iHT² Health IT Summit Atlanta 2014 - Case Study "Carilion Clinic’s Journey with Population Health Management and Health IT" with Stephen Morgan, M.D., SVP, CMIO, Carilion Clinic
Stephen Morgan, M.D.
Senior Vice President, Chief Medical Information Officer
Carilion Clinic
iHT2 case studies and presentations illustrate challenges, successes and various factors in the outcomes of numerous types of health IT implementations. They are interactive and dynamic sessions providing opportunity for dialogue, debate and exchanging ideas and best practices. This session will be presented by a thought leader in the provider, payer or government space.
The European, Chinese, and United States healthcare markets are a study of contrasts, each of which face a unique set of challenges and issues for their combined 2.4 billion citizens. Despite their differences, there are a number of opportunities for organizations to learn and profit through intercontinental collaboration on their paths to a more connected healthcare ecosystem. Panelists representing the three regions will provide an overview of their country’s unique healthcare landscape and offer a vision for a future of collaboration and progress.
• Brian O'Connor - Chair, European Connected Health Alliance
• Millard Chiang - Chairman, China Connected Health Alliance; Chair, Pegasus Holdings Group
• Julien Venne - Strategic Advisor & European Project Team Leader, European Connected Health Alliance
• David Whitlinger - Executive Director, New York eHealth Collaborative
New York eHealth Collaborative Digital Health Conference
November 18, 2014
New York State is in the process of undergoing an unprecedented transformation of its healthcare system through the implementation of the $6 billion Delivery System Reform Incentive Payment (DSRIP) program. Why? New York must not only reduce the vast cost of care, but it must also assure that individuals’ care is optimized through better collaboration. DSRIP will require comprehensive networks of providers to work together in Performing Provider Systems (PPSs), delivering population-based healthcare to Medicaid beneficiaries and uninsured New Yorkers. Through this process, the State intends to transform New York’s healthcare safety net, improve healthcare quality, and increase sustainability through payment reform. Success in the DSRIP program will require innovative strategies in communication, patient care, data analytics, and many other areas. Technology must therefore be foundational to a solid PPS platform. This panel of leading PPS participants and tech solutions providers will examine the vital role that healthcare technologies will play in DSRIP implementation, and the potential for DSRIP to accelerate the introduction of new, innovative technologies into New York’s healthcare delivery system.
• Jordanna Davis - Principal, Sachs Policy Group
• Stan Berkow - Co-Founder & CEO, Sense Health
• David Cohen, MD, MSc - Executive Vice President, Clinical Affairs & Affiliations; Chair, Department of Population Health, Maimonides Medical Center
• Lori Evans Bernstein - President, GSI Health
• Stephen Rosenthal - President & Chief Operating Officer, CMO, The Care Management Company of Montefiore Medical Center
New York eHealth Collaborative Digital Health Conference
November 17, 2014
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient's Power in Improving Health and CareHealth Catalyst
View a recording of this webinar here: https://www.healthcatalyst.com/webinar/the-patients-power-in-improving-health-and-care/
Around the globe, we are facing a trifecta of healthcare challenges: financial constraints, an aging population, and an increased burden of chronic disease. We need to turn healthcare upside down, empowering our patients to take action for their health and helping physicians, nurses, and healthcare professionals move from being sages to guides.
Patients, even those with chronic diseases, only spend a few hours each year with a doctor or a nurse, while they spend thousands of hours making personal choices around eating, exercise, and other activities that impact their health. How can we get patients to be more engaged in their care, and help physicians, nurses, and healthcare providers transition from a paradigm of “what’s the matter” to “what matters to you”?
Through her work at the Institute for Healthcare Improvement (IHI), Maureen Bisognano has worked diligently to support the IHI Triple Aim: improving the experience of patient care, improving the health of populations, and lowering costs. In this webinar she will present stories of patients and healthcare organizations that are partnering together with tools, processes, data, and systems of accountability to move from dis-ease to health-ease.
