Inability to send a Summary Record Document to enhance transitions of care

Transcription

1 Health 2.0 Needs Statement: Greater Cincinnati Beacon Community, Cincinnati, OH Your challenge Inability to send a Summary Record Document to enhance transitions of care EPIC-getting data out and to another EPIC site No viable tools to take ill-formatted data, format it and send data on in a usable format Few consumer facing technology solutions Practice Transformation tools that meet the NCQA Level III IT solutions Transition of Care IT Tools for providers, hospitals and home care How consumer ehealth technology could help We would like to learn how ehealth technology could help us address the above challenges and what tools we could host/ use as an HIE. We are attending to learn. The Greater Cincinnati community has shown remarkable commitment to using technology to improve care, as evidenced by the current high rates of HIE use (>90%) and EHR adoption (>40%). Using proven strategies for spreading innovations in our community, the GCBC will implement HIT/HIE enhancements (e.g., ED/admission/readmission alerts, EHR connectivity to repository, registry, data analysis/reporting, summary record exchange) incrementally, starting with demonstration practices and then spreading core HIT/HIE infrastructure enhancements across the community. About your Community We will be attending Health 2.0 to explore opportunities to enhance the work we are currently doing. We already have several IT solutions. We also have a very successful HIE and Business Analytics shop within our HIE. HealthBridge s current architecture is a messaging metaphor whereby virtually all clinical results (97% generated in the community as measured by hospital, lab and radiology discharges) are forwarded to physician EHR s or via EHR Meaningful Use package providing a rich set of clinical data. This includes Lab, radiology, cardiology, transcribed reports and all other reports. Registry for Adult and Pediatric practices Clinical messaging: ED/Admission alerts NHIN Direct Mail Mobile technology-voxiva Text HEALTH

2 The target population The target populations would be adults and pediatric patients with chronic illness. Specifically, we are working on pediatric asthma and adult diabetes as well as CHF. The Greater Cincinnati and Covington HHR area stretches over 7,480 square miles, includes 16 counties in three states and surrounds Greater Cincinnati; commonly referred to as the Tri State area. Based on Rural-Urban Continuum Codes (RUC) the service area is primarily urban; however, a limited number of small rural areas are served by service area health care providers. Table 1. Service Area Population STATE & COUNTY TOTAL POP. MINORITY POVERTY* Hamilton, OH 707,445 38% 23% Butler, OH 310,741 14% 19% Clermont, OH 195,385 4% 23% Boone, KY 102,165 7% 32% Campbell, KY 75,638 5% 23% Kenton, KY 138,963 8% 23% TOTAL 1,530,337 How are you measuring progress? GOAL 1: Achieve 60% EHR adoption by December 2012 across the 6-county service area. OBJECTIVE 1A Complete EHR secure compliant connectivity to 25 hospitals and 900 physicians offices by December Number of EHR implementations in region overall Percent increase in EHR adoption rates over baseline Number of EHR interfaces implemented by HealthBridge Number of level 4(machine to machine) interfaces with coded data suitable for for automated exchange, connected to repository for reporting and data analysis Percent increase in level 4 (machine to machine) data exchange Quality of Care Goals GOAL 2: Improve health of diabetes patients through enhanced coordination of care practices at 100% of the demonstration practices. OBJECTIVE 2A Rates of optimal diabetes care in ambulatory settings will increase by 5 percentage points from baseline, and will exceed rates in control practices by >30% by

