Care Coordination and Realtime Risk Stratification

Transcription

1 Care Coordination and Realtime Risk Stratification Vish Anantraman MD, MS Chief Information Architect North Shore LIJ Health System

2 North Shore LIJ Health System

3 Current Healthcare Delivery is Fragmented Skilled Nursing Facilities Acute Care - Silos of data - Disjointed processes - Disparate Technology stack Outpatient Home Care Emergency and Ambulance 3

4 IT Challenges for Value Based Purchasing Need to coordinate care across continuum Consolidate silos of data in real time for complete patient story Bridge process inefficiencies in transitions of care Care plans that need to span multiple systems cross system decision support Connect applications and partners across disparate technologies Rapid growth of IDNs Agile technology integration of mature systems Newer venues of care (e.g. urgent care centers, call centers) needing functionality of multiple existing systems Real time data driven operations Real time analytics to support throughput in specialized facilities Real time patient risk stratification e.g. Bundled payment Real time patient registries for managing populations 4

5 Key Technology Components High performance application integration engine More than just regular HL7 Enterprise Service Bus need to orchestrate next generation web services based capabilities in modern applications Comprehensive Health Record Patient record that spans all venues of care Normalized to remove redundancy of data. E.g. same allergy captured in 2 different systems Process Orchestration and rules engine Detect significant events in real time simple events like admission/discharge, complex events like change in clinical data Rules processing to act on events by automation e.g. auto-generate post discharge appointment or escalate for human intervention 5

6 NSLIJ Reference Architecture Source Systems EHRs Enterprise Service Bus Comprehensive Health Record and Business Process Management Engine Destination Systems EHR Billing HL7, MFT, CCD Reg ESB Normalize terminology and structure CHR B P M Portal Mobile Community RHIO Webservices, APIs Composite Apps Ancillaries EMPI, Provider Master, Location Master, HLI - Vocabulary Active Analytics EDW Master Data Management Real-time Analytics 6

7 Accelerated Short Term Roadmap Aggressive implementation of foundational data in 12 months Over 200 interfaces into Comprehensive health record HL7, CCDs, Web services Demographics, Problems, medications, allergies, orders, labs, radiology, cardiology Connect over 30 systems legacy main frames to ASP applications Event Notification use cases 30 day readmission notification Detect patient weight changes for CHF patients across continuum Care Coordination Care management application for bundled payment Care management for health home initiative Extend clinical data availability to clinical call centers 7

8 Bundled Payment Care Tool Built in a relatively short period of time to address need to identify and track patients across 6 BPCI programs Stroke Cardiac Valve replacement CABG COPD Hip and Knee replacement Tool leverages data in our internal Comprehensive Health Records (Healthshare) Tool alerts and decision support driven by Healthshare 8

9 Goals of the CareTool Efficient and early identification of BPCI patients Monitoring of critical utilization measures and clinical indicators reduce the noise Management of patient with smart alerts for care navigators across continuum across multiple clinical and non-clinical systems Fill in the white space where there aren t clinical systems to capture and view data in the continuum e.g. SNFs, Clinical Call Centers

10 30 Day Readmission 9/22/13- Mt.Sinai Real Time Patient Identification

11 Tracking Care Across Continuum

12 Tracking Care Across Continuum

13 Tracking Transitions of Care

14 Patient / Provider Contacts From Multiple Sources

15 Real-time text extraction to reduce LOS