In this webinar you will learn:
- Lessons from the “flipped school” in the education system and how they can be successfully applied in healthcare to improve patient behavior.
- How increased patient engagement can help to improve healthcare outcomes and deliver a better care experience while reducing costs.
- Ways that technology can effectively improve data capture, patient accountability, and decision-making.
- The impactful stories of four patients who became innovators in their own care.
improve data capture, patient accountability, and decision-making.
It’s no secret the U.S. health care system needs to change. The Affordable Care Act (ACA) introduced
a focus on new health care payment models, which placed clear economic incentives on providers
while also striving for better outcomes. Today, we see an emphasis on preventing hospital
readmissions, reducing emergency room visits and avoiding unnecessary health care utilization
while enhancing quality and the patient experience.
As a result, health care stakeholders are rethinking the way care is delivered, how data is used and
how people collaborate and communicate in more preventive, proactive ways. This means moving
from episodic, fee-for-service, disease treatment models toward value-based care delivery to
improve outcomes, better utilize resources and expand access to care. Improved population health
has become the Holy Grail of U.S. health care, with many early experiments and some promising
successes. We take a look at Banner Health, a pioneer in transforming their health delivery systems with Robert Groves, MD, Vice President, Health Management, Banner Health.
The European, Chinese, and United States healthcare markets are a study of contrasts, each of which face a unique set of challenges and issues for their combined 2.4 billion citizens. Despite their differences, there are a number of opportunities for organizations to learn and profit through intercontinental collaboration on their paths to a more connected healthcare ecosystem. Panelists representing the three regions will provide an overview of their country’s unique healthcare landscape and offer a vision for a future of collaboration and progress.
• Brian O'Connor - Chair, European Connected Health Alliance
• Millard Chiang - Chairman, China Connected Health Alliance; Chair, Pegasus Holdings Group
• Julien Venne - Strategic Advisor & European Project Team Leader, European Connected Health Alliance
• David Whitlinger - Executive Director, New York eHealth Collaborative
New York eHealth Collaborative Digital Health Conference
November 18, 2014
New York State is in the process of undergoing an unprecedented transformation of its healthcare system through the implementation of the $6 billion Delivery System Reform Incentive Payment (DSRIP) program. Why? New York must not only reduce the vast cost of care, but it must also assure that individuals’ care is optimized through better collaboration. DSRIP will require comprehensive networks of providers to work together in Performing Provider Systems (PPSs), delivering population-based healthcare to Medicaid beneficiaries and uninsured New Yorkers. Through this process, the State intends to transform New York’s healthcare safety net, improve healthcare quality, and increase sustainability through payment reform. Success in the DSRIP program will require innovative strategies in communication, patient care, data analytics, and many other areas. Technology must therefore be foundational to a solid PPS platform. This panel of leading PPS participants and tech solutions providers will examine the vital role that healthcare technologies will play in DSRIP implementation, and the potential for DSRIP to accelerate the introduction of new, innovative technologies into New York’s healthcare delivery system.
• Jordanna Davis - Principal, Sachs Policy Group
• Stan Berkow - Co-Founder & CEO, Sense Health
• David Cohen, MD, MSc - Executive Vice President, Clinical Affairs & Affiliations; Chair, Department of Population Health, Maimonides Medical Center
• Lori Evans Bernstein - President, GSI Health
• Stephen Rosenthal - President & Chief Operating Officer, CMO, The Care Management Company of Montefiore Medical Center
New York eHealth Collaborative Digital Health Conference
November 17, 2014
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
The Patient's Power in Improving Health and CareHealth Catalyst
View a recording of this webinar here: https://www.healthcatalyst.com/webinar/the-patients-power-in-improving-health-and-care/
Around the globe, we are facing a trifecta of healthcare challenges: financial constraints, an aging population, and an increased burden of chronic disease. We need to turn healthcare upside down, empowering our patients to take action for their health and helping physicians, nurses, and healthcare professionals move from being sages to guides.
