Health InformationResource Management and Policy:

Better Data for Better Care

J.D. Whitlock, MPH, MBA

Health Resource Management and Policy

CMH 6500

30 June 2016

2

Why Am I Passionate About This Topic?

1993-1995: MPH @ UCLA during HillaryCare debates

1996-2012: Operational & technical mgmt. roles in Military Health System

2012-Present: VP, Enterprise Intelligence, Mercy Health

Goals

1. Understand the (mostly) unharnessed potential of healthcare data in improving the delivery of care

2. Understand the role of Clinical & Business Intelligence as an essential enabler of the transition from volume-based care to value-based care

3. Based on the importance of #1 and #2, increase your level of knowledge and interest in healthcare analytics

Overview• Lingo

• “Transforming Health Care: The Role of Health IT” – Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

• Examples of Population Health Management C&BI

• Examples of Public Health Focused C&BI

• ACO Jobs for Public Health Peeps

• Electronic Health Record (EHR)

• Personal Health Record (PHR) / Patient Portal

• Health Information Exchange (HIE)– Public HIE

– Private HIE

• Health Insurance Exchange (HIX)

• Clinical & Business Intelligence (C&BI)

• Population Health Management (PHM)

• Accountable Care Organization (ACO) – Medicare Shared Savings Program

– Commercial ACO

– A healthcare provider organization capable of accepting risk

Transforming Health Care: The Role of Health IT

• Gaps and barriers

– Misaligned Incentives

– Lack of Health Information Exchange

– Limited Level of Consumer Engagement Using Electronic Tools

– Limited Levels of EHR Adoption

– Privacy and Security Concerns (HIPAA +)

– Multiple Federal Priorities Require Focus and Attention

http://bipartisanpolicy.org/sites/default/files/Transforming%20Health%20Care.pdf

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Easier Said Than Done

Why is this so hard?

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Review of Economics 101:Incentives Matter

One Example of Getting What You Pay For

An “Avalanche” of Unnecessary Care?

“Americans always do the right thing, after they have tried everything else”

– Winston Churchill

“First and prerequisite for other kinds of progress, the Nation must accelerate the transition to payment models that pay for value rather than volume”

Presidents Council of Advisors on Science and

Technology (PCAST)

“Better Health Care and Lower Costs: Accelerating

Improvement Through Systems Engineering”

(May 2014)

Volume-Driven vs. Value Driven

• Wellness and

Prevention

• Care Coordination

• Clinical Integration

• Care Management

• IT Connectivity

• Aligned incentives

• Admissions

• Visits

• Procedures

• Interventions

• Widgets

• Volume = Revenue

Volume-Driven Value-Driven

CMS Has Set Aggressive Goals for Transition to Value

Graphic: Premier Health Alliance

Significant Change in Medicare Payment Model

Value Based Reimbursement:Track 1 vs. Track 2

Graphic: Premier Health Alliance

MACRA Reform Timeline(Medicare Access and CHIP Reauthorization Act of 2015)

Graphic: Premier Health Alliance

Accountable Care Core Components

People Centered

Foundation

Medical

Home

High Value Network

Population Health Data

Management

ACO Leadership

Payor Partnerships

Foundational Philosophy: Triple Aim

The Bridge from Volume (FFS) to Value (Accountable Care)

What are the underpinning

building blocks?

CurrentFFS

System

AccountableCare

Measurement

Triple Aim:Enabled by C&BI

Pop Health Mgmt

Care Coordination

Quality Reporting

Comparative Effectiveness

Decision Support

Patient Engagement

Clinical & Business Intelligence

Components of an Accountable Care Organization (ACO)

Payer Partners

► Insurers

► Employers

► States

► CMS

A group of providers willing and capable of accepting accountability for the cost, quality, and experience of care for a defined population

Medicare Shared Savings Program (MSSP) Business Model

• CMS defines the population (patients already seeing the ACO’s PCPs) and sets financial targets

• Participating providers care for patients on fee-for-service basis

• 33 CMS prescribed patient satisfaction & quality measures are monitored

• CMS performs annual reconciliation of financial and quality performance

• Shared savings (if any) are distributed within the ACO

• Chronic disease management across the continuum in six major disease areas: – Asthma– Diabetes– CHF– COPD– Hypertension– Chronic depression

