Collaboration • Catalyst • Community PRESENTED BY: DSRIP Information Technology Bob Cawley 5/12/16 DSRIP Regional Health Innovation Team
Collaboration • Catalyst • Community
PRESENTED BY:
DSRIP Information Technology
Bob Cawley
5/12/16
DSRIP Regional Health Innovation Team
• Population Health Management– Health Outcomes of a group of individuals within a population
– Disparities in Care
• Data Sharing– Coordinated Care
– Integrated Delivery System
– Secure
• Performance Measurement– Quality Metrics
– Utilization Metrics
– Project Metrics
2
DSRIP
AHI PPS IT’s goals are to create an information architecture which helps transform health care delivery from a process which generates data, to a process which utilizes information to achieve improved clinical performance outcomes and reduced cost.
This will be achieved through individuals, partners, and other organizations providing patient-centered care to the Medicaid members served by the Program. To achieve these goals, AHI PPS is developing processes to:
• Ensure timely, easy, and secure access to appropriate and accurate information in the pursuit of their patient care activities
• Provide information that enables outcomes improvement
• Increase collaboration and information sharing among care providers to enhance patient care
3
PPS IT Goals
It is the goal of AHI PPS Information Technology (IT) to help further DSRIP Program goals by providing:
• Support to DSRIP partners in achieving goals and deliverables that transform care delivery for the PPS’s Medicaid population by increasing quality and efficiency and improving patient experience
• An interoperable system that uses clinical, utilization and administrative data to measure performance and identify actionable opportunities for improvement
• Services which both support the delivery of quality health care and improve the decision making process for effective and efficient management of resources
4
DSRIP IT Goals
• DSRIP IT initiatives are governed by the Information Technology & Data Sharing (IT&DS) Committee, which reports to the DSRIP Steering Committee
• IT&DS is responsible for developing and implementing an IT strategy for the AHI PPS, including:
– Leadership role in creation, implementation and oversight of PPS information and data management goals, standards, practices and processes
– Supporting all aspects of information and data governance, including data ownership, data protection, data privacy, information usage, classification and retention
– Aligning the PPS’s information technology to DSRIP program objectives
– Monitoring and evaluating information technology expenditures to maximize value and return on investment
– Reviewing and recommending processes and protocols for adoption and use of information technology that will be used by the PPS participants
• IT&DS has 3 workgroups:– Population Health Management, Performance Management, Analytics
– Interoperability / Data Exchange
– Data Security / Confidentiality
5
DSRIP IT Governance
24 meetings 10/23/14-10/15/15
• John Dudla Hudson Headwaters Health Network• Bob Cawley Adirondack Health Institute (AHI)• George DeAngelis Adirondack Health• Wouter J Rietsema MD The Univ. of Vermont Health Network / CVPH• Valerie Ainsworth, LCSW-R Mental Health Assoc. in Essex County• Ken Dales Mountain Lake Services• Jan M. Dahlen Behavioral Health Services North, Inc.• Martin (Marty) Brown Nathan Littauer Hospital• John Kelleher Glens Falls Hospital• Pete Gilhooly Glens Falls Hospital• Dennis Hadley St. Joseph’s ATRC in Saranac Lake, NY• Beth Foley Center for Disability Services• Andrew Bascom HCR Home Care• Andy Cruikshank Fort Hudson Home Care• Jorge Grillo St. Lawrence Health System
PHM Preview event on 6/25/15
6
HIT WG
Five meetings to date from 12/16/15 to 4/21/16
• Kim Atkins Planned Parenthood Mohawk Hudson, Inc.• Martin (Marty) Brown Nathan Littauer Hospital• Bob Cawley AHI• Andrew Cruikshank Fort Hudson Home Care• Ken Dales NYSARC North Country Management Services• John Dudla Hudson Headwaters Health Network (HHHN)• Jessica Fraser Hudson Headwaters Health Network (HHHN)• Jorge Grillo St. Lawrence Health System• Dennis Hadley St. Joseph's ATRC in Saranac Lake, NY• John Kelleher Glens Falls Hospital (GFH)• Aaron Kramer Adirondack Health• Mark Lukens Behavorial Health Services North (BHSN), Inc. • David Murray Center for Disability Services• Wouter Rietsema, MD The Univ. of Vermont Health Network-
Champlain Valley Physician Hospital (UVM HN-CVPH)
Ad Hoc Meetings, PPS CIO Meetings, Auditing participants
7
IT & DS Committee
Strengths Because of its strong relationships with its partners, AHI PPS is preparing to support DSRIP needs. These partners are providing AHI PPS with information on their IT capability which will allow thorough and realistic plans to be developed.