Patients, even those with chronic diseases, only spend a few hours each year with a doctor or a nurse, while they spend thousands of hours making personal choices around eating, exercise, and other activities that impact their health. How can we get patients to be more engaged in their care, and help physicians, nurses, and healthcare providers transition from a paradigm of “what’s the matter” to “what matters to you”?
Through her work at the Institute for Healthcare Improvement (IHI), Maureen Bisognano has worked diligently to support the IHI Triple Aim: improving the experience of patient care, improving the health of populations, and lowering costs. In this webinar she will present stories of patients and healthcare organizations that are partnering together with tools, processes, data, and systems of accountability to move from dis-ease to health-ease.
In this webinar you will learn:
- Lessons from the “flipped school” in the education system and how they can be successfully applied in healthcare to improve patient behavior.
- How increased patient engagement can help to improve healthcare outcomes and deliver a better care experience while reducing costs.
- Ways that technology can effectively improve data capture, patient accountability, and decision-making.
- The impactful stories of four patients who became innovators in their own care.
improve data capture, patient accountability, and decision-making.
It’s no secret the U.S. health care system needs to change. The Affordable Care Act (ACA) introduced
a focus on new health care payment models, which placed clear economic incentives on providers
while also striving for better outcomes. Today, we see an emphasis on preventing hospital
readmissions, reducing emergency room visits and avoiding unnecessary health care utilization
while enhancing quality and the patient experience.
As a result, health care stakeholders are rethinking the way care is delivered, how data is used and
how people collaborate and communicate in more preventive, proactive ways. This means moving
from episodic, fee-for-service, disease treatment models toward value-based care delivery to
improve outcomes, better utilize resources and expand access to care. Improved population health
has become the Holy Grail of U.S. health care, with many early experiments and some promising
successes. We take a look at Banner Health, a pioneer in transforming their health delivery systems with Robert Groves, MD, Vice President, Health Management, Banner Health.
Collaborative Leadership Insights - creating a digital health eco-systemAndrew M Saunders
Digital health is an essential enabler in achieving person centred health and wellbeing, A collaborative digital health strategy is required to manage the complexities of the complex hybrid health model in Australia, This presentation explores the approaches to leadership, transformation and culture that can be effective when working in a complex stakeholder environment.
Rethinking Value Based Healthcare
Around the world healthcare providers are busy exploring how value-based healthcare can both improve the efficiency and effectiveness of healthcare delivery and seed new opportunities for innovation. Continuing our collaboration with Denmark, we are very pleased to release a new perspective on how VBHC can have greater impact in practice. Based on insights from a recent event hosted by DTU Executive Business Education and undertaken in partnership with Rethink Value, this point of view looks at the key issues for patients, physicals, providers and payers.
It explores some of the associated implications for healthcare systems worldwide, highlights several leading early examples of VBHC in practice and looks at how it can have impact at scale. Recommendations focus on the structure of care, key metrics, moving beyond pilots, changes in reimbursement models and the need for greater insight sharing and deeper collaboration.
For related Future Agenda research see www.futureofpatientdata.org
In its January 2014 Issue Brief, the ONC announced its vision that, by 2020: The power of each individual is developed and unleashed to be active in managing their health and partnering in their health care, enabled by information and technology. And it began seeking feedback on new goals and strategies for health IT-enabled, patient centered care. With this vision in mind, this session will explore current and emerging technologies supporting person centered care in the ambulatory care setting.
Redesigning a care model for better health. CareOregon's MEDS (My Easy Drug System), Health Resilience program, and human-centered design programs are leading the way.
The Complexities and Challenges of Health and Aged Care System
The three primary goals of healthcare organisations today are:
• improve the experience of care
• improve the health of the population and
• reduce per capita costs of delivery.
This requires healthcare organisations to engage and impact the health of one person at a time. This can only be achieved with the right people, processes and information systems in place.