• Managing high risk populations

• Appropriate utilization of expensive diagnostics

• Pharmaceutical use / costs (e.g., use of generics)

Per Capita Cost Reduction Targets

ACO Innovations Turn Traditional Care Models on Their Head

• Virtual physician office visits• Electronic home monitoring• Hospital in the home concept• Growth in provider sponsored health

plans• Primary care based behavioral health

programs• Palliative and end of life care • Post-acute care management programs• Keeping patients out of the hospital• Keeping patients out of the ER

From The Institute of Medicine’s 2012 report, Best Care at Lower Cost:

Primary care providers are the only healthcare professionals who can effect transformation in health care. The systems and structures which will fulfill the Triple Aim can only be designed andimplemented by primary Healthcare Healers.

Patient Centered Medical Home(PCMH)

You Can’t Do ACO Without PHM, C&BI, and HIE

• Integrated elements of a successful ACO:

– Improved clinical outcomes and patient satisfaction linked to

– Care Coordination embedded in

– Patient Centered Medical Homes practicing

– Improvement Science Methodologies that support

– Population Health Management using

– Data Analytics across a Clinically Integrated Network

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Healthcare Information Exchange(First, the Bad News)

• A lot of federal grants went to states to set up HIEs, but few have resulted in HIEs with sustainable business models

• Public HIEs have difficulty getting competing healthcare organizations to agree on what to share

• Many technical barriers to exchanging “computable” summary of care data

• Private HIEs are now growing faster than public HIEs (because they are purpose built in line with existing incentives and business models)

Meaningful Use Stage 2 Mandated Electronic Exchange of Data for Transition of Care

“His care was materially different because his continuous lifetime record - inpatient, outpatient and emergency department - was available without going to a separate portal or adopting a new workflow”

http://www.healthcareitnews.com/blog/interoperability-real-life

Common Vocabulary and Code Sets

Is the glass half-empty or half-full?

http://www.healthdatamanagement.com/opinion/why-the-inability-to-exchange-data-stands-in-the-way-of-accountable-care

“SMART on FHIR”: The Future of Interoperability?

• SMART: Substitutable Medical Apps, Reusable Technologies

• FHIR: Fast Health Interoperability Resources

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Critical Need to Connect Directly with Patients

SMART-on-FHIR Example: Growth-tastic

• Growth-tastic presents a child’s growth data in easy to understand graphics aimed at parents

• Demonstrates the potential of app platforms to make health data available in the most useful way

Patient Portal & Activated Patients! (?)

Mobile Patient Monitoring

Leverage emerging wireless medical device technologies for remote monitoring of patient physiologic parameters

Air Force Patient Portal Study: What Patients Value Most

• Most Preferred Features (Top 5 of 18)

5.00 5.50 6.00 6.50

Track lab results

Medical information availableanytime from any web-enabled…

Securely message my providers

Print and/or exchange medicalinformation with providers

Emergency informationimmediately accessible

Patient Activation / Patient Engagement

“The Blood Test Gets a

Makeover”

Wired Magazine Dec 2010

http://www.wired.com/magazine/2010/11/ff_bloodwork

Personalized Risk Charts Showing Results of Behavior Modification

Sara Jane’s 80/20 Rule on Patient Activation

Consumerization of Healthcare = Convenience is King

“VIDEO IS ABOUT TO BECOME THE WAY WE ALL VISIT THE DOCTOR”

HTTP://WWW.WIRED.COM/2015/04/UNITED-HEALTHCARE-TELEMEDICINE/

• United Healthcare now charge the same co-pay for a video visit or office visit

• Combined with “Minute Clinic” model, major potential for disruptive innovation

• Discuss Washington Post article “Rating Hospitals by the Stars”

• What do you think?

• Should CMS publish the quality star ratings?

