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ACO = HIE + Analytics: Enabling Population Health Management


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ACO = HIE + Analytics: Enabling Population Health Management

  1. 1. ACO = HIE + Analytics Martin SizemoreDirector, Healthcare Strategy
  2. 2. About PerficientPerficient is a leading information technology consulting firm serving clientsthroughout North America.We help clients implement business-driven technology solutions that integratebusiness processes, improve worker productivity, increase customer loyalty andcreate a more agile enterprise to better respond to new business opportunities. 2
  3. 3. Perficient Profile Founded in 1997 Public, NASDAQ: PRFT 2012 revenue guidance of ~$327 million Major market locations throughout North America  Atlanta, Austin, Charlotte, Chicago, Cincinnati, Cleveland, Columbu s, Dallas, Denver, Detroit, Fairfax, Houston, Indianapolis, Los Angeles, Minneapolis, New Orleans, Philadelphia, San Francisco, San Jose, Southern California, St. Louis and Toronto Global delivery centers in China, Europe and India ~2,000 colleagues Dedicated solution practices ~85% repeat business rate Alliance partnerships with major technology vendors Multiple vendor/industry technology and growth awards 3
  4. 4. Our Solutions Expertise & ServicesBusiness Solutions Technology Solutions• Business Intelligence • Business Integration/SOA• Business Process Management • Cloud Services• Customer Experience and CRM • Commerce• Enterprise Performance Management • Content Management• Enterprise Resource Planning • Custom Application Development• Experience Design (XD) • Education• Management Consulting • Information Management • Mobile Platforms • Platform Integration • Portal & Social
  5. 5. Our SpeakerMartin Sizemore • Principal, Healthcare Strategic Advisory Services • A healthcare strategist, senior consultant and a trusted C-level advisor for healthcare organizations including both payers and providers • Specializes in clinical data warehousing, clinical data models and healthcare business intelligence for improving operational efficiencies and clinical outcomes. • A TOGAF certified enterprise architect with specialized skills in enterprise application integration and service oriented architecture.
  6. 6. Agenda• Accountable Care Organizations (ACO)• Definition, key components• ACO: Definition of success• ACO HIE requirements – use cases• HIE Current and Emerging views• ACOs require more than EHRs• Challenges to widespread ACO adoption• ACO = HIE + Analytics – Architecture• What are the typical use cases?• Summary
  7. 7. Accountable Care Organization Defined• A healthcare delivery system whose members share responsibility, financial risk and a common goal to improve healthcare delivery and the overall health status for a given population.• Acts collaboratively to coordinate patient care across the continuum and share both the payment and responsibility for quality of care for the covered patients.• Paid a specified amount for the population it manages, rather than a per transaction fee. ACOs can be incented if their quality and patient satisfaction scores are higher than expected; they can also receive decreased reimbursement if scores are lower than expected.* HIMSS ACO FAQ,
  8. 8. Key Components of an ACO• Patient‐centered medical homes• Primary care physicians• Specialists• Minimum of one hospital• Ancillary providers• Minimum of 5,000 Medicare beneficiaries (for Medicare demonstration funding)• Care coordination ability and mechanisms to support• Payer partnerships with reimbursement based on quality, efficiencies and patient satisfaction
  9. 9. Emerging ACO Models ‐ Governance Model Characteristics Current ExamplesIntegrated delivery • Own hospitals, physician practices, perhaps an • Geisinger Health System insurance plan. • Group Health Cooperative of Puget Soundsystems/networks • Aligned financial incentives. • Kaiser Permanente(IDN) • E-health records, team-based care. • Summa Health SystemMultispecialty • Usually own or have strong affiliation with a • Cleveland Clinic hospital. • Marshfield Clinicgroup practices • Contracts with multiple health plans. • Billings Clinic(MSGP) • History of physician leadership. • Virginia Mason Clinic • Mechanisms for coordinated clinical care.Physician-hospital • Nonemployee medical staff. • Greater Newport Physicians (partners with Hoag) • Function like multispecialty group practices. • St. Vincent Healthcare in Billingsorganizations • Reorganize care delivery for cost- • Methodist LeBonheur Healthcare(PHO) effectiveness. • Kettering Health NetworkIndependent Practice • Independent physician practices that jointly • Atrius Health (eastern Massachusetts) contract with health plans • Hill Physicians Group (southern California)Associations • Active in practice redesign, quality • Monarch HealthCare (southern California) improvement.Virtual Physician • Small, independent physician practices, often • Community Care of North Carolina in rural areas. • Grand Junction (Colorado)Organizations • Led by individual physicians, local medical • North Dakota Cooperative Network foundation, or state Medicaid agency. • Structure that provides leadership, infrastructure, resources*Source: Article by Stephen M. Shortell and Lawrence P. Casalino
  10. 10. Performance Measurement in ACOs CURRENT SYSTEM ACO SYSTEM Performance Measurement exclusively at the Measurement at the ACO level, across the individual/group level promotes fragmentation of care team, promotes an emphasis on care coordination and and an emphasis on encounter optimization as taking a long-term, holistic view of wellness. opposed to carrying a longitudinal view. ACO Patient PatientSlide courtesy of Oracle
  11. 11. ACOs from the Patient’s Perspective CURRENT SYSTEM ACO SYSTEM Quality Metrics & Cost Savings Payer Payer ACO Shared Savings Volume & Intensity Care Coordination Rewarded Care Coordination Patient PatientSlide courtesy of Oracle
  12. 12. ACO: Definition of Success Experience Metrics: Improving triple aim™ • Patient satisfaction of Care • PAM Scores (Patient Activation population outcomes Measures) Per Capita Metrics: • Total medical PMPM Costs • Total Medical Trend • Total Rx PMPM • Admissions/1000 Population • Readmission rate Metrics: Health • QUEST outcomes • Select HEDIS metrics • Health status – SF12 • Mortality rates Healthcare Business Intelligence will be the key to success in managing to these metrics* The term triple aim is a trademark of the Institute for Healthcare Improvement
  13. 13. Health Information Exchange (HIE) • Extension of EMRs • Integration or Interoperability role • Primarily data push or pull • Struggles with financial viability • Shifting from state-level efforts to private HIEs • Key element in the integration and coordination of care
  14. 14. HIE: Current View Demographics Rx Claims Demographics Rx Claims Labs Labs Medical Claims Medical Claims Health InformationBiometrics Bio-metrics Exchange Remote monitoring Remote Monitoring Focus: Data collection and Health Integration HRA Environmental Environmental Assessments Factors Lifestyle / Social behavioral /economic Lifestyle / Social / Behavioral Economic
  15. 15. HIE: Emerging ACO View Risk Financial Performance Risk Financial Management Management Performance (vs. paid claimsQualityReporting Quality Reporting Health Clinical Performance Clinical Information Performance Exchange Focus: Population Interventions Health Analysis Risk / predictive and tracking modeling Risk / Predictive Interventions Modeling Care plan Care plan deployment design Care Plan Care Plan Design Deployment
  16. 16. ACOs Require Far More Than EHRsRequirements Data Sources for Mining – Predictive modeling – Medical records – Registries – Clinical outcomes data – EHR interfaces – Patient billing systems – Reminder systems – Payer data – Claims and clinical data – Quality measures warehouses abstracts – Episode of care analysis – Charge master systems – Physician, payer, service – Specifications for integrated line utilization data claims and clinical databases – Infection surveillance – Patient portal options data – Health information – Labor, productivity and exchanges throughput records – Adverse drug events
  17. 17. Challenges to Widespread ACO Adoption• Silos lead to a disconnected business and IT infrastructure• Islands of computing create inefficiencies and underutilized assets• Missing or competing data standards, limited interoperability• Struggle with regulatory compliance, volume of information, data integrity and security• Resource constraints and difficulty managing complexity/change• Volume of data points and quality measures, in widely dispersed locations• Limited use among providers Meaningful Use Stage 2 and 3 to the rescue!
