population health management · analytics and analytic vendors lack data warehouse foundation for...

© 2015 The Chartis Group, LLC All Rights Reserved

17 November 2015

Webcast Session Four:

Creating and Deploying Powerful Information through

Technology and Analytics

Population Health Management: Advancing Your Position in the Journey

to Value-Based Care

© 2015 The Chartis Group, LLC All Rights Reserved 2

Welcome and Introductions

Stacy [email protected]

Gregg [email protected]

Mark Van Kooy, MDAssociate Principal, Clinical Transformation and Performance [email protected]

Tom Graf, MDNational Director of Population Health [email protected]

mailto:[email protected]





About The Chartis Group

Our mission is to materially

improve the delivery of

healthcare in the world.

Strategic and Economic Planning

Accountable Care Solutions

Clinical Transformation

Informatics and Technology

ProfessionalsWorking In:

~250

The Chartis Group is a national

advisory services firm dedicated to

the healthcare industry.

The firm is comprised of highly

experienced senior healthcare

professionals and consultants who

apply a deep knowledge of

healthcare economics, markets,

clinical models, technology and

organizational dynamics to help

clients achieve unequaled results.


Today’s Discussion

Discuss how organizations are developing and

implementing a technology and analytics plan that reflects

their population health management (PHM) ambitions

Explore the evolving field of tools and technologies

being developed by vendors to support care management,

patient engagement and other PHM activities

Share how organizations are integrating data from

disparate sources and converting the information

into actionable intelligence to manage the health of

populations and engage patients

Highlight data management structures and data

governance standards providers are developing to

create the foundation for their PHM platforms

5© 2015 The Chartis Group, LLC All Rights Reserved

An Integrated, Iterative Approach


Big Questions Surround Development of PHM IT Capabilities

Healthcare IT executives cite population health and analytics as high priority investments for value based

care, but obstacles exist.

Breakdown of Top IT PrioritiesPercentage of Senior IT Leaders Who

Ranked Given Topic as a Top Priorityn = 70

Biggest Obstacles to Adopting Analytics

Percentage of Senior IT Leaders Who Ranked

Given Topic as a Key Challenge n = 70

Source: Health Catalyst Survey (2014): https://www.healthcatalyst.com/news/analytics-outweighs-accountable-care-population-health-icd-10-as-an-it-priority-say-health-system-execs/

0 20 40 60

Consolidation-Related Initiatives

AccountableCare/Shared Risk

ICD-10

Population Health

Analytics

0 20 40 60

Confusion in the market aboutanalytics and analytic vendors

Lack data warehouse foundation forrobust analytics infrastructure

EMR rollout consuming time andresources

Lack of funding

Lack of expertise and/or resources


Creating and Deploying Powerful Information

Rigorously Assessing PHM IT Capabilities

Developing a Comprehensive yet Flexible Investment Roadmap

Clarifying Our PHM Aspirations

Crafting a multi-year investment and development plan that accounts for a

rapidly evolving technology landscape and changes in PHM priorities

Evaluating the IT platform’s ability to integrate data from disparate sources,

stratify patient populations and translate information into actionable insight

Defining the organization’s strategic priorities and goals before investing

significant time and resources into the IT platform

Today’s discussion will focus on three key principles.


Use the health system’s strategic priorities to create business requirements and IT requirements.


• Redesign care models to ensure

we provide high value triple aim

outcomes• Redesign network and payer strategies

and contracts

• Build a centralized PHM function

• Meaningfully engage target individuals

in managing their health

Strategic

Priorities

Strategic

Priorities

IT

Requirements

Business

Requirements

#1

#2

#3

• Analytics/Business Intelligence infrastructure (repositories,

warehouse, and presentation tools)

• Aggregation capabilities and tools for operational, financial, service,

quality, and other data required to support metrics

• Care management infrastructure and tools that support care team by providing

patient panels, worklists, alerts, prompts, and communication tools• Chronic disease management and health maintenance tools

• Tools for risk stratification, modeling, and analysis

• Understand sources of clinical variation and

utilize evidence-based pathways to deliver

highly reliable care

• Evidence-based pathways/alerts, including real-time,

point-of-care interventions for care gaps

• Embed disciplined approach to transition and patient

progression planning

• Common quality/outcomes measures, and ability

to monitor and report on measures

• Ability to monitor and report on variations


Participant Poll

Does your organization have a well-developed,

enterprise-wide PHM strategy?

29%

71%

Yes

No


When strategy or business requirements are vague, IT can determine which capabilities are

needed.



Rigorously Assessing Population Health IT Capabilities

Having defined the strategic priorities for the population health IT platform, the next step entails

conducting an in-depth assessment of capabilities and gaps across core competency areas.

