Automating Population Health Management to Deliver Sustainable, High-Quality Care. Michael Matthews, CEO MedVirginia / inhealth

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Automating Population Health Management

to Deliver Sustainable, High-Quality Care

Michael Matthews, CEO

MedVirginia / inHEALTH

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Objectives

• Describe how to use technology to meet the challenges of population health

management

• Transition from fee-for-service

reimbursement to accountable care

• Identify how to automate routine tasks, including identification of care gaps, risk stratification to patient engagement, and care management

• Develop a strategy for measuring

outcomes and using analytics to improve performance and financial sustainability

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The Journey Towards

Improved Patient Access,

Enhanced Clinical

Outcomes,

And Better Aligned

Incentives

Begins Here.

Improved Patient Outcomes Patient-Centered Medical Home Coordination of Care Agreement on Principles Health Information Exchange Patient Access and Engagement Population Health Analytics Better Aligned Incentives

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Corporate Resume

 In production for seven years

 First HIE in production on NwHIN (2009)



“ConnectVirginia” – Statewide HIE (2011)

 Author and first signatory to DURSA (2009)

 First HIE to connect to SSA (2009)

 First HIE to connect to VA and DoD health records systems

(2010)



One of 5 “HIEs to watch” by CMIO magazine (2011)



One of 12 “HIE Leaders” by NeHC (2011)

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Definition

“The population health improvement model highlights three components: the central care delivery and leadership roles of the primary care physician; the critical

importance of patient activation, involvement and personal

responsibility; and the patient focus and capacity expansion of care

coordination provided through wellness, disease and chronic care

management programs.”

Care Continuum Alliance

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Population Health:

A new idea??

“With our present amount of sanitary knowledge, it is as criminal to have a mortality of 17, 19, and 20 per 1000 in the Line, Artillery, and Guards in England, when that of Civil life is only 11 per 1000, as it would be to take 1100 men per annum out upon Salisbury Plain and shoot them”.

Florence Nightingale writing to Sir John Hall in 1857

.

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Tipping Point?

•Decision Support •EHR •HIE •Analytics •mHealth •Telemedicine •Safety •Best practice •Therapeutic •Diagnostic •Genomic •Pharmaceutical •Aging •Consumerism •Lifestyle •Right vs. Privilege •Uninsured •Percent GDP •Value •Medicare / Medicaid •Insurance •Tax codes •Employer engagement

Economic

Social

Techno-logical

Clinical

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“It’s not that complicated.”

 Will the world be different

in 10 years?

 If yes, should I do

nothing or do something?

 If do something, should I

start now or wait 10

years?

 If I start now, should I

turn my world upside

down over night or

implement low-risk,

high-yield, scenario

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New model of care:

Population Health Management

Traditional View

Patients Who Arrive

New View

Entire Patient Population

Fee for Service PCMH Accountable Care

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ACO Model Components

• Patient-centered health homes that deliver primary care and coordinate with other

providers.

• Aligned networks of specialists, ancillary

providers and hospitals focused on outcomes. • Explicit care integration and coordination

mechanisms.

• Payor provider partnership relationships and

reimbursement models identified under

healthcare reform that facilitate and reward high value, not high volume, healthcare.

• Population health information infrastructure

to enable community-wide care coordination.

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Scope of Automation

• Health information

exchange

• ADT clinical alerts

• Gaps in care

• Transitions in care

Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare

Institute for Health Technology Transformation

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HIE: High Impact Use Cases

• Emergencies

• Chronically ill

• Uninsured

• Minority

• Wounded warriors

• Disabled

• Rural

• Incarcerated

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Wounded Warriors

70 DoD

DoD-VA Continuum of Care

VA

Private Sector Care

60%

40%

Veterans receive approximately 40% of their care outside of VA treatment facilities. Up to 60% of service member’s healthcare is provided outside of the Military Health System. 14

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VLER Partners

Portsmouth Naval Hospital Fort Eustis

Fort Eustis

Langley AFB Langley AFB Fort Eustis

McGuire VA Medical Center

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Serving the Disabled

 Avg. disability determination:

 90 days

 With MedVirginia:

 65 days

 5% in 1-2 days

 CCD to SSA

 Algorithms by SSA

 Replication of model

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Project Impact

 Case study commissioned by

SSA

 Conducted by Kay Center for

eHealth Research

 Perspectives:

 Claimant

 Provider

 SSA

 ROI

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ADT Clinical Alerts

http://www.hibeacon.org/images/BeaconNation/Beacon_Nation _Learning_Guide_ADT_Feeds_Final.pdf

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Patients Are Not Receiving

Recommended Care

McGlynn et al

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• Risk stratification

• Target populations

• Outcomes

reporting

• Quality metrics

• Patient outreach

–

Telephonic

–

PHR

–

Text

_{PHYTEL Population Management}

Analytics and

Patient Engagement

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Robust Protocol Engine

Protocol Engine

Evidence based standards Guidelines combined with expert opinion Specific practice requests Innovative proprietary protocols

Patient Registry

Outreach Communications and

Patient Self-Management

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Scheduler or Care Manager

View of Outreach Events

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Ashok Rai, Paul Prichard, Richard Hodach, and Ted Courtemanche. Population Health Management. August 2011, 14(4): 175-180. doi:10.1089/pop.2010.0033.

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Results

Program data

3/1/12-2/28/13

Unique patients

identified with gaps in

care = 97,900

Contact success rate =

94%

ROI = 10X

48,400 Patients Booked 5,700 unsuccessful contacts 92,100 patients contacted 24

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Post Discharge Follow-up

Improving

Patient

Post

Discharge

Care

Improving

Patient

Satisfaction

Scores

Increasing

Physician

Services

Interactions

Readms

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Transition™: How it Works

26 Patient discharged Patient receives automated assessment

Alerts are sent back to the nurse or case

manager Patients contacted within 24-72 hours of discharge

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Transition Follow-up List

Follow-up list highlights patients with

responses that generate escalations.

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Riverside Medical Center

• 570 bed regional medical center • Level II Trauma/ 42 beds

• 60,000 ED visits per year

• Improved Press Ganey scores from 58 to 63% • Increased patient recommendation scores

from 60 to 64%

• Reached 55% of discharged patients through automated contact

• Improved quality of care by providing additional support to patients who need it

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Scope of Automation

• Health information exchange

– $2M revenue for 4 hospital system • ADT clinical alerts

– Emerging data results • Gaps in care

– 10X ROI for medical group • Transitions in care

– Readmissions – HCAPS scores

Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare

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