iht² health it summit atlanta 2014 - case study "carilion clinic’s journey with population...

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Carilion Clinic’s Journey with Population Health Management

and Health ITApril 16, 2014

Stephen A. Morgan, M.D.

Chief Medical Information Officer

Senior Vice President

Carilion Clinic

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Greetings from Western Virginia

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Carilion Clinic continues to be the premier healthcare delivery system in western Virginia

• Accountable medical group with approximately• 600 physicians, • 150 advanced care practitioners • 300 affiliated physicians.

• 850,000 primary care visits and 50,000 urgent care visits

• Full or partial interests in eight hospitals

• Full range of services and an active GME program

• 56 percent inpatient market share in total service area• More than twice that of nearest competitor (HCA)

• Health plan • Medicaid HMO

• The Market • 85% FFS• Dominant payor with 70% market share

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Carilion Clinic

• Mission: Improve the Health of the Communities We Serve

• Vision 2017: We are committed to a Common Purpose of Better Patient Care, Better Community Health and Lower Cost

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Building Blocks of our Success

• Physician leadership

• Technology• EHR – Epic • Data Analytics – Premier , IBM , Verisk

• Patient Engagement

• Partnerships• Payers – Aetna • Service Providers

• Provider Engagement

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What Drove Us To Transform?

• Rising health care costs• External pressures – ACA, payment change• Unstable economy• Changes in consumer demand• Advances in technology • Generational differences in physician work/life

balance• Working “to license” – team based • Workforce shortages

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Why Population Health?

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Our National SpendAverage Healthcare Spending per Capita,1980–2009

Adjusted for differences in cost of living

Source: OECD Health Data 2011 (June 2011).

Dollars

THECOMMONWEALTH

FUND

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•Life expectancy improved by 3 years•Years with disability increased •US fell from 14th to 26th compared to other nations. •Leading cause for premature deaths include

•CVD•Lung Cancer•CVA

•Leading cause of Disabilities •Back Pain •Musculoskeletal issues •Depression / Anxiety

Value?

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Demographic Trends

• 1/3 US population – Baby Boomers• 10,000 people a day reach 65• 1 in 10 Baby Boomers is managing multiple

chronic illnesses; by 2030:• 1 in 4 have diabetes• 1 in 2 have arthritis• 1 in 2.5 will be obese

• Treatment of patients with co-morbities cost 7 x those without chronic illness

• 2/3 Medicare spending - 5 or more chronic conditions

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Majority of Cost is from Chronic Conditions

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Challenges with Today’s Care

• Healthcare costs growing; burden to business

• Overuse; volume “treadmill”

• Inconsistent care; fragmentation

• Lack of coordination

• Payment model at odds with countering rising costs

• Data issues

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The Response Payment Reform

• To optimize the healthcare dollar and improve health

outcomes, both government and private payers are

(gradually) shifting from volume-based reimbursement to

value-based reimbursement• Fee For Service

• Shared Savings

• Global Risk

• P4P• Value Base Purchasing• Readmission Penalties• Bundled Payments• MSSP• ACO Arrangements

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Population Health 101

• In order to move from volume to value, and accept more risk, you must understand the patient population. • Define – Who am I responsible for? • Measure – standard metrics • Analyze – understand risk • Improve – what interventions • Control – Create accountability

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Key Considerations

• Able to manage risk

• Integration

• Engaged physician leadership

• Culture shift

• Effective HIT and data management

• Time to change – pace

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Our Strategic PathSince becoming a Clinic- 2006

• Developed a multi-specialty medical group• Physician leadership• Substantial quality, safety, and process improvements• Implemented EPIC enterprise-wide• Constructed Riverside campus• Opened a medical school in partnership with VT• Implemented medical homes in all primary care sites• Created MajestaCare, partnered with Aetna for

accountable care, MSSP (risk arrangements)• Built a culture of collaboration and team work

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Our Initial Areas of Focus

• Population Health• PCMH

• Care coordination for high-risk and high-frequency patients

• Wellness, prevention, Choosing Wisely• Transformation work

• Payment reform• Provider Engagement • Health IT / Data

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PHM INITIATIVES

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Carilion Clinic: PCMH TodayTotal Program Sites: 35

• Family Medicine - 29

• Internal Medicine - 4

• Pediatrics - 2

Recognition Status

• Level 3 Recognition – 27

Panel Size: 200,000

• 77% of Department Patients

Providers: 136

• Physicians - 106

• ACPs - 30

Care Coordinators

• Budgeted Positions: 22 FTEs

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System PHM Initiatives

• Transformation Oversight Committee• Oversees work of committees in 3 areas:

• Care Integration• Informatics• Finances/Contracting

• Initial focus on COPD

• Led by Chief Strategy Officer

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What is PHM and It’s Purpose?• Definition: The coordination of care delivery across a population

to improve outcomes through disease management, care management, and demand management

• Goal: To improve outcomes and reduce utilization for patient populations with clinical and financial risk

• ‘Populations’ are identified through community need assessments, clinical risk registries

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System PHM Initiatives

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Program Focus Areas Patient Risk Levels