Competency Definition

1. Data Sharing,

Governance,

and Standards

Data sharing and use agreements in place; Data governance policies and oversight structure in

place to ensure common data architecture, management, and data use cases

2. Data Aggregation

and IntegrationConsolidated data repositories to support integrated analytics needs; extraction, normalization, and

transformation of data from claims, clinical and financial systems

3. Innovation and

New TechnologyDefined processes and capabilities to assess new technology to support business innovation and

make proactive decisions

4. Patient Attribution, and

Risk StratificationAbility to identify and attribute individuals within a defined population and stratify defined

populations based on risk

5. Operational Analytics and

Performance ManagementSystems in place to measure, collect, track, and analyze quality, cost, and utilization data across the

care continuum

6. Decision Support and

Team CommunicationAdoption of toolsets and expertise to convert data and information into shared knowledge that is

communicated across care teams support clinical, financial, and operational decision making

7. Financial Management Processes and tools to support PMPM cost accounting, value-based payments, shared savings

accounting and distribution

8. Patient and Member

EngagementTools and capabilities to actively engage members in care management and health and wellness

activities


Competency #1:Data Sharing, Governance, and Standards


Conduct an in-depth gap analysis of IT capabilities across core competency areas.

Do not take on more than you can. Start with key areas that will generate the most value.

Develop and socialize use cases

Create a multi-year PHM data strategy and align the organization’s data management capabilities

Sharing, Governance and Standards = Data ManagementIt is an EVOLUTION and a journey.

What is it comprised of? Why is it important? What do you need?

Business intelligence strategy

Data governance

Standardized supporting

technology tools

The right data should be aligned with the

right metrics

Collaboration ensures data is shared

appropriately and the right people are

engaged

The program should be cost effective

with the right amount of resources and

support

Current state assessment -

technology, operations and

organizational structure

Establish a true governing model and

process

Align that model with your PHM

strategy

Staff and resource appropriately


Competency #1:Data Sharing, Governance and Standards


PEOPLE, POLICIES, TECHNOLOGY ADOPTION

PR

OD

UC

TIV

ITY

& Q

UA

LIT

Y

RIS

K

& W

AS

TE

Level 1:Local data;

no governance

Level 2:Pooling resources;

enterprise data points

Level 3:Collective vision;

Improving process and structure

Level 4:Predictive modeling;

Data-driven organization

Foundational Aspirational Proficient Transformed

HIGH

HIGH

LOW

LOW

Data in Spreadsheets

Dept. Data Experts

Enterprise Data Warehouse

Dept. Dashboards

Enterprise Analytics

Real-time Analytics

Data DrivenLeadership

Enterprise Chartered

Governance Closed Loop Analytics

Predictive Modeling

Standardized Reporting

Conflicting Data

Leadership

Awareness &

Initial Governance

Structure

Descriptive

Analytics

Data Management Maturity Model

Before making complex data management decisions, assess the maturity of your organization.


Competency #1:Data Sharing, Governance, and Standards


The following example highlights one leading health system’s approach to structuring its BI and

governance models to support population health and other strategic priorities.

Enterprise Data Governance (EDG) Facilitation• Led by Clinical Quality or Performance Lead

• Staffed by Director of EDG and Data Governance Facilitators

• Defines standards, policies, and roles related to EDG

• Ensures metric and data element definition, integrity,

standardization, and transparency

Data Steward Data Steward Data Steward

Enterprise Steering Committee• Confirms BI Strategy

• Resolves escalated issues

BI and EDG Subcommittee• Prioritizes analytics and improvement project request

• Approves EDG decisions (standards, processes, etc.)

• Provides oversight for the teams

Business Intelligence (BI) Strategy• Led by Head of Corporate Strategy

• Staffed by a VP of BI and Performance Management and

project manager(s)

• Ensures accountability (appropriate goals and progress)

• Provides consultation (translation of strategy to goals)

• Identifies and communicates overall direction of BI

Business Intelligence Strategy

(PHM strategy is a critical input)

Enterprise Data Governance

Clinical Advisory Committee• Analyzes clinical project

requests and makes

recommendations to the

Subcommittee

As-Needed Data

Governance Teams• Facilitated by EDG facilitator

• Membership is temporary and

depends on the issue

• Focus groups will be able to

address a lot of these issues

BI Triage Group• Facilitated by BI PM

• All the leads from the “verticals”

• Assesses feasibility of requests

for BI and EDG Subcommittee

• Fosters collaboration

Clinical and Business Stakeholders (data requestors)

and Data Analysts (data manipulators)



Key Considerations

Increasingly diverse

and robust data sets

needed from

traditional and non-

traditional sources

Increasing emphasis

on real-time

integration and

aggregation

Challenges with

attribution and

authenticity, coupled

with data

normalization

Security and storage,

especially for “data in

the cloud”

Significant work, “Buy

versus Build”

Competency #2:Data Aggregation and Integration

The need to manage diverse populations across care settings and over extended periods of time

elevates the importance of data aggregation.



