Beyond EHR Information Kit. Take Health IT to a new level of performance

Transcription

1 Beyond EHR Information Kit Take Health IT to a new level of performance

2 What can Smart Population Health Management do for Your Practice? Smart Solutions For Chronic Disease and Preventive Care Management Meaningful Use Patient-Centered Medical Home Community Healthcare Physician Medical Groups o o o

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4 Company Overview Helping You Achieve Excellence in Clinical Performance Founded in 2000, i2i Systems is a pioneer and leading provider of Population Health Management solutions and services. We are focused exclusively on creating healthier populations by partnering with and empowering healthcare organizations in their journey to deliver the highest quality care. We deliver business and population health intelligence through smart technology that supports easier and greater access to data and improves the efficiency of the care team staff. Success, we believe, occurs when smart tools enable dedicated providers to practice at their best. Today, health care professionals at over 1000 facilities, including over 70% of community health centers in California, 80% of community health centers in Iowa, and over 65% of community centers in Mississippi, rely on i2i Systems for critical clinical insights and powerful tools to improve the health of the communities they serve. The i2i Systems team includes experienced clinicians and software experts who together have created an innovative approach to managing patient populations, one that actually results in significant improvements to clinical outcomes, resulting in healthier populations. The i2i Systems family of population health management solutions enables clinicians to: Implement clinical guidelines of care across large populations. Analyze trends with sophisticated reporting and visualization tools. Identify patient subpopulations that are out of compliance. i2i Systems solutions go beyond typical reporting tools by automating specific action plans that allow care teams to proactively manage and coordinate care for defined patient groups. By managing clinical data to gain insights and implement action plans, i2i Systems solutions enable care teams to engage patients in their own care, meet targeted standards of care, achieve measurable improvement in chronic disease and enhance staff efficiency. The use of i2i Systems applications is creating realworld success today at clinics, physician practices and hospitals: Golden Valley Health Centers used i2itracks to reduce the average HbA1c from 8.9 to 7.6 in one year for over 4,000 diabetic patients. Primary Health Care, Inc. increased its pediatric immunization rate from 42% to 85% with i2itracks search and patient recall capabilities. Suncoast Community Health Centers saves $128,000 annually by using i2itracks to manage alerts and automate patient follow up. CHC of the Central Coast generates approximately $1.8 million in additional annual revenue with i2itracks by automatically sending 2000 recall letters each month to active and inactive patients. Clinic Ole generates over $300,000 in annual revenue by using i2itracks to identify and recall Child Health and Disability patients eligible for care. Minnesota Family Health Services increased the number of optimally managed diabetics by 20% within 6 months of implementing i2itracks. With i2itracks we can unlock the data in our EHR allowing us to easily generate mass patient recalls, decrease costs, and have complete confidence in the data that drives our decision making. Dr. Bery Engebretsen, Medical Director Primary Healthcare, Inc. Des Moines, IA

5 The i2i Systems product suite includes: i2itracks: The leading Chronic Disease (CDMS) and Population Health Management System (PHMS) nationwide. i2itracks is a day-to-day operational tool that uses customizable disease/condition registries, care models, and powerful patient searching and reporting tools to link clinical insights to specific staff actions that standardize and measurably improve the quality of care. i2itracks comes complete with the current Meaningful Use clinical quality measures, UDS, IHS, and GPRA clinical measures and collaborative reporting requirements. Hospitals Secure Hosting Center Medical Groups Subscriber Payer State Agency PCA HCCN Research Center Community Clinics i2ipopiq: A strategic cross-population analytics platform, i2ipopiq brings the proven capabilities of i2itracks to larger, multi-community populations. i2ipopiq is a cloud-based data aggregation and analysis platform specifically designed to work with i2itracks or an EHR to aggregate de-identified patient data and produce reports across millions of patients. i2ipopiq takes population data analysis to a higher level, enabling state regulators, healthcare networks, researchers and policy analysts to identify low and high performing sites and perform powerful what-if analysis to understand the impact of improving clinical measures and designing pay-for-performance programs. i2ilinks: A set of powerful data extraction and transformation tools and an extensive library of interfaces that connect data across your organization s HIT ecosystem. i2ilinks supports the use of i2itracks and i2ipopiq, by providing comprehensive data extraction and mapping capabilities to enable interfaces with Electronic Health Record systems, Lab Information systems and other patient data systems. i2ilinks EHR Labs Billing PM IMM Registries Pharm Other i2i Systems suite of products works together to give you the ability to manage strategically across sites and provide day-to-day operational reporting and activity management at each site all designed to improve the health of your patient populations. comes with pre-built interfaces to many vendors and all major Electronic Health Record and Practice Management systems. All i2i Systems products are supported by professional implementation services to assist you with the integration, implementation and optimization of your solution. A responsive technical support staff is also available to support you day to day. An extensive user community and user conferences allow you to discover new best practices from other practitioners in the market. Take The Next Step To learn more about i2i Systems products, watch users talk about their experiences with i2i Systems and read case studies, visit us at i2i Systems, Inc Laughlin Rd., Suite 200 Santa Rosa, CA phone toll-free fax All rights reserved.

