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A Web Services Approach to Public Health Clinical Decision Support

October 22, 2016
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CHOP informaticists use FHIR to match public health recommendations to relevant patient encounters in real time

Although it is still early days, I am increasingly convinced that the movement to bring a web services approach to healthcare is real. Every week brings announcements of new efforts to create modules that do one thing well and that providers could subscribe to from within their EHR. This approach makes so much more sense than each provider working with its software vendor to recreate the wheel.

This is especially appealing in the realm of clinical decision support (CDS), in which knowledge management is so time-consuming and difficult for provider organizations. But could hospital physicians and ambulatory providers subscribe to real-time public health clinical decision support information from within their EHR workflow? That is the question that two clinical informatics fellows at the Children’s Hospital of Philadelphia (CHOP) are seeking to answer with the creation of PHRASE (Population Health Risk Assessment Support Engine). As I understood it, their prototype solution takes advantage of FHIR to match up public health recommendations to relevant patient encounters in real time.

PHRASE was chosen as the first place winner of the Practical Playbook and the de Beaumont Foundation's Closing the Data Divide Challenge and also one of four to take first place in ONC's Provider User Experience Challenge.

On Oct. 20, Mark Tobias, M.D., and Naveen Muthu, M.D., the two informatics fellows and practicing physicians, gave a presentation at CHOP about the problems they saw in getting relevant public health information at the point of care and how their solution might help.

Muthu said that as part of their work, they checked in with approximately 30 different healthcare organizations to get a sense of where they are with CDS governance and what their needs are. He gave an anecdotal example of the type of problem they are trying to solve: How a physician knows how to get knowledge or support when they are seeing a pregnant patient who traveled to the Miami area and now has a fever. The clinician can go to the CDC website or look for an e-mail from the local department of public health that summarizes what to do. The CDC has found that providers know they are supposed to do something, but often don’t order all the tests that CDC suggests for optimal care. CDS is critical, Muthu said, because the knowledge base is changing so fast. “Clinical decision support removes the need for providers to know what they don’t know and provides them with in-context information.”

 They spoke with 30 healthcare organizations about how they keep up with updates such as CDC Zika guidelines in terms of CDS.

“Many said they don’t know how to implement a change management process, he said, One community hospital with 500 providers and a chief medical information officer told them that although the hospital has had CDS capability for several years, it has only built six pieces of CDS since the EHR went live. “They haven’t cobbled together the expertise to go through a CDS lifecycle,” Muthu said.

He said hospitals that use Epic or Cerner have to customize CDS.  “What they offer is a bucket of tools. But you have to build and maintain the knowledge. The knowledge management phase is where things fall apart entirely,” he said. “Many organizations don't have a process for review to make sure it is up to date.”

In crafting a potential solution, Muthu and Tobias looked at how to break up the elements in the CDS support lifecycle to determine which aspect the public health organizations can do and which the provider can do. The public health groups can identify formal definitions and logic conditions, and the providers can identify workflow scenarios and convert that to their platform.

In this scenario, the public health institution authors and maintains CDS knowledge artifacts and the provider integrates it into work flow.

PHRASE works as a CDS integrator sitting between the public health agency and the provider organization’s EHR, Tobias said.

As their website notes, “PHRASE offers a vendor-agnostic method to provide guideline recommendations to and receive data from electronic health records. For a healthcare organization, PHRASE offers an up-to-date knowledge base for clinical decision support systems that can be incorporated into local practices and workflows with ease.” The prototype was created using CHOP’s customized CDS within its flavor of Epic and alerts from CDC and the City of Philadelphia Department of Public Health.

As the clinical encounter is going on, the PHRASE engine sits between the EHR and the public health data repository in the cloud. Using FHIR requests against the EHR data, it checks to see if any of the criteria that would spur a public health recommendation are met, and if so the CDS alert pops up in the EHR. Tobias demonstrated how a clinical encounter documented in Epic brings over the recommendation from the public health agency.

To avoid providers getting too many alerts, they can turn on and off public health CDS from CDC and other local and state agencies.

PHRASE also allows reporting from frontline clinicians back to the content creators via real-time feedback. So while clinicians consume these recommendations in the EHR, they can also utilize one-click reporting of disease cases back to the public health department.

Muthu and Tobias are starting to pilot PHRASE’s use in areas of emerging illness such as the Zika virus, local surveillance for problems like lead poisoning, and recognition of patterns like toxidromes based on recent poison control data. 

They are reaching out to other provider organizations to have them test PHRASE in their environments.

“We have to determine the cost in time and resources for scaling the system across institutions,” Tobias said.

 

 

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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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Thursday, December 13, 2018 | 3:00 p.m. ET, 2:00 p.m. CT

Due to the complexity of the disease biology, rapidly increasing treatment options, patient mobility, multi-disciplinary care teams, and high costs of treatment - informatics canplay a more substantial role in improving outcomes and reducing cost of cancer care.

In this webinar, we will review how tumor board solutions, precision medicine frameworks, and oncology pathways are being used within clinical quality programs as well as understanding their role in driving operational improvements and increasing patient retention. We will demonstrate the requirements around both interoperability and the clinical depth needed to ensure adoption and effective capture and use of information to accomplish these goals.

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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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