CNYCC DSRIP HIT/HIE Webinar Joe Reilly CNYCC Tim Weldon Aspen Advisors
Presentation Agenda Review guiding principles Discuss population health definition as it relates to DSRIP Community vs. Organizational Model PHM Infrastructure Overview of the DSRIP HIT/HIE requirements HIT/HIE Level 1&2 diagram review Discuss healthcare community impact based on DSRIP requirements Review Phase 2 HIT project work streams Feedback from 1/21 DOH session
CNYCC HIE/HIT Guiding Principles Leverage Existing Infrastructure (i.e. Use of People, Process, Technology) Adopt incremental approach to developing the technology landscape Educate/Inform/Engage ensure participation is understood and embraced Develop technology solutions that are flexible enough to support other strategic initiatives with similar requirements Use a requirements driven approach let priorities drive focus
Population Health Management (PHM) Defined PHM is a strategy to provide a new model of care PHM will deliver appropriate preventive, routine services to the population at large, and evidence-based / consensus care to medically complex patients PHM requires an integrated infrastructure of people, process and technology to support: Data exchange across care-givers Coordination among providers PHM requires a technology roadmap that: Analytics Evaluates and identifies the best aggregate solutions Improves provider efficiency and effectiveness Sets forth a realistic timeline Provides a framework for Accountable Care and other future collaborative initiatives
Organizational vs Community-Wide PHM Radiology Images/Results Clinical Documentation Radiology Images/Results Clinical Documentation Lab Results Demographics Lab Results Demographics Organizational PHM Model Community PHM Model Integrated PHM Infrastructure Pharmacy Data Social Determinants Claims Data
Integrated PHM Infrastructure Data Management (Movement, Aggregation, Standardization, Normalization) Financial Risk Retrospective Utilization Prospective Utilization Retrospective Cost Prospective Cost Population Stratification Clinical Risk Chronic Disease Identification Disease Progression Chronic Disease Registries Quality and Preventative Care Best Practices/Gaps Care Coordination Utilization Alerts Care Planning/Barriers/Gaps Clinical Decision Support Care Transitions (Collaborative) Patient Engagement Care Manager Administration Outreach Management Reporting (Panel Management, Performance Management, Business Intelligence)
DSRIP Program HIT/HIE Requirements Breakdown The following diagram depicts the breakdown of HIT / HIE requirements, specifically which are core infrastructure requirements across most projects, and which are specific to individual projects: Core Requirements - RHIO Connectivity - Data Aggregation - Implementing Electronic Medical Records - MU/PCMH Certification - Patient Tracking - Reporting & Analytics Tools - Care Coordination/Collaboration - Clinical Information Sharing - Facilitating Transitions of Care - Real-time Messaging & Alerts - Risk Management Requirements Unique to Project 2.b.iii - Central Scheduling/Referral Systems Requirements Unique to Project 3.b.i - Workflow automation tools in EHRs to prompt for data collection and patient recall reminders Requirements Unique to Projects 2.a.iii, 2.d.i, 3.a.i, 3.b.i, 3.g.i, 4.a.iii - Registries implemented for specific patient populations or providers (Ex. Million Hearts campaign Registry) Infrastructure Unique to Project 2.d.i - Capture and track Patient Activation Measures across the care continuum