6 Product Overview Track and Proactively Use Patient Population Data Produce Real-World Improvements in Patient Health i2itracks 7 July 1, 2011 IG i2itracks is the leading Population Health Management System used today by over 1000 healthcare facilitiesclinics, hospitals and physician private practice sites - nationwide. i2itracks integrates with your Electronic Health Record (EHR) Practice Management System (PMS), Lab vendors, Pharmacies, Immunization Registries, and other systems, aggregating data about your entire patient population. Clinical staff, including case managers, panel managers, clinicians, nurses, and providers, use i2itracks every day to identify and actively manage groups of patients to improved health. Unlike typical EHR reporting solutions that can produce reports and graphs, but leave you without tools to manage activities for populations of patients, i2itracks breaks down the barriers to your data, bringing it to life, with tools to allow you to be proactive rather than reactive in managing patients. The resulting improvement in staff efficiency leads to improved clinical outcomes measures. i2itracks enables multiple clinical teams not database report writing experts to uncover differences in populations by patient age, race, gender, provider, location, payer and multiple clinical measures. Once a subpopulation is identified, i2itracks has tools built in to manage all types of recalls, tracking and follow-up including: Well-child visits and immunizations. Diabetic annual eye exam or flu shot, or special attention for those with a high HbA1c. Women with abnormal cancer screening tests. Pregnant women for ultrasound or other procedures. Patients who are referred to a specialist for consultation. i2itracks supports the care team in their efforts to ensure guidelines for care are completed. The results: Effective follow-up, better compliance from patients and ultimately, healthier populations. Auxiliary Data Systems Lab Results Immunization Registries Pharmacy Data EyePacs and other auxiliary systems Population Health Management System Practice Management System Demographics Billing and Insurance Appointment Scheduling EMR/EHR Systems Clinical Measures referrals, smoking status, etc. Problems Medications Lab Results Vital Signs Allergies, and more i2itracks integrates data from your EHR and PM systems, lab and other vendors to give you an advanced level of insight into population health. Real-world features real-world impact Clinics taking advantage of the capabilities of i2itracks report amazing clinical and business results: Clinic Ole increased treatment completion for patients with Tuberculosis from 8% to 44%. Santa Barbara Neighborhood Clinics received a $350,000 grant for diabetic and asthma care, based on improvements in the effectiveness of managing these two chronic disease populations. Primary Health Care, Inc. received $223,628 in incentive funds, by using i2itracks to develop a successful smoking cessation program that helped over 1,000 people quit smoking. Community Health Centers of the Central Coast used i2itracks to generate approximately $1.8 million in additional annual revenue by automatically sending out 2,000 recall letters each month.

7 i2itracks Features Complete and focused: Single integrated system focused exclusively on population health. Panel/Care Management: Capture and report data by specific populations or subpopulation. Actionability: Managing care according to specific guidelines of care, via integration with PMS, EHR. Comprehensive Reporting: Fully integrated, easy-to-use report/graph generator with standard reports for MU, UDS, HEDIS, and P4P. i2itracks Benefits Eliminate duplicate data entry and potential errors. Complete solution at the site and network level (with i2ipopiq). Our focus on population health management means you get the best new ideas from the entire industry added as new features. Isolating groups that are out of compliance enables focused action plans to be developed. Patients no longer fall through the cracks. Closed loop monitoring of an action plan based on your specific guidelines of care means that patients get the follow-up they need. You are no longer dependent on IT experts to generate your needed reports. Any staff member has easy access to data. Easily receive the most out of your result incentive programs. Get up and running quickly and affordably i2i offers comprehensive set-up, implementation, consulting and training services to ensure that your staff is ready to take full advantage of i2itracks from day-one. With more than a decade of experience automating hundreds of clinics and medical practices nationwide, our staff will train your team in best practices so that you can maximize the benefit of your i2itracks right away. Ongoing training and an active user group will help you take your team to the next level of efficiency with i2itracks, whenever you are ready. i2itracks is available as installed software operating in your facilities. Hosting and lease options are available to reduce the initial cost and to let you gain the benefits of i2itracks without having to add IT staff. From i2i Systems the Leader in Population Health Management Software i2itracks is part of the complete Population Management Health suite from i2isystems. Founded in 2000, i2i Systems is a pioneer and leading provider of Population Health Management solutions and services. We are focused exclusively on creating healthier populations by partnering with and empowering healthcare organizations in their journey to deliver the highest quality care. We deliver business and population health intelligence through smart technology that supports easier and greater access to data and improves the efficiency of the care team staff. Success, we believe, occurs when smart tools enable dedicated providers to practice at their best. For more information visit us at My team won t let anyone take i2itracks away. They got a hold of this great tool and decided it s what they want to use. It s easy, it s effective, and it s intuitive. That s my definition of success. Hal Paquin, Quality Improvement Coordinator Redding Rancheria i2i Systems, Inc Laughlin Rd., Suite 200 Santa Rosa, CA phone toll-free fax All rights reserved.