Dear all
Please go through the slides if you want to know something about "Core competencies for public health informatics".
I think these slides will be useful for you.
Validity and bias in epidemiological studyAbhijit Das
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Collaborative Leadership Insights - creating a digital health eco-systemAndrew M Saunders
Digital health is an essential enabler in achieving person centred health and wellbeing, A collaborative digital health strategy is required to manage the complexities of the complex hybrid health model in Australia, This presentation explores the approaches to leadership, transformation and culture that can be effective when working in a complex stakeholder environment.
Rethinking Value Based Healthcare
Around the world healthcare providers are busy exploring how value-based healthcare can both improve the efficiency and effectiveness of healthcare delivery and seed new opportunities for innovation. Continuing our collaboration with Denmark, we are very pleased to release a new perspective on how VBHC can have greater impact in practice. Based on insights from a recent event hosted by DTU Executive Business Education and undertaken in partnership with Rethink Value, this point of view looks at the key issues for patients, physicals, providers and payers.
It explores some of the associated implications for healthcare systems worldwide, highlights several leading early examples of VBHC in practice and looks at how it can have impact at scale. Recommendations focus on the structure of care, key metrics, moving beyond pilots, changes in reimbursement models and the need for greater insight sharing and deeper collaboration.
For related Future Agenda research see www.futureofpatientdata.org
In its January 2014 Issue Brief, the ONC announced its vision that, by 2020: The power of each individual is developed and unleashed to be active in managing their health and partnering in their health care, enabled by information and technology. And it began seeking feedback on new goals and strategies for health IT-enabled, patient centered care. With this vision in mind, this session will explore current and emerging technologies supporting person centered care in the ambulatory care setting.
Redesigning a care model for better health. CareOregon's MEDS (My Easy Drug System), Health Resilience program, and human-centered design programs are leading the way.
The Complexities and Challenges of Health and Aged Care System
The three primary goals of healthcare organisations today are:
• improve the experience of care
• improve the health of the population and
• reduce per capita costs of delivery.
This requires healthcare organisations to engage and impact the health of one person at a time. This can only be achieved with the right people, processes and information systems in place.
Dear all
Please go through the slides if you want to know something about "Core competencies for public health informatics".
I think these slides will be useful for you.
Validity and bias in epidemiological studyAbhijit Das
Validity and bias are essential aspects of any research—a brief description of internal and external validity and different types of bias related to the epidemiological study.
The Expansion and Acceleration of Value-Based CarePremier Inc.
This presentation highlights the rapid shift to value-based care that's occurring in the healthcare industry and was originally presented at Premier's annual Governance Conference.
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Advisor Live: Proposed Episode Payment Models for AMI, CABG, and Hip and Femu...Premier Inc.
On July 25, 2016, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule to establish three new bundled payment policies for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) and surgical hip and femur fracture treatment (SHFFT). Collectively, the models are referred to as Episode Payment Models (EPMs). The new payment models will be mandatory for hospitals in particular geographic regions.
CMS proposes to test the EPM models for a five-year performance period, beginning July 1, 2017, and ending Dec. 31, 2021. The proposed rule also includes changes to the Comprehensive Care for Joint Replacement Model and proposes to establish an incentive payment to hospitals for coordinating cardiac rehabilitation and intensive cardiac rehabilitation services. CMS is accepting comments on the proposed rule until Oct. 3, 2016.
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- Payment methodology,
- Quality performance in the payment methodology, and
- Legal waivers.
An Introduction to Business Intelligence for HealthcarePerficient, Inc.
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The Basics of Business Intelligence
BI Concepts and Definitions in the Healthcare Industry
The BI Maturity Model
This is an insightful introduction to business intelligence for healthcare.
