HIMSS Clinical & Business Intelligence Community of...

HIMSS Clinical & Business Intelligence Community of Practice

January 28, 2016

Welcome

Shelley Price, MS, FHIMSS C&BI Community Organizer Director, Payer & Life Sciences HIMSS

Arthur Panov, MPH, CPHIMS C&BI Community Co-Chair HIT Architect IBM Watson Health

Michael Berger, PE C&BI Community Co-Chair Head of Population Health Analytics Mount Sinai Health

Agenda • Welcome • HIMSS C&BI Community Updates / Announcements • Presentation & Discussion: “Care Team Transformation for Population Health

Management” o Karen Handmaker, MPP, PCMH CCE, Vice President, Population Health

Strategies, Phytel/IBM Watson Health

• Wrap-Up / Next Steps

C&BI Community Updates / Announcements

Agenda 3 Pillars: Education, Exhibition, Networking • Education: 2 key topic areas: Care Coordination & PopHealth; C&BI

• Exhibition: Knowledge Centers

– Population Health

– Clinical & Business Intelligence

• Networking:

– Receptions –

• PopHealth Reception | Reception | Knowledge Centers | Casanova Meeting Room, Booth 14000 | Tuesday, March 1, 2016 | 6:00-7:00pm PT

• C&BI Community Reception | Knowledge Centers | Casanova Meeting Room, Booth 14000 | Wednesday, March 2, 2016 | 6:00-7:00pm PT

– The HIMSS Spot – C&BI: Thursday, March 3, 2016 | 9:30-10:00am PT

The Digital Brochure is available now on-line.

http://www.himssconference.org/exhibition/specialty-exhibit-areas/population-health-knowledge-center

http://www.himssconference.org/exhibition/specialty-exhibit-areas/clinical-business-intelligence-knowledge-center

http://www.himssconference.org/exhibition/specialty-exhibit-areas/himss-himss16/himss-spot

http://apps.himssconference.org/brochure/index.html?utm_source=homepage&utm_medium=tile&utm_campaign=main_brochure



HIMSS16 C&BI and Population Health Knowledge Centers

Casanova Meeting Room | Booth 14000

C&BI & PopHealth Receptions

Tuesday, March 1 & Wednesday, March 2 | 6:00-7:00 pm | PopHealth and C&BI Knowledge Centers

HIMSS C&BI Community Meetup at The HIMSS Spot

Thursday, March 3, 2016 | 9:30-10:00am PT

#PutData2Work 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.

Working Concept: Clinical & Business Intelligence: Getting Smart on the Top Issues and Resources to Help You Turn Data into Action Where are you on your pathway to value using clinical and business intelligence? Are you defining your current state, needs, and goals for your C&BI program? Wrapping your arms around data and organizational governance? Trying to figure out how to use and integrate your data, open data, and Big Data for your strategic goals? Endeavoring to put it all in place and employ population health management tools and strategies to bring value to your population and organization? Or do you have war stories and best practices to share? Then come to this meetup with the C&BI Committee and its groups to learn about new HIMSS tools and resources – such as the population health management capabilities guide – and discuss the Top 10 key C&BI issues for today and tomorrow, all to help you on your journey to Turn Data into Action.

Thursday, March 3 | 9:30-10:00am

http://www.himss.org/value-suite/pathways-to-value/clinical-business-intelligence

http://www.himss.org/get-involved/committees/clinical-business-intelligence

http://www.himss.org/get-involved/committees/clinical-business-intelligence

C&BI Community Guest Speaker

…Please type your questions into the Q&A

box.

We will take questions at the

end of the presentation…

Turn Data into Action: Care Team Transformation for Population Health Management

HIMSS Clinical & Business Intelligence Community Karen Handmaker, MPP, PCMH CCE January 28, 2016

IBM Watson Health // ©2015 International Business Machines Corporation

Today’s Presentation

Objectives: • Describe the imperative for care team transformation in the context of

population health goals and new payment incentives • Provide a framework on how health systems redesigning care

management for population health management • Offer examples of how health information technology applications

enable advanced care team workflows today and what we can expect in the near future

“Clinical and business intelligence (C&BI) is the use and analysis of data captured in the healthcare setting

to directly inform decision-making.”


“Flipping Healthcare”: A Sign of the Times


Where is Your Organization On the Journey to Value?

