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Clinical and Technology Integration to Support

Transformation November 7, 2013

Stephen A. Morgan, M.D.

Chief Medical Information Officer

Senior Vice President

Carilion Clinic

Greetings from Western Virginia

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Carilion Clinic continues to be the premier healthcare delivery system in western Virginia

• Accountable medical group with approximately• 600 physicians, • 150 advanced care practitioners • 300 affiliated physicians.

• 850,000 primary care visits and 50,000 urgent care visits

• Full or partial interests in eight hospitals• Full range of services and an active graduate medical education program

• 56 percent inpatient market share in total service area• More than twice that of nearest competitor (HCA)

• Health plan • Offering Medicare advantage and Medicaid plans

• The Market • 85% FFS• Dominant payor with 70% market share

Carilion Clinic

• Mission: Improve the Health of the Communities We Serve

• Vision 2017: We are committed to a Common Purpose of Better Patient Care, Better Community Health and Lower Cost

Building Blocks of our Success

• Physician leadership

• Technology– EHR -– Data Analytics -

Building Blocks of our Success

• Patient Engagement

• Partnerships– Payers– Service Providers

• Provider Engagement

What’s Driving Change• Rising health care costs• Unstable economy• Changes in consumer demand• Advances in technology• Generational differences in physician

work/life balance• Working “to license”• Working in teams• Workforce shortages 8

An all too familiar story…

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Our National SpendAverage Healthcare Spending per Capita,1980–2009

Adjusted for differences in cost of living

Source: OECD Health Data 2011 (June 2011).

Dollars

THECOMMONWEALTH

FUND

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• Life expectancy improved by 3 years

• Years with disability increased • US fell from 14th to 26th compared to

other nations. • Leading cause for premature deaths

include • CVD• Lung Cancer• CVA

• Leading cause of Disabilities • Back Pain • Musculoskeletal issues • Depression / Anxiety

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Demographic Trends• 1/3 US population – Baby Boomers• 10,000 people a day reach 65• 1 in 10 Baby Boomers is managing multiple

chronic illnesses; by 2030:• 1 in 4 have diabetes• 1 in 2 have arthritis• 1 in 2.5 will be obese

• Treatment of patients with co-morbities cost 7 x those without chronic illness

• 2/3 Medicare spending - 5 or more chronic conditions

Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses

Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009

1%5%

10%

50%

65%

22%

50%

97%

$90,061

$40,682

$26,767

$7,978

Annual mean expenditure

Challenges with Today’s Care

• Healthcare costs growing; burden to business• Overuse; volume “treadmill”• Inconsistent care; fragmentation• Lack of coordination• Payment model at odds with countering rising

costs• Data held “close to the vest”

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The Hope

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• Improve access

• Improve health outcomes

• Reduce cost

The Strategy: Follow the Money

• To optimize the healthcare dollar and improve health

outcomes, both government and private payers are

(gradually) shifting from volume-based

reimbursement to value-based reimbursement

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Emerging Payment Models

• Bundle payments• Pioneer ACO• MSSP• ACO: Advanced payment model• FQHC• Medical Homes• Value based payment models-P4P• State engagement models – for integration of dual

eligible individuals

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Is Reform Possible?

• Able to manage risk• Integration• Engaged physician leadership• Effective health information management• Time to change – pace

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Our Areas of Focus• Population Health

– PCMH

• Care coordination for high-risk and high-frequency patients

• Wellness, prevention, Choosing Wisely

• Payment reform

• Provider Engagement

• Health IT

• Integration

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PHM INITIATIVES

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System PHM Initiatives

• Transformation Oversight Committee– Oversees work of committees in 3 areas:

• Care Integration• Informatics• Finances/Contracting

• Initial focus on COPD • Led by Chief Strategy Officer

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System PHM InitiativesProblem Focus Areas Patient Risk Levels

Low-risk 40-55% Patients without medical problems; goal is to keep healthy and connected to health system – focus on prevention and wellness

Area 2: High utilization management Pt engagement, extensivist team, palliative care; care transitions

Area 1: Disease-focused ambulatory case management Pt engagement; care coordinators, extensivist team; care transitions

Area 3: Ambulatory quality/P4P Cancer screening, BP, lipid, A1C control, etc.; in-office/between-visit/other pt contact components

Sickest and/or highest-utilizing 5-10% Advanced CHF, COPD, IHD, DM, asthma, cancer, psychosocial

Rising-risk 40-50% Patients with less severe chronic illnesses or behaviors that significantly elevate morbidity and mortality risks – HTN, DM, hyperlipidemia, smoking, obesity

