Building the IT Infrastructure for
Population Health and Care Management
February 23, 2014

Karen Handmaker, MPP
VP Popula...
Conflict of Interest Disclosure
Karen Handmaker, MPP
•
•
•
•
•

Salary: PHYTEL
Royalty:
Receipt of Intellectual Property R...
Learning Objectives
1. Appreciate the implications of the “volume to value”
transformation imperative in healthcare today
...
A Show of Hands
• Is your organization in an ACO or similar value-based
contract?

• Can you readily profile and stratify ...
The Big Picture:

What From Volume to Value Really Means
Are You Looking Below the Waterline?
Do you only focus on the top 3%?

>2/3
of catastrophic
patients this year
were not
ca...
The “Triple Aim” is Driving Change
Move from Volume to Value is Underway
PCMH Model Has Traction

Source: PCPCC
The Patient-Centered Medical Home’s Impact on Cost & Quality
An Annual Update of th...
Managing in PHM Model While Still in FFS
Current View
30 Patients Per Day
14 have Chronic Conditions
Unknown Health Risks
...
How Are We Getting There?

HIT’s Role in Population Health
and Care Management
PHM is a “Work in Progress”
Major Goals…
Strategic
Drivers

…But Emerging PHM Capabilities

Financial
Incentives

PHM
Infr...
Innovation Grant Includes PHM Technology
Center for Medicare &
Medicaid Innovation awarded
a $20.75 million Health Care
In...
2013 PCPCC Report:

Health IT is “Must Have” for PHM
TEN RECOMMENDED HEALTH
IT TOOLS TO ACHIEVE PHM:
1. Electronic Health ...
Population Health Management Visual

Source: Shifting to Value: Population Health Management Technologies for Accountable ...
Current (Manual)Processes Are Insufficient
2500 Patient Panel
Chronic Disease

10.6

Ann Fam Med 2005;3:209-214

Preventiv...
Automating the Population Health Model
Actionable Views of Your Population
Current State: Care Team Daily Work

Karen to create graphic
Automated Patient Engagement Works
Stratify for “Top of License” Workflows
Work Below the Waterline to Impact Top Line
Q: “How can our rate of uncontrolled diabetics
be increasing if I am managing ...
How Are These Providers Doing?
Scale and Automation Are Required
COPD

Diabetes

Hypertension

CAD

Asthma

Depression

Smoking
Track Performance to Target Improvement
• Monitor performance
measures
• Compare provider
and care team results
• Use dril...
Practice Innovations that Produce “Joy”

Source: In Search of Joy in Practice: A Report of 23 High-Functioning Primary Car...
What’s Next?

Extrapolate to the Future
Patient Engagement is the Holy Grail

Source: Bipartisan Policy Center,
“F” as in Fat: How Obesity Threatens
America’s Fut...
We WANT/NEED Patients to Pick the Right Path
• Our agenda for Oscar:

–
–
–
–
–

Medication adherence
Come to follow-up ap...
More Emphasis on Patient-Reported Data

1. Health and non-health
information
2. Gathered continuously;
not just at visit
3...
“I Am My Own Medical Home”
Advanced knowledge technologies allow self-care

Noninvasive
biomonitoring

Personal health
rec...
Questions?
Thank You!
Karen Handmaker MPP | VP, Population Health Strategies
11511 Luna Road, Suite 600 | Dallas, TX 75234...
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Building the IT Infrastructure for Population Health and Care Management