3 12/2012. Rates of optimal care (D5) in demonstration practices Rates of optimal care in demonstration practices (defined as patients with A1c less than 7.0, LDL < 100, BP < 130? 80, non-smoking and using aspirin when not contraindicated). GOAL 3: Improved health outcomes through enhanced coordination of care for asthma population across one hundred (100%) percent of the demonstration practices. OBJECTIVE 3A PHO objective: One hundred percent (100%) of PHO practices have care coordinators that have completed foundational training by 12/2012. Percent of care coordinators that complete foundational training OBJECTIVE 3B PHO objective: Eighty percent (80%) of PHO high-risk asthma population is rated well controlled by physicians and parents by 12/2012 Percent of high risk asthma population rated well controlled by physicians and parents. OBJECTIVE 3C Pediatric Population Objective: Achieve a two hundred percent (200%) increase in the high-risk Medicaid insured population that receives care coordination by 12/2012. Percentage increase in high-risk Medicaid insured population that receives care coordination. OBJECTIVE 3D Pediatric Population Objective: Sixty percent (60%) of Medicaid insured asthma population is rated well controlled by physician by 12/2012. Percentage of Medicaid insured asthma population that is well controlled Cost Efficiency Goals GOAL 4: Improve health care system efficiencies in one hundred percent (100%) of diabetic demonstration practices Financial target Decrease cost of diabetes in HRR 203 and 327 by 10%, or approximately $130 under this goal million. OBJECTIVE 4A Decrease ED visits by diabetic patients by 15% against baseline by 12/2012 Actual count of ED visits by adult diabetic patients in demonstration project practices OBJECTIVE 4B Achieve a decrease of 20% in 30 days of hospital readmissions among diabetic patients by 12/2012 Actual count of 30 day of hospital readmissions GOAL 5: Reduce diabetic care costs OBJECTIVE 5A Overall annual total care costs (inpatients, outpatient, and pharmacy) for adult diabetics in demonstration projects will be reduced by 5% in first 12 months, and 10% in 24 months compared to baseline. Actual count of inpatient costs, at conclusion of 12 month and 24 month date Actual count of outpatient costs, at conclusion of 12 month and 24 month date Actual count of pharmacy costs, at conclusion of 12 month and 24 month date

4 GOAL 6: Improve health care system efficiencies for asthma population across one hundred percent (100%) of asthma demonstration practices. Financial target under this goal OBJECTIVE 6A PHO objective: PHO asthma admission rates will be seventy-five percent (75%) lower among participant group verses comparison group by 12/2012 Percent difference in asthma admission rates. OBJECTIVE 6B PHO objective: PHO asthma ED/urgent care visit rate will be eighty-five percent (85%) lower vs. comparison group by 12/2012 Actual count of ED/urgent care visits. OBJECTIVE 6C PHO objective: PHO thirty (30) day asthma readmission rate will be fifty percent (50%) lower vs. comparison group by 12/2012 Percent difference in 30 day asthma readmission rates. OBJECTIVE 6D Pediatric Population Objective: Twenty percent (20%) reduction in Medicaidinsured asthma admission rates by 12/2012 Percentage reduction in Medicaid-insured asthma admission rates. OBJECTIVE 6E Pediatric Population Objective: Twenty percent (20%) reduction in Medicaid asthma ED/urgent care visit rate by 12/2012 Percentage reduction in Medicaid-insured asthma ED/urgent care visit rates. OBJECTIVE 6F Pediatric Population Objective: Combined Medicaid-insured asthma readmission/ed/urgent care visit rate within thirty (30) days of hospital discharge <2% by 12/2012. Combined Medicaid-insured asthma readmission/ed/urgent care visits percentage within 30 days of hospital discharge. Population Health Goals GOAL 7: Reduce self-reported smoking among diabetic participants at 100% of demonstration practices. OBJECTIVE 7A Achieve reduction in rates of self-reported smoking among adult diabetic patients in demonstration project by 5% points from baseline by 12/2012 and by 10% points by 12/2013. Actual count of self-reported smoking among participants in 12/2012 Actual count of self-reported smoking among participants in 12/2013 GOAL 8: Increase seasonal influenza vaccination rates for asthma population across one hundred (100%) percent of demonstration practices. OBJECTIVE 8A PHO objective: Ninety (90%) percent of high-risk asthma population receives seasonal influenza vaccine. Percentage of asthma population that receives seasonal influenza vaccines.

5 OBJECTIVE 8B Pediatric Population Objective: Seventy-five percent (75%) percent of Medicaidinsured asthma population that receives seasonal influenza vaccines. Percentage of Medicaid-insured asthma population that receives seasonal influenza vaccines.