Population Health Solution

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1 Population Health Solution Transform healthcare data into actionable clinical intelligence to deliver near real-time insights and facilitate effective and timely care collaboration. Introduction Population Health has emerged as a discipline from managed care that was purposed to define somewhat static standards of care and established the need for medical necessity determination and pre-authorizations. Managed care initiatives sowed the seeds for Generation-1 Population Health programs that focused primarily on risk stratification and identifying gaps in care. These programs incorporated a veneer of collaboration between payers and providers but were largely siloed, difficult to scale and based on dated claims information. The ongoing transition towards value-based reimbursement is exerting pressure on such Population Health programs due to heavy reliance on claims data, coarse grained risk stratification models, retrospective population monitoring, lack of linkage to financial contracts, manual monitoring of program KPIs and other performance measures such as HEDIS, STAR etc. and limited collaboration with providers. Limitations of Generation-1 Population Health Programs Lack of a single integrated end-to-end Population Health Management solution that identifies and stratifies the population, supports continuous monitoring of attributed population and facilitates care coordination amongst health care providers Lack of infrastructure to ingest, correlate and vend clinical, financial and administrative data in different formats between payers and providers Lack of system to manage population cohorts attributed to a value-based care program and monitor them for measures such as program KPIs and CSFs, HEDIS, STAR rating and CMS ACO measures Lack of transparency between business team creating value-based care programs and clinical team monitoring the attributed population Difficulty in identifying changes in health status at a population or patient level in real-time Inability to detect early the members who are at high risk or result in higher cost Varying capacity to reach out to appropriate care team members in near real-time to facilitate effective and timely care collaboration 1

2 The Solution Edifecs Population Health Solution transforms healthcare data into actionable clinical intelligence to deliver near real-time insights for healthcare partners to jointly manage their populations. Leveraging existing EDI infrastructure, it ingests, normalizes, de-duplicates, consolidates and stores all types of digital data from internal and external sources in different formats in a patient-centric Integrated Patient Record (IPR). It enables import of value-based care program setup data including organization details, participant providers, attributed population and measures through a custom feed to provide necessary information to the care team so they can efficiently manage their population. Population Health Solution provides out-of-box content packs to monitor clinical, financial and network KPIs of the program. It enables users to define business rules that are applied to incoming data sources prior to persistence in an operational data store. The solution uses edge of the enterprise technology to interrogate data at the earliest possible point of ingestion, delivering insights that are routed to population dashboards and case management systems. Population dashboards enable the care team to monitor and manage health of their population cohorts for high-cost or high-risk chronic diseases like COPD, diabetes and heart failure. Dashboards also provide visibility into compliance with contract quality measures as well. Figure 1: Edifecs Population Health Solution Note: The grey components are not part of Population Health (PH) solution but they share important information like member attribution, participant providers etc. with PH solution. 2

3 Capabilities Capability Integrated Patient Record Interoperable Information Platform Healthcare Data as a Service (hdaas) Edge of the Enterprise Technology Out-of-Box Content Packs Configurable Rules Population Dashboards Cross-Enterprise Care Coordination Workflow Description Ingests, normalizes, de-duplicates, consolidates and stores clinical, financial and administrative information from disparate internal and external sources into a member-centric Integrated Patient Record (IPR) Extends existing EDI channel to intake information in any format like HL7 messages, CCDs, X12 transactions, and even custom formats like care gaps, risk scores and notifications Normalized member data from the data repository is rendered onto Population Health portal. Also, the same and more services can be leveraged / API exposed to downstream applications Leverages existing EDI channel to analyze incoming information at the edge of the enterprise to detect any changes in member s health status and notify care team in real-time to intervene Catalog of out-of-box rules available for primary conditions covering both adult and pediatric populations. The catalog covers high cost comorbid conditions such as CHF, Sleep Apnea, Stroke, CKD, Diabetes and Hypertension to name a few Enables a team of analysts to define custom rules and policies for monitoring members for any challenges being managed by health plans such as controlling ER utilization, controlling Diabetes etc. Rules can be configured to monitor population cohorts for various performance measures such as program KPIs and CSFs, HEDIS, CMS ACO measures etc. Dashboard to monitor population cohorts enabling drill down for analysing disease progression and comorbidities, utilization and performance trends, identifying clinical risk factors, attributed members and providers Delivers real-time alerts to payer and providers care team to catalyze care coordination and manage transitions (continued) 3

