How to Enable Value-Based Care and Clinical Integration with Epic Cogito

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1 How to Enable Value-Based Care and Clinical Integration with Epic Cogito

2 Background Many newly formed, subsidiary organizations of integrated delivery networks are now the nucleus for clinical integration and valuebased care (VBC) program development. Led by boards of directors that include employed and independent physicians, the focus on the VBC strategic initiative stems from health systems anticipating the impact of healthcare reform and erosion of historically strong managed care health plan contracts. These entities often comprise a mix of employed and independent physician members who have joined together to participate in Shared Savings Agreements and thus collectively manage the health of a specific population(s) of patients. The concept of VBC suggests that over time, provider organizations make money based on the value of the services delivered verses simply the volume of services rendered. Like most industries in transition, healthcare is conflicted by the future of value-based care and the current state of sustaining growth and sufficient margins to fund capital investments. Due to this transitional state, many organizations are preparing for a future operating model, which is expected to have the flexibility to adapt to all forms of contracting that are deemed strategic by the health system. As such, many healthcare organizations are developing an operating model and automating core functions to associate with a value-based care framework. Perficient, a leader in analytics and data warehousing in the healthcare domain, has supported a number of value-based care programs, applying our expertise to implement the IT enablers that are required for the success of the program. In this paper, we examine support for a value-based care initiative via the build out of IT enablers that leverage the native capabilities of Epic, such as Cogito, Epic s data warehouse, Healthy Planet, Identity, and Radar, in addition to other Epic and non-epic analytics tools. Figure 1, below, depicts the five main functions contributing to a value-based care program, and highlights key considerations and requirements that must be satisfied for a program to be successful. These include: Health Plan Contracts The ability to negotiate, manage and support a variety of health plan contracts ( MSSP/Medicaid/BCBS etc.) Support key business functions, such as quality reporting to health plans, delegated credentialing, referral management and claims management Establish IT enablers, such as referral management systems Provider Networks Create a network of owned versus independent physician partners who are willing and supportive partners in the paradigm change Establish critical and effective communication channels to support patient care Enable a robust data integration environment with the ability to receive clinical data from providers that can be managed and reported from a central location Health Plan Contracts Provider Networks Member/ Patients Coordinated Care Managed Results Success Metrics. Portfolio of profitable contracts. Lives under management. Clinical integration. Mix of PCPs/ Specialists. Performance Standards. Member. Attribution. Patient Engagment and Satisfaction. Patient Retention. Retention of Referrals. Reduced Readmissions. Incentive Payments. Patient Outcomes. Quality Measures. Shared Savings Key Business Functions. Benefit Design. Risk Management. Managed Care Contracting. Contract Administration. Recruiting. Practice Transformation. EMR Implementation. Data Rendering. Beneficiary Management. Onboarding. Customer Service. Scheduling. Nurse Line. Care Transitions. Chronic Disease Management. Population Health. Medication Reconciliation. Quality Improvement. Monitor Provider Performance IT Enablers. Managed Care Contracting. Provider Portal. Quality Reporting. Analytics. EMR. HIE. Clinical Messaging. Patient Portal. CRM. Call Center. Enterprise Scheduling. Registries. Referral Management. Case Management. Care Plans. Telehealth. Image Sharing. Analytics. Contract Management Figure 1 2 How to Enable Value-Based Care and Clinical Integration with Epic Cogito

3 Members/Patients Attribute patients to physicians, so that there is appropriate support and accountability by a physician or group of physicians for a patient s care Proactively promote wellness programs and engage patients in wellness initiatives Coordinated Care Reduce the cost of care, improve patient quality outcomes, and improve patient satisfaction through a comprehensive care coordination program Identify high-risk patients, through risk stratification often using an integrated combination of claims/rx/emr data Managed Results Report results related to provider engagement, clinical quality and outcomes, and performance against specific annual targets Prepare, make available or distribute report results to system, health plans, physicians, and to support ongoing contract negotiations Establish individual physician-level and physician specialty reports based upon the measures established by the program quarterly with results aggregated at year end to reflect full-year performance 5. Ability to identify, categorize, and manage populations of chronically ill patients via the use of registries, risk assessment, and risk scoring 6. Methods and systems to attribute patients to physicians based on agreed upon logic for patient attribution 7. The ability to ingest data from a variety of sources and in a variety of formats into a central data warehouse repository capable of integrated analytics and reporting for clinical and business intelligence 8. The ability to integrate data points derived from claims and other external sources that are valuable reference points for patient care, into the EMR, so they are visible and actionable at the point of care Many healthcare organizations are leveraging the out-of-box features of their EMR to enable these VBC program capabilities. In cases where an integrated delivery network dominates or sponsors the partnership entity, and represents 50% or more of the participating physicians, the IDN s EMR is often leveraged as the platform from which the VBC program will be managed. Need for Program Capabilities To meet the requirements of an Accountable Care Organization (ACO) and value-based care program, organizations must deliver a suite of capabilities enabled by IT tools, so the entire membership of physicians can participate fully in contracts and in all aspects of the clinical integration program. This includes data analysis, care management, and guideline development and implementation. The Federal Trade Commission requires these elements in order for the organization to collectively negotiate on behalf of a wide variety of physicians. Key capabilities needed by a VBC program include: 1. Measures, scorecards and reports that define, standardize, track, and report key quality, engagement and utilization measures for participating member physicians and their patients 2. Define, understand, engage, and track patient populations, as well as measure and improve care processes and outcomes over time 3. The ability for clinicians to identify patients with important care considerations and make it practical for clinical leaders to manage key populations 4. Manage population health, outreach and care management, care coordination and planning, and patient engagement IT Tools to Satisfy Program Capabilities The primary objective of many healthcare providers that have fully deployed Epic is to leverage as much out-of-the-box native Epic as possible. Additionally, they configure and install selected modules of software supplied by Epic to enable the specific business functions and capabilities previously stated, or otherwise augment the core EMR with other tools where there may be gaps. Most healthcare organizations require the ability to measure and report on quality metrics as defined by the organization and within health plan contracts. They also desire the implementation of patient registries How to Enable Value-Based Care and Clinical Integration with Epic Cogito 3

