L1: Beacon Breakthroughs: using Technology as a...

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L1: Beacon Breakthroughs: using Technology as a Driver of InnovationByCarolBeasleyandRogerChaufournier

Learning Lab 1These presenters have

nothing to disclose

Sunday,December9,20121:004:30P.M.

Session Objectives

At the end off this session, attendees will be able to: Describe how technology enhancements can lead to better patient-centered care models;

Describe how to apply technology-based tools and resources to smooth the patient’s journey through the health care system

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Introductions

Facilitators: Carol Beasley and Roger Chaufournier

Beacon Program Office: Janhavi Kirtane

Beacon Communities:Greater Cincinnati Beacon Community: Pattie Bondurant

Crescent City Beacon Community (New Orleans): AnjumKhurshid and Kristin Lyman

Southern Piedmont Beacon Community (North Carolina): Jean Wright

Take a moment to introduce yourselves to the others at your table

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Agenda1:00‐1:10 Welcome and overview Carol Beasley

1:10‐1:25 Introduction to Beacon Communities Janhavi Kirtane

1:25‐1:35 Introduction of model community Roger Chaufournier

1:35‐2:00 Leadership and Governance Beacons

2:00‐2:35 Clinical Transformation Enabled by Health Information Technology

Beacons

2:35‐3:00 Reflection and integration Participants

3:00‐3:15 Break

3:15‐3:30 Data and Performance Measurement Beacons

3:30‐3:55 Sustainability and the Future of the Beacons Beacons

3:55‐4:15 Reflection and Integration Participants

4:15‐4:30 Beyond Beacon Janhavi

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Introduction: Our Health Care Modernization Agenda and the Beacon Community Program

Janhavi M. Kirtane ([email protected])Director of Clinical Transformation and Dissemination

December 9, 2012

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An Overview of…

• The National Context for Health Care Modernization

– HITECH Programs

– Meaningful Use

– Exchange, Standards and Interoperability

– Consumers

• How Beacon brings HITECH to life

– America’s most wired communities

– Goals

– Early results

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Health Information Technology

Improving patients’ experience of care within the Institute of Medicine’s 6 domains of quality: Safety, Effectiveness, Patient‐Centeredness, Timeliness, Efficiency, and Equity.

Better healthcare

Keeping patients well so they can do what they want to do. Increasing the overall health of populations: address behavioral risk factors; focus on preventive care.

Better health

Lowering the total cost of care while improving quality, resulting in reduced monthly expenditures for Medicare, Medicaid, and CHIP beneficiaries.

Reduced costs

$

Health IT:Helping to Drive the 3‐Part Aim

HITECH

What is America doing to modernize its Healthcare System through Health IT?

Why does America need to modernize using Health IT?

• Enable providers to securely and efficiently exchange patient health information.

• Give providers the right information, at the right time to offer their patients the right care.

• Give consumers tools to know their health information so that they can improve their health.

• Foundational to building a truly 21st century health system where we pay for the right care, not just more care.

Accelerating Meaningful Use

Showing Outcomes

Protecting Privacy and Security

Keeping Patients Safe

Promoting Exchange

Engaging Consumers

2012

1. Helping Providers Adopt (MU, REC, Workforce) 2. Standards & Interoperability (S&I Framework, HIE)3. Testing & Showing How the Pieces Fit Together (Beacon)

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A Remarkable Journey

Data capturing and sharing

Advanced clinical

processes

Improved outcomes

Meaningful Use the quality improvement program = Meaningful Use Goals + Meaningful Use Incentive +Meaningful Use EHR Certification +

Stage 1

Stage 2

Stage 3

Stages of Meaningful Use

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Progress of Eligible Providers toward EHR Incentive Payments as of 8‐31‐12

Source: CMS EHR Incentive Program Data

NAMCS Survey:

• The percentage of primary care providers who have adopted EHRs in their practice has doubled from 20 % to 40 % between 2009 to 2011

Note: The 2012 data will be available in 2013

Regional Extension Centers are working with 148,448 Primary Care Providers

http://dashboard.healthit.gov/rec/

2012 GAO Report: Providers 2.3 times more likely to achieve MU if working with an REC

Includes 70% of all primary care providers in the rural areas and 1,185 Rural or Critical Access Hospitals

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Exchange is increasing across the nation

State

% of Acute Care Hospitals Actively* Participating in Query‐Based Exchangethat is supported or enabled by State HIE

grantees**

Delaware 67%

New York 65%

Maryland 54%

New Jersey 32%

Arizona 27%

Colorado 26%

Nebraska 20%

Idaho 17%

Kentucky 16%

Michigan 15%

Tennessee 12%

State

% of Acute Care Hospitals Actively* Participating in Directed Exchange that is supported or enabled by State HIE grantees**

Delaware 100%

Vermont 79%

Michigan 48%

Arkansas 45%

New York 42%

Minnesota 34%

North Dakota 34%

Colorado 26%

California 20%

Alaska 18%

Utah 14%

* Active = at least one directed message sent between production end points or at least one patient recordquery during previous calendar quarter

** Data self‐reported by HIE grantees, Denominators calculated with 2011 Medicare Inpatient Hospital Data

18 states had more than 10% of their hospitals actively engaged in sharing health information electronically as of 6‐30‐12

Build and strengthen health IT infrastructure and exchange capabilities ‐

positioning each community to pursue a new level of sustainable health care quality and efficiency over the coming years.

Improve cost, quality, and population health ‐ translating investments in

health IT in the short run to measureable improvements in the 3‐part aim.

Test innovative approaches to performance measurement, technology

integration, and care delivery ‐ accelerating evidence generation for new

approaches.