Weaknesses Within this rural geography, recruitment of qualified HIT professionals is challenging. In addition, many of the smaller providers still have paper-based medical records, or have EHRs without sufficient functionality, requiring a lengthy and not-inexpensive conversion process so they can be full participants in the interconnected and performance-driven PPS as required by DSRIP.
Opportunities DSRIP presents opportunities for structured and coordinated partner collaboration. This can lead to efficiencies and more standardized processes that contribute to shared ownership in outcomes.
Threats Near term: Partners need to absorb DSRIP activities into their already-burdened workload and budgets, taking valuable time away from providing patient care or locating proxy representatives within their practice.
Longer-term: Partners will be burdened with implementing technology effectively to achieve program goals, within an environment having limited (or no) technology support. Partners participating in multiple projects will need to balance that effort with their day-to-day workflow. That workflow will ultimately be affected more as the program unfolds and specific performance-driven processes change.
8
SWOT
Needs Assessment
• Assess Infrastructure Needs (PHM, Performance Management, Care Management, Connectivity, etc.), Plan, Design
– Requirements Gathering
– RFP
• Acquire, Implement Hardware/Software Solutions
• Operate DSRIP Infrastructure, Upgrade as Needed
Interfaces, Data Collection
• Identify Interfaces
• Develop Data Collection Interfaces
• Collect Source Data via Interfaces9
Infrastructure
Population Health Management
• Data Analytics, Registry
• Care Management and Coordination
EHRs
• Identify EHR, Other Data Needs
• Implement Partner Upgrades to Existing EHRs
• Implement EHR/EHR Lite for Paper-Based Providers
• Document and Report Full EHR Data
Tracking Actively Engaged Patients (Due DY2Q4—3/31/17)
• Implement Electronic Tracking of Patients—Quarterly
• Track Actively Engaged Patients Electronically
10
Infrastructure
Alerts, Secure Messaging
• Assess Alerts, Secure Messaging Readiness
• Initial Implementation of Alerts, Secure Messaging
• Remaining Implementation of Alerts, Secure Messaging
• Alerts, Secure Messaging Across the PPS
Performance Reporting and Management
• DSRIP Project Metrics
• Reporting to DOH
• Reporting to PPS Partners
11
Infrastructure
Patient-Centered Medical Home:
• Assess PCMH Readiness
• Implement EHR Upgrades Needed for PCMH Recognition, Apply for Recognition
• Providers Operate as Patient-Centered Medical Homes
Stage 2 Meaningful Use (Due DY3Q4—3/31/18)
• Assess MU Readiness
• Implement EHR Upgrades Needed for MU
• Providers Attest to MU Stage 2
• Providers Continue to Be Eligible for MU Incentives12
PCMH and MU
13
IT Strategic Roadmap
Distribute second IT survey to AHI PPS
members
1. Kick-off Precedes – 2-3
Months selection, buy-in
2. 6-9 Months
Implementation after
kick-off
Q2 Along with Quarterly
Report submission of
identified Network
providers participating
in each project is due.
