ACO = HIE + Analytics - a Healthcare IT Presentation

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With the release of the Accountable Care Organization (ACO) regulations, healthcare providers must be able to identify, access, and seamlessly share patient information to drive efficiencies and enjoy a potential share in ACO program incentives. Additionally, more than half of the 93 draft National Committee for Quality Assurance (NCQA) ACO measures are also Meaningful Use measures, which further elevates the need to achieve meaningful use stage 2 or higher.


Given these goals, success will ultimately depend on an organization’s ability to share patient data at the point of care and its ability to gain meaning from historical and longitudinal data for use in managing population health. Healthcare organizations will need to give focused attention to the IT strategies, appropriate architectures, and roadmaps they will use to move from desired state to reality.


We discuss the practical architectural approach for creating an ACO. As Health Information Exchanges (HIEs) evolve into their second generation, they are able to the support the functional ACO tasks of delivering and managing care for a defined population, accept payment, distribute savings to participants, and perform disease management with predictive modeling to improve outcomes. We will also discuss the need to achieve meaningful use stage 2 or higher and the data/analytics requirements for ACO participants.

Presenter Martin Sizemore is the Director of Healthcare Strategy for Perficient. Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations, and is a certified Enterprise Architect with specialized skills in Enterprise Application Integration (EAI) and Service Oriented Architecture (SOA).

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  • Our agenda today is to quickly define what an accountable care organization is, review it’s key components, and define what will make an ACO a success. In addition, we’ll examine the use cases for an ACO, especially the HIE portion – today and in the future. Next, we’ll look at the challenges to adoption and, most importantly, we’ll jump into the architecture of combining the HIE with Analytics to power the successful ACO.
  • Is this level of technical architecture necessary? Absolutely. Medicine is an evidence driven enterprise but they would like to have the predictive tools to assist with objective assessments of a patient’s future. A wise person recently noted that healthcare organizations will have to compete on data.
  • Let Perficient’s Healthcare team be your rapid response to jumpstarting your 4010 to 5010 migration! We appreciate your time today and now we will take questions. While you are creating your questions in the chat window, I want to get you thinking about these questions as well.
  • Thank you for attending today. I hope that I sparked your interest in accountable care organizations and their relationship to healthcare analytics.
  • ACO = HIE + Analytics - a Healthcare IT Presentation