The Beacon Community Program: Where HITECH Comes to Life

17 communities each funded ~$12‐16M over 3 yrs to:

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17 Diverse Communities

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Hawaii County Beacon CommunityHilo, HI

Southeast Michigan Beacon Community

Detroit, MI

Crescent City Beacon CommunityNew Orleans, LA

Delta BLUES Beacon Community

Stoneville, MS

Keystone Beacon CommunityDanville, PA

y,

Utah Beacon Community

Salt Lake City, UT

Beacon Community of Inland NorthwestSpokane, WA

Great Tulsa Health Access Network Beacon CommunityTulsa, OK

Southeastern Minnesota Beacon CommunityRochester, MN ,

Rhode Island Beacon Community

Providence, RI

Greater Cincinnati Beacon Community

Cincinnati, OH

Southern Piedmont Beacon Community

Concord, NCSan Diego Beacon

CommunitySan Diego, CA

Western New York Beacon Community

Buffalo, NY

,

Colorado Beacon Community

Grand Junction, CO

Bangor Beacon CommunityBrewer, ME

Central Indiana Beacon CommunityIndianapolis, IN

Beacon Community Program Status

•Governance

•IT & measurement infrastructure

•Interventions logic models

2010

•First wave of interventions

•Innovation networks

•HIT roll‐out

2011

•Finish strong

•ONC “Virtuous Circle”

•National dissemination

2012 & 2013

1612/9/2012Office of the National Coordinator for

Health Information Technology

• Impact: As of September 2012, over 8,500 providers are participating in Beacon, with over 8 million lives affected

• Early results: 17 out of 17 communities have at least 2 key measures trending positively

• Partnerships• Beacon EHR Vendor affinity group• RWJ’s Aligning Forces for Quality• CMMI Pioneer ACOs

• Paths for sustainability: 1 Beacon-Pioneer ACO program, 3 regions involved in CMMI’s Comprehensive Primary Care Initiative, with more to come

• Dissemination: Nearly 150 on-line media clips highlighting Beacon work (an average of 20 per month, up from 2-3 articles in 2011), and nearly 50 in-person and on-line speaking events

We are here

Source: Based on self-reported data from the Beacon Communities in community fact sheets and quarterly data submissions.

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Health IT and Exchange

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Detroit, MI

Crescent City Beacon CommunityNew Orleans, LA

Delta BLUES Beacon Community

Stoneville, MS


Southeastern Minnesota Beacon CommunityRochester, MN ,


Providence, RI

San Diego Beacon CommunitySan Diego, CA

With newly established exchange capabilities7

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y,


Salt Lake City, UT

Southeastern Minnesota Beacon CommunityRochester, MN


Concord, NCSan Diego Beacon

CommunitySan Diego, CA


Buffalo, NY

Health IT and Exchange

Keystone Beacon CommunityDanville, PA

,


Providence, RI


8 Are wiring care and wellness partners

Public health: (5-CA, MN, NC, NY, UT)Long term/post acute: (4- ME, NY, RI, PA)

Schools: (3-NC, NY, PA)

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Crescent City Beacon Community

Keystone Beacon Community


Great Tulsa Health Access Network Beacon

Community

y

Greater Cincinnati Beacon

Community


San Diego Beacon Community


Bangor Beacon Community

Central Indiana Beacon Community


Innovation

Southeastern Minnesota Beacon

Community

Mobile: (5-CA, LA, MI, OH, UT)Tele-monitoring: (5-CA, IN, ME, MN, NY)Personalized CDS: (2-CO, OK)PHRs: (2-NY, PA)

13 Are testing new models of patient-centered care

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Connecting Health IT to Payment

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Greater Cincinnati Beacon Community

Cincinnati, OH

,


Grand Junction, CO


4 Are linking IT, care model innovation and CMMI payment pilots

Pioneer ACO: Bangor Comprehensive Primary Care Initiative: Cincinnati, Tulsa and Colorado

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Process/intermediate outcome measures for chronic disease

From To Notes

57%

85%

61%

65%

96%

77%

Bangor: LDL-C Control for patients with cardiovascular disease from Q4 2010 and Q3 2012

New Orleans: Diabetes HbA1c Screening rates from Q2 2011 and Q3 2012

Cincinnati: Proportion of their high-risk asthma patients rated "well controlled“ from Q1 2011 and Q3 2012

Where are we seeing early results?

58% 67%Preventative care, including cancer

screenings

Indiana: Colorectal cancer screening rate from Q1 2010 and Q2 2012

Source: Beacon Community October 2012 Data Submission, based on self-reported data from the Beacon Communities.

For the first time, 17 out of 17 communities are improving at least two key measures over baseline

Improvement

Public health, including tobacco cessation advice

From To Notes

63% 75% Rhode Island: Tobacco cessation intervention from Q2 2011 and Q3 2012

Where are we seeing early results?

Source: Beacon Community October 2012 Data Submission, based on self-reported data from the Beacon Communities.

Utilization (ED visits, admissions, readmissions)

38%

40%

21%

21%

23%

14%

Bangor: Hospital admission rate and ED visit rate (respectively) among its “high risk/high cost” patient cohort that have completed 12 months of care management

Keystone: 30-day Readmission Rate among KBC-managed patients with CHF from Q1 2011 and Q2 2012

Behavioral health, including depression

screening

68%

50%

93%

84%

Colorado: Depression screening for diabetics since the beginning of the Beacon intervention period

Rhode Island: Depression screening from Q2 2011 and Q3 2012

Improvement

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Introduction to Poundville

Hypothetical community

Tools for learning and reflection

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The “Ididntarod”






Beacons


3:00‐3:15 Break





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Leadership and Governance

Where is the will to lead on behalf of better population results at a community level?