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Similar to iHT² Health IT Summit Atlanta 2014 - Case Study "Carilion Clinic’s Journey with Population Health Management and Health IT" with Stephen Morgan, M.D., SVP, CMIO, Carilion Clinic
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iHT² Health IT Summit Atlanta 2014 - Case Study "Carilion Clinic’s Journey with Population Health Management and Health IT" with Stephen Morgan, M.D., SVP, CMIO, Carilion Clinic
1. 1
Carilion Clinic’s Journey with
Population Health Management
and Health IT
April 16, 2014
Stephen A. Morgan, M.D.
Chief Medical Information Officer
Senior Vice President
Carilion Clinic
4. 44
Carilion Clinic continues to be the premier
healthcare delivery system in western Virginia
• Accountable medical group with approximately
• 600 physicians,
• 150 advanced care practitioners
• 300 affiliated physicians.
• 850,000 primary care visits and 50,000 urgent care visits
• Full or partial interests in eight hospitals
• Full range of services and an active GME program
• 56 percent inpatient market share in total service area
• More than twice that of nearest competitor (HCA)
• Health plan
• Medicaid HMO
• The Market
• 85% FFS
• Dominant payor with 70% market share
5. 5
Carilion Clinic
• Mission: Improve the Health of the
Communities We Serve
• Vision 2017: We are committed to a
Common Purpose of Better Patient
Care, Better Community Health and Lower
Cost
6. 6
Building Blocks of our Success
• Physician leadership
• Technology
• EHR – Epic
• Data Analytics – Premier , IBM , Verisk
• Patient Engagement
• Partnerships
• Payers – Aetna
• Service Providers
• Provider Engagement
7. 77
What Drove Us To Transform?
• Rising health care costs
• External pressures – ACA, payment change
• Unstable economy
• Changes in consumer demand
• Advances in technology
• Generational differences in physician work/life
balance
• Working “to license” – team based
• Workforce shortages
9. 9
Our National Spend
Average Healthcare Spending per Capita,1980–2009
Adjusted for differences in cost of living
Source: OECD Health Data 2011 (June 2011).
Dollars
THE
COMMONWEALTH
FUND
10. 10
•Life expectancy improved by 3 years
•Years with disability increased
•US fell from 14th to 26th compared to
other nations.
•Leading cause for premature deaths
include
•CVD
•Lung Cancer
•CVA
•Leading cause of Disabilities
•Back Pain
•Musculoskeletal issues
•Depression / Anxiety
Value?
11. 11
Demographic Trends
• 1/3 US population – Baby Boomers
• 10,000 people a day reach 65
• 1 in 10 Baby Boomers is managing multiple
chronic illnesses; by 2030:
• 1 in 4 have diabetes
• 1 in 2 have arthritis
• 1 in 2.5 will be obese
• Treatment of patients with co-morbities cost 7 x
those without chronic illness
• 2/3 Medicare spending - 5 or more chronic
conditions
13. 1313
Challenges with Today’s Care
• Healthcare costs growing; burden to business
• Overuse; volume “treadmill”
• Inconsistent care; fragmentation
• Lack of coordination
• Payment model at odds with countering rising
costs
• Data issues
14. 1414
The Response Payment Reform
• To optimize the healthcare dollar and improve health
outcomes, both government and private payers are
(gradually) shifting from volume-based reimbursement to
value-based reimbursement
• Fee For Service
• Shared Savings
• Global Risk
• P4P
• Value Base Purchasing
• Readmission Penalties
• Bundled Payments
• MSSP
• ACO Arrangements
15. 1515
Population Health 101
• In order to move from volume to value,
and accept more risk, you must
understand the patient population.
• Define – Who am I responsible for?