14

FULL CLINICAL RISK New risk contracts fail to return significant margins without clinical transformation

OPTIMAL VALUE CREATION AND VALUE CAPTURE

OPTIMAL CLINICAL DELIVERY Clinical transformation allows value creation to accrue predominantly to the payer

CLINICAL TRANSFORMATION

RIS

K T

RAN

SFO

RM

ATIO

N

Max risk

Max transformation


But, Preparing for Value is a “Work In Progress”

PHM Strategy Confirmed

Buy/Affiliate to Complete Care

Continuum

Secure ACO, CIN and Direct

Employer Contracts

Reduce Total Cost of Care

Scale PCMH

Mixed Financial Incentives

FFS Dominant but Shifting

FFS Contracts Include Quality

Bonuses

Medicare and Commercial

Shared Savings

Funding for Care Teams Unstable

PHM Infrastructure

Evolving

Multiple Systems and

Data Sources to Integrate

Analytics Initially Focused on Cost and Care Gaps

Interoperability Not There Yet

Medical Neighborhood

Loosely Coordinated

Front Line Not Yet “Top of License”

Workflows Largely Manual and Vary Across

Practices

Actionable Data Minimal

Focused on “Tip of the Iceberg”

Patient Engagement Episodic and

Visit-Centered

15


New Questions for Care Teams to Answer

What is risk profile of my population? How do I compare to others on quality & costs? Who are my high-cost, high-risk patients? Which patients are likely to develop chronic conditions? How do I most effectively engage my population? How do I effectively manage them? How do I get paid for performance?


PCMH Building Blocks Designed to Build PHM

Infrastructure

Population Health

Improve Patient

Satisfaction

Reduce Health Care

Costs

Whole-Person/

Holistic Care Team- Based

Care Personal Clinician

Appropriate use of HIT

Quality Improvement

Performance Improvement


Technology PHM and

Engagement EMR

Analytics

People Knowledge,

Skills, Teams, Leadership,

Culture

Processes Efficient Ways

of Working, Scale

Technology Must Be Intentionally Designed In

Training LEAN & Process Design

Automation


“Bottom Up” Model Drives Scale and Improvement

QI

Patient Engagement

Enabled Care Teams

Line of Sight

Data Integrity


PCP Attribution: Is This a Process?

“At registration, the front desk should confirm the PCP for

every patient.”


REQUIRED: Structured Data, Sophisticated Algorithms, Real Time Reports and Behavior Change

BMI and Follow Up

Tobacco screening and cessation intervention

Scored together


Key Strategies to Improve Data Quality Measures 1. Provider Attribution

Consistently confirm and update PCP attribution to every patient so reports will be trusted

2. Existing Data Capture Use consistent locations in EMR for structured and scanned data (e.g., lab results, test orders, patient-reported data)

3. New Data Capture Create new structured fields rather than additional flow sheets for specific measures (e.g., fall risk assessment, Rx in care plan)

4. Eliminate Free Text Direct teams to use structured fields to collect data formerly entered as free text (e.g., tobacco cessation counseling, follow-up for positive depression screening)

5. Make Data Clean-Up Part of Standard Work Assign staff to regularly review provider attribution, invalid data entries, proper use of new workflows, etc. to enhance reliability


Line of Sight in Near Real Time is Essential

• Monitor performance measures

• Compare provider and care team results

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


We Must Go Deeper

>2/3 of catastrophic

patients this year were not

catastrophic the previous year

We must focus on patients below the waterline this year to prevent next year’s catastrophic cases.


Is A1c>9 An Effective Stratification Factor?

• The majority of 9+ (65%) were not 9+ the year before.

• 35% moved up from a lower group.

• 30% were not tested.

7 to 9 29%

9+ 35%

No Test 30%

<7 6%

Prior Year A1c Results for 9+ Patients


Stratify and Align Cohorts with Care Team Roles


Simplistic Example: Managing a Diabetes Population… High-Risk (1840 Diabetics) # % Avg /

PCP Workflow

Missing HbA1c; High HbA1c; High BP 1533 83% 73 Missing HbA1c; High HbA1c; High BP and scheduled appt

807 53% 38 Pre-Visit Prep

Missing HbA1c; High HbA1c; High BP and appt next week 8/17-21)

95 6% 5 Daily Huddle

Missing HbA1c; High HbA1c; High BP and NO appt

726 47% 35 Schedule Appt

Missing HbA1c; High HbA1c; High BP and NO appt and Depression, Anxiety or ALZ

240 16% 11 Care Management and Schedule Appt

Low-Moderate Risk (1840 Diabetics) # % Avg / PCP

Workflow

A1c 7-8, High BMI, Depression 238 13% 11 Coaching, BH

A1c < 8 940 51% 45 “Stay the Course!”