What existing structures/relationships contribute to effective governance?

What are the “fault lines” and how can they be addressed?

How do communities foster the will and skill to truly innovate?

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Greater Cincinnati Beacon Collaboration (GCBC)

Pattie Bondurant DNP, RN

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Goal

• Provide funding to communities to strengthen health ITinfrastructure and exchange capabilities and achieve measurable improvements in health care quality, safety, efficiency, and population health

Funding

• $13.75 million award to Cincinnati

Awarded

• Sept 1, 2010

Length of Initiative

• 30 month initiative

• 200+ Adult PCPs• 25,000 patients with Adult

Diabetes• 300+ Pediatricians• 30,000 patients with

Pediatric Asthma• 18 Regional hospitals

Regional Opportunities to Collaborate

Beacon Community award

Regional Extension Center

State HIE grant subrecipient (IN)

Nationwide Health Information Network – NwHIN Coordinating Committee member, Direct and CONNECT Live

Social Security Admin. MEGAHIT awardee

CMS C-HIEP - Transitions in care project

Robert Wood Johnson Foundation Aligning Forces for Quality partnership

AHRQ Community Value Exchange (CVE)

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Governance

• Governance of a large multi-stakeholder project

1. Shared risk across partners-community effort

2. Assure compliance of activities

3. Mitigate issues, remove barriers to completion of activities

4. Helps avoid conflicts, wasteful overlaps and gaps

5. Assure scale and spread of effective activities

Anjum Khurshid, PhD, MDand

Kristin A. Lyman, JD, MHA

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Crescent City Beacon Community Goals

Reduce the burden of chronic diseases, mainly diabetes and cardiovascular disease, by accomplishing the following goals:

• Improve the quality of care for chronic disease patients in patient-centered medical homes, enabled by HIT

• Reduce healthcare costs by decreasing preventable emergency department and inpatient visits through better coordination of care

• Engage consumers in the healthcare process by using innovative technologies and strategies

GNO Healthcare Landscape• Greater New Orleans Area

o Poor health outcomes

o Large uninsured population

o High poverty rate

• Health Care Delivery System Post-Hurricane Katrina

o Network of community health clinics funded by state and federal support (PCASG, Medicaid Waiver)

o High quality care in safety net

o Uncertain hospital market

o Managed Medicaid started in 2012

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Governance Framework

Governance FunctionsAdministrative Committee

GNOHIE Adoption

Strategic Planning

Sustain-ability

Org. Structure/

Legal Entity

Fiscal Respon-sibility

Membership Expansion

Criteria

Provider Engage-

ment

Interven-tion

Sustain-ability

Funding Sources

Payer Engage-

ment

TOC

Analytics &

Reporting

HIT Use Optim-ization

CCM

Data Use/

SharingAccess /Creden

-tials

Patient Align-ment

Privacy

Physical Infra-

structure

Organizational

Sustainability Clinical QI

HIT

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Jean Wright MD MBA

©2012 David F. Lobach

SP Beacon Community

3-county region with population of 377,024

1 of 14 care management networks with NC Medicaid

Multi-disciplinary care management team Care managers, social workers, pharmacists

6,940 patients in active care management

22 frontline care managers

Provider Environment 3 Hospital-based Health Systems each with 1 Hospital + ED

75 Primary Care Clinics, 1 FQHC

3 Health Departments

Audacious Goal: to improve health in the region

Cherokee

Graham

Swain

ClayMacon

Jackson

Haywood

Madison

Buncombe

Henderson

McDowell

Rutherford

Polk

Burke

Cleveland

Watauga

Caldwell Alexander

Catawba

Lincoln

Gaston

Ashe

Wilkes

Alleghany

Surry

Yadkin

Iredell

Mecklenburg

Union

Stanly

Cabarrus

Rowan

Davie

Stokes

Forsyth

Davidson

Anson

Rockingham

Guilford

Randolph

Montgomery

Richmond

Caswell

Chatham

Orange

Person

Lee

Moore

Hoke

Scotland

Robeson

Cumberland

Harnett

Wake

Franklin

Warren

Johnston

Sampson

Bladen

Columbus

Brunswick

Pender

Duplin

Wayne

Wilson

Nash

Halifax

Northhampton

Edgecombe

Pitt

Greene

Lenoir

Jones

Onslow

Craven

Pamlico

Beaufort Hyde

Martin

Bertie

Hertford

Gates

WashingtonTyrrell

Dare

Alam

ance Durham

Granville

Hanover

Chow

an

a

r

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Beacon Arrives


1. Leadership & Governance

3 Competing Health Systems

Other than serving on a Board for the network that manages Medicaid in this region they had never worked together.

3 Separate Health Departments

While not competitive, each had their own issues

Original focus of application was on HIE development

Size of the grant compared to the experience managing funds was overwhelming

Shifts in leadership

ONC, Beacon, Southern Piedmont, Project Managers

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Changing Decision Makers

Are we building an HIE?

What’s a Care Transition?

Are we doing population health management?

How can we move faster?

Go forward, Go Back

Questions? Comments?

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Clinical Transformation and HIT

What clinical challenges are most amenable to improvement through technology?

What strategies are helping close the gap between today’s technology assets and the desired technology future?

How do clinicians and technology experts come together to improve and innovate?

What innovative technology solutions are the most promising?

