Using EHRs, HIE, & Data Analytics to Support Accountable Care. Jonathan Shoemaker June 2014

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1 Using EHRs, HIE, & Data Analytics to Support Accountable Care Jonathan Shoemaker June 2014

2 Agenda Allina Health overview ACO framework- setting the stage Health Information Technology and ACOs Role of Interoperability and HIE in ACOs Other relevant interoperability work Opportunities and Constraints 2

3 3 Allina Health Overview

4 Allina and the EMR Epic EMR since 2004 (branded Excellian) One patient, one record All hospitals, clinics, ambulatory care centers, and retail pharmacies A dozen affiliated hospital and clinic organizations use Excellian as their EMR product 3,000,000 Patient Records 33,000 Excellian Users 335,000 MyChart Users (PHR) Completed Meaningful Use Stage 1, Years 1 & 2 Over 4 GB of data added per day 4

5 Allina ACO Strategy and Work Allina s Aim A healthy, lifelong relationship based upon trust and empowerment. Primary Care Physician, Care Guide, Care Team, Family Nurse Health Promotion Family Health Manager Lifetime Fitness Community Prevention/Heart of New Ulm Optimal Access Nurse Advice Minute Clinic Ambulatory Clinic Urgency Emergency Chronic Illness Management Congestive Heart Failure Diabetes COPD Complex Care Navigation VPCI Neurological Cardiovascular Senior Care Navigation Services Geriatric Medical Group Senior Homes Integration End of Life Care Home Residential Integration Initiatives Accountable Care, AIM Network, Data, Analytics, Clinical Service Lines 5

6 Allina ACO Goals & Initiatives The Quality Roadmap: Goal 1) Perform under payment for quality and value models 2) Align incentives across employed and affiliated providers 3) Give providers the data and information needed to improve outcomes 4) Provide consistently exceptional care without waste 5) Support transformation with new skills development Initiative(s) Accountable care pilots- Pioneer ACO, Commercial partnerships Allina Integrated Medical Network Advanced analytics infrastructure Enterprise data warehouse Primary care team model redesign Care management/patient engagement Clinical service lines programs Allina Advanced Training Program 6

7 Leveraging HIT- ACO Components May be multiples Centralized data access for reporting EHR Analytics/Reporting Data Warehouse Portals/Decision Support May be multiples Integration in EHR 7

8 ACO Clinical Intelligence Tools PPR Dashboard Readmissions Model Specific Potentially Preventables Census Dashboard Modeling of Potentially Preventable Events General Enterprise Data Warehouse Reporting Workbench Retrospective What happened? Real time What is happening? Predictive What may happen? 8

9 HIE Interoperability What is it? Definition: HIE is defined here as the capability to move or consolidate information from across disparate information systems, while maintaining the meaning of the information. May mean Peer to Peer or building a clinical EDW Can vary in content- summary information, full data sets, or specific unique elements Often drive by use cases 9

10 The Value of Interoperability Clinical Value Share data real-time across systems Create efficient transition of care workflows Retrospective and prospective analytics will ultimately leverage outside data Harmonize clinically relevant information for use in decision making and the point of care experience Develop best practice information and rules across a clinically integrated network Technical Means and Components Privacy/consent management Data messaging (interfaces) Data aggregation and normalization Information portals Centralized Data Repository Master patient index 10

11 Rings of Growth for Interoperability Full Clinical Data Exchange Shared Summaries of care Ancillary Data Sharing (fax replacement) Lab tests. Rad results Partial picture of patient Summary of the patient Unparsed CCD Push/Pull triggers Batch Retrospective data Discrete and Full EMR data Real-time Native EMR access Retrospective data Prospective data Best practice rules/alerts Decision support data 11

12 Blueprint for HIE in ACOs DATA INTEGRATION POINT-OF-CARE 12

13 HIE- connecting Data and Patient Care 1. Defining populations in one dataset 2. Decision support Disease management testing values and trending Specialist assessments Complete patient history 3. Predictive models Algorithms for best practice shared across networks and data Ex- alerts based on risk factors, condition, time prompt clinicians regardless of EMR or organization 4. Care coordination Referral management Care transitions 5. Cost Containment Reduce test duplication Reduce HIM resource time (calls, faxing, scanning, etc) Reduce time delays- data is available when you need it 13

14 Related Interoperability Topics State HIO and MNehealth work State and Federal activities Grant activities DIRECT Healtheway Meaningful Use 14

15 Opportunities and Constraints 1. Vendor capabilities 2. Maturity of EMR use, analytics and decision support 3. Expertise 4. Competing integration work (external) 5. Competing priorities (internal) 6. Understanding the drivers and need Critical for long term success for meeting goals of the triple aim- top priority: 1. Consumer engagement 2. Cost/quality equation 3. Interoperability and analytics 15

16 thank you!

17 Appendix Continuity of Care Document (CCD) Patient Name Demographic Information Insurance Current Problem List Current Med List Current Allergy List Procedures Immunizations Results Vital Signs Referring Providers Name & Office Information Reason for Referral Care Plan Including Goals & Instructions Advance Directives Encounters Encounter Diagnosis Family History Social History Functional Status Cognitive Status 17

18 Peer to Peer Architecture (example) Allina Health Partners Fairview Essentia 18

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