4 EPIC DATA. Visits, admissions. Patients, providers. Medications, labs. Problems, diagnoses. Charges, claims. And more NON-EPIC DATA Patient satisfaction Claims And more Cost Epic-like data 2. Healthy Planet, Epic s population health module, helps healthcare organizations define, understand, engage, and track patient populations, as well as measure and improve care processes and outcomes over time. As illustrated in Figure 3 (on the next page), the goals for many Perficient clients are to: Stand up the Cogito Warehouse and enable the measurement, analysis, and reporting on quality, utilization and engagement metrics Implement Healthy Planet and its model registries and care management workflows in order to manage the care and improve the health outcomes for the patient population under management COGITO DW Epic + non-epic data Dimensional model Leveraging the Cogito Data Warehouse enables the integration and aggregation of Epic data with external data, for use in reporting and analysis including inclusion/exclusion rules and the population metrics. Furthermore, data stored in Cogito can be integrated back into Epic Chronicles and is available and actionable at the point of care. The data can also be leveraged and made available in the disease and wellness registries, and reported on within care management or via Epic Radar reports. Enabling Value-Based Care: Typical Client/Perficient Project Scope To achieve a composite view of all patients under management by a particular program, it is often necessary to integrate data into Cogito from disparate EMRs, or if that proves to be cost/time prohibitive, to leverage and integrate data from claims to provide the data needed for the program requirements. Figure 2 REPORTS DASHBOARDS AD-HOC ANALYSIS to track and improve clinical outcomes by chronic diseases. From a technology perspective, this will require implementation of a number of Epic modules, including Epic Cogito as a core technology, Epic s proprietary data warehouse solution. In the next section we explore the Epic modules and their role in supporting a value-based care program. 1. Epic Cogito (Figure 2) is a data warehouse. The Cogito Data Warehouse can help report more easily on a variety of topics from allergies and procedure orders to billing transactions and hospital admissions. The data warehouse is meant to bring together Epic and external data to allow users to create reports to meet their own needs. Below is an example from a Perficient client engagement depicting the scope of work necessary to define an operational program for value-based care. 1. Data Intake One must first focus on the development and implementation of data intake and the normalization process for bringing external data into Epic Cogito (Figure 3). Typically data intake involves the ingestion of data files and sources similar to those described below: CMS files - MSSP Post-adjudicated claims file Patient roster Health Plan(s) Claims Post adjudicated claims file Patient roster Medicare Claims Post-adjudicated claims file Patient roster Pre-adjudicated claims from claims clearing houses 4 How to Enable Value-Based Care and Clinical Integration with Epic Cogito