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Incomplete Knowledge of Diabetes and Asthma Care Quality

• Data exists in silos – need more complete data for improvement• No single health system, hospital or practice has complete view of patient

care • Many gaps in information, data sharing only partially electronic

Preventable ER visits: • Patients need appropriate primary care rather than emergency care

Hospital Readmissions:• Hospitals will be challenged on reimbursement for readmissions – big

financial impact• Patients need appropriate primary care to prevent readmission

Transitions in Care: • PCP lacks information from patient’s hospital visit• Specialists lack most current information from PCP

Opportunities to Address

Use HIT Meaningfully HealthBridge Tri-State Regional

Extension Center Services include:

• EHR Selection and Implementation Assistance

• Meaningful Use Education

• Guidance on Applying for Incentive Payments

• Supported and Hosted Meaningful Use Solutions

• Privacy and Security Assistance

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GCHC Adult Diabetes ProjectClinical Quality Transformation: Using Health IT

• Goal is a 10% improvement in overall D5 composite score (Registry or EHR-MU Stage 1)

• Reduction of ED/Admissions by 10% (ED/Admit Alerts)

• 80% of Beacon adult PCP practices will achieve Level III recognition (All Health IT tools)

Alerts (CDS Data)+MU+PCMH=Enhanced Coordination of Care (Adult Primary Care Practices)

EHRs: EPIC-NextGen-AllScripts MDs and NPs helped design a Process Map which

outline the following steps:

• Open alert report each day

• Categorized patient as high-risk or low-risk (optional)

• Create a clinical update message in patient’s EHR sent to MD/RN/Front Office Staff

• Clinical update alert the FOS to schedule a follow-up appointment with patient as necessary

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Direct with PDF Attached-Batched ED/Admission Alerts

ED Alert Process WorkflowReview Alerts Daily: Verify Accuracy

Risk Stratify Patient List

Review Clinical Information

Contact Patient – Make Appt

Document Call

Complete QM Activities

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Risk Stratification

• Agree risk stratification process to assign intensity level of follow up actions to be taken• Option 1 – Utilization Model

Simple to use initially or ongoing

Based on ED and Admission history

Minimal clinical judgment required

• Option 2 – Clinical Factor Model

Takes into account demographic and clinical results

Requires some degree of clinical judgment and experience

Cincinnati Children’s Pediatric Asthma

Elements of Care Coordination

• Link to care coordinators for High Risk Patients

• Home health pathway

• Pharmacy delivery intervention for home meds

• ED/Admission Alerts – for utilization outside CCHMC

• Integrated Registry – highly customized for asthma patients to identify gaps in care

• Flu season interventions – VOIP calls

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During an August 2012 visit to Cincinnati Children’s, Secretary Kathleen Sebelius talks with patients and parents from Cincinnati Children’s primary care clinics that have received better care due to the interventions used under the Greater Cincinnati Beacon Program

Pediatric AsthmaCare Coordination Supported by Alerts Using intensive care coordination and health IT, the Cincinnati Children’s Beacon team has increased the time between utilizations from 173 days (baseline) to 340+ days) for a Medicaid high-risk population.

Disparities in Care

• Have standardized the collection of race, ethnicity and language (REL) data across 18 hospitals/health systems; systems changed IT flows to accommodate standardized categories Developed best practices guidelines for collection protocols and training of front-line staff to ensure community-wide data integrity

• Moving standardization into the physician practice settings

• Have stratified community-wide readmissions data by REL to begin to identify potential disparities and to inform readmission reduction efforts

• Percent of hospitals collecting standardized REL data moved from 56% to 94%

• Developing dashboard of community-wide measures to track progress toward equitable care

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Disease Registry

Txt4Health - What is it?

Interactive, personalized 14 week text-based program that:

• Assesses a participant’s risk for developing diabetes

• Connects individuals to the best LOCAL resources to help them improve health (e.g. providers, pharmacy discounts, local 5K walks, health and wellness programs/websites)

• Sets goals and tracks weight and activity levels

• Sends tailored educational and motivational messages to encourage healthy diet and increased exercise based on risk level

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Txt4Health - Desired Outcomes•Engage people through the public health campaign &

product

•Connect people to relevant LOCAL resources

•Improve health and reduce risk of participants

•3,200 people who are pre-diabetic have enrolled

•Subset of 65 patients with Diabetes & Severe

Mental Health issues



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Chronic Care Management Framework

Chronic Care Management Optimization

Chronic Care Management Optimization

EMR System

EMR System

EMR Optimization

EMR Optimization

Data Standard-ization and Reporting

Data Standard-ization and Reporting

Care Team &

Workflow

Care Team &

Workflow

PCMH ToolkitPCMH Toolkit

Practice CoachingPractice

Coaching

Clinical Workgroup

Clinical Workgroup

EMR Optimization Initiative• Precipitated by desire to meet PCMH 2011

requirements and a recognition of EMR workflow inefficiencies.

• EMR user group formed to conduct a crosswalk to identify the following for each PCMH standard/ element/factor:– Tested EMR system capacity

– Identified workflow challenges

– Recommended and implemented system enhancements

– List of standardized reports on CCBC quality metrics

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EMR Optimization: PCMH Toolkit• Reviews requirements for documenting adherence to

NCQA PCMH standards

• Provides instructions on how to use EMR functions and enhancements to implement PCMH standards and capture data for reporting

• Facilitates the import of report templates into the customer database

• Sample policies and procedures from NCQA PCMH recognized customers that can be adapted and implemented by clinics

Practice Coaching• Core CCM activities focus on 16 community

primary care practices

• PCMH-model: holistic, patient-centered care; not episodic

• The core set of interventions includes: o Care management / Care team strategies

o Population-based disease registries

o Risk stratification

o Clinical decision support

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Diabetes Mellitus QI Measures

47%

83%

34%

71%

35%

52%

88%

32%

74%

38%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

A1C < 8.0 A1C Testing BP < 130/80 LDL Testing LDL < 100

Q2 - 6/1/10 – 5/31/11Q7 - 9/1/11 – 8/31/12

↑ 12%

↑ 6%

↑ 5%

↑ 9%↓ 6%

Q2 Q7 Q2 Q7 Q2 Q7 Q2 Q7 Q2 Q7

Sites 11 13 10 13 11 13 11 13 11 13

Numerator 1801 2818 2679 4727 1306 1721 2719 3987 1342 2053

Denominator 3845 5378 3222 5378 3845 5378 3845 5378 3845 5378

Care CoordinationImproved care coordination to help ensure the seamless transition of patients between primary care, specialty care and hospitals, enabled by the Greater New Orleans Health Information Exchange.

