July 15, 2019 / Issue 4

EXECUTIVE SPONSOR

PHYSICIAN SPONSOR

NURSING SPONSOR

POP HEALTH SPONSOR

VISION STATEMENT

Together, we will design and implement a patient-

centered, clinically-led fully integrated electronic medical

record to improve the health and outcomes for the

communities we serve.

SUCCESS LOOKS LIKE...

• Satisfied patients and caregivers

• Improved access

• Increased patient portal use/patient access

• Increased utilization/decreased redundancy

• Increased market penetration

• Improved specific disease metrics

• Increased number of practices reporting quality metrics

David P. Hughes, MD, MPHExecutive Vice President and

Chief Medical OfficerKaleida Health

Population health: Moving from reactive care to proactive health

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EXECUTIVE SPONSOR

Healthcare delivery traditionally has been a reactive process. A person presents at one of our locations and receives care. Outside of these face-to-face interactions, we often have little or no interaction with that person.

In order to better serve those in our community, we need to know the characteristics of the populations we’re serving. We need to shift our focus over time from providing reactive care to being able to proactively manage people’s health. The strategy is to know, engage and manage outcomes at both the personal level and the population level, whether it’s the population of a single practice, health system or larger community.

Although there are a number of suppliers offering population health services and technologies, our decision to partner with Cerner was based on a number of factors:

• Cerner is highly rated for both product capabilities and market execution.

• Data aggregation and normalization: Cerner’s big data platform, HealtheIntent, can process and reconcile diverse data sets from any system – the multiple EMRs used across Great Lakes Health and our affiliated partners, as well as the claims files from CMS, the New York State Department of Health and private payers.

• Massive, highly scalable and programmable platform: HealtheIntent supports any size population to provide a common platform across our various

business initiatives.

• Near real-time intelligence: HealtheIntent applies intelligence to our data to push actionable information to care teams within the context of what they do each day to identify, predict and measure health

outcomes. An example is the Sepsis algorithm that warns

the care team of patients at risk of developing sepsis based on

clinical data captured within GLIMR.

• Strategic advisory services: Cerner is providing advisory services to help us navigate the transformation of health care by bringing people, processes and technology together to achieve our organizational goals.

• Ecosystem for innovations: in partnership with the University at Buffalo, HealtheIntent will allow us to provide resources and advanced data discovery services for research on the populations we serve in order to discover innovative approaches to keeping people healthy.

Look to page 4 of this newsletter for more information about the strategy we’re employing to make all that happen. In future communications, we’ll provide information on the specific solutions being deployed and the value we’re obtaining from their use.

~ TABLE OF CONTENTS ~

Dr. Hughes Report .................................1GLIMR Advance .....................................2

GLIMR Expand .......................................3GLIMR Population Health .....................4

Cheryl Klass, RNExecutive Vice PresidentChief Nurse Executive

Kaleida Health

NURSING SPONSOR

2

That’s the average amount of time providers save per patient after a one-on-one consultation with a trained EMR coach.

The session can be conducted during normal business hours, at your convenience. There is no need to block out time or lighten your schedule.

Scan the QR code below with your phone or call the IT service desk at 859-7777, option 1, to schedule a one-on-one EMR coaching session today.

How would you like to shave 06:33 per patient?

Clinical Performance Excellence (CPE): two more solutions in the pipeline

Readmission Prevention provides capabilities in near real time to assist you with activities such as screening for high-risk patients and reporting on progress. Readmission Prevention helps us not only adhere to guidelines from the Centers for Medicare & Medicaid Services (CMS) but also cut overall readmissions while saving money on day-to-day activities.

This innovation uses patient-centered best practices and technology to support early recognition and management as an aid to the readmission reduction program. The innovation also offers outcome and analytic tracking for patients determined to be at higher risk for readmission.

Readmission Prevention is designed to identify patients at risk of being readmitted through a series of algorithms. The algorithms identify patients at the greatest risk using a set of rules based on CMS guidelines and automated identification of clinically relevant factors — such as demographics, comorbid conditions, healthcare utilization, procedures, medications and labs — to give the patient a probability score for being readmitted.

The Palliative Care solution delivers a systematic approach to identify, engage and manage palliative care patients by addressing the physical, emotional, spiritual and social care concerns of individuals with a serious illness or chronic pain. With early identification and treatment, Palliative Care facilitates the development of a joint care plan between the clinicians, patient and care team to set and reach individual-specific health goals. Through a multi-disciplinary approach to palliative medicine, the solution aids the entire care team by generating the required documentation and helping to reduce the length of stay and overall costs to treat the sickest, most expensive patients.

Features include an algorithm to identify patients who might benefit from a palliative care consult and then alert clinicians; an electronic worklist to manage and prioritize their patient population; and role-specific palliative care electronic documentation that is available across clinicians.

In the last issue we covered these solutions: Referral Management, Rapid Response, Sepsis Management and VTE Prevention. CPE is scheduled to go live Sept. 10, 2019.

Readmission Prevention helps to cut overall readmissions while saving money on day-to-day activities

Palliative Care presents a holistic approach to improving a patient’s quality of life and well-being

A new capability in the patients’ electronic

medical record (EMR)

went live on June 25. Rather than keying in information when administering vaccines, clinicians can now scan directly from the label on the vaccine into the EMR.

