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