Areas of focus:

• Emergency Department/Inpatient Notification: Alerts are sent to primary care providers about patient visits to emergency departments and hospital admissions.

• Electronic Specialty Care Referral: Referral requests and supporting documentation of the referring provider are sent electronically to the specialist and the specialist consult summary is received back by the referring provider.

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Jean Wright MD MBA


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Definition of CDS

The act of providing clinicians, patients and other healthcare stakeholders with pertinent knowledge and/or person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care.*

* Osheroff JA, Pifer EA, Teich JM, Sittig DF, Jenders RA. Improving outcomes with clinical decision support: an implementer’s guide. Chicago: Healthcare Information and Management Systems Society Press; 2005.

The right information to the right person at the right time in the right setting in the right format.

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A Lesson in Leveraging

AHRQ→NPCCNCDS for Care Transitions for Medicaid beneficiaries with complex health issues in 6 counties

ONC→SPCBCDS for Care Transitions for all patients in 3 counties

CCNC→State of NCCDS for Care Transitions statewide

Prototype

Practice

Production

Leverage•3 successive projects•3 increasingly larger populations•3 levels of potential impact


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Project Description

Identification of Care Transitions – ADT Data Hospitalizations ED visits Specialty care consults

Notification about Transitions Primary care clinics – “medical homes” Patients Care managers

Request of Information Discharge summaries ED encounter notes Specialty care consult notes

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Sample Provider Notice

Event of Commission

Building upon an earlier model of Clinical Decision Support


Notifications in CMIS

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Intervention Overview

CDS System

NPCCN HIE

CommunityNetworkClinical

Database

EventReports

QueryDatabase

Data from Hospitals EmailNotices

Patients

CareManagers

Care Sites:Hospitals,

Emergency Departments,

Specialty Clinics

PatientLetters

Data from Medical Homes

Data from NCHSS Claims

Data from Care Manager Notes

Release ofInformation

MedicalHome


CDS Infrastructure

1. HL7 ADT and clinical data feed

2. Clinical Data Repository

3. Web services layer

4. Rules engine

5. Patient Registry

6. User-facing applications

Care Management Information System (CMIS)

Provider Portal

Web Services

Clinical Data

Repository(CDR)

Patient Registry

Rules Engine

Controller

DLL Components

ClinicaDM

Incoming ADT Feeds

CCD /CDR Objects

CMIS, Provider Portal, etc.

External

Web Services

Beacon Hospitals and Clinics

1

2

3

4

5

6

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ADT Data Processing

1. Real time and batched ADT data is acquired through Web service

2. Raw data is saved to CDR

3. Rules engine identifies ADT events of interest

4. CCD request is sent to HIE

5. Rules Engine processes all available data on patient with ADT event as context

6. CMIS API is used to create tasks and notify CMIS users

Web Services

Clinical Data

Repository(CDR)

Patient Registry

Rules Engine

Controller

DLL Components

ClinicaDM

Incoming ADT Feeds

CCD /CDR Objects

CMIS, Provider Portal, etc,

External

Web Services

Beacon Hospitals and Clinics

1

2

3

4

5

6


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Reflection and Adaptation

Table discussion:What did you hear that might be useful in your setting?

What experiences have you had in your setting that might be helpful to others?

What questions do you have at this juncture?

General discussionObservations from your colleagues

Questions for ONC and/or the Beacons

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Break Time – Back in 15 Minutes

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Beacons


3:00‐3:15 Break





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Data and Performance Measurement

To what degree are data systems able to drive improvement in real time and at the point of care?

What population aims are the stakeholders committed to achieving?

In what innovative ways can existing (and imperfect) measures be put to practical use?

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Data will NOT be released to the public. Data use primarily for improving patient treatment in

demonstration projects. Limited data sets (diabetes, asthma related data) and

limited time frame (for the period of the grant) For practices participating in an improvement cohort,

aggregated, de-identified data will be reported quarterly to the Office of the National Coordinator

o Not released publicly for comparison

• GCHC required 225+ data use agreements and BAAs

Data Protections under Beacon

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Codified• Data in codified fields can be queried

• Provider must work with their EHR vendor to build as many reportable fields as possible

templates

flow charts

medication lists - NDC codes, RxNorm codes

examples of how data entered:

Medication List

Aspirin 81mg Once a day

ASA 81 Daily

Aspirn

Key Lessons Learned - The 3 C’s

Consistent• Train staff and providers to enter data in reportable fields

if implementing a new EHR, the time to start is NOW

have provider and staff review progress

correct bad data - give credit where credit is due

examples of how data entered:

Height Weight

6 ft 3 in 175.25

75 inches 175 ¼ lbs.

6’ 3” 175..25

Diabetic Foot Exam Date

Diabetic Foot Exam Value

05-01-2010 normal

05-07-2010 nl

05-10-2010 .