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System PHM InitiativesProgram Infrastructure Areas 1 and 2: Disease-Focused

Ambulatory Case Management

and High Utilization Management

Area 3: Ambulatory Quality / Pay

for Performance (P4P)

INFORMATION & GUIDES    Data Analytics and Reporting    Clinical Protocols and Pathways    CULTURE CHANGE & ENGAGEMENT    Patient Education and Engagement    Organizational Change Management (Provider

and Staff Training and Engagement)    

TOOLS & RESOURCES    Point-of-Care Decision Support    Centralized Patient Outreach    EHR Care Plans    Extensivist Team    Palliative Care and Hospice    Home Health    

Carilion Clinic: PCMH TodayTotal Program Sites: 27• Family Medicine - 21• Internal Medicine - 4• Pediatrics - 2

Recognition Status• Level 3 Recognition – 27

Panel Size: 200,000• 77% of Department Patients

Providers: 136• Physicians - 106• ACPs - 30

Care Coordinators• Budgeted Positions: 22 FTEs

PAYMENT REFORM

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Accountable Care Activities

• Payor Arrangements– Managed Medicare and Medicaid

• Owned – Medicaid HMO– MajestaCare

• Contracted MAP– Humana, UHC

– Aetna ACO (Whole Health)• Doctors Connected

– ACO• MSSP

• Commercial– Anthem PC2

PROVIDER ENGAGEMENT

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Physician Compensation• Moving from Volume to Value• Major Components:

– Personal RVUs (~ 85%)– ACP oversight (RVUs) (~ 5%)– Performance metrics (~ 10%)

• Panel size• Quality metrics• Expense management

Care Integration

• Sub-Group of Transformation Oversight • Oversight of integrated projects

– Representatives from all departments – Education for first year

• Payment reform • Understanding our data / opportunities

– Process improvement – Transitions of care

• Employed providers 32

Working with Community Providers

• Open Medical Model - Hospitals• Involvement of medical directors with LOS

committee • Data sharing and transparency• Involvement in decision making • EMR• Joint leadership and affiliation

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HEALTHCARE IT AND ACCOUNTABLE CARE

“Health IT is essential not only to accountable care organizations (ACO) but also healthcare in general”

Kathleen Sebelius, MPA,

Secretary of the U.S. Department of Health & Human Services

Population Health Management

• Fundamental to every major healthcare reform initiative today– Patient-Centered Medical Home– Accountable Care Organization

• EHRs alone are not sufficient to manage populations effectively

• Provider groups and health systems that automate the spectrum of population health functions will be best positioned to succeed

Healthcare IT and ACOsThe Critical List

• Population identification - attribution• Identification of care gaps – Decision Support • Risk Stratification• Cross Continuum Care management • Quality and Outcomes measurement• Patient engagement• Telemedicine • Mixing claims and clinical data • Predictive modeling • Clinical information exchange

PATIENT ENGAGEMENT

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Bridging the gap between home, hospital , office and beyond…

CARE COORDINATION

Chronic Disease Registries

High Risk Patients for Re-admission

Care Plans Across the Continuum

• Developing a disease management section in the EMR navigator

• High risk patients flagged • Using problem lists and linked episodes • Viewed by IP, AMB, and ED.

TRANSPARENT DATA DELIVERY TO PROVIDERS

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Primary Care Group Dashboard

PAYOR DATA

ED Frequent Flyers

ER Visits % of TotalAbdominal Pain 116 9%Angina/chest Pain 93 7%Accidental Injury/assault 86 6%Migraine/other Headaches 84 6%Throat Disorders 57 4%Sprains/strains 45 3%Skin Disorders - Other 41 3%Gastroenteritis 39 3%Cellulitis/abscess 38 3%Back Pain/degenerative Disorders 38 3%Kidney Stones 32 2%Fractures 30 2%Neurologic Disorders - Other 28 2%Contusion/crushing Injury 26 2%Complicated Pregnancy - Other 23 2%Mechanical Joint Disorders 23 2%Respiratory Disorders - Other 21 2%Urologic Infections 21 2%Intestinal Disorders - Other 20 2%Muscle/ligament/fascia Disorders 20 2%Syncope/hypotension 17 1%Acute Bronchitis 16 1%Complication - Medical Care 13 1%Arrhythmia - Other 12 1%Eye Disorders - Other 12 1%

