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AMIA’s iHealth Was All About Pop Health

May 7, 2017
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Execs from Children’s Hospital of Philadelphia Describe EHR Tools Designed for Population Health Efforts
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The AMIA iHealth 2017 Conference here in Philadelphia last week had a strong population health flavor to it. It kicked off with a great keynote address by the City of Brotherly Love’s own pop health guru, David Nash, M.D., founding dean of Thomas Jefferson University's School of Population Health.

Nash, who always tinges his talks with humor, put up a slide of a deer in headlights. He told the crowd of informaticists that this represented their medical staff president trying to cope with the forces of change brought on by the shift to value-based payment. “She is a well-meaning physician with no additional training who is looking to you for leadership on the data piece,” he said.

Nash suggested several things are key to changing the culture in health systems:

• Practice based on the evidence.

• Reduce unexplained clinical variation.

• Reduce slavish adherence to professional autonomy.

• Continuously measure and close the feedback loop.

• Engage with patients across the continuum of care.

Although he believes the country is inexorably moving in the right direction, Nash said the population health approach hasn’t had enough impact yet. For instance, he told the audience that despite having more academic medical centers than any other city in America, Philadelphia ranks last among Pennsylvania counties in most population health measures. So all the talent and brainpower at these institutions is not having an impact locally in terms of population health — yet.

But that doesn’t mean local health systems aren’t making an effort. Executives from the Children’s Hospital of Philadelphia (CHOP) described how they have responded to value-based payment. CHOP has implemented EHR-based care plans, patient outreach workflows, and registry/reporting tools for high-risk care management, wellness, asthma, and other chronic disease programs such as sickle cell and inflammatory bowel disease.

These tools, built into Epic, were rolled out and tested across a 31-practice primary care network with a patient population of 260,000 children and adolescents.

Anthony Luberti, M.D., EHR medical director of the CHOP Care Network, noted that decision support and patient management tools in most EHRs are built for when the patient is right in front of you for a one-on-one consultation. “In terms of population health management, and dealing with patients not in your office, there need to be different approaches, work flows, and tools,” he said. “The vendors haven’t quite caught up to population health management yet.”

Jonathan Crossette, senior manager of value-based primary care at CHOP, noted that the measures that commercial payers are putting in its contracts are population health measures. To make sure you are hitting targets on adolescent wellness visits, you have to know where the gaps are and identify where you need to make interventions. CHOP now has financial incentive to reduce emergency room utilization. “We have to understand why folks are still going to the ER for non-emergencies when we have 24x7 nurse triage and extended office hour in urgent care,” he said.

Matt Dye, a clinical data analyst and programmer with the population health team, talked about how data is supporting population health efforts at CHOP.  He noted that in 2015, CHOP entered into an accountable care organization (ACO) contract with a large commercial payer, covering approximately 27,000 CHOP patients. As a part of this agreement, CHOP gained access to claims data on patients in the cohort. That gave CHOP execs the ability to analyze data on care occurring outside of CHOP. They can gain insight into outpatient pharmacy data, which is limited at CHOP. But there are challenges as well. The claims data is structured very differently than clinical data, Dye said, and the metrics used by payers are difficult to understand and replicate.

In one example of how they are using this new data, he mentioned targeting ED high utilizers with asthma.  He said the ACO claims data showed them patients’ utilization at outside hospitals, EDs, and urgent care centers. His team has integrated the payer’s monthly data files into the CHOP data warehouse and can use this data to better manage high utilizers with asthma and keep them out of the ED and hospital. Dye said that an initial analysis shows that the added insight from the payer’s data could double CHOP’s identification of asthma high utilizers (to about 5% of asthmatics).

Elizabeth Brooks, senior program manager for population health, described some of the EHR tools CHOP has developed, around registries and care plans.

A few years ago a lot of the work to manage population health involved Excel spreadsheets, lots of paper and e-mailing files around, she said. Since then, an effort has been made to move these tools into the EHR. “Now users can log in and run reports on patients they are working with who have chronic conditions,” she said. “We are trying to use the power of the EHR and retire the paper-based processes.”

She said CHOP uses Epic’s collection of population health management tools, including:

• Longitudinal care plans

• Patient goals and emergency instructions

• Registries

• Real-time patient management reports

For instance, CHOP created a wellness registry for all patients actively seen in CHOP primary care. It is used as the foundation for patient management reports, patient outreach activity about gaps in care, and tracking of quality measures. “We are using it to drive automated portal reminder messages,” she said.

It also created a chronic care registry to identify and monitor patients for care management and care planning across the network.

Many of the EHR population health tools needed to be customized for pediatrics and CHOP’s multi-site primary care network. Most weren’t usable out of the box, the CHOP executives stressed.

Now that they have the foundation built in EHR, they have begun hiring more regional care coordinators to try to address the needs of the 5,000 complex patients CHOP has identified.

The CHOP team's story was just one presentation on the application of informatics tools to population health challenges. There were several others, an encouraging sign.




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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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