggest challenges in Humana’s senior population is that one-third of them have a fall every year. As such, Humana is using advanced analytics to figure out who’s most likely to fall among that senior population, and then enabling them with the right so­lutions to prevent a fall, or making sure that they are in a program in which they have a device that triggers an alert if there’s a fall. “That makes a big difference in their quality of life,” says Gopal. “It increases mobility and confidence, and these are the fundamentals we are tackling, with analytics as the starting point. You need to identify members and communities first, and then put solutions in place.”

In the end, sources interviewed for this piece are in agreement that healthcare’s traditional fee-for-service mentality in which physicians want to maximize the pa­tients they see—thus maximizing their charges—does not encourage an environment in which it’s important to spend time looking at a patient’s social determinant data. But when that physician is getting paid for qual­ity outcomes, all of a sudden, it makes sense to look at these other health factors.

And that right there is the crux of population health management—using analytics and insight to focus on a group of individuals with similar healthcare needs, and improve those patients’ outcomes. Says Gopal, when asked about putting all of this together for improved care: “It’s a nice sweet spot, the intersection of data and medicine that is coming together and revolutionizing this population health management space.”

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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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