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Connected• Interface with your HIE (Health Information Exchange)

one connection to receive community results

data placed in discrete fields

PDF or scanned results cannot be captured easily for quality reporting

gateway for your EHR to securely send and receive data

Hemoglobin A1C Value Reference Range

HbA1c 6.5 %

A1C 8.2

hb 7.2 Normal Range 12.0-15.5 G/DL


Shared IT & Data Background• HealthBridge implemented new

Accountable Care-ready Shared Community IT Infrastructure over the last two years that can:

• Positively identify patients across different data sets

• Help link patients and providers accurately (attribution)

• Translate data across different IT systems

• Combine large, rich clinical & claims data sets

• Provide a neutral, credible source for analyzing performance across many domains of care

• Support quality and population health improvement

• Support better care coordination and transitions of care

• Improve access to sophisticated data reporting and analysis

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Alignment Among ProgramsQuality Measures Framework

S2 MU-CMS’s measurement and reporting aligned with: Hospital Inpatient Quality Reporting Program, PQRS, CHIPRA, and ACO Programs. Also aligned with National Quality Strategy to ease reporting burden.

Hospital Inpatient Quality

Reporting Program

PQRS

CHIPRA

ACO



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Background• LPHI’s role within CCBC is to collect, aggregate,

& report on clinical quality / outcome metrics

• CCBC follows NCQA / National Quality Forum measures for Diabetes & Cardiovascular Disease

• Feasibility Study (Summer 2011) revealed need for assistance to report quality and outcomes metrics at the practice, community, and vendor level

StrategyTo standardize data reporting among 13

diverse primary care practices via:• Measure reference sheets & reporting manual

• Learning collaborative with QI/Data Managers

• Partnership with SuccessEHS to build standardized reporting templates

• Co-host data workshops

• Rapid feedback regarding data errors

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CCBC Data Reporting Project Framework

Engage stakeholders/

leaders on measures developed

Assess capability and needs with data

managers at partner sites

Tailor approach based on findings

Conduct quality checks

Provide rapid feedback

Benefits / Results• Measure Harmonization

• Reduced Data Errors– Mean Data Error Proportion reduced from 33.5% to

13.5% (p = 0.00)

– Reduced Data Errors by >50% in 11 of 13 practices

• Identified common data error types & miscalculations

• Creating a culture of continuous learning, sharing & quality improvement

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Technology ChallengesEMR/HIT Configurations

• Practice management configurations continuously updated

• Non-structured lab data fields

• Use of non-standardized or highly customized ICD-9 and CPT Codes

Practice-level:

• Data Managers not well integrated with clinical team (geographically, access privileges, etc.)– Lack key updates and changes to practice that can

affect reports

• Communication / dissemination of measure definitions and appropriate codes beyond data managers to clinical team

• Provider data entry practices

Practice Challenges

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Jean Wright MD MBA

Data and Performance Issues

Outside of the Medicaid population, accessing clinical and claims data became increasingly difficult.

Queries were developed based on the Medicaid experience, and replicated in the Hospital Systems analytic departments

An important query like:

#Diabetes under management

# diabetics with HbA1c within a year

# Diabetics with HbA1c >9

# Diabetics with a current LDL

# Diabetics with an LDL in the normal range

Beyond claims data, much of the info needed some manual extraction

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Sustainability and Beacon Futures

What models are emerging now?

To what extent are purchasers (e.g. health plans and employers) playing a role in sustainability?

How do sustainability options relate to the changing policy and payment environment?

P94

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Pattie Bondurant

CincinnatiComprehensive Primary Care Initiative

• Seven regions across the US selected

• Through CMMI – Different rules apply for this project

• 75 practices selected in August 2012

• Balance of rural, urban, employed, independent

• Starting with 18 of ACO quality measures

• Primary care only – (OB, FQHC’s, specialists, ACO’s not eligible)

• Year 1 & 2 average of $20 PMPM from Medicare

• Years 3 & 4 average of $15 PMPM from Medicare

• Medicaid, 8 commercials also provide a PMPM

• Shared cost savings in years 3 and 4

• Can spread if successful

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Health IT leaders who make a difference

“Having an EHR and all the capabilities that it provides has revolutionized our practice. We now run reports that can help our providers identify patients who are due for such things as flu shots or mammograms.”

•Summit Family Physicians was a paper-based practice in mid-2011. •REC helped with EHR adoption, EHR live Sept. & attested in December 2011. •It is a Beacon Medical Home and applied for Level 3 NCQA certification.

Dr. Mark Fraser and

Leah Brunie,

ANPof Summit

Family Physicians

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HIE Value Progression –Meaningful Use, Medical Home and Payment Reform

Basic HIE

• Stage 1 MU • EHR Adoption (REC Services)• Basic Electronic Messaging (NHIN DIRECT)• Community Portal • Web-Based Results Delivery • Value: Dramatic reduction in redundant paper, phone contacts; Greater efficiency

Intermediate HIE

• Stage 2&3 MU• Structured Data Delivery to EHRs• Results Delivery (Lab, Rad, ADT, etc.)• Summary Record Exchange (CCD)• Value: Necessary to achieve truly electronic workflows; Dramatic increase in efficiency

Advanced HIE

• PCMH, ACO & Payment Reform Readiness•Data Warehouse & Analytics • Disease Registry•Quality Reporting Support•Full Integration Services & Bidirectional Exchange•Value: Dramatic improvements in quality and performance

What We Are Learning

1. HIT is part of the transformation equation. • MU + PCMH + Alerts (CDS/Data) = Enhanced Care Coordination

• Health IT can not be implemented as a stand alone solution.

• Health IT & Quality Improvement are necessary partners – alerts work because practice transformation is underway

o PCMH principles – open access, team based care, everyone at the top of their license

o Medical homes see ED visit as a “failure” that they can fix.

o Alert is the real-time notice that a failure has occurred.