8 Product Overview Integration Leads to New Insights and Operational Efficiency The first step to improving healthcare delivery is to get accurate data from disparate systems consolidated into a single manageable structure. In today s medical practice world, that challenge involves interfacing with Electronic Health Record Systems, Practice Management Systems, Lab Information Systems, and other patient data systems, each with its own unique data format and interfacing challenges. It s no surprise that many healthcare organizations never get past the point of data integration on the road to improving population health. i2i Systems developed i2ilinks specifically to help organizations of all sizes overcome the challenge of accurate and supportable data integration from diverse systems and providers. i2ilinks is a set of powerful data extraction and transformation tools and an extensive library of interfaces that connect data across an organization s HIT ecosystem. Using i2ilinks, your healthcare organization can be integrated across multiple sites, systems and providers in much less time and at much lower cost than developing these interfaces internally or Auxiliary Data Systems Lab Results Immunization Registries Pharmacy Data EyePacs and other auxiliary systems Population Health Management System Practice Management System Demographics Billing and Insurance Appointment Scheduling EMR/EHR Systems Clinical Measures referrals, smoking status, etc. Problems Medications Lab Results Vital Signs Allergies, and more i2ilinks is a powerful data integration and transformation tool that has prebuilt interfaces to most popular EHRs, PM systems, labs and other external providers. By providing such broad integration, i2ilinks increases the kinds of analyses and insights that may be gained from your data. through consultants. Integration with custom or legacy systems may also be built and maintained faster and more cost effectively using i2ilinks. i2ilinks Features i2ilinks Benefits Prebuilt library of interfaces to many popular systems constantly updated. Rapidly and easily connect to most existing systems interfaces updated as underlying systems change. Standardize data from multiple health centers with different systems. Enables cross-site reporting and analysis for new insights. Automated integration to eliminate duplicate data entry. Data scrubbing: automated routines to reconcile inconsistent data from EHRs and PMs. Improved data accuracy. Time savings. Transforms unusable data into usable data to enable accurate reporting. Forms-based data import reconciliation. Allows clinicians or IT staff to reconcile mismatched patients and address other data quality issues.

9 One Product a World of Integrations i2ilinks supports integrations to many data sources, including those below. New data sources are constantly being added. Electronic Health Records eclinicalworks EHS GE Centricity Healthport IC Chart NextGen Allscripts Athenahealth Immunizations, Pharmacy and other CAIR IZ Florida Shots IZ Reg PPC Pharmacy EyePACS RIDE IZ Registry QS1 Pharmacy ID Card[Patient Picture] SDIR IZ Registry HL7 Pharmacy Interface NextGen IZ Non HL7 Pharmacy Interface Labs Diamond Labs eclinicalworks Elincs Fletcher Flora Labs HealthRamp HexLab Horiba Labs Hunter Labs Keane Interface LabCorp Labcorp (Dynacare Lab) LabWest Labs Mckesson MD Rhythm (TechSoft) Lab MediTech Merritt mlab Nationwide Labs Novious Labs Orchard Harvest Labs Patient Demographics Bi-Directional Add-On Quest Labs Schuyler Lab Sunquest Lab West Coast Lab Whitefield Labs Practice Management Systems Centricity Practice (GE Centricity) Chorus PM V7.1 (Chorus) CompuGroup v eclinicalworks EHS (ehealthcare Systems) Epic Freedom Medical Systems (Custom Computing Corp) HealthPro Legacy (Sage) HealthPro XL (Sage) ICCONS Invision (Siemens) Keane McKesson MD Rhythm (Techsoft) MDServe(Chorus) MED/FM (MED3000) Medical Manager (Sage) MedInformatix Meritt NextGen QSI Signature (Siemens) From i2i Systems the Leader in Population Health Management Software i2ilinks is part of the complete Population Management Health suite from i2i Systems. Founded in 2000, i2i Systems is a pioneer and leading provider of Population Health Management solutions and services. We are focused exclusively on creating healthier populations by partnering with and empowering healthcare organizations in their journey to deliver the highest quality care. We deliver business and population health intelligence through smart technology that supports easier and greater access to data and improves the efficiency of the care team staff. Success, we believe, occurs when smart tools enable dedicated providers to practice at their best. For more information visit us at i2i Systems, Inc Laughlin Rd., Suite 200 Santa Rosa, CA phone toll-free fax All rights reserved.

10 Product Overview Aggregate Data Globally for New Population Level Insights i2ipopiq delivers on the promise of population health science. A complement to point-of-care population health management solutions, such as i2itracks, i2ipopiq is a global data aggregation and reporting solution designed for comparative analysis and decisions at the network level. i2ipopiq empowers health networks, state agencies, researchers, funders and payers to make knowledge-driven decisions to improve the health and financial well-being of the communities they serve. Hospitals Secure Hosting Center Medical Groups Subscriber Payer State Agency PCA HCCN Research Center Community Clinics i2ipopiq is a cloud-based system that automatically extracts, standardizes and aggregates de-identified health data across organizations and delivers it through an easy-to-use web interface. Each publishing organization may specify the frequency with which the mapped data is collected and transmitted to the i2ipopiq service. Online reporting tools bring this data to life, unlocking insights and answers to your toughest questions. i2ipopiq utilizes a new approach to analyzing complex data across millions of patients. The result is an easyto-use system, capable of running reports in seconds that would take hours on some competing systems. i2ipopiq breaks through the silos of existing systems, analyzing complex data across millions of patients. With i2ipopiq you can answer tough questions like: Which sites in my network are most / least effective at following evidenced based guidelines of care? Do the corresponding outcomes measures correlate with their level of effectiveness? What is the average performance for specific clinical outcomes measures across my network? How is it changing over time? Are the changes in process of care, care team design or policy having the projected effect on the health of defined populations? Do these outcomes point to disparities in health for specific patient subpopulations? When doing research on a specific method of care for a defined population, what is the effect compared to a similar population that does not receive the intervention? EHR Labs Billing PM IMM Registries Pharm Other i2ipopiq extracts data from i2itracks or other HIT systems to create an aggregated cross-population view into population health. The resulting insights can be used to negotiate with payers, change guidelines of care and improve the health of multi-facility populations. Powerful yet easy-to-use reporting lets clinicians and executives explore the data to uncover new insights and develop new strategies.