  1. 1. Building the IT Infrastructure for Population Health and Care Management February 23, 2014 Karen Handmaker, MPP VP Population Health Strategies, Phytel 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.
  2. 2. Conflict of Interest Disclosure Karen Handmaker, MPP • • • • • Salary: PHYTEL Royalty: Receipt of Intellectual Property Rights/Patent Holder: Consulting Fees (e.g., advisory boards): Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau): • Contracted Research: • Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): • Other: © 2014 HIMSS
  3. 3. Learning Objectives 1. Appreciate the implications of the “volume to value” transformation imperative in healthcare today 2. Understand how an effective HIT infrastructure enables population health and care management 3. Extrapolate to the future
  4. 4. A Show of Hands • Is your organization in an ACO or similar value-based contract? • Can you readily profile and stratify your population? • Are your care teams managing all of your patients or only those who present at the office or identified as “high risk”? • Is there room to “lean out” manual tasks and “design in” automation to increase care team capacity?
  5. 5. The Big Picture: What From Volume to Value Really Means
  6. 6. Are You Looking Below the Waterline? Do you only focus on the top 3%? >2/3 of catastrophic patients this year were not catastrophic the previous year You must focus on everyone below the waterline this year to prevent next year’s catastrophic cases. Source: Healthcare Risk Adjustment and Predictive Modeling, Ian Duncan
  7. 7. The “Triple Aim” is Driving Change
  8. 8. Move from Volume to Value is Underway
  9. 9. PCMH Model Has Traction Source: PCPCC The Patient-Centered Medical Home’s Impact on Cost & Quality An Annual Update of the Evidence, 2012-2013 - January 2014 http://www.pcpcc.org/resource/medical-homes-impact-cost-quality/
  10. 10. Managing in PHM Model While Still in FFS Current View 30 Patients Per Day 14 have Chronic Conditions Unknown Health Risks Visits Too Short for Coaching Volume-Based/Episodic New Population View 2500 Patient Population 900 have Chronic Conditions 1100-1250 have Mod-High Health Risk Care Teams Leveraged by HIT Value-Based/Continuous
  11. 11. How Are We Getting There? HIT’s Role in Population Health and Care Management
  12. 12. PHM is a “Work in Progress” Major Goals… Strategic Drivers …But Emerging PHM Capabilities Financial Incentives PHM Infrastructure PCMH Recognition Payer P4P Common EMR but Use Varies Workflows Largely Manual MSSP Award MSSP Shared Savings CMs Employed and PayerSubsidized Actionable Data Minimal Integration of PCP Acquisitions MU Stage 2 Patient Portal and HIE Coming Soon Care Teams Not at “Top of License” Medical Neighborhood Loosely Coordinated Focused on “Tip of the Iceberg” Direct Employer Contracting Best Practices
  13. 13. Innovation Grant Includes PHM Technology Center for Medicare & Medicaid Innovation awarded a $20.75 million Health Care Innovation Challenge grant to TransforMED, VHA and Phytel • Grant awards collaborative partnership • Funds 3 yr national project in 15 communities • Expands the PCMH concept to the Patient Centered Medical Neighborhood – connecting hospitals with physician practices for better quality and patient experience at a more affordable cost
  14. 14. 2013 PCPCC Report: Health IT is “Must Have” for PHM TEN RECOMMENDED HEALTH IT TOOLS TO ACHIEVE PHM: 1. Electronic Health Records 2. Patient Registries 3. Health Information Exchange 4. Risk Stratification 5. Automated Outreach 6. Referral Tracking 7. Patient Portals 8. Telehealth / Telemedicine 9. Remote Patient Monitoring 10. Advanced Population Analytics Source: PCPCC – Managing Populations, Maximizing Technology http://www.pcpcc.org/resource/managing-populations-maximizing-technology
  15. 15. Population Health Management Visual Source: Shifting to Value: Population Health Management Technologies for Accountable Care. www.phytel.com
  16. 16. Current (Manual)Processes Are Insufficient 2500 Patient Panel Chronic Disease 10.6 Ann Fam Med 2005;3:209-214 Preventive Care 7.4 Am J Public Health 2003 Apr;93(4):635-41 Acute Care 4.7 J Fam Pract 1198;46:377-389 Non-patient care 2.1 AAFP survey May 2005 Total Hours per Day 24.8 “Working harder is the worst plan” -W. Edwards Deming
  17. 17. Automating the Population Health Model
  18. 18. Actionable Views of Your Population
  19. 19. Current State: Care Team Daily Work Karen to create graphic
  20. 20. Automated Patient Engagement Works
  21. 21. Stratify for “Top of License” Workflows
  22. 22. Work Below the Waterline to Impact Top Line Q: “How can our rate of uncontrolled diabetics be increasing if I am managing all of them?” A: “The majority (65%) were not 9+ last year, so you have to find them BEFORE they become 9+.” Source: American Journal of Managed Care
  23. 23. How Are These Providers Doing?
  24. 24. Scale and Automation Are Required COPD Diabetes Hypertension CAD Asthma Depression Smoking
  25. 25. Track Performance to Target Improvement • Monitor performance measures • Compare provider and care team results • Use drill-down capabilities to find outliers and take action
  26. 26. Practice Innovations that Produce “Joy” Source: In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices, Ann Fam Med 2013;11:272-278. doi:10.1370/afm.1531.
  27. 27. What’s Next? Extrapolate to the Future
  28. 28. Patient Engagement is the Holy Grail Source: Bipartisan Policy Center, “F” as in Fat: How Obesity Threatens America’s Future (TFAH/RWJF, Aug. 2013)
  29. 29. We WANT/NEED Patients to Pick the Right Path • 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 DecisionMaking • Oscar’s agenda for Oscar: – – – – Grieving for his wife Transportation Managing Rx side effects Seeing his grandchildren
  30. 30. More Emphasis on Patient-Reported Data 1. Health and non-health information 2. Gathered continuously; not just at visit 3. Patient satisfaction 4. Quality measurement Source: Premier, Inc.’s Fall 2013 Economic Outlook
  31. 31. “I Am My Own Medical Home” Advanced knowledge technologies allow self-care Noninvasive biomonitoring Personal health record Facilitated Disease Network Wellness & disease mgmt. apps Digital coach (“avatar”) http://altfutures.org/primarycare2025
  32. 32. Questions? Thank You! Karen Handmaker MPP | VP, Population Health Strategies 11511 Luna Road, Suite 600 | Dallas, TX 75234 direct 214-750-9922 ext 143 | toll free (800) 559-3057 mobile 502-751-7764 | fax 1-888-664-0142
  33. 33. Please use blank slide if more space is required for charts, graphs, etc.
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