RHIO Image Appliance Ambulatory Care Environments Primary Care Tertiary Care Connectivity Client Connectivity Client Other State & Federal Data Sources - DoD -VA - Other State Required Data - Human Service Agencies - UFIN - CBO Connectivity Client Central Scheduling CYNCC Front End Rev Cycle Management Applications Central Registration Central Referrals (ED to PCP) EMS Transportation Concierge Non- Emergent Transporters ` Imaging CNYCC Integration Eco-System Provider Patient PHM Unified Communication Program (Mobile) Secure Messaging Health Plan Lab(s) Rx Orchestration and Management R/T Messaging Batch ETL Master Data Management HIE Hospital Systems (standard and nonstandard facilities) Clinical Information Systems CNYCC Population Health Management System Care Transition and Case Management (I/P, O/P, transitions) Financial Systems Administrative Systems I/P Case Management Systems Clinical Systems Auxiliary Systems Business Applications RHIO Components Key CNYCC Technical Ecosystem Non-DSRIP Future Positioning Population Health System CNYCC Enterprise Information Management Environment HealtheConnect Clinical DW CNYCC EDW Performance Reporting and Analytics Population Health Analytics Business Intelligence Public HIE (SHIN-NY) CNYCC & Partner Corporate Systems Accounting and Financial Mgmt Back-End Patient/Rev Cycle Mgmt Corporate ERP HR, Staffing, Supply Chain Provider Network Mgmt Infrastructure - Level 1 Diagram
Images served by HealtheConnect Image HealtheConnect Viewer Image Viewer Appliance (locally installed) Lab Systems Internal Labs Outreach Labs Blood Bank Retail Pharmacy ***Y3 MMIS (CMS) Oasis MDS Rx Commercial Payers & TPA(s) Imaging Systems Various Internal Imaging Systems **Y2 Outreach Imaging Facilities **Y2 Key Clinical CNYCC Technical Systems Ecosystem Auxiliary Non-DSRIP Systems Future Positioning Business Population Health Applications System ContractsClaims RHIO Flatfile X12 Components Red Lettering DSRIP Relevant Interface Black Lettering Non-DSRIP Interface Ambulatory Care Environments (Data Sources and Endpoints) Primary Care Providers Tertiary Care Providers Ambulatory FQHC Long Term Care Skilled Nursing Home Health Community Provider & Other Facilities Facilities Care Health Orgs Connectivity Hub Connectivity Hub ***Y3 Connectivity Hub ***Y3 Connectivity Hub **Y2 Connectivity Hub ***Y3 Connectivity Hub Orders Results CCDs / CCRs Lab Orders Referrals Lab Results Release of ADTs SIUs (Scheduling Info Unsolicited) Data Process Rx Legal Medical Record HIM Orders Confirm (e.g. 3M HDMS) Rx Rx Confirm. CNYCC Integration Eco-System (Provided by HealtheConnection) Orchestration Flatfile X12 Images and Image indexes Management & Governance of Contracts Regulatory Agencies SureScripts R/T Batch Data Public/ Messaging/ Integration Private HIE HL7 (aka ETL/ELT) HISP Master Data Management (e.g. Patient, Physician) Flatfile X12 Clinical Patient Physician Relationship(s) CNYCC Pop. Health Management System Care Transition and Care Management (I/P, O/P, transitions) CNYCC Corporate Systems SaaS/Central (Rev Cycle Backend ) Patient List Cost Accounting ***Y3 Risk Stratification HR, Contract Management ***Y3 Funds Management CNYCC Enterprise Information Management Environment Clinical Financial Performance/ Bus. Intell./ 3 rd Party Data Utilization Mgmt Performance Contract Analysis Clinical DW Reporting Imaging File Store Patient and Clinical Risk and Performance Satisfaction Analytics Attribution Benchmarking Surveys Survey ***Y3 Benchmarks (CAHPS) Risk Scores Attributions Clinical Information Quality Measures Population Financial DW Operational DW Health Patient/Disease Analytics Registry Etc.. Image Requests to HealtheConnect Other State & Federal Data Sources CNYCC Revenue Cycle Management Front End Applications Behavioral Public Health - DoD Health - VA Central - Other State Required Data Central Central Referrals Concierge Tracking and Scheduling Registration (ED to PCP) Reporting ` Systems - Human Service Agencies - UFIN - CBO (Salient) **Y2 Orders * Connectivity Hub ***Y3 Connectivity Hub Connectivity Hub Results CCDs / CCRs Referrals Transportation Contracts Non-Emergent EMS Transporters Engagement Technologies (s, Mobile) Orders Results CCDs / CCRs Referrals ADTs SIUs Rx Result s Survey Preferences Bill payment Scheduling Lab HRA Bio Screening