11 i2ipopiq is: Scalable: Single, scalable solution seamlessly aggregates data from multiple organizations with hundreds of thousands, even millions, of patients. Interoperable: Access data from the disparate Population Health and Electronic Health Record systems used by the organizations in your network. Customizable: Take charge of your data with tools to easily create custom reports and graphs without investing in an expert data analyst to write timeconsuming reports and graphs. Affordable: Offered as a cloud-based solution, there are no new computers to buy and no additional IT staff to hire. It s all hosted as part of a low monthly subscription. i2ipopiq Features HIT Integration Fully integrated with i2itracks, and may be integrated with other population health systems and EHRs. Hosted Services Offered as a hosted service (SaaS). Large Scale Reporting Data architecture specifically optimized for large scale patient data reporting, enabling aggregation at network, state and regional levels. Analytics & Dashboards Smart tools to discover health disparities, best practices and financial opportunities. Side-by-side comparisons of organizations and subpopulations. Dynamic views of clinical indicators by demographic filter (gender, age, race, etc.). i2ipopiq Benefits Easy Access to Your Data Aggregate data from your existing systems easily. Add new organizations to your network and easily integrate their data sources. Turnkey Solution No new burden on existing IT staff. Low monthly service fee. High Performance Run reports as often as needed without fears of slowing down the whole system. Customized Views Create views by user type. Design views to illuminate data insights in seconds. From i2i Systems the Leader in Population Health Management Software i2ipopiq is part of the complete Population Management Health suite from i2isystems. Founded in 2000, i2i Systems is a pioneer and leading provider of Population Health Management solutions and services. We are focused exclusively on creating healthier populations by partnering with and empowering healthcare organizations in their journey to deliver the highest quality care. We deliver business and population health intelligence through smart technology that supports easier and greater access to data and improves the efficiency of the care team staff. Success, we believe, occurs when smart tools enable dedicated providers to practice at their best. For more information visit us at i2i Systems, Inc Laughlin Rd., Suite 200 Santa Rosa, CA phone toll-free fax All rights reserved.

12 White Paper Contents Introduction... 3 Managing Populations of Patients... 4 Population Health Management A Key Addition to Your Electronic Health Record Why EHR Isn t Enough?... 5 Population Health Management... 8 EHR and PHM Comparison... 9 Why both EHR and PHM? Rosemarie Nelson, MS Principal Consultant, MGMA About the Author About i2i Systems, Inc Sponsored by:

13 Introduction Office-based medical practice is changing fast. The government is providing incentives to those practices that use electronic prescribing and electronic records systems and will soon penalize those that don t. Health reform will shortly deliver many newly insured patients to your office. A host of new patient care models aimed at making health care more teambased are emerging. Reimbursement tied to outcomes will demand a greater level of patient management and engagement in the care process. Meanwhile, as practices continue to face declining reimbursement and The Care Continuum Alliance naturally rising operating costs defines population health (think about energy and supply management (PHM) as a proactive, accountable and pa- costs and retaining staff with competitive wages), the result is tient-centric population shrinking profit margins. It may health improvement approach centered on a physi- seem impossible for practices to sustain and even increase profitability despite the challenges ery system and designed to cian-guided health care deliv- posed by a business environment enable informed and activated patients to address both that demands even higher levels of patient service, delivery of clinical benchmark data, and strict illness and long-term health. attention to financial detail. But it s not. When the bottom line is in jeopardy, most practices initial instinct is to cut costs, especially with the threat of dramatically different reimbursement models on the horizon. That s why my suggestion to invest in a key technology called a population health management system (PHM), sometimes referred to as a patient registry, may feel counter-intuitive. But the right PHM application can do more to increase profitability than can reducing staff hours. PHMs have also been shown to be a key driver of improving quality measures; can cut down on internal staff time (and associated costs) on a number of communication and administrative tasks; and will likely play an important 3 role in care delivery for the accountable care organizations (ACO) that are emerging. This white paper will define PHMs and examine how they can be used to: manage population health with a focus on specific disease states and preventive care services; engage patients to take actions necessary to maintain their health; remind patients who have not been seen recently, filling appointment schedules; secure and increase pay-for-performance (P4P) revenue; help you differentiate your practice from the rest, to compete effectively in a modern healthcare delivery environment. Now, some of you may be scratching your head and saying to yourself, I thought my EHR system did all that. Let me assure you that, while EHR systems have reporting solutions, in this paper we will show how the functionality provided by PHMs and the impact that a PHM can have on your practice is distinct and worthwhile in addition to your EHR. Managing populations of patients The work of population health management includes coordinating the delivery of care across a population of patients to improve clinical and financial outcomes, through disease management, case management and demand management. The work begins with the identification of a patient population and flows through the entire process of delivering and evaluating interventions, ending with concurrent measurement. There are many reasons a practice may need to identify and work with a defined group of patients. Primarily, there is a need to identify and proactively work with patients to insure they are receiving care according to the evidenced based standards agreed upon by the practice. Practices may be participating in an incentive program designed by an insurer to manage all health plan members who have a disease, regardless of the severity of individual cases. 4