• MDs and NP and teams designed process for using real-time alerts

o Open alert report each day

o Categorize patient as high-risk or low-risk (optional)

o Create a clinical update message in patient’s EHR sent to MD/RN/Front Office Staff

o Clinical update notifies FOS to schedule appt.

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What We Are Learning2. Medical Home and IT are empowering new roles in

care coordination.

• BIG WIN: Alerts empower team-based care - Expanded responsibilities of CSCs, MAs and RNs who help providers manage patients who had been to ED or had an admission

• Utilizing alerts as a Clinical Decision Support Tool (CDS)

• “Utilization” risk stratification to create a manageable number of high-risk patients

• More proficient practices using disease risk stratification to further define patients needing higher degree of care coordination



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Key Sustainability Questions• How do we financially support:

– Ongoing operations

– Continued investment in new capabilities

• What are the services we will deliver?

• Who will value the services?

• Why will they value the services?

• What will they pay for the services?

• Why will they buy services from LPHI/CCBC?

Sustainability Framework

Under and uninsured population

Managed Medicare

Managed Medicaid

Commercial Product

Employer sponsored

Other Populations

Clinical Condition

Care Management

System

Delivering Value TODAY

Growing and Enhancing the Care Management System

Delivering Value TOMORROW

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ContactAnjum Khurshid, PhD, MD

Director, Health Systems Division

Project Director, Crescent City Beacon Community

Louisiana Public Health Institute, New Orleans

[email protected]

www.crescentcitybeacon.org

504-301-9800


Associate Director, Health Systems Division

Project Manager, Crescent City Beacon Community

Louisiana Public Health Institute, New Orleans

[email protected]

www.crescentcitybeacon.org

504-301-9800


Jean Wright MD MBA

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Value of aligning

Since the eventual model was built around aligning with the felt needs of the 3 big systems, and the state informatics center each project has a sustainability plan underdevelopment to keep that project moving forward

Anna – the Transition of Care Avator

Patient Safety Net – the respiratory failure detection program

COPD – Management of patients across the Continuum

Virtual Diabetes Management by iPads

Mental Health transition of care

Building with a statewide vision

Many of the tools were built in a way that they focused first on Beacon, the on the dual eligibles, and then available for broader spread across the other Medicaid networks.

Health Landscape

Patient Activation Management

Transition of Care (connecting the alerts to the CCNC case managers CMIS tool).

Connections for ADT feeds from large hospital systems to the state informatics center.

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Reflection and Adaptation

Table discussion:What did you hear that might be useful in your setting?

What experiences have you had in your setting that might be helpful to others?

What questions do you have at this juncture?

General discussionObservations from your colleagues

Questions for ONC and/or the Beacons

P110

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Looking forward Beyond Beacon

Janhavi M. Kirtane ([email protected])Director of Clinical Transformation and Dissemination

December 9, 2012

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Beyond Beacon

1. Finishing Strong

2. Dissemination

3. Informing the Health IT policy agenda

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Critical path items to future success

Leadership and Stewardship

Clinical Transformation

Health IT

Data and Performance Measurement

Sustainability

1. Demonstrated capacity for community collaboration

2. Successful execution of innovative projects

3. Achieved physician and patient target numbers for clinical interventions

4. Demonstrated effective consumer engagement

5. Demonstrated effective provider engagement

6. Achieved a positive trend line on at least two key measures

7. Achieving electronic health information exchange (e.g., messaging, analytics, alerts etc) for providers

8. Having an IT-enabled infrastructure for community-wide health measurement

9. Demonstrated achievement toward sustaining services, infrastructure, or tools that will support Beacon goals around better coordinated care, patient access, more efficient care, etc.

10. Completion of grants close out activities

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Beacon Communities explore new

frontiers of HIT

Beacon Communities

generate market and policy insights

Beacon Communities

inform ONC policy making

ONC engages Beacons to serve as test beds for new

standards and polices

1. HIT and ACOs/payment2. Standards & Interoperability Implementation Workgroup for pilots and testing3. HIT and behavioral health4. Privacy and security needs at the community level5. Others?

Long‐term Value to ONC

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115

•Finish strong

•ONC “Virtuous Circle”


2012 & 2013

Long‐term Value to the Country

Priority Opportunities for 2013 (Swinging for the Fences)

• Peer-review publications• HIT-payment storyline• Creative ways to share knowledge

• Distillation of most salient lessons

• Flexibility for different audiences• Evidence of uptake (vs. passive dissemination)

• New audiences: business community, payment pilot participants, others?

2013 Continuation of Existing Efforts (The Floor)

• Community-led dissemination

• ONC-led dissemination• Partnerships with national organizations

• www.healthit.gov• On-line Beacon reference library: content and people

Your suggestions appreciated!

•Finish strong•ONC “Virtuous Circle”


2012 & 2013

What will it take to light up the country?

Discussion

Are there tool‐kits you find helpful?

Do you have webinar fatigue?

Will the “buddy system” help with movement, e.g., partnerships with sister communities or

organizations

What’s the right on‐line forum for learning?

What other tools are helpful for IT‐enabled improvement?

What are your go‐to channels or organizations for learning?

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Thank You, and Enjoy the Forum!

Appendix Materials

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BiographiesCarol Beasley, MPPM, Vice President for Business Development, Institute for Healthcare Improvement (IHI), has overseen numerous projects, including health information systems in primary care, and the IHI Triple Aim initiative focused on improving population health and individuals' experience of health care, while stabilizing or reducing per capita cost. She is trained in management, strategy, leadership and organizational change, and holds a Masters in Public and Private Management from Yale University.

