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
• 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.