5 The DW is required to bring in claims data and is required to populate the Plan/Program specific registries Cogito Data Warehouse Claims Data Epic Standard Model Content Registries Configured specific to each plan/program s inclusion and execlusion criteria and metric definitions Asthma CHF Hyper Tension CAD Diabetes Provider Global Total Patient Population MSSP (Medicare) Health Plan(s) HMOI Health Plan(s) Employee Plan IHM 2015 State Medicaid Adult Wellness (8) Pediatric Wellness (3) MSSP Program Report State Medicaid Program Report Care Management & Population Management Reports Health Plan(s) Employee Plan Report Health Plan(s) HMOI Report IHM 2015 Report Figure 3 Physician rosters Measure lists with targets Lists of clinical specialties Press Ganey data Other reference data Perficient leverages our strong domain knowledge of Cogito and Microsoft SSIS for data integration, extending the native Cogito data model as required to meet the reporting and analytics needs of the organization. Since patient data in a value-based care model is coming from multiple sources, it is necessary to establish a master patient record, by matching patients associated with data external to Epic with Epic patient records. Epic Identity is used to facilitate patient matching. When there are gaps in data, for example, the full complement of data needed to support a measure is not available within the claims file, an Epic Abstractor workflow may be enabled to facilitate manual entry of data points required for metrics (e.g. a blood pressure value). Patient Matching Use of Epic Identity Manager and import utility to match with existing patients and establish net new patient records when necessary Abstractor workflow for non IDN work staff Enable data entry to predetermined metrics 2. Quality Measures Value-based care programs have a high demand for analytics and quality measures and involve the development and implementation of quality reporting to support the initial set of quality measures as defined. The number of metrics often expands over time, and requires a definition of measures and sources of data and a definition of basic reports. Many healthcare organizations prefer to leverage native Epic reports and Radar dashboards before considering custom business intelligence (BI) development for the rendering of physician scorecards, analysis or health plans reporting. However, in cases where custom BI development is needed, Perficient provides reporting and analytics solutions leveraging the Microsoft Business Intelligence stack, Business Objects, Tableau and other tools. 3. Disease & Wellness Registries Epic Registries are often configured and deployed to define, understand, engage, and track patient populations, as well as to measure and improve care processes and outcomes over time. The data to populate the registries originates from Epic and Cogito, and Smart Data Elements (SDE) are created when data is required to be passed from Cogito into the registries for inclusion in key metrics and inclusion/exclusion rules. SDE allow data to be pushed from Cogito back into Cache/Chronicles for this purpose. How to Enable Value-Based Care and Clinical Integration with Epic Cogito 5

6 Healthy Planet Registries allow you to: Define patient cohorts using registries Understand populations through risk stratification and benchmarking Engage populations through population outreach, high-risk care management, longitudinal care planning, and interactive patient engagement tools Track populations and evaluate the success of clinical programs with patient outreach tracking and analytics Create a set of disease and wellness registries and operationalize them 4. Risk Stratification One key aspect of managing patients is managing risk associated with chronic diseases and comorbidities. Healthcare organizations often seek to risk stratify patients, allowing the organizations to focus their attention on high-risk patients. A host of approaches can be taken to achieve risk stratification: Attributes used for defining risk scores can be limited to data elements within Epic with specific rules configured in registries to help highlight the high-risk patients amongst the cohort recorded with a specific chronic disease The Medicaid risk scores may be populated (not calculated) within Epic 5. Patient Attribution Patient attribution is critical to a VBC program as it assigns the care of patients to physicians based upon a pre-defined and agreed upon set of attribution rules and logic. Cogito plays a key role in patient attribution, as the algorithm is often defined within the data warehouse and the attributed physician values integrated back into Epic for use in the assignment of care, physician scorecards, care management workflows and quality performance reporting, and as a reference point in the patient s records. Patient attribution includes: Develop patient attribution logic Define the patient attribution logic within Cogito Migrate the logic to Epic Provide the ability for the attributed physician to be manually updated Perficient is fully conversant with conceptualizing and developing the attribution models to accommodate the unique requirements of client use cases and documenting any metadata as appropriate. Conclusion Value-based care initiatives are complex and highly dependent on a number of IT enablers that are necessary to support the program. Perficient offers a VBC readiness assessment to identify where an organization may have gaps, from an IT enablement perspective to ensure the program is positioned for success. Perficient is a leading systems integration firm with demonstrated experience implementing Epic Cogito-based solutions. We have worked with Cogito since version 5.0 through current version 8.0. Perficient s knowledge of Epic and our Microsoft practice specializing in SQL Server and SSIS, coupled with a host of BI and analytics competencies, makes Perficient the proven partner choice to join you in your VBC implementation journey. Contact Perficient to find out how you can take advantage of our complimentary VBC Readiness and Cogito Implementation Assessments. About Perficient Perficient, Inc. is a leading information technology consulting firm providing business-driven technology solutions to Global 2000 and other large enterprise clients throughout North America. If you would like more information about the topics discussed in this white paper please feel free to contact the author or send an to Copyright Perficient, Inc. All rights reserved. This material is or contains Proprietary Information, Confidential Information and/ or Trade Secrets of Perficient, Inc. Disclosure to third parties and or any person not authorized by Perficient, Inc. is prohibited. Use may be subject to applicable non-disclosure agreements. Any distribution or use of this material in whole or in part without the prior written approval of Perficient, Inc. is prohibited and will be subject to legal action. SUBSCRIBE TO PERFICIENT BLOGS ONLINE Perficient.com/Thought-Leadership BECOME A FAN OF PERFICIENT ON FACEBOOK Facebook.com/Perficient FOLLOW PERFICIENT ON TWITTER Twitter.com/Perficient DOWNLOAD PERFICIENT WHITE PAPERS Perficient.com/WhitePapers Global Headquarters 555 Maryville University Drive Suite 600 St. Louis, MO Perficient.com 6 How to Enable Value-Based Care and Clinical Integration with Epic Cogito

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