Area 2: High Utilization Management

Area 1: Disease-Focused Ambulatory Case Management

Area 3: Ambulatory Quality / Pay for Performance (P4P)

Behavioral Health / Psycho-social

Sickest and/or highest-utilizing 5-10%

Rising-risk 40-50%

Low risk 45-55%

Advanced CHF, COPD, IHD, DM, asthma, cancer, psychosocial problems

Patients with less severe chronic illnesses or behaviors that significant elevate morbidity or mortality risks; HTN, DM, hyperlipidemia, tobacco use, obesity

Patients without medical problems; focus on prevention, wellness, and connectivity to health system

Patient engagement, Extensivists, palliative care, transitions of care protocols

Patient engagement, care coordination, Extensivists, transitions of care protocols

Cancer screening, BP, lipid, A1c, etc.; various patient engagement and contact components

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System PHM InitiativesProgram Infrastructure Areas 1 and 2: Disease-Focused

Ambulatory Case Management

and High Utilization Management

Area 3: Ambulatory Quality / Pay

for Performance (P4P)

INFORMATION & GUIDES Data Analytics and Reporting Clinical Protocols and Pathways CULTURE CHANGE & ENGAGEMENT Patient Education and Engagement Organizational Change Management (Provider

and Staff Training and Engagement)

TOOLS & RESOURCES Point-of-Care Decision Support Centralized Patient Outreach EHR Care Plans Extensivist Team Palliative Care and Hospice Home Health

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PAYMENT REFORM

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Accountable Care Activities • Payor Arrangements

• Managed Medicare and Medicaid• Owned – Medicaid HMO

• MajestaCare

• Contracted MAP• Humana, UHC

• Aetna ACO (Whole Health)• Doctors Connected

• ACO• MSSP

• Commercial• Anthem

• Enhanced Personal Health Care Initiative

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PROVIDER ENGAGEMENT

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Physician Compensation

• Moving from Volume to Value

• Major Components:• Personal RVUs (~ 85%)• ACP oversight (RVUs) (~ 5%)• Performance metrics (~ 10%)

• Panel size• Quality metrics• Expense management

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Care Integration

• Sub-Group of Transformation Oversight • Oversight of integrated projects

• Representatives from all departments • Education for first year

• Payment reform • Understanding our data / opportunities

• Process improvement • Transitions of care

• Employed providers

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Working with Community Providers

• Education

• Involvement of medical directors with LOS committee

• Data sharing and transparency

• Involvement in decision making

• EMR

• Joint leadership and affiliation

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HEALTHCARE IT AND ACCOUNTABLE CARE

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“Health IT is essential not only to accountable care organizations (ACO) but also healthcare in general”

Kathleen Sebelius, MPA,

Secretary of the U.S. Department of Health & Human Services

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Population Health Management

• Fundamental to every major healthcare reform initiative today• Patient-Centered Medical Home

• Accountable Care Organization

• EHRs alone are not sufficient to manage populations effectively

• Provider groups and health systems that automate the spectrum of population health functions will be best positioned to succeed

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Transitions of Care-Patient Engagement

Data

Claims Data

HIE

Visibility

Attributed Population

• Gaps in Care• Risk Stratification• Predictive Models• QM & Outcomes

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Healthcare IT and ACOsThe Critical List

• Population identification - attribution• Identification of care gaps – Decision Support • Risk Stratification• Cross Continuum Care management • Quality and Outcomes measurement• Patient engagement• Telemedicine • Mixing claims and clinical data • Predictive modeling • Clinical information exchange

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PATIENT ENGAGEMENT

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Bridging the gap between home, hospital , office and beyond…

Telemedicine

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CARE COORDINATION

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Chronic Disease Registries

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High Risk Patients for Re-admission

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Gaps in Care Patient Lists

Number of members

Percent of members

HbA1c Determination 686 92.7%

LDL-C Screening 610 82.4%

Nephropathy Screening 446 60.3%

NETWORK_NO NETWORKNAME1 PCP PCPNAMEMEMBER_ALT_ID MEMBER_NAME HBA1C LDL_C NEPHROPATHY

Measurement_Period_Members

7000000 CARILION00010000027 LAZO, M.D., ROBERT L. 8565173911 CAROL WHITAKER 1 1 1 1

7000000 CARILION00010000027 LAZO, M.D., ROBERT L. 8728319211 NANCY STAMPER 1 1 0 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8320176601 DEXTER SLUSHER 1 1 0 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8334701741 HAWTHORNE STUART 1 1 1 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8347362421 INA MARTIN 1 1 0 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8355332541 DOROTHY BOLT 0 1 0

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8495612601 SIDNEY WEBB 1 1 0 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8529433351 SHIRLEY CONNER 1 1 1 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8571966511 CURTIS TURNER 1 1 1 1

7000000 CARILION00010000104 HORNEY, M.D., WAYNE D. 8592308431 CURTIS TURNER 1 1 0 1

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Care Plans Across the Continuum

• Developed a disease management section in the EMR navigator

• High risk patients flagged

• Using problem lists and linked episodes

• Viewed by IP, AMB, and ED.