14 For example, a health plan in California is paying providers a bonus for working with their patients with diabetes to achieve these targets: 64.8% have a HbA1c below % have LDL less than 100; and 61.1 % have BP below 140/80. By managing an entire population with a given disease, interventions can be targeted to sub-populations to achieve improved individual outcomes that, in turn, improve outcomes measures for the entire population. A practice may choose to identify and concentrate resources on those patients who do not meet the above targets. This has a triple benefit of improving the outcomes for these at-risk patients, decreasing the likelihood of debilitation and high-cost complications and ensuring revenue from participating in P4P programs. Stage 2 and 3 of Meaningful Use is projected to include the requirement to meet targets for clinical measures. A Population Health Management system is necessary to reach set targets because it gives the care team access to the data for each population, and sub population, every day. This makes it possible to test interventions designed to improve outcomes, measure their effectiveness, redesign them and spread them when they are proven effective. This insures receiving the incentive payments for each stage of Meaningful Use and, in the future, maximum Medicare reimbursement rates. Why isn t an Electronic Health Record enough to manage and report on a specific population of patients? As HIT solutions have evolved, providers have become more adept at using solutions to meet their needs. For example, when only a practice management system was available, we determined that we could use that system to create a report to list all the patients with a specific diagnosis based on billing (claims) data. Today, a practice management system may be able to list all the patients with a specific diagnosis that haven t been seen in the last X months, but can t easily eliminate any of those patients from that list if the patient has an appointment scheduled in the next 6 weeks. Also, with only a practice management system available, thousands of physicians receive incentive payments a percentage of their Medicare reimbursement for the year, from the national Patient Quality Reporting System (PQRS) by entering and submitting special billing codes transmitted on the insurance claim to reflect the care given to patients. Using a practice management system for population health management is limited to identifying patients in a population and reporting on those patients singularly, or with only one dimension of care. Today actual clinical data (vs. claims data) about populations of patients is more readily available because about a third of all physician practices use an EHR. This number grows every day, another third are predicted to implement an EHR within in the next few years. An EHR is designed to support documentation needed for billing; it collects and stores data for each individual patient, creating a care plan and a chronological record of their care. In the traditional practice setting, a physician records, reviews and evaluates patients records, one patient at a time. In the paradigm population health management, the physician or, in a growing number of practices, the care team looks simultaneously at all patients with a particular diagnosis, or in need of preventive services. Multiple unique populations, and subpopulations, are identified and proactively worked with to bring them into compliance with standards of care. In a typical EHR, the registry can be used to query the data, however there are significant limitations. EHR registries are commonly used to identify patients who are receiving a medication for which some change is recommended or required, as in the case of a safety recall or the availability of a new and more effective or less expensive alternative. EHR registries can be used to identify patients overdue for a cancer prevention screening tests or patients with a chronic disease needing a single lab test. For example, using the P4P measures above, it is not possible to simultaneously 5 6

15 identify patients with diabetes who are overdue for an appointment, do not have an appointment scheduled, and are outside of the targets for their HbA1c, LDL and BP. This would most likely require multiple separate queries and then it would require someone to manually reconcile them, without custom programming skills in the practice. Each query in an EHR most often produces an Excel spreadsheet, which is only actionable with some difficulty. Once a list of patients, with addresses and phone numbers, is created, it can be exported to Excel. It is then possible to merge that list with a letter. The challenge in using an EHR, in both of these examples, is that it is a cumbersome, multi-step, multi-application process and the effectiveness is difficult to determine. Once the letters are sent, the issues only continue. For example, how does the staff know who responded to the letter, and more importantly, who did not and therefore A PHM system interfaced to an EHR provides a comprehensive tool-set for identifying populations of patients, engaging patients in their care, documenting encounters, and on-demand reporting. needs a second follow up action? How many different populations and sub populations, of patients must be contacted at regular intervals in order to proactively manage their care? Using an EHR, each day a new Excel spread would be needed, to capture the patients who now due for a test or screening, with no indication of which ones were contacted the day before. Care managers find themselves working with multiple pieces of paper and colors of highlighters, in an attempt to track their work. It is also worth noting that the ability to create a list of patients using the registry and analytics in an EHR or in a PHM is predicated on the use of structured documentation features within the EHR. For example, capturing smoking status and identifying patients who smoke and do not have a cessation plan requires the use of structured data. If a provider or care team member documents smoking status and cessation plan in unstructured text notes, it is nearly impossible in most commercially available EHRs to create a registry list based on this unstructured information or to get this same data into a Population Health Management system. Population Health Management to the rescue The nature of technology is iterative. The more we use it, the more we want it to do for us. Physicians and practices need to consider technology to support their population-level care management, not only as an essential component to effective practice within the Chronic Care Model, but also as a necessary tool for responding to the forces driving quality improvement, such as pay-for-performance and incentives for achieving Patient Centered Medical Home recognition. Without EHRs, and without active and effective use of PHMs, physicians and practices will have much greater difficulty in efficiently delivering safe and effective preventive care and care for patients with acute and chronic problems. A PHM system interfaced to an EHR provides a comprehensive tool-set for identifying populations of patients, engaging patients in their care, documenting encounters, and on-demand reporting. The EHR is focused on capturing the data about each individual patient and the PHM system takes this data, aggregates it and supports taking action with groups of patients, creating an environment where quality improvement and improved reimbursement goals can be achieved with greater efficiency, thereby improving profitability. The PHM system supports the provider and the provider led-care team by regularly, even daily, monitoring patients by age, gender, diagnosis and/or conditions. It delivers tools to easily take action to reach out to patients. You can identify a specific group of patients and with the click of one button send a customized or produce a letter printed, folded and sealed, ready for pick up by the postal service. For example, you can easily use the PHM to find the patients in the P4P example earlier: patients with diabetes whose HbA1c is greater than 9, an LDL greater than 100, a BP over 140/80. With a PHM, unlike a registry in an EHR, it is possible to see which patients fall into one, two or all three of these 7 8

