The Path To Population Health Management

The Path To Population Health Management Creating an IT Foundation for a Successful ACO White Paper Suzanne Cogan, Vice President Healthier Populations

Table of Contents Introduction 3 The vision for ACO success 4 Key Learnings 4 EHR Insufficiency 4 Criticality of longitudinal patient records 5 Include the whole population 5 Claims data is essential 5 Creating a path to Population Health Management 6 Acquisition 6 Aggregation 7 Access 8 Adoption 8 Analytics 9 Action 9 Entering the Golden Age of Healthcare 10

Introduction Healthcare organizations across the U.S. are investing significant resources in re-architecting their care delivery infrastructures to enable them to adapt successfully to new, value-based Accountable Care Organization (ACO) payment and delivery models. As these entities prepare to go at risk and take outcomes-based capitated or bundled payments, they face a broad set of challenges. These challenges range from acquiring or partnering for resources that will enable them to deliver and control the full continuum of care, to understanding their new cost structures and determining if they can survive and thrive financially in an ACO world. One of the most complex and critical aspects of building the foundation for a successful ACO is developing an IT infrastructure that will enable clinicians and administrators to access and share the clinical and financial information they need, and allow them to streamline and automate their processes to ensure the most efficient clinical and administrative workflows. As organizations seek to integrate data and workflows across community practices, acute care, long-term, behavioral health and rehab facilities, the technical and organizational challenges can become daunting. Fortunately, today we can draw on the experience of a number of entities that have adopted health information exchange (HIE) and population health management technologies for guidance on the road to becoming a successful ACO. Drawing from the lessons learned by large integrated delivery networks (IDNs) and HIEs, early ACOs have succeeded in building IT infrastructures that effectively enable collaboration around accurate, comprehensive and up-to-date data, without requiring constituent entities to standardize on monolithic systems or put an undue burden on their sometimes limited technical resources. The best practices that have emerged from those early implementations offer valuable guidance for second-wave organizations taking the ACO path. According to the U.S. Department of Health & Human Services, more than four million Medicare patients are under the care of an ACO today i, and a recent study by Premier indicated that ACO participation is expected to double by the end of 2014 ii. Chances are your organization is somewhere along the path to accountable care and looking for answers to the tough IT challenges you face. This paper will boil down the knowledge gleaned from ACO rollouts to give you some of the most important high-level insights from those projects and then detail critical success factors for ACO and population health strategies.

The vision for ACO success An ACO can mean different things to different individuals, organizations and government entities. The Centers for Medicare & Medicaid Services (CMS) defines its vision for a Medicare ACO as Groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients, with a goal to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. iii According to the American Hospital Association (AHA), The ACO concept envisions multiple providers assuming joint accountability for improving health care quality and slowing the growth of health care costs. iv Whatever your definition, there are common fundamental requirements that tie all ACOs together, including the need for an IT infrastructure that facilitates communication and the effective use of data. Kaiser Permanente Chairman and former CEO, George Halvorson, may have summed up the shared vision for ACO best in his presentation at AHIP Institute 2013, when he said, We are entering a golden age of healthcare where our quality of care improves due to so much data being at our disposal. But the requirement is that healthcare must be patient-centric. The specifics can vary from community to community, but some core aspirations consistently emerge for most ACO-focused organizations to: Track and document all patient interactions in realtime Prompt caregivers with trusted, actionable information when they need it Continuously gather and learn from data so that we are constantly improving the quality and efficiency of care, while decreasing unnecessary duplication and costs Clearly, the IT infrastructure is a key enabler for organizations seeking to embrace the vision for ACO and achieve its goals. Key learnings Looking across multiple ACO and population health initiatives, some common threads emerge as the important lessons organizations learn on the path to ACO success. Following is a quick review of these key learnings: EHR Insufficiency Every provider organization understands that the electronic health record (EHR) will be an essential component of their ACO initiative - both for gathering critical data and for delivering actionable information to the point of care. Some - perhaps swayed by vendor hyperbole - fail to recognize that while necessary, even the most sophisticated enterpriseclass EHR is insufficient for conducting effective population health management on its own. EHRs are not designed to effectively gather, aggregate and normalize data from multiple heterogeneous sources, neither are they typically as strong on data analytics as they need to be. V Collect all patient data across the continuum of care Facilitate coordination and collaboration across the circle of care Proactively identify at-risk patients and deliver comprehensive intervention and ongoing care

