ACO = HIE + Analytics: Enabling Population Health Management
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Transcript of ACO = HIE + Analytics: Enabling Population Health Management
ACO = HIE + Analytics
Martin SizemoreDirector, Healthcare Strategy
About Perficient
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Perficient is a leading information technology consulting firm serving clients
throughout North America.
We help clients implement business-driven technology solutions that integrate
business processes, improve worker productivity, increase customer loyalty and
create a more agile enterprise to better respond to new business opportunities.
Perficient Profile
Founded in 1997 Public, NASDAQ: PRFT 2012 revenue guidance of ~$327 million Major market locations throughout North America
Atlanta, Austin, Charlotte, Chicago, Cincinnati, Cleveland,
Columbus, Dallas, Denver, Detroit, Fairfax, Houston, Indianapolis,
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San Jose, Southern California, St. Louis and Toronto
Global delivery centers in China, Europe and India ~2,000 colleagues Dedicated solution practices ~85% repeat business rate Alliance partnerships with major technology vendors Multiple vendor/industry technology and growth
awards
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Our Solutions Expertise & Services
Business Solutions• Business Intelligence• Business Process Management• Customer Experience and CRM• Enterprise Performance Management• Enterprise Resource Planning• Experience Design (XD)• Management Consulting
Technology Solutions• Business Integration/SOA• Cloud Services• Commerce• Content Management• Custom Application Development• Education• Information Management• Mobile Platforms• Platform Integration• Portal & Social
Our Speaker
Martin Sizemore• Principal, Healthcare Strategic Advisory Services • A healthcare strategist, senior consultant and a trusted
C-level advisor for healthcare organizations including both payers and providers
• Specializes in clinical data warehousing, clinical data models and healthcare business intelligence for improving operational efficiencies and clinical outcomes.
• A TOGAF certified enterprise architect with specialized skills in enterprise application integration and service oriented architecture.
Agenda
• Accountable Care Organizations (ACO)• Definition, key components• ACO: Definition of success• ACO HIE requirements – use cases• HIE Current and Emerging views• ACOs require more than EHRs• Challenges to widespread ACO adoption• ACO = HIE + Analytics – Architecture• What are the typical use cases?• Summary
Accountable Care Organization Defined
• A healthcare delivery system whose members share responsibility, financial risk and a common goal to improve healthcare delivery and the overall health status for a given population.
• Acts collaboratively to coordinate patient care across the continuum and share both the payment and responsibility for quality of care for the covered patients.
• Paid a specified amount for the population it manages, rather than a per transaction fee. ACOs can be incented if their quality and patient satisfaction scores are higher than expected; they can also receive decreased reimbursement if scores are lower than expected.
* HIMSS ACO FAQ, www.himss.org
Key Components of an ACO
• Patient‐centered medical homes• Primary care physicians• Specialists• Minimum of one hospital• Ancillary providers• Minimum of 5,000 Medicare beneficiaries (for Medicare
demonstration funding)• Care coordination ability and mechanisms to support• Payer partnerships with reimbursement based on quality,
efficiencies and patient satisfaction
*Source: Article by Stephen M. Shortell and Lawrence P. Casalino
Emerging ACO Models ‐ Governance
Model Characteristics Current ExamplesIntegrated delivery systems/networks(IDN)
• Own hospitals, physician practices, perhaps an insurance plan.
• Aligned financial incentives.• E-health records, team-based care.
• Geisinger Health System• Group Health Cooperative of Puget Sound• Kaiser Permanente• Summa Health System
Multispecialtygroup practices(MSGP)
• Usually own or have strong affiliation with a hospital.
• Contracts with multiple health plans. • History of physician leadership. • Mechanisms for coordinated clinical care.
• Cleveland Clinic• Marshfield Clinic• Billings Clinic• Virginia Mason Clinic
Physician-hospitalorganizations(PHO)
• Nonemployee medical staff.• Function like multispecialty group practices.• Reorganize care delivery for cost-
effectiveness.
• Greater Newport Physicians (partners with Hoag)• St. Vincent Healthcare in Billings• Methodist LeBonheur Healthcare• Kettering Health Network
Independent Practice Associations
• Independent physician practices that jointly contract with health plans
• Active in practice redesign, quality improvement.
• Atrius Health (eastern Massachusetts)• Hill Physicians Group (southern California)• Monarch HealthCare (southern California)
Virtual Physician Organizations
• Small, independent physician practices, often in rural areas.
• Led by individual physicians, local medical foundation, or state Medicaid agency.
• Structure that provides leadership, infrastructure, resources
• Community Care of North Carolina• Grand Junction (Colorado)• North Dakota Cooperative Network
Performance Measurement in ACOs
Patient
CURRENT SYSTEM ACO SYSTEM
ACO
Patient
Performance Measurement exclusively at the individual/group level promotes fragmentation of care and an emphasis on encounter optimization as opposed to carrying a longitudinal view.