Population Health RoadmapDY0
Q1 IT/EHR/PHM/RHIO/data sharing current state re-assessment & change management strategy
DY1* DY2* DY3* DY4*
HIXNY Discussions
IT and DS Committee
Governance
DY5*
Workforce Development
People, Program and Change Management
Population Health Management
Promote Adoption of EHR / HIE Capabilities at Member Level
Vendor Selection
Implementation
Planning
Conduct Patient Engagement
Design
Build and Integrate
Quality Assurance
Go-
Live
Opti-
mize
Ongoing Monitoring, Reporting, and
Refreshes
Q4 Establish clinical governance structure (PPS-wide and per project)
Q4 Workforce Strategy Budget Update #1
Q4 PHM Roadmap
Q1 Kick-off
Other DSRIP Milestone
PHM Dependent Milestone
DY = DSRIP Year
(Not to Scale)
Quarterly Reports
Current State
Q1 Project Implementation plans due (All workstream components, Project 2.a.i,
and Patient Engagement speed for all applicable projects)
Q3 Baseline assessment
of revenue linked to VBP
Q1 ‘Pay for Reporting’
TBD Finalize plan
toward 90% VBP
network
Q2 Finalize governance and sub-committee structure and finalize bylaws
Q2 Award Contract
MAPP & Salient
Discussions
Target Operating Model Work
Q2 Vendor Fair
DOH-Imposed Deadline
In order to measure quality, identify high risk patients, and provide care management for patients to improve outcomes, the PHM supports providers, staff and the PPS to become a data-driven, evidence-based system.
• Analyze PPS PHM Needs, Develop RFP, Contract w/ Vendors
• Design, Build, Test, Implement PHM Solution(s) across PPS
• Analyze (Risk Strata, Disease Patterns, etc.), Report, Adjust Care to Patient Needs
15
Population Health
PHM Requirements Executive Summary16
The following functional and sub-functional areas were defined through the requirements documentation process;
Alerts
Patient Portal
Patient Satisfaction Survey
Secure Messaging
Alerts
Medication Management
Psychosocial Management
Secure Messaging
AHI PHM
Solution
Population
Identification &
Stratification
1.
Care Planning
2.
Coordination of Care
Between Providers
3.
Reporting and
Decision Support
5.
Patient Engagement
4.
Administration
Alerts
Care Management /
Coordination
Disease Management
Evidence-Based Protocols
Medication Management
Psychosocial Management
Referral Management
Utilization Management
Outlier Management
Patient Registry
Population Stratification
Risk Scoring
Benchmark Reporting
Custom Reports
Dashboard View
Medication Management
Outlier Management
Performance Reporting
Predictive Modeling
Report Format
Risk Scoring
Security Access
Standard Reports
Utilization ReportingPayment
Administration
6.
17© 2015 KPMG LLP, a Delaware limited liability partnership and the U.S. member firm of the KPMG network of independent member firms affiliated with KPMG International
Cooperative (“KPMG International”), a Swiss entity. All rights reserved. NDPPS 364161
AHI PPS Member Maturity Model
Year HOSP PCP BH/SA LTC/HCBS PREV/PH
0-1* Tier 2 Tier 0 – 3 Tier 0 – 1 Tier 0 – 1 Tier 0
2-3 Tier 3 Tier 2 - 3 Tier 2 - 3 Tier 2 - 3 Tier 2 - 3
4-5 Tier 3 – 4 Tier 3 – 4 Tier 3 – 4 Tier 3 – 4 Tier 3 – 4
Tier 4
Population Health Approach
Data Exchange
Data Transformation
Data Aggregation
Tier 2
Data Processing
Tier 1
Data Aggregation & Exchange
Tier 3
Clinical Documentation
Data Exchange
Data Transformation
Data Aggregation
Data Quality Control
Data Normalization
Retrospective Analysis
Limited EHR
Data Exchange
Data Transformation
Data Aggregation
Data Quality Control
Data Normalization
Retrospective Analysis
EHR
Patient Engagement
Limited EHR
Data Exchange
Data Transformation
Data Aggregation
Data Quality Control
Data Normalization
Retrospective Analysis
EHR
Value Measurement
Care Management
Risk Stratification
Patient Identification
Current State Summary and Target Future State Maturity
Each type of member in the AHI PPS will need to progress through 4 levels of maturity in population health adoption. As a Network,
adoption of population health at lower tiers will need to be accomplished in order to implement a comprehensive PHM program.