Criticality of longitudinal patient record Providers need the actionable insights that an effective population management system can provide, but for those insights to be practical and useful for the provider, they must be in context. Accessing a full longitudinal record with historic claims, lab data and medication history gives providers the holistic view they need to evaluate the patient and act on recommendations. vi Include the whole population Much of the literature and vendor information available on ACOs focuses on the ability to identify at-risk populations and individuals, and to close gaps in care for patients with specific disease states or co-morbidity combinations such as diabetes and metabolic syndrome. Realizing that they are losing the forest through the trees is increasingly heard from population health managers who find that by zeroing in primarily on the sickest patients, they can miss opportunities to identify population level health trends, prevention intervention windows and issues specific to certain communities. vii The advent and broad adoption of EHR systems has been one of the most essential building blocks for successful population health and ACO initiatives. However, a single EHR rarely contains comprehensive information on the patient, especially when it comes to what happens beyond the encounter, such as care plan compliance and treatment outside of the home system. Patients can have critical information residing in multiple EHRs and paper records, and the lack of a single, longitudinal record can be a significant obstacle to efficiently providing optimal care. Claims data is essential Claims data provides important insight into historic care, care provided by other provider organizations, test data and medication compliance to round out the longitudinal record. So while, the EHR knows the patient was seen in one organization s emergency department (ED) twice over the past month, the claims data can show that this patient in fact had two other ED visits in the same time period at different organizations. This type of data becomes critical as ACOs seek to get more sophisticated in their use of analytics to identify optimal care paths and proactively manage patients. viii

Creating A Path To Population Health Management At the highest level, for an organization or group of affiliated organizations to operate effectively as an ACO, they need to be able to gather all of the relevant historic and timely data from constituent facilities and systems; normalize and combine that data; find the actionable insights; get the information and recommendations to the care-givers and administrators on the front-lines as well as to patients; and track the ongoing implementation of those recommendations. Successful ACOs use a variety of terms and concepts to break down the key elements of their IT infrastructure, but looking across many of these initiatives the core common critical success factors can be broken down into six steps Acquisition of data, Aggregation of data, Access to data, Adoption of system components, Analytics and Action. Let s take a look at these steps in order: Acquisition organization format, store and share data in many different ways. That complexity is multiplied as they start to bring in data from an even greater variety of EHR and practice management systems in use by community practices as well as the long-term care, rehab and home health systems that fill out the continuum of care. As noted above, claims data, gathered from clearinghouses and health plans is also a critical component of gathering a comprehensive universe of patient data. The essential IT infrastructure requirements to support effective data acquisition include integration engine technology for accurate and reliable interoperability with this wide array of systems, and secure exchange and information transport (using the DIRECT protocol or the ehealth Exchange Gateway). Together, these technologies comprise the end-toend process of protecting the privacy and security of patient information. For most aspiring ACOs, key data resides in a wide range of internal and external source systems. Multiple EHRs and other clinical systems within the

Aggregation Each of the systems contributing data to the ACO has its particular characteristics and conventions for formatting and sharing data. Even common EHR and other Healthcare Information System (HIS) platforms can alter their data formats from version to version of the software. The differences get much more dramatic when you start to bring in data from labs, health plans, pharmacies and tertiary care. Normalizing that data is not only an extremely complex challenge, it is one that must be engineered to deliver scrupulous quality of data. Small errors can mean big problems in individual patient care, and when you multiply that by thousands or millions of records, the impact is significant to population level metrics. The essential IT infrastructure requirements to support effective data aggregation include enterprise master patient (empi) and master provider index and identity management systems, to ensure that as the data is aggregated it is always associated with all of the correct entities (patient, provider, facility, payer, etc.) Terminologies and translators are also essential to ensuring an effective and accurate semantic layer that can normalize diagnoses and other critical components of the record that are expressed differently across multiple systems. The clinical data repository is also a key requirement for aggregation, serving as the fundamental source of normalized data for access, analytics and action.

Access Several different types of stakeholders will need secure access to various aspects of the ACO s data. Providers of various types need access, of course, but so too do administrators, health information management (HIM) professionals, patients, family, insurers and many others. Each constituency has its own unique set of priorities, permissions and levels of technical and clinical sophistication to consider, but for all of them, the access to data must be as frictionless as possible to support initial and ongoing adoption. Providers, for example, will typically be best served by giving them access to ACO data within the EHR itself, whereas patients and family will need a webaccessible secure patient portal. The essential IT infrastructure requirements to support effective data access include direct EHR integration, personal health record (PHR), multi-stakeholder portal, mobile application, secure messaging, single sign on (SSO) and workflow integration for care managers and other professionals. Adoption Every stakeholder needs or wants access to ACO data, but humans tend to be deeply resistant to change, and getting everyone to use ACO-related systems initially and on an on-going basis can be a major challenge. Adoption is as much an issue of technical prowess making the data seamlessly easy to get to and impeccably accurate as an emotional and behavioral one, and those two sides of the challenge are inextricably intertwined. It is also a bit of a chicken and egg challenge, because if clinicians and care coordinators fail to adopt, key information will not be used for decisionmaking and outcomes will suffer. Both effects are potentially devastating to the survival of the ACO. The essential IT infrastructure requirements to support effective ACO systems adoption echo many of those relating to access: electronic health record integration, personal health record, single sign on and portal all contribute to successful adoption. Great consulting support, ideally from clinicians with a deep understanding of ambulatory and inpatient workflows, and a userfriendly interface are also critical to adoption. To understand the right ways to make technology work for a range of stakeholders and to navigate the choppy waters of change management requires very specific skills and experience.