4 Capabilities (continued) Edifecs Population Health Solution enables health plans to efficiently manage high-cost / high-risk chronic conditions like diabetes, COPD, heart failure etc. that directly impact top line. As per the latest figures released by CDC, in million people or 9.3% of the population had diabetes that resulted in an estimated outlay of $245 billion. 1 As a result, controlling diabetes is amongst the top priority for health plans across the nation. Many health plans use HEDIS - Comprehensive Diabetes Care (CDC) measure to comply with suggested care standards and ensure that their diabetic population is well managed. 2 One of the components of CDC measure requires that all members 18 to 75 years of age with diabetes (either Type 1 or Type 2) should get their Hemoglobin A1c (HbA1c) testing done during the measurement year. Edifecs Population Health solution can be used to set up a rule to monitor diabetic population to ensure that they get their yearly tests done within the measurement year and send a notification to the care team in case of non-compliance. In addition, the solution can provide raw data to be submitted to HEDIS engine for HEDIS measure calculations. Intervention Gateway with Clinical Rule Setup 1. Define rule to monitor HEDIS Diabetes measure that requires members 18 to 75 years of age with diabetes (either Type 1 or Type 2) to undergo yearly HbA1C test in the measurement year 2. Intervention Gateway will monitor incoming data and apply this HEDIS rule to instantly trigger an alert to the care team when it observes noncompliance of annual testing or uncontrolled diabetes. Figure 2: View of Intervention Studio used to define HEDIS Diabetes rule to monitor diabetic population cohort 1 Centers for Disease Control s Diabetes Report Card published in NCQA What is current state of quality of care in Diabetes? - Diabetes/WhatistheCurrentStateofQualityofCare.aspx#sthash.gX6fqbf1.dpuf 4

5 Capabilities (continued) Population Dashboard with Dashboard View for Program Director 1. The dashboard provides a high-level view of the diabetic population cohort under a valuebased program that aims to keep Type-2 diabetes under control 2. It enables monitoring of population for HbA1c HEDIS Diabetes measure by providing drill down for trend analysis, identifying clinical risk factors, attributed diabetic members and providers working with the diabetic population Figure 3: View of At risk of Diabetes dashboard part of Population Dashboards Population Dimensions with Care Team Member View 1. Notifies care coordinator that the member Bob Moe who is currently under treatment for diabetes has an elevated HbA1c Figure 4: View of Integrated Patient Record on Population Dimensions portal* * Disclaimer: The patient data displayed in Figure 4 is fictitious. 2. Care coordinator is prompted to contact Bob Moe to discuss his plan for managing his blood glucose levels. 5

6 Why Edifecs? Benefits Improves trust and transparency between payers and providers Proactive population monitoring Scales partnerships Improves visibility Reduces costs Supporting Features Increases transparency between payers and their value-based partners by providing a single shared and comprehensive view of patient and population level data Aligns notification triggers to value-based contract KPIs, CSFs, HEDIS, STAR and CMS ACO measures to enable providers to manage their members better Near-now detection enabled through business rules that execute at the edge of the enterprise to monitor admits and discharges, eligibility checks, prior authorization requests and claims to identify at-risk members or populations Identify members that need additional care coordination efforts to steer them from ER, Urgent Care and inpatient hospitalizations Replicate a successful shared savings model for another program by leveraging out-of-box rules sets, clinical definitions and existing EDI infrastructure Ability to configure and create custom business rules that make sense for a particular program. Business rules can be clinical, administrative and financial metrics Population Dashboards with drill downs provide near real-time visibility into high-risk or high-cost members and allows population monitoring for inpatient, ER and Urgent Care visits Monitor eligible populations for improving quality measures such as HEDIS, STAR and also ACO metrics Leverages existing EDI channel to consume clinical data from providers, labs, medical devices, mobile applications and wearable devices Out-of-the-box content packs that help monitor members with chronic and comorbid conditions results in reduced cost associated with professional service hours Edifecs Inc. is a global healthcare software company committed to improving outcomes, reducing costs, and elevating value of healthcare for everyone. Edifecs delivers the industry s premier IT partnership platform to providers, insurers, pharmacy benefit management companies, and other trading partners. By mobilizing its leading solutions at the front end of the healthcare information pipeline, Edifecs provides a unified platform for partners to flexibly pilot and scale new initiatives using their existing enterprise system. Since 1996, hundreds of healthcare customers have relied on Edifecs partnership solutions to future-proof their leading initiatives in the midst of a dynamic healthcare landscape. Edifecs is based in Bellevue, WA, with operations internationally. Learn more about us at edifecs.com Edifecs Corporation. All Rights Reserved. PN:

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