Session 79 - How Accountable Care Organizations Can Harness the Power of Health Data and Analytics. Farzad Mostashari, CEO, Aledade, Inc.

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1 Session 79 - How Accountable Care Organizations Can Harness the Power of Health Data and Analytics Farzad Mostashari, CEO, Aledade, Inc.

2 Agenda Overview of Accountable Care Competencies for Independent Physicians Practice Perspective The Role of Health Data and Analytics 5 Key Competencies Quality Measurement and Improvement Managing Attribution and Risk Managing High Risk Patients Transitions of Care/Emergency and Inpatient Utilization Referral Management Data to Support Population Health Getting Practice Data Getting HIE/Community Data Quality Reporting and Practice Workflow Q&A

3 Learning Objectives Identify and address key challenges to harnessing health data and analytics to support independent doctors focused on population health Demonstrate potential of health data and analytics at point of care Assess current landscape and potential for accountable care, especially for independent physicians

4 To Succeed in Accountable Care Prevent Panel Churn Measure and Improve Quality Avoid preventable emergency room visits Cut readmissions and post-acute days Reduce acute episodes for high risk patients Target high-value referrals

5 Practice Perspective For those in small independent practices, sometimes our world feels like this

6 Interop - From Sneakernet to Live Data Manual Data Extracts EHR Vendor Integration Connector Agent CCDA Claims(837) Appointments(SIU) Raw Data sftp (30) vpn (21) DIRECT (1) Lightweight Data Normalization/Standardization Data Consumed by Analytics and Apps

7 The Role of Data and Analytics Transformed into Action Example Annual Wellness Visits Patients prioritized on key factors: - Time since last primary care physician visit - Potential to benefit from care coordination Drawing on multiple data sources: - Medicare patient list (practice) - Claims reports (practice) - CCD from EHR (practice) - Potential for under-coded chronic conditions - Upcoming appointments scheduled - Upcoming appointment list (practice) - ADT feeds (hospital) - Monthly claims reports (CMS, starting 2015)

8 Panel Churn Managing Attribution and Risk Annual Wellness Visits with Aledade Intervention Workflow Competencies Patient Outreach and Recall Patient call lists Appropriate risk coding Wellness Visit EHR workflow Data and Analytics Needs Patient diagnoses Practice claims and/or CCDA Risk stratification Coding opportunities Patient prioritization Data are for Aledade Delaware and Primary Care ACOs. AWV is number of Medicare AWV claims; AWV payments is total Medicare payments for AWV Claims. Source: Medicare Claim and Claim Line Feed data. Challenges Getting data EHR optimization Shifting schedule capacity focus

9 Quality Improvement/Measurement Pneumococcal Vaccination with Aledade Intervention Workflow Competencies Capture clinical quality measures ID and mitigate care gaps Care management for high risk Provider training Data and Analytics Needs Clinical data interfaces at practice level Terminology mapping Data normalization Challenges Workflow adherence Vendor CCDA limitations Integration speed and costs Workflow integration ACO->EHR

10 Reduce Acute Episodes for High Risk Patients Workflow Competencies ID and monitor chronic patients Dedicated chronic care management ID increasing spend Comprehensive care plan Data and Analytics Needs Cohorting Risk scoring Event Surveillance 360 Claims Feed ADT Feeds Challenges Practice resources to provide care management Hospital Data Feeds Tracking CCM time Shared care plans

11 TOC Cut Readmissions and Post-Acute Days Aledade Transitional Care Management Impacts 30-day Readmissions (n=3,274 Medicare Discharges) 35% Workflow Competencies Patient Outreach and Recall Tracking TCM Visits Convincing some patients to come in 30% Readmission (%) 25% 20% 15% 10% No TCM With TCM Data and Analytics Needs ADT Hospital Feeds App for notifications Challenges 5% Getting data 0% Patient Risk Category (Predictive Model) TCM Workflow Tools

12 Avoid Preventable Emergency Room Visits Preventable ED% Workflow Competencies Schedule Access Provider Availability Patient Outreach Data and Analytics Needs ADT Hospital Feeds % ED Visits During Office Hours Challenges Practice Change Patient Education

13 Target High Value Referrals Workflow Competencies ID Preferred providers Provider Availability Patient Education Data and Analytics Needs Cost, Utilization, and Quality Data for downstream providers Challenges Determining quality, tiering Getting commercial cost data Availability of alternatives

14 Clinical Data Integration (C-CDA) 28% 68% $7,500 Support C-CDA Manual Batch Export Less than 1/3 of EHR vendors provide practice staff the ability to export in bulk C-CDA XML data portability documents at the point of care Support Outbound C-CDA Automation Only 2/3 of EHR vendors have the capability to generate and transmit C-CDA documents after a visit without manual intervention from the provider 3 Year Median Cost of Ownership Based on 11 representative vendors, the median 3 year total cost of ownership of a C-CDA interface is $7,500 for a 3 provider practice. Costs range from $200 to as much as $58,000 per vendor.

15 Clinical Data Availability Key clinical data for population health management aren t always available in a structured format with the C-CDA interface High Availability Problem List Medications Allergies Tobacco Use Vitals Immunizations Frequently Unavailable Diagnostic imaging / surgical procedure orders and results Lab results with LOINC codes Health Maintenance Documentation Extremely Low Availability Preventive Screenings (Fall Risk and Depression Screens) Counseling and Patient Education Specialty Referrals

16 HIEs and ADT Alerts 11 of 11 87% v. 63% $0-$.12 States where communitybased HIEs are offering ADT alerting services 9 of these HIEs can provide ADT alerts in near real time (w/in 1 hour of the event) 2 can provide ADT alerts from all hospitals in the state Percentage of ED visits with alerts when a patient panel is used for matching v. provider NPI Providers receive alerts on a greater proportion of ED visits when ADT data is matched on patient demographics rather than provider NPI Most common patient panel demographics requested by HIEs: DOB First and last name Gender Address Phone SSN Medicare ID Cost per patient per month for ADT panels Matching ADT feeds with patient panels often incurs a fee for each person on the panel Before ambulatory providers may receive alerts, most HIEs also require them to become HIE participants, which often involves separate fees

17 Practice EHR/PM Integration 29 Vendors, ~115 Practices The Good Best (and worst) experiences with VARs On premise often easier to implement than cloud vendors Shortest implementation=3 weeks Using 3rd party agent works The Bad Typically 6-9 months from first contact through contracting to go-live with dedicated project management. The Ugly

18 Farzad Mostashari, Edwin Miller, MBA Paul Kleeberg, MD

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