Top Diagnoses for Members with Mult ER Visits

ENTERPRISE DATA WAREHOUSE

Putting it all together

Enterprise Data Warehouse

Claims Data

AetnaEmployee

Group,ACO

(Wholehealth)Claims

LabRx

Eligibility

TMGMedicare

AdvantageClaims

CMSMedicare Shared Savings

SAP/BusinessObjects

Enterprise

EPIC EMROperationalDatabase(Cache)

QNTXMedicare

HMO (Majesticare)

OtherPlans - TBD

CLAIMS/PlanData Sources CARILION CLINIC

NIGHTLY

ETL

ET

L

Clarity Relational Database

Cloud-Based/ASP services

TemporaryClaims Staging

Database

Care Conerns/Gaps,

Risk

Stratific

ation Data

PopulationAdvisor

Premier/Verisk

Web-based User Interface

Enterprise Data Warehouse

EPIC EMR

EARLY OUTCOMES

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Aetna Whole Health ACO Outcomes

Baseline Current

(2011) (2012-2013)

Bed Days/1,000 125.7 118.3

Readmission Rate 5.6% 4.9%

Avoidable ER Visits/1,000 113.3 85.9

Hi-Tech imaging/1,000 69.2 62.8

Aetna Whole Health ACO Outcomes

Quality Metric Baseline 2011 Current 2012-2013 *Benchmark

Colorectal Screening 76% 83% 63%

Diabetes HgbA1c testing

91.2% 93.8% 91%

Diabetes Lipid Profile testing

88% 89% 87%

Patients with CAD on lipid lowering RX

100% 99% **98%

*Benchmark= HEDIS 2012 75 percentile**Aetna Benchnark

Carilion Patient Centered Medical Home Outcomes

Comparative Clinical Performance Measures: 2009-2012

Q-42009

Q-22012

PercentChange (%)

1. Body Mass Index (BMI) Measured for Patients <18 Years of Age 39.5% 92.9% 135.2%

2. Pneumococcal Vaccination for Patients >65 Years of Age 74.2% 79.0% 6.5%

3. Breast Screening for Female Patients 40-69 Years of Age 56.2% 66.8% 18.9%

5. A1c Testing for Diabetics 18-75 Years of Age 85.2% 91.9% 7.9%

6. Persistent Asthmatics with Controller Medications Prescribed 86.2% 93.1% 8.0%

7. Diabetics with Blood Pressure Controlled at <140 SBP / 90 DBP 68.4% 72.2% 5.6%

8. Hypertensive Patients with Blood Pressure Controlled at <140 SBP / 90 DBP 64.6% 67.6% 4.6%

Source: 70,000 patient study in 20 Carilion mature medical homes during the period 2009 – 2012; "The Impact of the Patient-Centered Medical Home on Hypertension."

Care Coordination – Early Success in Quality Metrics

Two Year Retrospective Study

2,800 Diabetes Mellitus (DM) Patients with Care Coordination compared to 30,000 DM patients with usual care in Carilion

Clinical Outcome DataDiabetic Patients in PCMH Sites who received Care Coordination

Relative Impact

A1c Reduction• No Care Coordination - 0.07• Care Coordination - 0.60 8.5

LDL Reduction• No Care Coordination - 9.5• Care Coordination -14.2 1.5

BMI (Body Mass Index) Reduction• No Care Coordination - 2.8• Care Coordination - 5.0 1.8

DBP (Diastolic Blood Pressure) Reduction• No Care Coordination - 2.1 • Care Coordination - 3.8 1.8

SBP (Systolic Blood Pressure) Reduction• No Care Coordination - 2.8 • Care Coordination - 5.0 1.8

0

200

400

600

800

1000

1200

1400

3.8 4.4 4.75

5.3 5.6 5.9 6.2 6.5 6.8 7.1 7.4 7.78

8.3 8.6 8.9 9.2 9.5 9.8 10.1

10.4

10.7 11

11.3

11.6

11.9

12.2

12.5

12.8

13.1

13.4

13.7 14

14.3

14.6

14.9

15.2

15.5

15.8

16.1

16.4

17.1

17.6

18.3

Distribution of FCM & IM Patients' Last A1C ValueMarch 2012 - Feburary 2013

Median = 6.8

Average = 7.3

80%

N = 23,473 patients with type 2 DM

Key Drivers

• Physician Leadership and engagement – CMO, CSO, CMIO, Department Chairs

• Information Technology– EMR – EPIC, MyChart– Telemedicine– Data Warehouse

• Aligned Incentives– System Balanced Scorecard– Physician Compensation

• Contracting / Payment Reform

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