CMS Hospital Comparehttps://www.medicare.gov/hospitalcompare/search.html

54

Summa Health Website: “Quality Outcomes”(Door-to-Provider is 1 of 16 measures)

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Meaningful Use

• Incentive payments to providers and hospitals for “meaningful” use of certified EHRs

• $34B of your tax dollars

• 5 Major Components– Improve Quality, Safety, and Efficiency

– Engage Patients and Families

– Improve Care Coordination

– Improve Population and Public Health

– Ensure Privacy and Security for Personal Health Information

Dr. Farzad Mostashari, 7 May 2013

“We’re about halfway through the

process of computerizing and

digitizing America’s hospitals and

doctor’s offices, and we’re about 5

percent of the way through changing

workflows and redesigning care to

take advantage of those

technologies”

“We seek the development of a learning healthcare system designed to generate and apply the best evidence for the collaborative health care choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.”

A Learning Health System(“Better Data for Better Care” Freely Shared)

Data

Information

KnowledgeInsight and action

A “virtuous” cycle of discovery

Eugene KolkerChief Data Officer

Seattle Children's Hospital

“People talk about technology, and we need to have it. Data science, analytics? Absolutely. Business practices? Definitely. But still the major focus is people – who are going to make decisions or not, make interventions or not. The whole focus of what we do is to help people make better, data-driven decisions."

How Do We Fix This?

Better C&BI and a Learning Healthcare System!

• Report recommendations:

– Align Incentives

– Accelerate Health Information Exchange Efforts

– Accelerate and Support Engagement of Consumers Using Electronic Tools

– Expand Education and Implementation Assistance

– Address Concerns About Privacy and Security

Transforming Health Care: The Role of Health IT

Your medical information is worth 10 times more than your credit

card number on the black market

http://www.reuters.com/article/2014/09/24/us-cybersecurity-hospitals-idUSKCN0HJ21I20140924

Privacy and Security 101

Privacy and Security 102

• Discuss WSJ article: “Should Every Patient Have a Unique ID Number for All Medical Records?”

• Which side are you on?

• Does it make a difference if the Unique ID is voluntary?

• What are the public health implications of this debate?

• Is (de-identified) clinical data a public good?

Examples of Population Health Management C&BI

This Does Not Work

At Risk Contracts

• Payer A

• Payer B– Plan B1

– Plan B2

• Payer C

• Payer D

• Payer E– Plan E1

– Plan E2

– Plan E3

PHM Platform / Care Coord / Set of CQMs

• Payer A

• Payer B– Plan B1

– Plan B2

• Payer C

• Payer D

• Payer E– Plan E1

– Plan E2

– Plan E3

This Can Work(And is the differentiator for ACOs)

At Risk Contracts

• Payer A

• Payer B– Plan B1

– Plan B2

• Payer C

• Payer D

• Payer E– Plan E1

– Plan E2

– Plan E3

Single:

PHM Platform / Care Coord / Set of CQMs

Quality

Measure the experience, results and active

participation of covered population

Provider Analytics

Manage/maintain consistency,

effectiveness and openness of care

delivery

Population Health

What are the behaviors, norms and risk profiles of the local population

Total Cost of Care

Covered individual and total population

utilization & spend

Improved Outcome, Spend, Utilization & Access

Tools Required for Value-Based Care

Claims

Nominal ACO / PHM Architecture

Physicians

Analytics Team

Care Coordinators

Pop Health MgmtPlatform

EHR

Data Warehouse / Total Cost of Care

EHREHR (s)

OtherData

Claims Analysis: Risk Profiling, Utilization Reporting

Example ACO Metrics

PHM Analytics Within Mature EHRs

1. EHR Registry identifies a cohort of patients in a PCP panel that need some type of outreach (e.g. diabetic patients that need an A1c test)

2. EHR workflow enables bulk ordering of test / bulk communication to patients in their preferred format (Secure messaging vs. phone vs. letter)

3. Outreach and results are tracked

Readmission Risk Scores + Case Mgmt Workflow

Acute Care Real Time Quality Monitoring

Clinical Decision Support

• Good Clinical Decision Support (CDS) is:– Not intrusive (whack-a-mole pop-ups)

– Imbedded into clinical workflow (or easily accessible from clinical workflow)

– Evidence-based

– Actionable (or likely actionable) by the provider

• Really good CDS is:– Tailored to the individual patient based on clinical

data (and even genomic data)