16 groups and take actions accordingly. In addition, a Population Health Management system fulfills the constantly changing need for access to clinical data by delivering reporting tools designed specifically for clinical data. EHR analytic solutions are most often imported from other industries, requiring an expert data analyst to adapt them for use with clinical data. Each clinical report and adaptation of a report requires hours of the analyst s time, which is a costly investment many practices cannot afford. Another important component of population health management work is to coordinate follow-up with patients who have a specific test result, for example those with an abnormal cervical cancer screening test. Compare and contrast how an EHR and a PHM each do this work. 1. Test result delivered to provider 2. Provider tasks support staff to contact patient (via letter, or phone) 3. Staff creates a recall action for a repeat test within the prescribed time period We can see from this comparison how and why a PHM is considerably more effective and efficient at following up with patients. The impact of this on a practice is significant, given the complexities of follow up protocols and the increasing number of different groups of patients requiring follow-up action. The effective use of health information technology (HIT) depends on integrating diverse systems in order to record, organize and use data to maintain a longitudinal patient record, for decision-making, proactively working with patients and reporting. Why both EHR and PHM? The effective use of health information technology (HIT) depends on integrating diverse systems in order to record, organize and use data to maintain a longitudinal patient record, for decision-making, proactively working with patients and reporting. EHR model: 4. Staff manually tracks patient return for test using paper log. Periodically, calling patients or printing and manually addressing letter for mailing. or, alternately A data analyst develops a custom analytics report, identifying patients with a recall action that is overdue and no future appointment is scheduled for that patient. Run report periodically, export to Excel, merge with letter that is printed and mailed. Each time, manually working list to exclude patients who received a letter from a previous mailing. PHM model: 4. Standard query set up and run regularly identifying all patients due and single click action to generate letter, or text message to patient. Automatic tracking in the PHM identifies patients that did not respond, for a second and even third contact at defined intervals, with no custom reporting or manual tracking. At the practice level, the electronic health record (EHR), and a Population Health Management system are the informatics backbone. Population Health Management systems have been used when working with populations of patients for more than a decade. The strategies supported by a PHM system represent an important opportunity to maximize patient outreach, engagement and coaching that, in turn, promote self-care and healthier populations. PHM systems foster comprehensive, successful accountability for the clinical, economic and patient experiential outcomes of an attributed population. We ve talked about the EHR and PHM and how they work together. An EHR is core to cost-efficient information exchange, visit documentation, and e-prescribing. PHM is core to achieving quality outcomes and improving population health. An EHR without a PHM is like a practice management system without a clearinghouse 1 ; as the song says, you can t have one without the other. 9 1 A clearinghouse is essential for filing insurance claims and getting paid. 10

17 About the Author: Rosemarie Nelson, MS Principal Consultant, MGMA About the Sponsor: Rosemarie Nelson s, experience in medical office management and information technology, combined with her years of consulting to physicians and practice professionals, gives her unique insight into the needs of and challenges facing physicians and medical practices. As a medical practice consultant, Rosemarie has established significant expertise in system implementation. As a manager in the Office of the Future project, she led new technology planning and development for improved clinical operations. Rosemarie has managed project implementation teams and software engineers in the design and implementation of medical practice software and subsequent training of personnel. Drawing on diverse operational, clinical and financial experience, she provides practical solutions help medical groups achieve success in their objectives. Founded in 2000, i2i Systems is focused exclusively on creating healthier populations, by helping healthcare organizations achieve excellence in clinical performance. Today, health care professionals at over 700 facilities including over 70% of all community health centers in California, rely on i2isystems for critical clinical insights and powerful tools that improve the health of the communities they serve. i2i Systems family of population health management solutions enables clinicians to implement clinical guidelines of care across large populations and identify patient sub populations that are out of compliance. i2i goes beyond typical reporting tools, by automating specific action plans that allow the care team to proactively manage and coordinate the care of defined patient groups, in order to meet targeted standards of care. By both managing clinical data to gain insights and proactively implement action plans, i2i Systems enables practices to maximize their pay for performance revenue and improve staff efficiency, ultimately improving profitability. For more information visit us on the web at or call Copyright 2011 i2i Systems, Inc. All Rights Reserved. 11