    1. 1. ACO = HIE + Analytics Martin SizemoreDirector, Healthcare Strategy November 10, 2011
    2. 2. About PerficientPerficient is a leading information technology consulting firm servingclients throughout North America.We help clients implement business-driven technology solutions thatintegrate business processes, improve worker productivity, increasecustomer loyalty and create a more agile enterprise to better respondto new business opportunities.
    3. 3. PRFT Profile Founded in 1997 Public, NASDAQ: PRFT 2010 Revenue of $215 million 20 major market locations throughout North America — Atlanta, Austin, Charlotte, Chicago, Cincinnati, Cleveland, Columbus, Dallas, Denver, Detroit, Fairfax, Houston, Indianapolis, Minneapolis, New Orleans, Philadelphia, San Francisco, San Jose, St. Louis and Toronto 1,500+ colleagues Dedicated solution practices 500+ enterprise clients (2010) and 85% repeat business rate Alliance partnerships with major technology vendors Multiple vendor/industry technology and growth awards
    4. 4. Our Solutions Expertise & ServicesBusiness-Driven Solutions Perficient Services• Enterprise Portals  End-to-End Solution Delivery• SOA and Business Process  IT Strategic Consulting Management  IT Architecture Planning• Business Intelligence  Business Process & Workflow• User-Centered Custom Applications Consulting• CRM Solutions  Usability and UI Consulting• Enterprise Performance Management  Custom Application Development• Customer Self-Service  Offshore Development• eCommerce & Product Information  Package Selection, Implementation Management and Integration• Enterprise Content Management  Architecture & Application Migrations• Industry-Specific Solutions  Education• Mobile Technology• Security Assessments Perficient brings deep solutions expertise and offers a complete set of flexible services to help clients implement business-driven IT solutions 4
    5. 5. Our SpeakerMartin Sizemore• Enterprise Architect with specialized skills in Enterprise Application Integration (EAI) and Service Oriented Architecture (SOA).• Martin has been a consultant and trusted advisor to CEOs, COOs, CIOs and senior managers for global multi-national companies and healthcare organizations.• His deep industry experience as a consultant in manufacturing, healthcare and financial services industries has provided him with a broad knowledge of IBM hardware and software offerings with numerous certifications and recognitions from IBM including On- Demand Computing and SOA Advisor.• He is experienced with Microsoft general software products and architecture, including SharePoint and SQL Server and has worked closely with Microsoft architects on healthcare products including their healthcare CRM, Amalga, and HealthVault offerings. 5
    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-a definition• 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, www.himss.org
    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. 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
    11. 11. 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
    12. 12. 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
    13. 13. HIE: Emerging ACO View Risk Financial Performance Risk Financial Management Management Performance (vs. paid claims)QualityReporting 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
    14. 14. 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 abstracts warehouses – Charge master – Episode of care analysis systems – Physician, payer, service line – Specifications for integrated utilization data claims and clinical databases – Infection surveillance data – Patient portal options – Labor, productivity and – Health information exchanges throughput records – Adverse drug events
    15. 15. 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 of analytics among providers
    16. 16. Moving beyond Operational AnalyticsHealthcare increasingly will use advanced analytics to drive clinical andoperational improvements to meet business challenges Analytic Technique Critical Business Question How can we achieve the best outcome Stochastic Optimization including the effects of variability? Advanced Analytics Prescriptive and Optimization How can we achieve the best outcome? Predictive Predictive modeling What will happen next if …? Support new business models and opportunities Forecasting What if these trends continue? Simulation What could happen…. ? Alerts What actions are needed? Operational Analytics Competitive Advantage Query/drill down What exactly is the problem? Support ongoing business operations Ad hoc reporting How many, how often, where? Meet compliance requirements Standard Reporting What happened? Degree of Complexity Based on: Competing on Analytics, Davenport and Harris, 2007
    17. 17. ACO: High Level Architecture ACO Performance Management will be the key to success
    18. 18. ACO = HIE + Analytics: Architectural View Data Mapping and Data Warehouse Business Access InformationData Sources Integration Health Info. Exchange Information Delivery transport and Data Marts Services Consumers Data Marts Business Intelligence & Enterprise Internal Clinical Population Services Information Web Transaction RepositoryPatient Financial Portal (EIP) Portal Physician Allergies Organization Standard Reporting Portal Billing Operational Email, User Access Methods Lab Orders & Results Data Publish /Provider Claims SMS Medications Subscribe Standardization Ad-Hoc Analysis Patient Portal Encounter Core Warehouse Diagnosis Excel,Clinical Cubes PDF Procedures Bi-directional Patient Services Enterprise Services Backbone (HL7/CCD) Surgery Enterprise Services Backbone (HL7/CCD) Schedule Interfaces Survey Reports Fax,Pharmacy Printer R&D Care Notifications Management Others Data Validation Disease RegistersBilling Personalize / Other Campaign Provider Messages/Services Share Management CHF Asthma Reports Identity Resolution Hubs Purpose SpecificEMR’s Community Patient Registry (EMPI) COPD Diabetes HIE Services Health Provider Registry Data, Transform Other (CCR/CDA/etc)Claims Campaigns Query Tool and Load Registries. Data Research System Access Methods Organization Registry Extracts Campaign Services , FTPRegisteries Physician Reference (Terminology) HUB Community Contact Services Groups Unified Standard Code HIE Portal Message Sets (HLI, UMLS) BusEligibility Data Quality Extract Metrics Routines Local Code Sets Cohort Services FileOther Reference Data Deliver y Taxonomy SnoMed , RxNorm, etc. Data Modeling/ Metadata Management Data Quality Management Identity Management & Security Multi-tenant Infrastructure Services Governance
    19. 19. HIE + Analytics: What are typical use cases? Use Cases Use CasesDetermine and model total cost of care across all settings ID risk to patients by looking at environmental factors e.g.(acute, ambulatory, home care) by population or individual asthma, flu breakoutCare 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 Mgt./Prescription Physician attribution and/or care team – quality outcomesfill compliance – 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 settings (cost,management, preferences, outcomes care)Support 65 ACO measures Comparative Effectiveness / waste reductionMonitor/track patients experience beyond HCAPS Creation of new evidence base for guidelines(coordinate w/workforce, predict experience) 19
    20. 20. Why build this level of technical architecture?• Move from retrospective reporting to predictive modeling of population health• Create the data analytics necessary to move to evidence-based medicine and modeling of outcomes• 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
    21. 21. Metadata is VERY important Data Lineage is the key to integrity and troubleshooting Business Glossary & IS Users ETL Operational Metadata (Job Run Information) BI Reports Physical Schemas Industry Data Models DW Design Model ETL Job Design 2121
    22. 22. Advanced Analytics Architecture Presentation Layer Embedded Master Data Management Analytics Business Rules Common Definition Dashboards Engine Management Cogno Deployment s Applications Federated Data Mash ups Spreadsheet SOA Web s Service Financial Planning Integrated Scorecards Terminology Warehouse Services Cubing Services Healthcare Information Exchange Appliance• HL7 Acquisition Data Repository• Routing Multidimensional Data Definition• Remote Analysis Glossary Configuration & Data Mining Archive Monitoring Data Staging • Data Integration EMPI Operational Source Systems • Data Quality Structured / Unstructured Data • Data Delivery 22
    23. 23. ACO = HIE + Analytics SummarySafety Pharmacy Analysis Harm Avoidance AHRQ AlertingQuality Practitioner Profiling & Quality P4P HEDIS 2010 (select measures) Patient Satisfaction 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 23
    24. 24. To enable a smarter healthcare system that offers better care, better value and better health.To get the big picture and truly use healthcare IT to improve care in real time, our systems must enable care teams to: – Access a patient’s medical history from a secure, yet accessible cloud. – View anything and everything that could have an impact on a patient’s care, including past procedures and past medications. – Review evidence-based examples of how to customize and tailor treatments to produce the best possible outcomes for individual patients. – Evaluate whether treatments are effective over the long term and compare results with other providers. – Balance the privacy interests of each patient and the societal benefits of greater access to powerful, aggregated intelligence. 24
    25. 25. Poll QuestionWhat is the most important reason for analytics in anACO? A. Manage costs and operational efficiency B. Manage population health including chronic illness C. Clinical research on best practices D. All of the above 25
    26. 26. Q&A
    27. 27. Join Perficient at HIMSS 2012 Healthcare IT Conference & Exhibition February 20th – 24th Venetian Sands Expo Center, Las VegasVisit us in Booth No. 1274 to speak to ourhealthcare technology experts on: • Business Intelligence & Analytics • System Interoperability • Health Information Exchange • Portal Collaboration • Regulatory ComplianceDrawing for Perficient client badges to bepulled from today’s registration list!
    28. 28. Follow Perficient Online Perficient.com/SocialMedia Daily unique content about content management, user experience, portals and other enterprise information technology solutions across a variety of industries.Twitter.com/Perficient_HC Facebook.com/Perficient
    29. 29. Thank you

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