Make HIT A Member of the Care Team

EMR Registries

Portals Mobile Devices

Risk Stratification Care Gap Profiles

Pre-Visit Prep Automated Outreach

Quality Reporting

Patient Service Rep or MA • Schedule visits • Activate

standing orders • Send out pre-

visit communications

• Conduct follow up using automated Campaigns

Care Manager

• Stratify patients by risk

• Reach out to patients with care gaps

• Coach through personal and automated patient education

Physician

• Review Registries

• Assign high risk patients to Care Managers

• Address all diabetes care opportunities at every encounter

CMO/Quality Committee • Review

performance by location and provider

• Meet with MDs and Care Teams at least monthly to review progress


An Outreach Strategy is a Must

29


Optimize the Encounter: Pre-Visit Preparation and Daily Huddles

IBM Watson Health // ©2015 International Business Machines Corporation 31

Personalized for every patient AUTOMATION THAT MATTERS

Catastrophic All >9 A1c and no office visit are sent a text message to call care manager

Chronic All >9 and BMI >35 are sent an automated invitation to a group visit with diabetes dietician

At risk All between A1c 7 and 9 are sent to an automated message to encourage visit website to take diabetes self-management course

Healthy All diabetic <7.0 are sent an email message emphasizing the importance of nutrition and exercise to maintain low A1c levels with a link to a mobile app to track their progress


The Patient’s Agenda Steers the Interventions

• 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


Avoidable Admissions: Engage Patients Sooner


Most Factors that Impact Health are Not Clinical

Exogenous data (Behavioral, Socioeconomic Environmental)

60% of determinants of health

Genomics data


Clinical data


34

Source: “The Relative Contribution of Multiple Determinants to Health Outcomes”, Laura McGovern et al., Health Affairs, Health Policy Brief, 2014


Continuous QI

Planned Care Team

(95% of patients)

Complex Care Team (5%)

Quality Management

(Across Practices) • Usual Care

• Between Visit and Chronic Condition Care

• Highest risk • Collaborates

with Planned Care Team

• Can be practice-based, shared or centralized

• Tracks performance overall and by payer

• Initiates improvement projects with Care Teams

HIT Platform Adapted from: Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit


Moving To A Tech-Enabled 24/7 Patient-Centered Community Care Management Clinical Analytics Clinical Decision Support Advanced Care Planning

Patient Population of the Primary Care Office

Care of a patient

Primary Care Office

Others who supply/require information and coordination Specialty Care Hospitals Device Radiology, Lab, Rx Referral Tracking/HIEs

Patient Engagement Mobile Automated Outreach Patient Portals

Claims and Cost Risk Stratification

Payer

Distance Monitoring Telehealth/Telemedicine Remote Patient Monitoring


Smart Care Teams

37

Current State

Patient-centered team fully integrated with specialty and ancillary that is multi-channel and 24/7

Integrated clinical, claims, financial, lifestyle, and biometric data providing real-time cognitive analytics

Longitudinal engagement across care settings that is personalized and adaptive in real-time

Automated and actionable using full range of clinical, financial & lifestyle data, with a single integrated workflow across care team

Care team

Data & analytics

Team activity

Workflow tools

Broad PCP-led team, with coordination across specialty and ancillary

Integrated with hospital and specialty data using analytics based on clinical data and implied financial impact

Patient engagement pre/during/post visit using an approach based on patient segmentation

Clinical decision support tools within EMR and care management workflow solutions that leverage broad set of information

Future State


Population Health: One Person at a Time

Data and knowledge driven

Every person has a plan

Team based Automation to manage a population down to

the individual

38


Thank You! Karen Handmaker [email protected]

Questions?

mailto:[email protected]

• Want to get involved?