  18. 18. ACO: High-Level Architecture ACO Performance Management will be the key to success
  19. 19. HIEs Require Document Sharing (XDS) Oracle Health Sciences Information Manager (HIM) • First Register and Store ORACLE HIM QUERY AND RESPONSE PROCESS Documents from providers Requestor/ESB OHMPI Registry Repository • Providers Retrieve Documents: – Find Patient – Then Locate Documents Patient Lookup Potential Matches – Then Retrieve Document Display Record Set Documents Supports centralized, Select Patient Associated • Query XDS.b Registry with Patient federated and hybrid data models Display record headers, store pointers Select Extract full Individual Query XDS.b Repository data set/ record/ • HIM facilitates installation Document document and coordination of XDS Displayed Detailed result(s) componentsSlide courtesy of Oracle
  20. 20. Oracle HIE Architecture Oracle Desktop Virtualization Oracle Identity & Access Management Caregiver Mobility SSO User Provisioning LDAPOracle Sun Ray Oracle Portals and ApplicationsThin Client Consumers Clinicians Administrators Consent Mobility Empowerment Oracle Health Sciences Information Gateway Web Service Orchestration Web Service DMZ Gateway Data Center Adapter Oracle Business Process Management Suite Registries CONNECT CONNECT/Direct ESB BPEL Business Process Manager Process Analysis PKI Security Fixed Web Service Orchestration Adaptive Web Service Design & Orchestration Certificate Authorities Oracle Health Sciences SOA-based Integrations Other Health Information Manager Information Other SOA Service Endpoints DMZ Firewall & Internet Organizations’ Web Services & Features Message-based Support Data Center Firewall Secure Health Healthcare Master Health Policy Monitor Email Person Index Health Sciences Integration Engine Health Policy Engine Health Record Locator Healthcare TransactionStandardized Public Key Directory Healthcare Analytics Base“Front Door” EHA: HDWF-- HDM – ORA -- PSCAHIETransactions Oracle Databases, Clusters & Enterprise Manager Enterprise Linux Solaris Containers Oracle VM Database Encryption EXALOGIC Oracle Hardware Servers & Storage EXADATA Slide courtesy of Oracle
  21. 21. Oracle HIE “Edge-Server” Architecture Solving CIO Worries by Providing an Internet “buffer” to PHI data sources Firewall Penetrations Edge Servers for EHR Users Multiple Internal and Desktop Virtualization back channelEnd Users PHI Data Sources Cloud Computing Data Center Web Service DMZ Registries Edge Servers Proxy Servers Electronic PKI Security for the Certificate Health Record Authorities Health Information System(s) Other Health Information Internet Cloud DMZ Firewall & Internet Organizations’ Web Services & Data Center Firewall Secure Health EmailStandardized Edge Servers supports Secure, Controlled Health“Front Door”HIE Information Exchange of PHI to and from the EHRTransactions System(s) Prepared for the future of consumer-oriented healthcare and wellness management Slide courtesy of Oracle
  22. 22. ACO/HIE as a Population Health Platform Research (Evidence-Based De-identified Medicine)People Person HL7, CCD, EDI, P Client Opt HR, Batch, Web Applications In/Out Services Data Clinic Raw Data Enhancing Transformation knowledge Health Coach Claims and Normalization Structured Data translation and the Read byHospital adoption of Clinical Longitudinal Record QxMed evidence- based Primary Care Wellness Analytics Physician practice Master Patient Index Satisfaction Vocabularies IdentifyDevice Master Data Mgmt Predict Organization Prevent or Patient Intervene Home Health Assistant HIE Consent Measure Advanced Analytics Personalized Health Plan VP of Population Health Payer Mgmt
  23. 23. Why Build This Level of Technical Architecture?• Move from retrospective reporting to predictive modeling of population health to manage risk and share savings• Create the data analytics necessary to move to evidence-based medicine and modeling of outcomes, meet coming demand of healthcare consumer analytics• Predictive modeling provides an objective assessment of a patient’s future illness burden and associated health costs based upon their historical conditions as captured through claims and clinical information – key to ACO success! – It is a method for prioritizing members for population health management and care management and stratifying them based upon their morbidity burden and financial risk
  24. 24. ACO = HIE + Analytics SummarySafety Pharmacy Analysis Harm Avoidance AHRQ Alerting P4PQuality Practitioner Profiling & Quality Patient Satisfaction HEDIS 2010 (select measures) Performance ImprovementWaste and Operations Management Savings OpportunitiesHarm Optimization Harm AvoidancePopulation Benchmarking Efficiency & EffectivenessHealth Outcome Analysis AnalysisManagement ACO Analytics and Management Disease ManagementValue Analysis Value Based Pricing Actuarial Analysis Claims AdjudicationSpend Analysis Labor Supply Optimization Claims Handling Supply Chain Optimization Claims Adjudication 24
  25. 25. HIE + Analytics: What are typical use cases? Use Cases Use CasesDetermine and model total cost of care across all ID risk to patients by looking at environmental factorssettings (acute, ambulatory, home care) by population e.g. asthma, flu breakoutor individualCare coordination New age case management (CRM for patients)Match payer and provider data-verify rollout of ID labor savings. Correlate staffing to predictedpreventative programs demand/activityMeds Mgmt./Reconciliation/Med Therapy Physician attribution and/or care team – qualityMgt./Prescription fill compliance outcomes – patient satisfactionAnalyze population health levels based on various Monitor and track (real time) compliance to regulatorygrouping (geo, facility, provider, etc.) and/or clinical guidelines across settingsUnderstand resource utilizing productivity, throughput Chronic care cost modeling to support payments andand access allocationEvaluate readmission across continuum Support transitions of care through transfer of dataResource planning/physician profitability (contract Aggregate and manage data across all care settingsmanagement, preferences, outcomes (cost, care)Support all 65 ACO measures, not just the initial 33 Comparative Effectiveness / waste reductionMonitor/track patients experience beyond HCAPS Creation of new evidence base for guidelines(coordinate w/workforce, predict experience) 25
  26. 26. Thank You / Questions?