18 i2itracks & Patient-Centered Medical Home Recognition Patient-Centered Medical Home (PCMH) is a model of care that seeks to strengthen the physician patient relationship by replacing episodic care, based on illnesses and patient complaints, with proactive, coordinated care and a long term healing relationship. In the PCMH model, the physician led care team is responsible for ensuring that all of a patient s care needs are met. This includes referring and tracking care delivered by other qualified physicians. PCMH also assures timely care through open scheduling, expanded hours and prompt communication. Several organizations offer PCMH frameworks and assessment tools. This document references those from the National Clinical Quality Association (NCQA) ~ Transformed ( and The Joint Commission ( also offer frameworks and tools. From Traditional Practice to PCMH Transforming a traditional practice into a PCMH involves a number of changes. The first steps involve reorganizing care delivery, moving from a provider model to a care team. The goal is to standardize care, establish protocols and delegate routine tasks across the team. This gives the physician time to perform specific tasks and establish a long-term, healing relationship with each patient. The care team, led by the physician, may need new members, updated job descriptions and retraining. Corresponding operational changes, including changes to the physical layout of the facility, may be needed to equip the practice for these changes. The next set of changes comes in response to the open access requirements of PCMH. A practice needs to develop the ability to see patients within a short period rather than filling the schedule months in advance which results in a high no show rate. After-hours and electronic two-way communications are also part of this requirement. The number of organizations receiving NCQA PCMH recognition has increased 400% in the past year, indicating a groundswell of interest in achieving recognition. (Source: NCQA) Population Health Management and PCMH Population health management and continuous quality improvement are two significant requirements of PCMH. To achieve NCQA PCMH recognition, organizations must identify at least three preventive and three chronic care services, remind patients and families of these service and provide outreach to patients not recently seen. Data for these measures must be reported to demonstrate improvement as the result of a continuous quality improvement program. This performance data needs to be stratified for vulnerable populations.

19 For NCQA PCMH recognition, sites are assessed and scored based on a point scale (subject to 6 must-pass elements) with three levels of certification: Level 1 Level 2 Level points and all 6 must-pass elements points and all 6 must-pass elements points and all 6 must-pass elements i2itracks, the leading Population Health Management system, empowers organizations to achieve PCMH recognition. As described in the following table, i2itracks directly impacts more than seventy-five percent of the points required to meet PCMH requirements. Utilizing i2itracks to Achieve PCMH Recognition (2011 Scoring) Standard 2: Identify and Manage Patient Populations NCQA Requirement Points i2itracks and PCMH Requirements A. Patient Information 3 i2itracks interfaces with PM and EHR systems, accessing all collected demographic data. As a result, i2itracks can produce the required numerator and denominator for each of the patient information elements collected. i2itracks can report on missing data and provide insight into clinic performance in data collection. B. Clinical Data 4 With an EHR interface, i2itracks can report for Factors 2, 3, 4, 5, 6 and 8, with required numerator and denominator. D. Using Data for Population Management* 5 i2itracks is a purpose-built Population Health Management system designed to generate all required lists and support proactive care for patient populations. Standard 3: Plan and Manage Care NCQA Requirement Points i2itracks and PCMH Requirements A. Implement Evidence- Based Guidelines B. Identify High-Risk Patients 4 i2itracks delivers proactive care modules, like i2itracks Today (customized dashboard) and Patient Search, to identify and engage patients who are lacking services as per evidence-based guidelines. 3 i2itracks reports are easily produced. Reports display data based on high-risk criteria and measure the percentage of high-risk patients in a population. i2itracks also delivers a powerful Population Analytics module that can be used to evaluate resource use and identify patients with co-morbidities or who are out of compliance. C. Manage Care* 4 i2itracks outreach modules support communication with patients regarding appointments, re-care needs, outstanding referrals and pre-appointment needs (e.g. labs or referrals). i2itracks Patient Summary helps care teams prepare for patient visits and becomes educational material for the patient. i2itracks Patient Search tool identifies follow-up with patients who do not keep important appointments or simply need additional communication on treatment plans and self-management goals. i2itracks Today provides quick access to information that can be used to prepare for patient visits and discover all care opportunities that should be addressed during the upcoming visit.

20 Standard 4: Provide Self-Care and Community Support NCQA Requirement Points i2itracks and PCMH Requirements A. Self-Care Process* 6 i2itracks provides the tools to track, and report progress on, measurable self-care goals. B. Referral to Community Resources 3 i2itracks delivers a complete referral tracking module for referral care management. This module enables reporting on frequency and the types of referrals made to community agencies. Standard 5: Track and Coordinate Care NCQA Requirement Points i2itracks and PCMH Requirements A. Test tracking and Followup 6 i2itracks delivers tools to track lab and imaging tests and notify patients/families of results. (e.g. cancer screening for women) B. Referral tracking and Follow-up* 6 i2itracks referral tracking module tracks all aspects of referrals to a specialist, internal or external. The module monitors all outstanding referrals, generates reminders and follow-ups, and supports referral management to meet time requirements. This module enables reporting on all data related to referrals including referring provider, specialist, and the types of referrals. C. Coordinate with Facilities/Care Transitions 6 Factors 4: i2itracks facilitates patient and family contact within the appropriate period following hospital admission or emergency department visit. Factor 6: i2itracks provides tools to track the completion of a care plan when patients transition from pediatric to adult care. Standard 6: Measure and Improve Performance NCQA Requirement Points i2itracks and PCMH Requirements A. Measure Performance 4 i2itracks Population Analytics module enables reporting and performance review on any number of preventive care measures and chronic or acute care clinical measures. Reporting can be by organization, site or provider. Performance data can be stratified to access disparities in care. B. Patient/Family Feedback 4 i2itracks can or mail patient satisfaction surveys and could be used to record and report results. C. Implements Continuous Quality Improvement D. Demonstrates Continuous Quality Improvement 4 I2iTracks reports produced in D. and E. below can be submitted as evidence of Implementation of CQI. Reports can be used at any point in CQI process to guide and inform efforts, including identifying disparities and highlighting vulnerable areas of focus. 3 i2itracks supports regular reviews of performance data and performance evaluation against goals. As a reporting tool, i2itracks makes it easy to show effects of interventions and clinical outcome improvements, including producing graphs of data over time. E. Performance Reporting 3 i2itracks enables reporting on performance data for all measures in A., by individual clinician and across the practice. Results can be reported to patients or publicly by practice or clinician. F. Report Data Externally 2 i2itracks is certified for reporting Meaningful Use clinical measures and supports the electronic submission of data to an immunization registry or information system. Total 70 *must-pass element As the table above illustrates, i2itracks plays a vital role in PCMH attainment, especially for those elements highlighted in golden. In addition, i2itracks supports Meaningful Use and P4P target achievement. For more information or a demonstration of i2itracks, please contact i2i Systems today at or visit us on the web at