• Measure – standard metrics
• Analyze – understand risk
• Improve – what interventions
• Control – Create accountability
16. 1616
Key Considerations
• Able to manage risk
• Integration
• Engaged physician leadership
• Culture shift
• Effective HIT and data management
• Time to change – pace
18. 1818
Our Strategic Path
Since becoming a Clinic- 2006
• Developed a multi-specialty medical group
• Physician leadership
• Substantial quality, safety, and process improvements
• Implemented EPIC enterprise-wide
• Constructed Riverside campus
• Opened a medical school in partnership with VT
• Implemented medical homes in all primary care sites
• Created MajestaCare, partnered with Aetna for
accountable care, MSSP (risk arrangements)
• Built a culture of collaboration and team work
19. 1919
Our Initial Areas of Focus
• Population Health
• PCMH
• Care coordination for high-risk and high-
frequency patients
• Wellness, prevention, Choosing Wisely
• Transformation work
• Payment reform
• Provider Engagement
• Health IT / Data
21. 21
Carilion Clinic: PCMH Today
Total Program Sites: 35
• Family Medicine - 29
• Internal Medicine - 4
• Pediatrics - 2
Recognition Status
• Level 3 Recognition – 27
Panel Size: 200,000
• 77% of Department Patients
Providers: 136
• Physicians - 106
• ACPs - 30
Care Coordinators
• Budgeted Positions: 22 FTEs
22. 22
System PHM Initiatives
• Transformation Oversight Committee
• Oversees work of committees in 3 areas:
• Care Integration
• Informatics
• Finances/Contracting
• Initial focus on COPD
• Led by Chief Strategy Officer
23. 2323
What is PHM and It’s Purpose?
• Definition: The coordination of care delivery across a population
to improve outcomes through disease management, care
management, and demand management
• Goal: To improve outcomes and reduce utilization for patient
populations with clinical and financial risk
• „Populations‟ are identified through community need
assessments, clinical risk registries
24. 2424
System PHM Initiatives
24
Program Focus Areas Patient Risk Levels
Area 2: High Utilization
Management
Area 1: Disease-Focused
Ambulatory Case Management
Area 3: Ambulatory Quality /
Pay for Performance (P4P)
Behavioral Health / Psycho-social
Sickest and/or highest-utilizing 5-10%
Rising-risk 40-50%
Low risk 45-55%
Advanced
CHF, COPD, IHD, DM, asthma, cancer, psychosoci
al problems
Patients with less severe chronic illnesses or
behaviors that significant elevate morbidity
or mortality risks;
HTN, DM, hyperlipidemia, tobacco
use, obesity
Patients without medical
problems; focus on
prevention, wellness, and
connectivity to health system
Patient
engagement, Extensivists, palliative
care, transitions of care protocols
Patient engagement, care
coordination, Extensivists, transitions of
care protocols
Cancer
screening, BP, lipid, A1c
, etc.; various patient
engagement and
contact components
25. 25
System PHM Initiatives
Program Infrastructure Areas 1 and 2: Disease-Focused
Ambulatory Case Management
and High Utilization Management
Area 3: Ambulatory Quality / Pay
for Performance (P4P)
INFORMATION & GUIDES
Data Analytics and Reporting
Clinical Protocols and Pathways
CULTURE CHANGE & ENGAGEMENT
Patient Education and Engagement
Organizational Change Management (Provider
and Staff Training and Engagement)
TOOLS & RESOURCES
Point-of-Care Decision Support
Centralized Patient Outreach
EHR Care Plans
Extensivist Team
Palliative Care and Hospice
Home Health
29. 29
Physician Compensation
• Moving from Volume to Value
• Major Components:
• Personal RVUs (~ 85%)
• ACP oversight (RVUs) (~ 5%)
• Performance metrics (~ 10%)
• Panel size
• Quality metrics
• Expense management
30. 3030
Care Integration
• Sub-Group of Transformation Oversight
• Oversight of integrated projects
• Representatives from all departments
• Education for first year
• Payment reform
• Understanding our data / opportunities
• Process improvement
• Transitions of care
