1. Care Redesign: Information Systems Needs Alexander K. Baker Chief Operating Officer Partners Community Healthcare, Inc. September 22, 2011

2. What is PCHI?

• P artners C ommunity H ealthCare, I nc.

• • Established in 1994

• • Provider Network consisting of ~6,400 physicians and 9 acute care hospitals organized into 17 Regional Service Organizations (RSO)

• • Management Services Organization (MSO) providing performance improvement infrastructure for the network.

• • 100% EHR adoption as of 12/31/2009

3. Care Redesign Conceptual Model HEALTH OUTCOMES COST VALUE FOR PATIENTS Health Outcomes Value Metric = Cost of Delivering Outcomes

4. Network Characteristics needed to succeed in Population Management

5. Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management

6. Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals

7. Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing

8. Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing Decision Support Systems

9. Care Redesign Themes Take a condition-specific approach Focus on outcomes that matter to patients and their families Develop value metrics to track performance Identify pause points Coordinate care delivery Increase reliability Population Management Patient Portals Business Intelligence and Data Warehousing Decision Support Systems Referring Physician Solutions

10. Five Elements of Population Management

• Identify members of the cohort

• • Leverage multiple data sources: EHR, billing, claims, ADT

• • Develop algorithms to identify cohort members

• • Consider clinicians (including referring physician) and patient as sources

• Gather information on the cohort into a database or registry

• • Organize relevant clinical and financial data

• • Present tabular views and visual representations of data

• Develop logic to highlight cohort members in need of follow-up

• • Fail to meet a process standard

• • Fail to meet a clinical outcome standard

• • Fail to meet a measures that matter standard

• Develop population management software to track patient interventions

• • Document attempts to contact patients

• • Capture results of contact and interventions

• Gain insight through reporting and analytic tools

• • Population reports to describe the population and its status

• • Operational reports to quantify the services provided

• • Outcome reports to assess the impact of services

11. Business Intelligence and Data Warehousing

• Quality and quantity of Partners data are rapidly improving

• Much of this data resides in our transactional systems

• • Transactional systems are not organized for efficient reporting

• • Reporting off transactional systems drags down their performance

• Critical need for coordinated, enterprise data warehousing strategy

• • Build on current data warehousing islands

• • Enterprise coordination of multiple activities

• • • Data governance, access and security policies

• • • Data modeling

• • • Data extraction from transactional systems

• • • Database management

• • • Analytic tool selection and user support services

• Success tied to multiple strategic initiatives

• • Population management

• • Accountable Care Organization

• • Payment reform (e.g., global risk, bundled payments)

12. Decision Support

• Pause points Decision support opportunities

• Increase depth and sophistication of decision support

• • Focus on condition-specific care redesign teams

• • Express decision support at pause points

• • Incorporate checklists and other guidance

• Increase breadth of decision support

• • Leverage financial and administrative data

13. Patient Portals

• Online engagement of patients and their families

• • Access to patient medical record

• • Access to library of health information

• • Message with physician practice

• Tools to support more efficient care delivery

• • Patient-entered data

• Platform for alternative care delivery strategies

14. Referring Physician Solutions

• Referring physician portal

• • Delivery of consult information

• • Access services

• • Coordination of care

• Regional Health Information Exchange (HIE)

• • Platform to support health information exchange at scale

15. Care Redesign: Information Systems Needs Alexander K. Baker Chief Operating Officer Partners Community Healthcare, Inc. September 22, 2011