Analytics Mining data for views into population health, finding the actionable insights that can drive improvements to quality and efficiency, keeping up with the ongoing and ever-increasing regulatory reporting requirements all of these issues and many more drive the need for analytics as a fundamental component of the successful ACO. Leveraging data-driven intelligence to improve care delivery is also something that a well-constructed ACO IT infrastructure is uniquely able to do. With solid data acquisition and aggregation comes the ability to learn from and act on data in very powerful ways. The essential IT infrastructure requirements for ACO data analytics include all of the foundational data gathering, normalization and repository creation components we have discussed so far. Additionally, solid business intelligence tools that not only allow analysts as well as non-technical users to mine data for useful insights, but also automatically generate the core reports and dashboards that deliver data to the point of impact are key. For regulatory reporting purposes, ACOs need analysis and reporting tools that automate the process of staying up- to-date on the latest requirements and meeting them in a timely fashion. and coordinators the tools to insert actionable insights into their daily workflow, allowing them to continue to do their jobs but with the added value derived from population and individual patient data analyses. The essential IT infrastructure requirements for putting ACO data into action include some of the provider collaboration and patient communication technologies we have discussed, including secure messaging, EHR integration and multiconstituency portals. Another key technology is care coordination workflow tools that enable care managers to deploy consistent care plans based on patient and population data, and to document and communicate care plan progress with the providers and patients they support. We are entering a golden age of healthcare where our quality of care improves due to so much data being at our disposal. But the requirement is that healthcare must be patient-centric. George Halvorson Chairman of the board of directors and CEO from 2012-2013, Kaiser Permanante Action Sometimes the last mile is the most challenging aspect of ACO implementation for healthcare organizations and communities. Too much data and too many ways to use it can create paralysis and diffusion of resources. Putting the ACO IT infrastructure to work in support of effective data-driven action means giving care providers

Entering the golden age of healthcare Looking back to George Halvorson, the emergence of these best practices and the rapid acceleration of ACO deployments in the U.S. and of similar organizations abroad, truly does signify the dawn of a golden age of healthcare where as a nation and a global community we have the opportunity to start to learn much more rapidly from all of the data we are gathering, put those insights into action and actively start to measure the impacts for continuous improvement of care. The implications for access, affordability and quality of care are staggering, but we have a long way to go and some very important first steps to take. The guidelines and best practices outlined at a high-level in this paper can help provide a roadmap for organizations seeking to chart the course for IT infrastructure development as part of their ACO journey. If our communities of care can do this fundamental piece right, they will set the stage and make it possible for their organizations to achieve high performance at a reduced cost and with great outcomes. i More Doctors, Hospitals Partner to Coordinate Care for People with Medicare, HHS.gov. 10 January 2014; press release. ii Accountable Care Organizations and Population Health Management Trends; Fall 2013 Economic Outlook, Premier, Inc.; December 2013: page 2. iii Accountable Care Organizations (ACO): What is an ACO, CMS; Web. 14 January 2014: n. pag. iv American Hospital Association. 2010 Committee on Research. AHA Research Synthesis Report: Accountable Care Organization. Chicago: American Hospital Association, 2010. v Parton, Ron. Population Health for ACOs: A Patchwork Quilt, Accountable Care News. March 2012. vi Sarabu, Naveen. Building an effective ACO: Longitudinal records enable collaboration, Government Health IT. 24 December 2013. vii Safyer, Steven M. Montefiore s Experience in Pioneering an ACO: 1996 Present, presented at Alliance for Health Reform ACO Panel. 23 September 2013. vii Terry, Ken. ACOs Need Claims Data for Analytics, InformationWeek. 16 September 2013. To find out more about Orion Health: Visit www.orionhealth.com Copyright 2015 Orion Health group of companies All rights reserved www.orionhealth.com Path_to_Population_Health_WhitePaper_042015_US_Letter