*Denotes current state range of AHI PPS Members
PHM Requirements Executive Summary18
# of Requirements by Priority
Critical High Medium Low
The following charts depict the number of requirements captured by priority and by functional area;
Functional Area # of Requirements
Care planning 23
Coordination of care between providers 8
Data/information exchange 13
Patient engagement 5
Payment administration 2
Population identification and stratification 11
Reporting and Decision Support 32
Total 94
• Assess metrics and data needed, define reporting needs, establish data governance, plan interim & long-term performance management solutions
• Obtain data to/from HIE/RHIO/payers, impact of SHIN-NY, data connectivity and how to achieve it
• Develop reports and dashboards; develop, implement interim performance management solutions– Specify data definitions, data ownership– Define metrics (for DOH reporting, for project and partner performance)– Define benchmarks, targets, thresholds, calculation definitions
• Report on PPS and partner performance, identify improvements needed, develop/execute action plans– How to use data to improve performance– How to identify reports—data requirements, standard reports, recipients– What actions they are to take on reports
19
Performance Management
Data Sources Layer Data Management Layer Data Reporting Layer Results Management Layer
20
DSRIP Performance Management Structure
Reporting Database
Enterprise Data
Warehouse
Medicaid Data—Member Roster,
Claims (DOH)
Claims Data (MCO, Partners)
PAM Data (Insignia)
Project Data (Performance
Logic)
Public Health/ PrevData (State,
Region, Local)
Client Engagement Data (CBO)
EHR/ Clinical/Telehealth/Registry
Data (Partners)
RHIO/HIE
Partner A
Me
as
ure
s / R
ep
ort
Ca
lcu
lati
on
s
Re
po
rt D
istr
ibu
tio
n
Clinicians, Clinical
Management, Support Staff
Pop Health / Care
Managers
PPS Project Managers
Patient Navigators /
Client Support
PPS Management
Improvements, Actions
Dat
a R
eq
uir
em
en
ts /
De
fin
itio
ns
Interfaces
Medicaid Data—
Member Roster,
Claims (DOH)
DOH / MAPP
Reports
KPIs
Dashboards
Performance Metrics
Population Health
Analytics App
Partner B
Partner C
Data Collection & Reconciliation
Quality/Cost Analytics
Pop Health Analytics
Current State Summary - PPS Technological Capability
Currently PPS members have a varying range of technological capabilities. The following chart is a representation of the varying levels of the technological capability within the PPS. This graphic is based on the results of IT survey and KPMG conducted interviews.
PPS Members at Varying Levels of Technological Capabilities
BH / SACM
HOSP LT / HCBS PCP PREV / PH
Paper
Records
EHR
HIE /
RHIO
PHM
Larg
e Te
chn
olo
gica
l Cap
abili
ty G
ap
Complement not Duplicate
Data Security & Confidentiality: Ensure that our system is secure at all levels and patients can trust that their privacy is preserved, while being able to share the information they authorize. (Due DY2Q1—6/30/16)• Plan, submit SSP Workbooks• Fill security gaps, prepare environment, submit security affidavit, address DOH
feedback• Accept PHI
RHIO/HIE Connectivity, Clinical Interoperability: Connecting care settings and supporting organizations to one another via the Health Information Exchange (HIE) or Regional Health Information Organization (RHIO), to create a regional, patient-centered record for all patients. (Due DY3Q4—3/31/18)• Plan, design• RHIO/HIE connectivity for selected projects/providers• RHIO/HIE connectivity for all projects• Clinical integration / interconnectivity for all projects, all partners 22
Data Security & Confidentiality / Interconnectivity
Telehealth / Telemedicine: Utilizing telemedicine to address gaps in care. The region is largely rural; access to specialty care as well as integrating primary care and behavioral health can be supported using telemedicine. Patient home monitoring can extend care management resources to better care for patients with multiple chronic conditions.
• Identify Services Needed
• Vendor Contracts
• Establish Program
• Operate Telehealth/Telemedicine Program
Home Monitoring
• Identify Services Needed
• Implement Mobile Technology (e.g., Tablets), Spirometry Equipment
• Operate Spirometry Equipment23
Telehealth / Telemedicine / Home Monitoring
• Analyze HIT Survey results– Identify capability gaps—EHRs, interconnectivity, population health
– Use gaps to inform action plans and budget
• Establish infrastructure– Performance Management structure, metrics (DOH, projects),
reporting
– Change management process
– Interconnectivity/Engage RHIOs
• Population Health Management solution search & selection– Identify, engage vendor(s)
– Implement PHM solution across the PPS24
Next Steps