Speaker or topic ideas

Key note presenter

Blogger, twitter

Contact Shelley Price

• Community Website

www.himss.org/ClinBusIntelCommunity

Wrap-Up

http://www.himss.org/ClinBusIntelCommunity

JOIN US! • Next meeting: Thursday, February 18, 2016

Architecting a Next Generation Data Platform: Quest Diagnostics Information and Analytics Blueprint

Jason O’Meara, MHA, BSE Director, Analytics Architecture Quest Diagnostics | Healthcare Technology and Analytics Solutions

Next Steps

FY16 Leadership and Contact Information Co-Chairs: Mike Berger, PE Head of Population Health Analytics Mount Sinai Health [email protected] Arthur Panov, MPH, CPHIMS HIT Architect IBM Watson Health [email protected] HIMSS Community Organizers: Shelley Price, MS, FHIMSS Director, Payer and Life Sciences HIMSS [email protected]




Thank You

Appendix

John Middleton, MD, MSc FY16 C&BI Committee Chair VP/CMIO SCL Health David Butler, BSME, MBA, FHIMSS FY16 C&BI Committee Vice-Chair President Heartland Innovations, LLC Cheryl Bowman, CPHIMS* Data Manager University of Wisconsin Hospital and Clinics Raj Lakhanpal, MD, FACEP* CEO Spectramedix

John S. Moses, MA Director of Enterprise Architecture, The University of Chicago Medicine

Ravi Narayanan, MS Director, Research Data Management and Analytics Medica Research Institute Stuart Rabinowitz, MBA, BC* Director Federal Markets - Socrata Socrata Chester H Robson, DO, FAAFP* Medical Director, Clinical Programs and Quality Walgreen Co. Deborah Jane Rupe, RN, MS, FHIMSS Clinical Analyst, Shriners Hospitals for Children - Tampa Hospital Ahmad Sharif, MD, MPH, SCPM Chief Medical Information Officer, Resolute Health Louise Sulecki, MBA Systems Analyst, Cleveland Clinic J.D. Whitlock, MPH, MBA, CPHIMS* Vice-President, Clinical & Business Intelligence Mercy Health

* Indicates a returning

committee member

2015-2016 C&BI Committee Members

C&BI Community of Practice The goal of the C&BI Community is to bring together thought leadership and share knowledge that will support the future success of our members by improving their ability to understand and form partnerships to manage C&BI as a part of doing business and providing accountable and quality care to their members. The Community will support activities that promote peer-to-peer networking, problem solving, solution sharing, and education.

Topics of focus may include:

• Storage and Management of Data and Supporting Technologies

• Knowledge Management to Support Accountable and Quality Care

• Case, Risk & Cost Management

• Best Practices Clinical & Business Analytics

• Clinical Decision Support

• Research Data Warehousing/EDW

• Data Lifecycle Management

C&BI Community of Practice

• Open to all HIMSS members (current membership: approx 6,700 people)

• Will meet virtually 6 times/year

• Agenda for the meetings may include:

• Commencing with a short series of 2-Minute Drills presented various Community members

• Topical discussion with key note presenter

The ‘2-Minute Drill’ is based loosely on the sports analogy, and in this case

is a fast-paced (short in length) presentation on a hot, emerging, or timely topic, news event (e.g. research paper, game-changing market or technology news), or recent and relevant event (e.g., federal public meeting, legislative/federal/judicial news, critical conference or educational event).

2-Minute Drills foster greater peer-to-peer networking, member engagement, problem solving,

solution sharing, and education. If you are interested in presenting any drills, please contact Nancy or Shelley.

http://www.clker.com/clipart-12908.html




C&BI Task Force NEW! C&BI for Population Health Task Force CO-CHAIR: Karen Golden Russell, FHIMSS, MA, MBA | Vice President, Population Health | Verisk Health CO-CHAIR: Michelle Vislosky, M.B.A., FACHE | Zone Sales Executive – East Region of Canada & the United States | Caradigm This group creates resources and tools that employ practical guidance and unbiased information to help healthcare organizations (providers, hospitals, integrated delivery networks, health plans and other stakeholders) use C&BI to harness, use and analyze data captured in the healthcare setting to execute population health management initiatives and improve care and health outcomes. Meeting times: 3rd Tuesday of the month, 3:30-4:30pm ET

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