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Population Health in Maryland: ‘The Stars Are in Alignment’

April 10, 2017
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Hospitals will be held accountable for the health of populations
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Last week I wrote something about how the Maryland Health Care Commission (MHCC) had awarded telehealth grants to three organizations to assess the impact of remote patient monitoring on reducing hospital encounters, improving patient care and decreasing healthcare costs.

As that article mentioned, three years ago the State of Maryland launched a bold experiment to improve care. With a waiver from the Centers for Medicare & Medicaid Services, the state converted its hospital payment system from traditional fee-for-service to a global system, in which hospital total revenue for all payers is set at the beginning of the year. The MHCC recognizes that if the state is to succeed with the All-Payer Model, providers need to consider adopting non-traditional approaches to care delivery. 

Coincidentally, last week I also saw a great presentation by Jonathan Weiner, DrPH, director of the Johns Hopkins University Center for Population Health Information Technology (CPHIT) in Baltimore. He spoke about the center’s first five years and why he is so excited about the future of population health, particularly in Maryland.

Weiner said it is an exciting time for population health because EHRs provide a new data source. They have been around for 40 years, but only in the last few years has their use become widespread. Although 95 percent of hospitals and doctors are using health IT, only 5 to 8 percent of EHRs are used for population health so far, he estimated, so the potential is huge. 

Among the highlights of Weiner’s talk was his perspective on the role population health IT can play in Maryland’s experiment in changing how provider organizations are paid.

“We are excited that the State of Maryland approached us, working with CRISP [the state health information exchange] and other colleagues to develop a framework for understanding population health,” Weiner said, “not because it is a pretty academic slide from the Bloomberg School of Public Health, but because it may be a new framework for how the hospitals and doctors of Maryland will be paid and held accountable. The folks at CMS said if you want to continue your waiver, and get the extra billion dollars you are getting now, you must include population health metrics.”

Over time, the hospitals will be held accountable for the health of populations if they want to stay in existence, Weiner explained. “We have for the first time in history the attention of all the hospital directors when it comes to population health. It is very exciting. The stars are in alignment to make Maryland something quite unique. One of the reasons that CRISP, our HIE, is as successful as it is, with 100 percent of all hospitals collaborating, is because the hospitals have no choice if they want to get paid.”

The proposed framework includes health system factors, social determinant factors, and various outcomes not at the patient level, but at the level of the community, which Weiner stressed was key. “We have a wonderful hospital across the street, but this is not a healthy community,” he said. “In the future, a proportion of every hospital’s revenue — and one day it could be a very significant portion — will be held accountable for what is happening in this community, and that will turn things on their head.”

For example, as competitors, all the Baltimore-area hospitals, Johns Hopkins, MedStar and Mercy, are beginning collaborate to make sure people in their catchment area are getting care without regard to where they have been hospitalized. This is a way to bring together data, he said, to look for diabetes visits to the emergency room. “That should not happen,” Weiner stressed.  “Asthma visits to the emergency room.  that should not happen.

Johns Hopkins will start looking not just at the people who walk into the emergency room, but at the people in particular Zip codes and census tracks.  To do that, you need data across all the EHRs, from public health, and all the insurance claims for all people insured. In Maryland, they have most of that. “Not everything we would like to have in a population health database is fully available,” Weiner said, “but that is our responsibility over time to develop. If I sound excited, it is because I am,” he said. “I have never seen anything as close as where we are today. This is a 15- to 20-year journey, but we have never been this close before.”

Before getting into how CPHIT is working with the State of Maryland to begin to change how hospitals deal with the communities around them, Weiner introduced Hadi Kharrazi, M.D., Ph.D., research director of the CPHIT, who gave several examples of the type of partnerships the center is forming. In one case, Johns Hopkins researchers have teamed up with the Veterans Health Administration’s (VHA) on perhaps the largest study of body mass index (BMI) to date. They can see the BMI of 30,000 veterans in a single day. Using the VHA data warehouse, they have developed a metadata repository for obesity and analyzed the effect of different population denominators on existing obesity rates among VHA members. They also have created a series of predictive models to forecast the obesity trajectory in a given population denominator, which could be eventually tailored as feedback to clinicians, policy makers and others. “These are all objective, EHR-driven measures, not surveys,” Kharrazi stressed.

Kharrazi talked about the VHA’s GIS-clustered Population-based Risk Prediction Modeling (GIS-PRPM) for obesity. It can generate a series of risk prediction models to forecast obesity trajectory for a given patient and/or a larger population over a defined period of time. The outputs can be used in various levels of care from a clinical point-of-care to a larger strategic planning for the VHA’s population health activities. “They can predict the BMI of certain neighborhoods,” Kharrazi added. It has interactive tools so that higher-ups at the VA can drill down and bring in other data sources to see what is contributing to it.”