BiographiesPattie Bondurant DNP, RN is currently the Director of the Beacon Program for HealthBridge. HealthBridge is a nonprofit health information organization located in Cincinnati, Ohio. It is recognized as one of the largest, most advanced and financially successful health information exchange (HIE) organizations in the United States. The Beacon Community Program is a national program funded by the Office of the National Coordinator for Health Information Technology.Greater Cincinnati and HealthBridge are one of 17 Beacon Program awardees nationwide. The aim of the Beacon Program is support advance communities’ efforts to build and strengthen their health information technology (health IT) infrastructure and exchange capabilities to improve care coordination, increase the quality of care, and slow the growth of health care spending. In December 2010, Pattie joined the staff of HealthBridge, contributing her knowledge and expertise in clinical quality improvement. Pattie has overall program responsibility for the $13.75 million grant award for the Greater Cincinnati Beacon Collaboration.

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BiographiesRoger Chaufournier, MHSA, Chief Executive Officer, CSI Solutions, LLC, has extensive international experience in organizational and health system improvement, hospital management, group practice administration, and managed care. Prior to founding CSI, a company dedicated to the spread of innovation as a strategy for organizational success, he served for six years as Chairman of the Board and CEO of Patient Infosystems. Mr. Chaufournier spent 12 years in progressive senior leadership positions in hospital administration at the George Washington University Hospital and University, three years as the Assistant Dean for Strategic Clinical Initiatives for the Johns Hopkins University School of Medicine, and three years as COO for a national health plan. He was a Malcolm Baldrige National Quality Award Examiner for three years. Mr. Chaufournier is a frequent lecturer and keynote speaker, and he continues to serve on the faculties of the Johns Hopkins School of Public Health and the Institute for Healthcare Improvement.

BiographiesJanhavi M. Kirtane, MBA, is the Director of Clinical Transformation and Dissemination for the Beacon Community Program, where she supports execution, innovation and learning collaborative efforts related to clinical interventions. She also leads national efforts to share program-wide lessons learned, and supports Beacon Community efforts to drive local adoption of promising IT-enabled interventions, including collaboration with the Center for Medicare and Medicaid Innovations. Prior to the joining the ONC, Janhavi spent 10 years working with healthcare delivery leaders across the country to lead strategic planning and clinical operations initiatives, most recently as a Senior Consultant with the Chartis Group, LLC, and previously with APM. Janhavi’s project portfolio included ED and OR redesign, inpatient care model redesign, integrated delivery system strategy, and mergers and acquisition operational evaluation. Her recent clients have included academic medical centers, children’s hospitals, and multi-hospital systems. Janhavi has a BA in Economics, with honors, from Harvard College and an MBA from the Wharton School, University of Pennsylvania.

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BiographiesAnjum Khurshid, PhD, MD, MPAff is the Director of Health Systems Division for the Louisiana Public Health Institute (LPHI). Dr. Khurshid oversees a wide range of healthcare initiatives including quality improvement of primary care and behavioral health services and the use of information technology and electronic medical records to improve population outcomes. He also leads the Crescent City Beacon Community program, a federally-funded program focused on quality improvement for diabetes and cardiovascular disease management enabled by health information technology. Dr. Khurshid earned his PhD in Public Policy and Master in Public Affairs from the University of Texas at Austin and his medical degree from King Edward Medical University, Lahore. He is a Clinical Assistant Professor of Medicine in the School of Medicine, an adjunct faculty in the Department of Global Health Systems in the School of Public Health and Tropical Medicine at Tulane University and a Board Member of the Louisiana Health Care Quality Forum.

BiographiesKristin A. Lyman, JD, MHA joined the Louisiana Public Health Institute in April 2011 and serves as an Associate Director in the Health Systems Division as well as a Project Manager for the Crescent City Beacon Community (CCBC) Initiative. Kristin is closely involved in the development and implementation of the Greater New Orleans Health Information Exchange (GNOHIE) in the areas of transitions of care, data sharing, patient consent, and governance. From June 2008-April 2011, Kristin was a member of the Quality and Risk Management Department at Tulane Medical Center, managing accreditation, core measures, and performance improvement. From August 2007-June 2008, Kristin worked at Amedisys, Inc., a large home health care and hospice company. At Amedisys, Kristin participated in the formation of the Strategic Sourcing Department, with responsibility for identifying and managing cost savings initiatives through the analysis of organization-wide spending data, consolidation of suppliers, negotiation of new contracts, and improvement of internal processes. Kristin graduated from the Juris Doctor / Master of Health Administration joint degree program at Tulane University in May 2007, and was sworn in as a member of the Louisiana Bar in October 2007. Kristin graduated magna cum laude and Phi Beta Kappa from the University of North Carolina at Chapel Hill in 2000 with a Bachelor of Science in Psychology.

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BiograpjiesJean Wright MD MBA is Vice President of Innovation for Carolinas Healthcare System (CHS). CHS is the 2nd largest non-profit Healthcare system comprised now of over 40 hospitals, 600 practice locations and 60,000 team members. Jean is the principal investigator for the $ 15.9 million dollar Beacon Community Grant, which links Health IT to improve the health of the community in the Southern Piedmont area of North Carolina. Jean is a graduate of the University of Michigan (BS), and the Wayne State School of Medicine (MD). She holds an MBA from the Emory Goizuetta School of Business. She is a pediatric anesthesiologist and intensivist. She has held a variety of physician executive roles from VP Medical Management at Children’s Health of Atlanta, to Executive Director Women & Children’s at Memorial Health in Savannah, and more recently, the Chief Medical Officer for CMC-NorthEast.

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