MassTLC PCHI presentation: Care Redesign, IT needs

Care Redesign: Information Systems Needs Alexander K. Baker Chief Operating Officer Partners Community Healthcare, Inc. September 22, 2011

What is PCHI?
P artners C ommunity H ealthCare, I nc.
Established in 1994
Provider Network consisting of ~6,400 physicians and 9 acute care hospitals organized into 17 Regional Service Organizations (RSO)
Management Services Organization (MSO) providing performance improvement infrastructure for the network.
100% EHR adoption as of 12/31/2009

Care Redesign Conceptual Model HEALTH OUTCOMES COST VALUE FOR PATIENTS Health Outcomes Value Metric = Cost of Delivering Outcomes

Network Characteristics needed to succeed in Population Management

Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management

Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals

Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing

Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing Decision Support Systems

Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing Decision Support Systems Referring Physician Solutions

Five Elements of Population Management
Identify members of the cohort
Leverage multiple data sources: EHR, billing, claims, ADT
Develop algorithms to identify cohort members
Consider clinicians (including referring physician) and patient as sources
Gather information on the cohort into a database or registry
Organize relevant clinical and financial data
Present tabular views and visual representations of data
Develop logic to highlight cohort members in need of follow-up
Fail to meet a process standard
Fail to meet a clinical outcome standard
Fail to meet a “measures that matter” standard
Develop population management software to track patient interventions
Document attempts to contact patients
Capture results of contact and interventions
Gain insight through reporting and analytic tools
Population reports to describe the population and its status
Operational reports to quantify the services provided
Outcome reports to assess the impact of services

Business Intelligence and Data Warehousing
Quality and quantity of Partners ’ data are rapidly improving
Much of this data resides in our transactional systems
Transactional systems are not organized for efficient reporting
Reporting off transactional systems drags down their performance
Critical need for coordinated, enterprise data warehousing strategy
Build on current data warehousing “islands”
Enterprise coordination of multiple activities
Data governance, access and security policies
Data modeling
Data extraction from transactional systems
Database management
Analytic tool selection and user support services
Success tied to multiple strategic initiatives
Population management
Accountable Care Organization
Payment reform (e.g., global risk, bundled payments)

Decision Support
Pause points Decision support opportunities
Increase depth and sophistication of decision support
Focus on condition-specific care redesign teams
Express decision support at pause points
Incorporate checklists and other guidance
Increase breadth of decision support
Leverage financial and administrative data

Patient Portals
Online engagement of patients and their families
Access to patient medical record
Access to library of health information
Message with physician practice
Tools to support more efficient care delivery
Patient-entered data
Platform for alternative care delivery strategies

Referring Physician Solutions
Referring physician portal
Delivery of consult information
Access services
Coordination of care
Regional Health Information Exchange (HIE)
Platform to support health information exchange at scale

Care Redesign: Information Systems Needs Alexander K. Baker Chief Operating Officer Partners Community Healthcare, Inc. September 22, 2011

MassTLC PCHI presentation: Care Redesign, IT needs

by MassTLC on Sep 23, 2011

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MassTLC PCHI presentation: Care Redesign, IT needs — Presentation Transcript