Trackers Insurance Credit Trackers Patient Education RHIO PHM RHIO Health Unified Secure Physician Physician Patient Communications Plan Message Program Scorecards ***Y3 (Mobile) Alerts Treatment Protocols Educational Materials TBD Based on TBD Dependent Program (e.g. Tele- Changes Psych will require EOB different data from Life Events Tele-Check) Hospital Systems - Standard In-Patient Care Environments (incl. Care Centers and Satellite Clinics, etc.) Clinical Information Systems Financial Systems CPOE Patient Accounting Financials and Management Surgical Financial ICU Rehab Anesthesiology System Reporting and Orders Perinatal DSS Accounting System Behavioral Results Lab System I/P NICU, Labor/ CCDs / CCRs Health Deliver, Nursery Referrals ADTs ED /PM I/P Imaging/ Mgmt I/P EKG SIUs Systems Radiology Rx I/P Case Management and Information Applications Contracts Administrative Systems I/P Case Management HR, Staffing, Supply Chain Time Management Management, Contract Mgmt I/P Clinical Performance Mgmt Clinical DW/BI System Patient Management Eligibility Clinical Decision Support, Order Sets and Care Guidelines Orders Results CCDs / CCRs Referrals ADTs SIUs VHR Public HIE CNYCC DSRIP External Provider (SHIN-NY) Organizations Quality Patient Reporting Education **Y2 ***Y3 Infrastructure - Level 2 Diagram
DSRIP Partner HIT/HIE Requirements Breakdown DSRIP Goal: Create an Integrated Delivery System focused on Evidence-Based Medicine and Population Health Management to reduce inappropriate utilization by 25%. Ensure that systems used by participating providers meet Meaningful Use and PCMH Level 3 (where applicable) standards by the end of Demonstration Year 3. Perform population health management activities to improve the health of the targeted population by actively using s and other IT platforms, including use of targeted patient registries. Develop an ability to share relevant patient information in real time so as to ensure that patient needs are met and care is provided efficiently and effectively.
DSRIP Partner HIT/HIE Requirements Breakdown Adoption of data governance requirements to ensure PPS success (documentation standards, data confidentiality/security) Support linkage by actively participating in the local health information exchange/rhio/shin-ny including supporting notifications/secure messaging. By DSRIP Year 3, all eligible participating providers in the Performing Provider System s integrated delivery system will need to be connected to the local RHIO/SHIN-NY and be actively sharing information across all key clinical partners. Evaluate performance by tracking process and outcome metrics Develop a reporting mechanism to share required clinical quality/outcome metrics with PPS Conduct quality assessment and improvement activities
Phase 2 Project Work Streams HIT/HIE Infrastructure assessment rollout strategy IT/Data governance strategy Vendor selection process for required systems Integration of HIT into project plans
Feedback from DOH HIT Session Held on 1/21 Tracking DSRIP Success By the end of DY1, 90% of the required metrics will be available to the PPS through the Medicaid Analytics Performance (MAPP) By the end of DY2, 95% of the required metrics will be available through MAPP MAPP data points to include: Doman 1 metrics (as reported by the PPS) Domain 2 & 3 metrics (as captured through claims data) Domain 4 metrics (as captured through public health data) Health Home/Managed Care data Utilization data (total cost) PPR (Inpatient)/PPV (ED) data (as calculated by 3M) Composite Scores for Chronic disease quality measures
Feedback from DOH HIT Session Held on 1/21 Identifying Patients Patient level information for the claims based metrics (Domains 2 & 3) will be available to the PPS through the Salient Interactive Mining Tool CNYCC will be able to share this information with PPS partners that have appropriate data sharing agreements in place
Questions?