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1 Population Health Management: The Health Informatics Platform for Analytics and Actions P. Nelson Le, MD Clinical Advisor

2 Objectives 1. Specifications for Population Health Management 2. Five Rights of Strategic Interoperability 3. Engaging communities of patients and providers 4. Creating opportunities with analytics for action 5. Population Health Management as a strategy

3 creative partner for technology breakthroughs 35 years offices in 25 countries customers in over 100 countries value long-term relationships

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5 Global Healthcare Challenges 2011 Spending (% of GDP) AU CA DK NL NO NZ SE SZ UK US Medical Errors (% in 2 yrs) AU CA DK NL NO NZ SE SZ UK US Mortality After Heart Attack (%) AU CA DK NL NO NZ SE SZ UK US

6 Public Views of Health System Australia Canada 24% 38% 55% 51% 21% 11% Works well, minor changes needed France Germany 42% 38% 47% 48% 11% 14% Fundamental changes needed Netherlands New Zealand 51% 37% 41% 51% 8% 12% Need to be completely rebuilt Norway 40% 47% 13% Sweden 45% 46% 9% Switzerland 46% 45% 9% United Kingdom 62% 34% 4% United States 30% 42% 28%

7 Care Coordination and Transitions of Care Care Coordination Problems (%) AU CA FR GE NE NZ NO SE SZ UK US Key Information Not Shared Among Providers (%) AU CA FR GE NE NZ NO SE SZ UK US Gaps in Hospital Discharge Planning (%) AU CA FR GE NE NZ NO SE SZ UK US

8 The Complexity of Healthcare Rapid rate of change Vast amounts of complex data Extensive cross-organization activity Health Informatics Platform Data - Connectivity - Insight

9

10 Breakthrough Solutions in Population Health Management: Must Haves 1. Must break down silos of data 2. Must provide the end user with information 3. Must integrate with existing workflows 4. Must engage patients and providers seamlessly 5. Must apply analytics that will drive action

11 Identify Analyze Define Engage Steps for Population Health Management I D E A

12 Identify Analyze Define Engage Steps for Population Health Management I D E A

13

14 Patients change Populations change

15 Identify Analyze Define Engage Steps for Population Health Management I D E A

16 Five Rights of Strategic Interoperability: Right data Right amount Right person Right time Right action

17 North Shore Long Island Jewish Prenatal Community Practices Affiliated Practices NSLIJ Faculty Practices Labor & Delivery Perinatal EMR Inpatient Postnatal Inpatient EMR Post- Partum Community Practices Affiliated Practices NSLIJ Faculty Practices

18 North Shore Long Island Jewish InterSystems HealthShare Prenatal Imaging Centers Labor & Delivery Inpatient Postnatal Post- Partum

19 Identify Analyze Define Engage Steps for Population Health Management I D E A

20 Engaging Patient Community N Engl J Med 2007; 356: Average patient sees 7 clinicians in 4 different settings

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22 Engaging Provider Community A primary care provider needs to coordinate care with 229 physicians and 117 different practices to care for an entire panel of patients. Ann Intern Med Feb 17;150(4):236-42

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24 15% Reduction in Readmission Rates

25 Identify Analyze Define Engage Steps for Population Health Management I D E A

26 Retrospective data will only tell you where you have been. It will not keep you moving forward.

27 Analytics for Action Continuous Current Information Qualitative and Quantitative Embedded within the Platform

28 Outcomes Cost Performance

29 Identifying Patients at Risk for Hepatitis C HCV risk group drivers Injecting Drug User (IDU) HIV Country of origin: HCV prevalence > 2% High ethnic mix area LFT: elevated ALT Transfusion before 1992 Piercing Acupuncture Tattoo Men having sex with men (MSM) Household & sex partners of Hep Carriers Prison stay Positive risk alert Alert and outcome score Clinical support Guidance on additional questions Testing recommendation Links to knowledge base Patient Database Algorithm Risk indicator Hep C Test

30 Dynamic Clinical Alerting Shortcomings with existing alerting protocols: Each system has isolated data set when triggering alerts Each system has different trigger points Does not look at a patient holistically Need enterprise alerting protocols that incorporates real-time data EXAMPLE: DIAGNOSIS LAB VALUE MEDICATION ALERT Diabetes Type II LDL = 212 mg/dl Not on Statin SEND

31 Tracking the Delta Prescription Written Prescription Filled/Refilled Compliance Appointment Scheduled Patient Registration Missed Follow-Up Ancillary Studies Scheduled Result Delivery Missed Study

32 Population Health Management needs a strategy not a tool Uphold interoperability at a strategic level Coordinate existing processes and technologies within the community Incorporate dynamic clinical data and capabilities Benchmark along the axes of outcomes, performance, and cost Define the fastest path to the Continuity of Care Maturity Model Stage 7

33 Population Health Management needs a strategy not a tool Uphold interoperability at a strategic level Coordinate existing processes and technologies within the community Incorporate dynamic clinical data and capabilities Benchmark along the axes of outcomes, performance, and cost Define the fastest path to the Continuity of Care Maturity Model Stage 7

34 Population Health Management needs a strategy not a tool Uphold interoperability at a strategic level Coordinate existing processes and technologies within the community Incorporate dynamic clinical data and capabilities Benchmark along the axes of outcomes, performance, and cost Define the fastest path to the Continuity of Care Maturity Model Stage 7

35 Population Health Management needs a strategy not a tool Uphold interoperability at a strategic level Coordinate existing processes and technologies within the community Incorporate dynamic clinical data and capabilities Benchmark along the axes of outcomes, performance, and cost Define the fastest path to the Continuity of Care Maturity Model Stage 7

36 Population Health Management needs a strategy not a tool Uphold interoperability at a strategic level Coordinate existing processes and technologies within the community Incorporate dynamic clinical data and capabilities Benchmark along the axes of outcomes, performance, and cost Define the fastest path to the Continuity of Care Maturity Model Stage 7

37

38 Objectives 1. Specifications for Population Health Management 2. Five Rights of Strategic Interoperability 3. Engaging communities of patients and providers 4. Creating opportunities with analytics for action 5. Population Health Management as a strategy

39 Population Health Management: The Health Informatics Platform for Analytics and Actions P. Nelson Le, MD Clinical Advisor

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