Dr. Sean Rogers Medical Director Bend Memorial Clinic Case Study "Using Health IT for PCMH, Accountable Care and Population Health" Learning obectives: ∙ Discuss how Bend Memorial transitioned to the patient-centered medical home delivery model ∙ Understand the key healthcare IT solutions toward population health management ∙ Identify key technologies and registries for patient outreach and patient engagement ∙ Discuss the quality and outcomes achieved for Bend Memorial (reduced admissions, reduced ED visits, and enhanced chronic care management)

1. CASE STUDY: USING
HEALTH IT FOR
PCMH, ACCOUNTABLE
CARE AND POPULATION
HEALTH
IHT2 – SAN FRANCISCO MARCH
27, 2013
M. Sean Rogers, MD Medical Director
Bend Memorial Clinic Bend, OR

2. It’s the
Patient, Stupid

7. Healthcare in America – 2013
 10K Baby Boomers turn 65 every day
 Looming Medicare insolvency
 Misaligned payment incentives
 Inequitable access and spending
 Focus on acute, episodic care

8. Triple Aim
 Improving the individual
experience of care
 Improving the health of
populations
 Reducing the per capita cost of

10. New model of care: Population Health
Management
Traditional View New View
30 Patients Per Day 2500 Patient Population
Fee for Service PCMH Accountable Care

11. Enhanced Access Payment reform
Quality
Personal
and
Physician
Safety
Physician-led Coordinated and
Team-based Whole Person Integrated Care
Care Orientation

12. Patient-Centered Medical Home
 Right Care
 Right Patient
 Right Time
 Right Location

13. HIT and Population Health
 EHR
 Patient Portal
 Electronic disease registry
 Patient outreach
 Quality metrics reporting
 Referral tracking
 Transition of care coordination
 PHI access for external providers (read-only access)
 Clinical decision support
 HIE
 Predictive Modeling

14. Data Sources
 EHR
 PM
 Claims data
 Enterprise Data Warehouse
 Manually input discrete data
 Medical Home notes

21. Lessons Learned – Must Haves
 Communication is critical
 Physician champions
 Senior management buy-in
 Adequate resources
 Data validation
 Maintain a sense of urgency

22. Guiding Principles
 Truth is hard
 Change is ever-present
 Constancy of purpose
 Take the long view
 Nothing is trivial
 Make a conscious decision to be successful

24. Contact Information
M. Sean Rogers, MD
Medical Director
Bend Memorial Clinic
Bend, OR 97701
srogers@bmctotalcare.com
Cell 858-733-1421

25. Additional Material

26. BMC Medical Home
 Same Day Appointment slots
 Team-based care
 Using staff to the height of their licenses
 Standardization/Optimization
 Exam rooms
 Physician/Staff Work flow
 Task Management
 Supply ordering
 Check-in and Check-out processes

27. BMC Medical Home (cont’d)
 Updates occurring every patient, every visit
 Vaccinations
 Medications
 Health maintenance
 Creation of Medical Home notes
 Care Manager
 Pharmacy integration
 Medication Refill protocol
 Patient counseling
 Prior authorization