Immunizations are going digitalIn addition to meeting regulatory requirements and streamlining the process of administering vaccines, barcode scanning technology will improve the accuracy of our reporting and increase patient safety.

Soon, immunization status will be reported to the New York State Immunization Information System electronically.

Spin-off benefits include:

• Ensuring that immunizations are monitored

• More precise inventory and stock control

• Improved comm-unication among a patient’s providers, whether they are part of Kaleida Health or not

N E W T E C H : V A C C I N E B A R C O D E S C A N N I N G

Peter Winkelstein, MD, MBAVice President and

Chief Medical Informatics OfficerKaleida Health, Chief Medical

Informatics Officer UBMD

PHYSICIAN SPONSOR

Overview

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RECENT ACCOMPLISHMENTS

As of 7/2

• Project % completed is at 18%, up from 15% last week

• Workshop 4 is completed

• Version One training conducted for IT analysts and DCW contributors

• Addressed Foundational DCWs with mitigation plans

• Value Management Workshop held on 6/26

• Health Plan Master DCW in testing and targeting validation mid-August

UPCOMINGThrough 7/10

• GLIMR Expand Revenue, Operations and Physician Committee

• Orders Workbook - Completed order synonyms 6/24 and submitted to build on 6/25; Tentative validation on 7/10

• Organization/Locations DCW- build submitted

This important question is not asked — and answered — as often as it should be when an organization is rolling out a new project. Asking and answering the success question was the point of the Value Measurement Workshops that were conducted on June 26.

Key Performance Indicators (KPIs)

How do we know when we have succeeded?

At these working session meetings, operational stakeholders from UBMD, GPPC and ECMC’s ambulatory clinics met to determine what core Key Performance Indicators (KPIs) were the most important outcomes for measuring success in the GLIMR Expand initiative.

A list of clinical/operational KPIs and a list of revenue cycle KPIs were developed and discussed. These KPIs will be measured and tracked by each entity.

The preliminary list of core KPIs is listed below.

CLINICAL/OPERATIONAL CORE KPIs CATEGORY

• Percent of patients with secure messaging • Patient experience

• Patient portal use • Patient experience

• %age of no-show appointments • Efficiency

• Provider time in chart review • User experience/efficiency

• Time spent documenting after hours • User experience/efficiency

• Provider time in documentation • User experience/efficiency

REVENUE CYCLE CORE KPIs CATEGORY

• Denial rate decrease • Patient accounting

• Percent of claims that need to be reworded • Patient accounting

• Monthly claim totals • Patient accounting

• Clean claim rate • Patient accounting

• Reimbursement received for Medicare wellness visits • Ambulatory

• Visits without charges • Cerner practice management

Next steps include determining operational owners for each KPI at each organization, developing specific improvement goals and determining a measurement plan for each KPI.

Workshop 4 was held the week of June 17 in the University at Buffalo’s stunning new Jacobs School of Medicine and Biomedical Sciences building. Pictured here: Tammy Cleary, quality director for GPPC, and Michelle Finlay Jackson, Cerner clinical consultant.

Thank you, UB!

Mark ZygajExecutive Director

Great Lakes Integrated Network and Optimum Physician Alliance

POPULATION HEALTH SPONSOR

Moving from reactive care to proactive health in a medical neighborhood

Value-based care requires going beyond the traditional healthcare model which limits our interaction with patients to those occasions when they present at one of our locations to receive care.

Significant changes are occurring within the populations we serve. The proportion of older individuals is growing rapidly, with an accompanying increase in chronic conditions such as diabetes and cardiovascular disease. The continued increase in healthcare costs has led many organizations to offer high-deductible health plans, resulting in a heightened focus on the cost of care delivery for consumers and employers. Federal, state and private payers are shifting more of the financial risk of managing health to us.

To better serve those in our community and thrive as these changes continue, we need to shift our focus over time from providing reactive care to being able to proactively manage people’s health. So, how are we going to do this and transition toward value-based care?

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Our strategy is designed to enable us to know, engage and manage at both a person and population level. We need to know the characteristics of the populations we’re serving. Who is at risk? Where are the rising risks? How can we collaborate to ensure that we address the concerns that exist today and prevent the progression of risk in order to manage outcomes and avoid costly or unnecessary services?

When we have a solid understanding of our populations, we’ll develop strategies to more effectively engage people, their families and their care teams. While these interactions may at times occur in a similar manner as before, we’ll see increasing use of virtual care to reduce costs and make the interaction more convenient for everyone involved.

Lastly, once these strategies have been implemented, we’ll need analytical capabilities to help manage and predict outcomes by monitoring our performance and adjusting our strategies as needed to attain the optimal outcomes.

POPUL ATION HE ALTH

To know, engage and manage our populations, our approach is to ensure availability of people’s data from across the health continuum to empower both themselves and their care team to be better connected.

When a person is seen in the emergency room, we want their home care team to be aware of the visit and have the pertinent data available when they next encounter the patient. By being better connected, we believe everyone will be more informed and accountable – enabling the shift from reactive care to proactive health.