Measurement at the ACO level, across the team, promotes an emphasis on care coordination and taking a long-term, holistic view of wellness.
Slide courtesy of Oracle
ACOs from the Patient’s Perspective
Patient
CURRENT SYSTEM ACO SYSTEM
Payer
ACO
Patient
Payer
Volume & IntensityRewarded
Care Coordination
Care CoordinationShared Savings
Quality Metrics& Cost Savings
Slide courtesy of Oracle
ACO: Definition of Success
Experience of Care
Per Capita Costs
Population Health Metrics:
• QUEST outcomes• Select HEDIS metrics• Health status – SF12• Mortality rates
Metrics:• Total medical PMPM• Total Medical Trend• Total Rx PMPM• Admissions/1000• Readmission rate
Metrics:• Patient satisfaction• PAM Scores (Patient Activation
Measures)
Improving triple aim™ population outcomes
* The term triple aim is a trademark of the Institute for Healthcare Improvement
Healthcare Business Intelligence will be the key to success in managing to these
metrics
Health Information Exchange (HIE)
• Extension of EMRs• Integration or
Interoperability role
• Primarily data push or pull
• Struggles with financial viability
• Shifting from state-level efforts to private HIEs
• Key element in the integration and coordination of care
HIE: Current View
Rx Claims
Medical Claims
Remote monitoring
Environmental
Social /economic
Lifestyle / behavioral
HRA
Bio-metrics
Labs
Demographics
HealthInformation
Exchange
Focus: Data collection and
Integration
Rx Claims
MedicalClaims
RemoteMonitoring
EnvironmentalFactors
Social /Economic
Lifestyle /Behavioral
HealthAssessments
Biometrics
Labs
Demographics
HIE: Emerging ACO View
Financial Performance
Clinical Performance
Risk / predictive modeling
Care plan design
Care plan deployment
Interventions
Quality Reporting
Risk Management
HealthInformation
ExchangeFocus: Population
Health Analysisand tracking
Financial Performance(vs. paid claims
ClinicalPerformance
Risk / PredictiveModeling
Care PlanDesign Care Plan
Deployment
Interventions
QualityReporting
RiskManagement
ACOs Require Far More Than EHRs
Requirements– Predictive modeling– Registries– EHR interfaces– Reminder systems– Claims and clinical data
warehouses– Episode of care analysis
systems– Specifications for integrated
claims and clinical databases– Patient portal options– Health information
exchanges
Data Sources for Mining– Medical records– Clinical outcomes data– Patient billing systems– Payer data– Quality measures
abstracts– Charge master– Physician, payer, service
line utilization data– Infection surveillance
data– Labor, productivity and
throughput records– Adverse drug events
Challenges to Widespread ACO Adoption
• Silos lead to a disconnected business and IT infrastructure• Islands of computing create inefficiencies and underutilized
assets• Missing or competing data standards, limited interoperability• Struggle with regulatory compliance, volume of information,
data integrity and security• Resource constraints and difficulty managing
complexity/change• Volume of data points and quality measures, in widely
dispersed locations• Limited use among providers
Meaningful Use Stage 2 and 3 to the rescue!
ACO: High-Level Architecture
ACO Performance Management will be the key to success
HIEs Require Document Sharing (XDS)
• First Register and Store Documents from providers
• Providers Retrieve Documents:
– Find Patient– Then Locate Documents– Then Retrieve
Document
• Supports centralized, federated and hybrid data models
• HIM facilitates installation and coordination of XDS components
ORACLE HIM QUERY AND RESPONSE PROCESS
Patient Lookup
Documents Associated with Patient
Select Patient
Select Individual record/ Document
Extract full data set/ document
Potential Matches
Requestor/ESB OHMPI Registry Repository
Display Record Set
Query XDS.b Registry
Display record headers, store pointers
Query XDS.b Repository
Displayed Detailed result(s)
Oracle Health Sciences Information Manager (HIM)
Slide courtesy of Oracle
Oracle Health Sciences Information Manager
EXALOGIC Oracle Hardware Servers & Storage EXADATA
DM
Z Fi
rew
all &
Inte
rnet
Oracle Portals and ApplicationsConsumers Clinicians Administrators Consent Mobility Empowerment
Oracle Identity & Access ManagementSSO User Provisioning LDAP
Oracle Desktop VirtualizationCaregiver Mobility
Oracle Databases, Clusters & Enterprise ManagerEnterprise Linux Solaris Containers Oracle VM Database Encryption
Oracle HIE Architecture
Oracle Health Sciences Information Gateway Oracle Business Process Management Suite
ESB BPEL Business Process Manager Process Analysis
Fixed Web Service Orchestration
Data Center AdapterCONNECT/Direct
DMZ GatewayCONNECT
Web Service Orchestration
Adaptive Web Service Design & Orchestration
Dat
a Ce
nter
Fire
wal
l
Oracle Sun Ray Thin Client
FeaturesHealth Policy MonitorHealth Policy EngineHealth Record Locator Public Key Directory