• Employed providers
31. 3131
Working with Community
Providers
• Education
• Involvement of medical directors with LOS
committee
• Data sharing and transparency
• Involvement in decision making
• EMR
• Joint leadership and affiliation
33. 3333
“Health IT is essential not only to
accountable care organizations (ACO)
but also healthcare in general”
Kathleen Sebelius, MPA,
Secretary of the U.S. Department of Health & Human Services
34. 3434
Population Health Management
• Fundamental to every major healthcare
reform initiative today
• Patient-Centered Medical Home
• Accountable Care Organization
• EHRs alone are not sufficient to manage
populations effectively
• Provider groups and health systems that
automate the spectrum of population health
functions will be best positioned to succeed
36. 3636
Healthcare IT and ACOs
The Critical List
• Population identification - attribution
• Identification of care gaps – Decision Support
• Risk Stratification
• Cross Continuum Care management
• Quality and Outcomes measurement
• Patient engagement
• Telemedicine
• Mixing claims and clinical data
• Predictive modeling
• Clinical information exchange
43. 4343
Gaps in Care Patient Lists
Number of
members
Percent of
members
HbA1c Determination 686 92.7%
LDL-C Screening 610 82.4%
Nephropathy Screening 446 60.3%
NETWORK_NO NETWORKNAME1 PCP PCPNAME
MEMBER_ALT_I
D MEMBER_NAME HBA1C LDL_C NEPHROPATHY
Measurement_Peri
od_Members
7000000CARILION
0001000002
7 LAZO, M.D., ROBERT L. 8565173911 CAROL WHITAKER 1 1 1 1
7000000CARILION
0001000002
7 LAZO, M.D., ROBERT L. 8728319211 NANCY STAMPER 1 1 0 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8320176601 DEXTER SLUSHER 1 1 0 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8334701741 HAWTHORNE STUART 1 1 1 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8347362421 INA MARTIN 1 1 0 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8355332541 DOROTHY BOLT 0 1 0
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8495612601 SIDNEY WEBB 1 1 0 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8529433351 SHIRLEY CONNER 1 1 1 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8571966511 CURTIS TURNER 1 1 1 1
7000000CARILION
0001000010
4 HORNEY, M.D., WAYNE D. 8592308431 CURTIS TURNER 1 1 0 1
44. 4444
Care Plans Across the Continuum
• Developed a disease management section
in the EMR navigator
• High risk patients flagged
• Using problem lists and linked episodes
• Viewed by IP, AMB, and ED.
60. 6161
Carilion Patient Centered
Medical Home Outcomes
Comparative Clinical Performance
Measures: 2009-2012
Q-4
2009
Q-2
2012
Percent
Change (%)
1. Body Mass Index (BMI) Measured for
Patients <18 Years of Age 39.5% 92.9% 135.2%
2. Pneumococcal Vaccination for Patients
>65 Years of Age 74.2% 79.0% 6.5%
3. Breast Screening for Female Patients
40-69 Years of Age 56.2% 66.8% 18.9%
5. A1c Testing for Diabetics 18-75 Years of
Age 85.2% 91.9% 7.9%
6. Persistent Asthmatics with Controller
Medications Prescribed 86.2% 93.1% 8.0%
7. Diabetics with Blood Pressure
Controlled at <140 SBP / 90 DBP 68.4% 72.2% 5.6%
8. Hypertensive Patients with Blood
Pressure Controlled at <140 SBP / 90
DBP 64.6% 67.6% 4.6%
Source: 70,000 patient study in 20 Carilion mature medical homes during the
period 2009 – 2012; "The Impact of the Patient-Centered Medical Home on
Hypertension."
63. 6565
Is it Easy?
• Costly
• HIT steep learning curve
• Disrupted relationships
• Staff felt disengaged
• Leadership turnover
• Staff felt disengaged
• Management in new territory
• Support systems not ready for change
64. 66
Key IT Drivers
• Physician Leadership and engagement
• A seat at the table
• CMO, CSO, CMIO, Department Chairs
• Culture matters a lot !!
• Information Technology
• Develop your roadmap – First things first
• EMR integration
• Telemedicine
• Patient portals / patient engagement
• Build your ability to analyze and display data
• Data Warehouse (Buy or build?)