Building the IT Infrastructure for Population Health and Care Management

February 23, 2014

Karen Handmaker, MPP

VP Population Health Strategies, Phytel

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Disclosure

Karen Handmaker, MPP

• Salary: PHYTEL

• Royalty:

• Receipt of Intellectual Property Rights/Patent Holder:

• Consulting Fees (e.g., advisory boards):

• Fees for Non-CME Services Received Directly from a Commercial

Interest or their Agents (e.g., speakers’ bureau):

• Contracted Research:

• Ownership Interest (stocks, stock options or other ownership interest

excluding diversified mutual funds):

• Other:

© 2014 HIMSS

Learning Objectives

1. Appreciate the implications of the “volume to value”

transformation imperative in healthcare today

2. Understand how an effective HIT infrastructure

enables population health and care management

3. Extrapolate to the future

A Show of Hands

• Is your organization in an ACO or similar value-based

contract?

• Can you readily profile and stratify your population?

• Are your care teams managing all of your patients or

only those who present at the office or identified as

“high risk”?

• Is there room to “lean out” manual tasks and “design

in” automation to increase care team capacity?

What From Volume to Value Really Means

The Big Picture:

>2/3

of catastrophic

patients this year

were not

catastrophic

the previous year

Are You Looking Below the Waterline?

Source: Healthcare Risk Adjustment and Predictive Modeling, Ian Duncan

Do you only focus on the top 3%?

You must focus on everyone below the waterline

this year to prevent next year’s catastrophic cases.

The “Triple Aim” is Driving Change

Move from Volume to Value is Underway

PCMH Model Has Traction

Source: PCPCC

The Patient-Centered Medical Home’s Impact on Cost & Quality

An Annual Update of the Evidence, 2012-2013 - January 2014

http://www.pcpcc.org/resource/medical-homes-impact-cost-quality/

Managing in PHM Model While Still in FFS

Volume-Based/Episodic Value-Based/Continuous

Current View

30 Patients Per Day

14 have Chronic Conditions

Unknown Health Risks

Visits Too Short for Coaching

New Population View

2500 Patient Population

900 have Chronic Conditions

1100-1250 have Mod-High Health Risk

Care Teams Leveraged by HIT

HIT’s Role in Population Health and Care Management

How Are We Getting There?

PHM is a “Work in Progress”

Strategic Drivers

PCMH Recognition

MSSP Award

Integration of PCP

Acquisitions

Direct Employer

Contracting

Financial Incentives

Payer P4P

MSSP Shared Savings

MU Stage 2

PHM Infrastructure

Common EMR but Use Varies

CMs Employed and Payer-Subsidized

Patient Portal and HIE

Coming Soon

Medical Neighborhood

Loosely Coordinated

Best Practices

Workflows Largely Manual

Actionable Data Minimal

Care Teams Not at “Top of

License”

Focused on “Tip of the Iceberg”

Major Goals… …But Emerging PHM Capabilities

Center for Medicare &

Medicaid Innovation awarded

a $20.75 million Health Care

Innovation Challenge grant to

TransforMED, VHA and Phytel

• Grant awards collaborative partnership

• Funds 3 yr national project in 15

communities

• Expands the PCMH concept to the

Patient Centered Medical

Neighborhood – connecting hospitals

with physician practices for better

quality and patient experience at a

more affordable cost

Innovation Grant Includes PHM Technology

2013 PCPCC Report:

Health IT is “Must Have” for PHM

TEN RECOMMENDED HEALTH

IT TOOLS TO ACHIEVE PHM:

1. Electronic Health Records

2. Patient Registries

3. Health Information Exchange

4. Risk Stratification

5. Automated Outreach

6. Referral Tracking

7. Patient Portals

8. Telehealth / Telemedicine

9. Remote Patient Monitoring

10. Advanced Population Analytics

Source: PCPCC – Managing Populations, Maximizing Technology

http://www.pcpcc.org/resource/managing-populations-maximizing-technology

Population Health Management Visual

Source: Shifting to Value: Population Health Management Technologies for Accountable Care. www.phytel.com

Current (Manual)Processes Are Insufficient

“Working

harder is the

worst plan”

-W. Edwards Deming

2500 Patient Panel

Chronic Disease Ann Fam Med 2005;3:209-214

10.6

Preventive Care Am J Public Health

2003 Apr;93(4):635-41

7.4

Acute Care J Fam Pract 1198;46:377-389

4.7

Non-patient care AAFP survey May 2005

2.1

Total Hours per Day 24.8

Automating the Population Health Model

Actionable Views of Your Population

Current State: Care Team Daily Work

Karen to create graphic

Automated Patient Engagement Works

Stratify for “Top of License” Workflows

Work Below the Waterline to Impact Top Line

A: “The majority (65%) were

not 9+ last year, so you have

to find them BEFORE they

become 9+.”

Q: “How can our rate of uncontrolled diabetics

be increasing if I am managing all of them?”

Source: American Journal of Managed Care

http://www.ajmc.com/publications/issue/2013/2013-1-vol19-n6/Population-Health-Approach-for-Diabetic-Patients-With-Poor-A1C-Control

How Are These Providers Doing?

Scale and Automation Are Required

Diabetes

CAD

COPD

Hypertension

Asthma

Smoking Depression

Track Performance to Target Improvement

• Monitor performance measures

• Compare provider and care team results

• Use drill-down capabilities to find outliers and take action

Practice Innovations that Produce “Joy”

Source: In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, Ann Fam

Med 2013;11:272-278. doi:10.1370/afm.1531.

Extrapolate to the Future

What’s Next?

Patient Engagement is the Holy Grail

Source: Bipartisan Policy Center,

“F” as in Fat: How Obesity Threatens

America’s Future (TFAH/RWJF, Aug.

2013)

We WANT/NEED Patients to Pick the Right Path

• Our agenda for Oscar:

– Medication adherence

– Come to follow-up appointments

– Improved self-monitoring

– Participation in PT

– Nutritious food choices and increased calories

– Living Will

– Participate in Shared Decision-Making

• Oscar’s agenda for Oscar:

– Grieving for his wife

– Transportation

– Managing Rx side effects

– Seeing his grandchildren

More Emphasis on Patient-Reported Data

Source: Premier, Inc.’s Fall 2013 Economic Outlook

1. Health and non-health

information

2. Gathered continuously;

not just at visit

3. Patient satisfaction

4. Quality measurement

“I Am My Own Medical Home” Advanced knowledge technologies allow self-care

Facilitated Disease

Network

Personal health

record

Noninvasive biomonitoring

Digital coach (“avatar”)

Wellness & disease

mgmt. apps

http://altfutures.org/primarycare2025

Questions? Thank You!

Karen Handmaker MPP | VP, Population Health Strategies 11511 Luna Road, Suite 600 | Dallas, TX 75234 direct 214-750-9922 ext 143 | toll free (800) 559-3057 mobile 502-751-7764 | fax 1-888-664-0142

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