Healthcare Master Person Index
Healthcare Transaction Base
SOA-based IntegrationsOther SOA Service Endpoints
Healthcare AnalyticsEHA: HDWF-- HDM – ORA -- PSCA
Message-based SupportHealth Sciences Integration Engine
Web Service Registries
PKI Security CertificateAuthorities
Other HealthInformationOrganizations’ Web Services & Secure Health Email
Standardized“Front Door” HIETransactions
Slide courtesy of Oracle
DM
Z Fi
rew
all &
Inte
rnet
Solving CIO Worries by Providing an Internet “buffer” to PHI data sources
Dat
a Ce
nter
Fire
wal
l
Web Service Registries
PKI Security CertificateAuthorities
Other HealthInformationOrganizations’ Web Services & Secure Health Email
End Users
DMZProxy Servers
Cloud Computing Data Center
Firewall Penetrations Multiple Internal and back channel
PHI Data Sources
Standardized“Front Door” HIETransactions
Edge Servers for EHR UsersDesktop Virtualization
Edge Servers for the Health Information Internet Cloud
Electronic Health Record System(s)
Edge Servers supports Secure, Controlled Health Information Exchange of PHI to and from the EHR System(s)
Prepared for the future of consumer-oriented healthcare and wellness management
Slide courtesy of Oracle
Oracle HIE “Edge-Server” Architecture
De-identified
Client Opt In/Out
Organizationor Patient Consent
HL7, CCD, EDI, PHR, Batch,
Web Services
Research(Evidence-Based
Medicine)
Structured Data
Longitudinal Record
Analytics
Claims
Clinical
Wellness
Satisfaction
Raw Data
IdentifyPredictPreventInterveneMeasure
Personalized Health Plan VP of
PopulationHealthMgmt
Home Health Assistant
Primary Care Physician
Health Coach
Device
People
Clinic
Hospital
Payer
Person
Applications
ACO/HIE as a Population Health Platform
HIE
Advanced Analytics
DataTransformation
and Normalization
Master Patient IndexVocabularies
Master Data Mgmt
Enhancing knowledge translation and the adoption of evidence-based practice
Read byQxMed
Why Build This Level of Technical Architecture?
• Move from retrospective reporting to predictive modeling of population health to manage risk and share savings
• Create the data analytics necessary to move to evidence-based medicine and modeling of outcomes, meet coming demand of healthcare consumer analytics
• Predictive modeling provides an objective assessment of a patient’s future illness burden and associated health costs based upon their historical conditions as captured through claims and clinical information – key to ACO success!
– It is a method for prioritizing members for population health management and care management and stratifying them based upon their morbidity burden and financial risk
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ACO = HIE + Analytics Summary
Benchmarking Outcome AnalysisACO Analytics and Management
Population HealthManagement
Spend Analysis
Value Based PricingClaims Adjudication
Value Analysis
Quality
Labor Supply OptimizationSupply Chain Optimization
Waste and Harm
Operations ManagementOptimization
Efficiency & Effectiveness Analysis
Disease Management
Practitioner Profiling & Quality HEDIS 2010 (select measures)
Savings OpportunitiesHarm Avoidance
Safety Pharmacy Analysis AHRQ
Harm AvoidanceAlerting
Actuarial Analysis
Claims HandlingClaims Adjudication
P4PPatient SatisfactionPerformance Improvement
HIE + Analytics: What are typical use cases?
Use Cases Use Cases
Determine and model total cost of care across all settings (acute, ambulatory, home care) by population or individual
ID risk to patients by looking at environmental factors e.g. asthma, flu breakout
Care coordination New age case management (CRM for patients)
Match payer and provider data-verify rollout of preventative programs
ID labor savings. Correlate staffing to predicted demand/activity
Meds Mgmt./Reconciliation/Med Therapy Mgt./Prescription fill compliance
Physician attribution and/or care team – quality outcomes – patient satisfaction
Analyze population health levels based on various grouping (geo, facility, provider, etc.)
Monitor and track (real time) compliance to regulatory and/or clinical guidelines across settings
Understand resource utilizing productivity, throughput and access
Chronic care cost modeling to support payments and allocation
Evaluate readmission across continuum Support transitions of care through transfer of data
Resource planning/physician profitability (contract management, preferences, outcomes
Aggregate and manage data across all care settings (cost, care)
Support all 65 ACO measures, not just the initial 33 Comparative Effectiveness / waste reduction
Monitor/track patients experience beyond HCAPS (coordinate w/workforce, predict experience)
Creation of new evidence base for guidelines
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Thank You / Questions?