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TRANSPARENT DATA DELIVERY TO PROVIDERS

505050

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Primary Care Group Dashboard

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PAYOR DATA

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ED Frequent Flyers

ER Visits % of TotalAbdominal Pain 116 9%Angina/chest Pain 93 7%Accidental Injury/assault 86 6%Migraine/other Headaches 84 6%Throat Disorders 57 4%Sprains/strains 45 3%Skin Disorders - Other 41 3%Gastroenteritis 39 3%Cellulitis/abscess 38 3%Back Pain/degenerative Disorders 38 3%Kidney Stones 32 2%Fractures 30 2%Neurologic Disorders - Other 28 2%Contusion/crushing Injury 26 2%Complicated Pregnancy - Other 23 2%Mechanical Joint Disorders 23 2%Respiratory Disorders - Other 21 2%Urologic Infections 21 2%Intestinal Disorders - Other 20 2%Muscle/ligament/fascia Disorders 20 2%Syncope/hypotension 17 1%Acute Bronchitis 16 1%Complication - Medical Care 13 1%Arrhythmia - Other 12 1%Eye Disorders - Other 12 1%

Top Diagnoses for Members with Mult ER Visits

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Analyzed Claims Data

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ENTERPRISE DATA WAREHOUSE AND ADVANCED ANALYTICS

Putting it all together

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Enterprise Data Warehouse

Claims Data

AetnaEmployee

Group,ACO

(Wholehealth)Claims

LabRx

Eligibility

TMGMedicare

AdvantageClaims

CMSMedicare Shared Savings

SAP/BusinessObjects

Enterprise

EPIC EMROperationalDatabase(Cache)

QNTXMedicare

HMO (Majesticare)

OtherPlans - TBD

CLAIMS/PlanData Sources CARILION CLINIC

NIGHTLY

ETL

ET

L

Clarity Relational Database

Cloud-Based/ASP services

TemporaryClaims Staging

Database

Care Conerns/Gaps,

Risk

Stratific

ation Data

PopulationAdvisor

Premier/Verisk

Web-based User Interface

Enterprise Data Warehouse

EPIC EMR

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Future Direction

Advanced Analytics

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EARLY OUTCOMES

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Aetna Whole Health ACO Outcomes

Baseline Current

(2011) (2012-2013)

Bed Days/1,000 125.7 118.3

Readmission Rate 5.6% 4.9%

Avoidable ER Visits/1,000 113.3 85.9

Hi-Tech imaging/1,000 69.2 62.8

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Aetna Whole Health ACO Outcomes

Quality Metric Baseline 2011 Current 2012-2013 *Benchmark

Colorectal Screening 76% 83% 63%

Diabetes HgbA1c testing

91.2% 93.8% 91%

Diabetes Lipid Profile testing

88% 89% 87%

Patients with CAD on lipid lowering RX

100% 99% **98%

*Benchmark= HEDIS 2012 75 percentile**Aetna Benchnark

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Carilion Patient Centered Medical Home Outcomes

Comparative Clinical Performance Measures: 2009-2012

Q-42009

Q-22012

PercentChange (%)

1. Body Mass Index (BMI) Measured for Patients <18 Years of Age 39.5% 92.9% 135.2%

2. Pneumococcal Vaccination for Patients >65 Years of Age 74.2% 79.0% 6.5%

3. Breast Screening for Female Patients 40-69 Years of Age 56.2% 66.8% 18.9%

5. A1c Testing for Diabetics 18-75 Years of Age 85.2% 91.9% 7.9%

6. Persistent Asthmatics with Controller Medications Prescribed 86.2% 93.1% 8.0%

7. Diabetics with Blood Pressure Controlled at <140 SBP / 90 DBP 68.4% 72.2% 5.6%

8. Hypertensive Patients with Blood Pressure Controlled at <140 SBP / 90 DBP 64.6% 67.6% 4.6%

Source: 70,000 patient study in 20 Carilion mature medical homes during the period 2009 – 2012; "The Impact of the Patient-Centered Medical Home on Hypertension."

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3.8 4.4 4.75

5.3 5.6 5.9 6.2 6.5 6.8 7.1 7.4 7.78

8.3 8.6 8.9 9.2 9.5 9.8 10.1

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Distribution of FCM & IM Patients' Last A1C ValueMarch 2012 - Feburary 2013

Median = 6.8

Average = 7.3

N = 23,473 patients with type 2 DM

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SUMMARY

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Is it Easy?

• Costly

• HIT steep learning curve

• Disrupted relationships

• Staff felt disengaged

• Leadership turnover

• Staff felt disengaged

• Management in new territory

• Support systems not ready for change

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Key IT Drivers

• Physician Leadership and engagement • A seat at the table

• CMO, CSO, CMIO, Department Chairs

• Culture matters a lot !!

• Information Technology• Develop your roadmap – First things first

• EMR integration

• Telemedicine

• Patient portals / patient engagement

• Build your ability to analyze and display data

• Data Warehouse (Buy or build?)

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Tonight’s Topic

Health IT And

Population Health