• Examples of really good CDS might look like …

http://geekdoctor.blogspot.com/2007/11/data-information-knowledge-and-wisdom.html

The Explorys Value Based Care Big Network

• Over 360 hospitals and 317,000 providers

• $69 billion in care delivered annual by network members

• 50 million unique patients

• Comprehensive view of care including all venues of delivery representative of all major diseases, treatments, and demographics

“Big Data” in Healthcare

Example of Big Data PHM Platform

Clinical Quality Dashboards

Advanced Risk Scores(paid claims + EHR clinical data)

• Concurrent risk score: Overall utilization risk

• Mortality risk: Which patients need palliative care rather than intense care coordination?

• Risk of ED visit in next 30 days: Based on meds/Dx/encounters/demographics (AUC = 0.8)

(Synthetic Patient Data for demo purposes only)

Patient Summary:Comprehensive view of Risk Profile and Care

Opportunities using data from claims and EHR(s)

Uses of Explorys Risk Model (ERM)

Scenario How is the Explorys risk weight used?

ProspectiveUtilization

The risk weight of 2.80 can be multiplied by an average $400 PMPM (example) to get a predicted utilization of $1120. This is equivalent to saying a member will cost 2.8 x average cost.

Risk Stratification

The risk weight of 2.80 would put a patient in a specific bin. For example, a low risk bin may be formed by grouping patients with a risk of 2 or less into GROUP 1 and between 2 and 8 into GROUP 2 and above 8 into GROUP 3 to allocate scare resources.

Acuity adjusted panels

The risk weight of 2.80 can be added to the risk weights of all other members of a specific provider to obtain an average (e.g., 1.5) – this average risk score of 1.5 can be used to adjust the actual panel size of 1,600 patients to create an acuity adjusted panel of 2,400 (1,600 x 1.5) so that work load can be more accurately compared.

Benchmark performance

The risk score can be used to adjust actual costs and quality metrics to control for severity. Actual costs of $1350 PMPM can be compared to a predicted of $1300 PMPM.

Holy Grail of Value Based Analytics1) Centralized EHR with Pop Health Mgmt capabilities baked in2) Well integrated clinical + claims + patient reported data to deliver

holistic view of patient with advanced risk modeling, registries, care gaps, advanced clinical decision support (leveraging patient-specific clinical data)

3) Analytics from #2 delivered to care team within clinical workflow Ideally, supporting data is crunched outside EHR and imported back into EHR At worst, analytics are one click away with patient context sensitive single sign on

4) Patient Portal with appointment scheduling including virtual/video visits; integration of clinical & health plan experience; gamifiedwellness platform integrated with social media; easy integration with home monitoring & fitness devices

5) Mature Enterprise Data Warehouse, mature Business Intelligence capabilities, and a robust analyst team with both clinical & claims data skillsets

6) Industry-wide concurrence on <50 measures to monitor Triple Aim Quality + Pt Experience for all ACO patients

7) Open source library of core clinical decision support algorithms

Examples of Public Health Focused C&BI

Genomics & Personalized Medicine:A “Revolution”?

http://io9.com/how-obamas-precision-medicine-initiative-will-revolutio-1680866890

… or “Not So Fast” …

http://jama.jamanetwork.com/article.aspx?articleid=2344586

… or “Slow Progress, Starting with Oncology”

http://www.washingtonpost.com/sf/national/2015/06/27/watsons-next-feat-taking-on-cancer/

SAP Offers State of the Art Genomics to Employees for Personalized Cancer Treatment

• Software generates an individual tumor analysis for each patient 300x faster than previous technology

• Provides a clinical interpretation of the genomic patient data to support their oncologist in making the best individualized treatment decisions

• Tumor sequencing, and the big data analytics required to process genomic data, is quickly becoming standard of care in oncology

http://www.healthdatamanagement.com/news/SAP-Offers-Software-to-Employees-for-Personalized-Cancer-Treatment-48199-1.html

Turbocharging Clinical Research

• Comparative Effectiveness Research

– Is that fancy new drug / treatment / diagnostic worth it (efficacy / cost)?