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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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NIH’s All of Us Program Teams with Fitbit for Data Collection

January 16, 2019
by Heather Landi, Associate Editor
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The All of Us Research Program, part of the National Institutes of Health (NIH), has launched the Fitbit Bring-Your-Own-Device (BYOD) project. Now, in addition to providing health information through surveys, electronic health records, and bio-samples, participants can choose to share data from their Fitbit accounts to help researchers make discoveries.

According to All of Us research program officials, the project is a key step for the program in integrating digital health technologies for data collection.

The All of Us Research Program, established by the White House in 2015, aims to advance precision medicine by studying the health data of 1 million diverse Americans over the next five years. One aim of the project is to include groups that have been historically underrepresented in research. As of September 2018, more than 110,000 people have registered with the program to begin the participant journey, and more than 60,000 have completed all elements of the core protocol.

The participants are sharing different types of information, including through surveys, access to their electronic health records and blood and urine samples. These data, stripped of obvious identifiers, will be accessible to researchers, whose findings may lead to more tailored treatments and prevention strategies in the future, according to program officials.

Digital health technologies, like mobile apps and wearable devices, can gather data outside of a hospital or clinic. This data includes information about physical activity, sleep, weight, heart rate, nutrition, and water intake, which can give researchers a more complete picture of participants’ health.” The All of Us Research Program is now gathering this data in addition to surveys, electronic health record information, physical measurements, and blood and urine samples, working to make the All of Us resource one of the largest and most diverse data sets of its kind for health research,” NIH officials said.

“Collecting real-world, real-time data through digital technologies will become a fundamental part of the program,” Eric Dishman, director of the All of Us Research Program, said in a statement. “This information, in combination with many other data types, will give us an unprecedented ability to better understand the impact of lifestyle and environment on health outcomes and, ultimately, develop better strategies for keeping people healthy in a very precise, individualized way.”

All of Us participants with any Fitbit device who wish to share Fitbit data with the program may log on to the All of Us participant portal at https://participant.joinallofus.org and visit the Sync Apps & Devices tab. Participants without Fitbit devices may also take part if they choose, by creating a free Fitbit account online and manually adding information to share with the program.

All of Us is developing additional plans to incorporate digital health technologies. A second project with Fitbit is expected to launch later in the year, NIH officials said, and this project will include providing devices to a limited number of All of Us participants who will be randomly invited to take part, to enable them to share wearable data with the program.

The All of Us research program plans to add connections to other devices and apps in the future to further expand data collection efforts and engage participants in new ways.

Related Insights For: Population Health


NorthShore to Lead “Largest Primary Care-Based Genomics Program in U.S.”

January 14, 2019
by Rajiv Leventhal, Managing Editor
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The Chicago-based NorthShore University HealthSystem and genomics technology company Color are partnering on a new initiative that will aim to deliver the power of genomics to routine primary care at population scale.

Known as "DNA10K," the initiative will engage more than 10,000 patients and will be the largest known primary care-based genomics program in the U.S., according to officials who made an announcement last week.

The approach will build on NorthShore's years of experience in genomics and actionable electronic medical records (EMR) information, while providing access to Color's clinical-grade genetic testing and whole genome sequencing to inform patients about their risk for certain hereditary conditions, according to company executives.

“The knowledge will help patients learn about their genetic makeup, including risk factors for certain disease types such as common hereditary cancers and heart diseases. This insight will help NorthShore personalize care for each patient to support improved outcomes, prevention and overall health,” officials noted.

The announcement comes on the heels of a recent pilot between NorthShore and Color that looked to unlock the benefits of genetic information in routine care.

As officials explained, in less than two months, more than 1,000 patients signed up for the Color population health program as a part of their primary care visit, an adoption rate of more than 40 percent of those eligible and significantly beating expectations of the pilot program. “This is a strong indicator of patients' interest in understanding genetic factors that can influence health and the opportunity to work with NorthShore care providers to make more informed treatment or prevention decisions,” they attested.

Overall, the DNA10K initiative supports NorthShore's efforts to improve patients' health outcomes at a population level, with genomics as a foundation for informing individualized healthcare.

Patients who take advantage of the "DNA10K" offering will provide a blood sample, which is then analyzed in Color's CLIA-certified, CAP-accredited lab, and results are returned to healthcare providers and their patients. In addition to their NorthShore primary care provider, patients will also have access to board-certified genetic counselors and clinical pharmacists from Color and NorthShore, officials explained.

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