21 Tracks Today TM i2itracks Today view is a fully customizable population care dashboard that improves health organization staff efficiency. It shows critical lab values, immediate care needs, tasks that must be completed today, and a view of health indicators your organization would like to monitor for proactive care all without leaving the screen. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

22 Population Analytics Custom Reporting General Health Status Report Provider Performance Diabetics with Abnormal Paps Trending i2itracks gives you the ability to generate and easily share custom reports on the patient population indicators you want to analyze. Integrated report writing can be done on demand without third party reporting software. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

23 Population Analytics Preventative Health Dashboards i2itracks gives you the reporting power you need to improve outcomes and provide better patient care. Easy-to-make graphs help staff analyze information across preventative health and disease management measures. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

24 Patient Search Engine i2itracks patient search engine makes it easy to quickly find any patient or group of patients. Easily save searches on-the-fly and use search results to create tracking types, manage cases build panels, target outreach, and perform population research. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

25 Proactive Patient Recalls i2itracks proactive patient recall manager empowers staff to create standard or custom recall types and schedules, while automating patient recall correspondence through customizable letter and templates. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

26 My Patient Today TM i2itracks My Patient Today view presents a 360-degree snapshot of all clinical data in a summary view and is powered by i2i Systems integrated systems interfaces, connecting and mapping i2itracks to your Practice Management, EHR, Labs, Pharmacy, etc. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

27 Patient Summary View i2itracks unlocks the rich information value stored in your disparate health information technology systems by intelligently interfacing with your labs, pharmacy, immunizations, EHR and practice management systems. Easily view and act on all historic patient data in real time. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

28 Patient Visit Summary Morning Huddle i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

29 SMART PAP TM i2itracks SMART PAP feature is a powerful women s health management tool that intelligently reads and analyzes narrative Pap results, then categorizes them for immediate provider and health center action. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

30 Referral Management You can create reports on the number and percentage of referrals by type (for example, pain management), the number of referrals in a time period (for example, the last 60 days by type), the overall referral rates that go out by doctor, or the number of referrals waiting for approval by the user. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

31 Patient-Centered Medical Home Selected Patient Centered Medical Home Activity Report Patient-Centered Medical Home Certification i2itracks helps high-performance health organizations like yours gain valuable points on their quest for Patient-Centered Medical Home certification. i2itracks can help you earn up to 71 points in the following NCQA Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) requirements: Patient Tracking and Registry Functions Care Management Patient Self-Management Support Test Tracking Referral Tracking Performance Reporting and Improvement i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

32 Patient-Centered Medical Home i2itracks helps high-performance health organizations like yours gain valuable points on their quest for Patient-Centered Medical Home certification. Our versatile reporting engine lets you quickly trend your Patient-Centered Medical Home activity over time. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

33 Health Disparities Collaborative Report i2itracks has the ability to generate Health Disparities Collaborative Reports. The reports cover all of the measures discussed on the Health Disparities website and print those measures on one report. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

34 Comprehensive Healthcare Maintenance Report Comprehensive Healthcare Maintenance reports are used to view outcome and clinical data on a selected population of patients. With these reports, you are able to look at a selected group of patients and view statistics (both clinical and demographic) about that specific group. You can have an unlimited number of Comprehensive Healthcare Maintenance reports. For example, you can have a report for Diabetes, Asthma, Depression, etc. You will decide the population of patients for the report, as well as define what prints on the report. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

35 PQRS Diabetes Measures PQRS Diabetic Measures i2itracks supports eligible providers who participate in the 2012 Physician Quality Reporting System (PQRS) in their ability to satisfactorily report data on quality measures or measures groups for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B Fee-for-Service (FFS) beneficiaries. Successful PQRS reporting will qualify eligible professionals to earn a Physician Quality Reporting incentive payment equal to 0.5% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

36 Meaningful Use Reports i2itracks integrated report writer provides you with Meaningful Use clinical quality reports out-of-the-box. This integrated reporting can be done on-demand without customization or third party reporting software. All built-in reports can be easily updated and adapted to meet any reporting in federal policy. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA

37 HEDIS Measures i2itracks offers One-click HEDIS reports. Search, query, report, and analyze HEDIS data and create custom measures quickly and easily. i2i Systems, Inc N Laughlin Rd, Ste 200 Santa Rosa, CA