• Translational Research

– Reducing “Bench to Bedside” time

• Mining large repositories of clinical data for hypothesis generation & patient cohort ID

• Computer models of human physiology to evaluate clinical trials

Geographic Information Systems Applied to Public Health …

Overdose and Suicide:Leading Causes of Death

Mercy’s Cincinnati Service Area

Leading Causes of Premature Death Due to Injury

12,029 Years of Potential Life Lost in 2012

Mercy’s Cincinnati Service Area

YPLL75 = Sum of years lost for deaths before the age of 75

Mortalities Due to Overdose (Rate per 100k)

Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances

Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified

Mortalities Due to Suicide (Rate per 100k)

Intentional Self-Harm By Other And Unspecified Firearm And Gun Discharge

Intentional self-harm by hanging, strangulation and suffocation

Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances -

Mortalities Due to Overdose (Rate per 100k)

Mortalities Due to Suicide (Rate per 100k)

Importance of geospatial visualization & granularity

• CDC’s Biosense program provides local, state, and federal partners a timely regional and national picture of trends in disease syndromes and situation awareness

• BioSense 2.0 integrates current health data shared by health departments from a variety of sources to provide insight on the health of communities and the country

• By getting more information faster, local, state, and federal public health partners (e.g. DoD and VA) can detect and respond to more outbreaks and health events more quickly

Modeling Spread of Disease from Social Interactions

http://www.cs.rochester.edu/~sadilek/publications/Sadilek-Kautz-Silenzio_Modeling-Spread-of-Disease-from-Social-Interactions_ICWSM-12.pdf

http://www.nytimes.com/2013/06/23/opinion/sunday/theres-a-fly-in-my-tweets.html

Military Health System:Virtual PTSD Experience (Second Life)

http://t2health.dcoe.mil/vwproj/

Better Data … Less Fraud?

• Estimated 12% of Medicare and 10% of Medicaid is lost to fraud ($700B)

• Better data tools allow better identification and prosecution of the bad guys

• Still a long ways to go obviously …

http://www.nextgov.com/big-data/2016/06/better-data-just-saved-taxpayers-900-million-medicare-fraud/129357/

ACO JobsFor Public Health Peeps?

The Ideal ACO Analyst

• Years of experience in practice management operations (understand clinical data and workflows)

• Years of experience in health plan operations (understand claims data and workflows)

• Years of healthcare analyst experience

• “Data Scientist”

• PCMH expert

• Change Mgmt guru

Guess What?

• Not a lot of these superheroes exist

• Ergo, they are expensive

• Ergo, ACOs must generally rely on mere mortals like you to partner with clinicians & executives and transform healthcare

Monster.com Job Ad for:“Accountable Care Consultant

Analyst”• Duties:

– Improving access to care by using practice level population data to analyze overall capacity/demand for appointments and visit patterns by clinic

– Implementing process improvements to reach mutual goals and improve patient access

– Analyzing trends and work with all Community stakeholders to agree on and implement proactive strategies to address issues, and measure impact using a PDSA rapid cycle improvement approach

– Measuring and monitoring success of outreach and develop strategies to simplify processes and ensure optimal care for patients

– Analyzing and reporting measurable progress against goals at monthly meetings with practices and hospitals

• Qualifications:

– Master's Degree or higher from an accredited university

– Minimum 1 years of experience in Practice Management and/or Operations

– Advanced level proficiency with clinical documentation systems

Get Smart on Accountable Care!(a.k.a. Value-Based Care)

• If you can …

– “Speak ACO”

– Sound smart about imperatives for the transition to value based care

– Understand at least a little about clinical + claims data requirements for Population Health Management

… then you are going to get an ACO job over someone who cannot

• Translate your Public Health background into ACO-speak on your resume

ACO-Get-Smart Resources

• Healthcare Informatics Magazine ACO articles:

– http://www.healthcare-informatics.com/category/policy/accountable-care-organizations-acos

• National Association of ACOs:

– http://www.naacos.com

J.D. Whitlock

VP, Enterprise Intelligence

jdwhitlock@mercy.com

https://www.linkedin.com/in/jdwhitlock