Pre-conference workshop at HIMSS14, "Building the IT Infrastructure for Population Health and Care Management"

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. 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. 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. 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. The Big Picture:
What From Volume to Value Really Means

7. 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

8. The “Triple Aim” is Driving Change

9. Move from Volume to Value is Underway

10. 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/

11. 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

12. How Are We Getting There?
HIT’s Role in Population Health
and Care Management

13. 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

14. 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

15. 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

16. Population Health Management Visual
Source: Shifting to Value: Population Health Management Technologies for Accountable Care. www.phytel.com

17. 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

18. Automating the Population Health Model

19. Actionable Views of Your Population

20. Current State: Care Team Daily Work
Karen to create graphic

21. Automated Patient Engagement Works

22. Stratify for “Top of License” Workflows

23. 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

24. How Are These Providers Doing?

25. Scale and Automation Are Required
COPD
Diabetes
Hypertension
CAD
Asthma
Depression
Smoking

26. Track Performance to Target Improvement
• Monitor performance
measures
• Compare provider
and care team results
• Use drill-down
capabilities to find
outliers and take
action

27. 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.

28. What’s Next?
Extrapolate to the Future

29. Patient Engagement is the Holy Grail
Source: Bipartisan Policy Center,
“F” as in Fat: How Obesity Threatens
America’s Future (TFAH/RWJF, Aug.
2013)

30. 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

31. 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

32. “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

33. 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

34. Please use blank slide if more space is
required for charts, graphs, etc.