• High Intensity / High Touch

• Leverage AMH high-risk care

managers with integrated specialty

care capabilities for intensive clinical

management

• Moderate Intensity

• Actively manage via primary care-

based advanced medical homes

• Promote access to full array of virtual

care options and self-management tools

• Low Intensity / Low Touch

• Ensure access to online self-

management tools and virtual care for

episodic needs

• Promote utilization of customized

digital platform to guide and inform

decision making regarding healthcare

and well-being

Parents with newborns

“Weekend warriors”

Tech-savvy, high-touch

professional

Teen

athletes

ESRD

Diabetics requiring

social support

Patients with

epilepsy

Patients with

depression

Pre-diabetics

Trans-plant

SPMI1Frail

elderly

Socially isolated, chron. ill members

1 Serious and persistent mental illness.

Cancer

Competency #4:Population Definition, Patient Attribution, and Risk Stratification

In assessing an patient identification and stratification capabilities, it is critical to understand the

competencies that advanced PHM practitioners have developed.

Early Identification Stratification

Clinical Risk / Social Determinants /

Engagement Preference

Clinical Model Characteristics

Members stratified

at enrollment and

continuously through

the care process



Evolution of Decision Support and Team Communication Capabilities

Value to

Population

Health

Enterprise

Sophistication of Decision Support Tools

Emerging

Expanding

Advanced

• Alerts & reminders

embedded in clinical

information systems

• Care mgmt. tools in use in

isolated care settings

• Integrated communication

platform with basic

functionality

• Support teams embedded in

select areas

• Care mgmt. capabilities

accessible in all care

settings

• Workflow engines support

clinical protocol adherence

• Communication and alerts

targeted by team member

and role

• Fully integrated

communication platform

with comprehensive

functionality

• Real-time decision support

presented in an end-user

optimized configuration

• Patient preferences

integrated into learning

databases

• Care mgmt. system

incorporates data entered

by patients, community

partners

• Continuous performance

evaluation and improvement

program refining the

platform

Competency #6:Decision Support and Team Communication

In assessing patient identification, stratification, and support capabilities, it is critical to

understand the capabilities that advanced systems have developed.



Increase interaction with

patients at all stages of

health

Improve care outcomes

and effectiveness by

creating continuous care

systems

Change patient behavior

with clear and targeted

information and meaningful,

real-time interactions with

the clinicians

Improve efficiency by

delivering care in more cost-

effective settings and

enhancing care system

responsiveness

Drive patient loyalty by

strengthening the

connection between the

patient and their physician

and other caregivers

Aspirations for Patient

Engagement

Technology Platform

New

Access

Modalities

Retail Access

Points

Traditional

Access

Points

Community-Based

Access Points

Virtualized

Access Points

Patient Portal

Telemedicine

Consults

E-Visits

Video Visits

School/Work-Based

Clinics

Community Health

AgentsHospitals

Physician offices

Skilled Nursing

Facilities

Stand-alone

Kiosks

Urgent Care

Centers

Retail Clinics

Competency #8:Patient and Member Engagement

In developing their patient engagement capabilities, providers need to focus on creating tools

and processes that support informed decision-making and can influence patient behavior.



?

QuestionsRigorously Assessing PHM IT Capabilities





Multiple vendors offer multiple evolving products to satisfy IT requirements in the core

competency areas.

Data Aggregation

and Integration

to Support

Data Governance

Population Definition,

Patient Attribution,

and Risk Stratification

Operational Analytics

and Performance

Management and

External Reporting

Decision Support

and Team

Communication

Financial

Management

Patient and Member

Engagement

HIE/regional HIEs

Enterprise Master

Member Index

Transformation of

data from claims,

EMR, other

Rules engine

Integration engine

Example Vendors:

Orion

Allscripts/

DBMotion

Medicity

Intersystems

Physician and

Hospital Service

contracting

PHM partner

reimbursement

PHM Cost

accounting system

Risk modeling and

Incentives analysis

Example Vendors:

Advisory Board

COMPASS

Optum One

Allscripts EPSI

Verisk

Operational

performance tools

Physician

performance tools

EDW/data marts

Dashboards

Example Vendors:

Wellcentive

IBM Explorys

Medicity

Advisory Board

Crimson

General BI tools:

Business Objects,

Qlikview, Tableau

against EDW

Care management

Longitudinal care

plan

Care pathways,

interventions, goals

Alerts, notifications

Example Vendors:

Wellcentive

Allscripts/dbMotion

Caradigm

Lightbeam

IBM Phytel

Conifer

AthenaHealth

Physician and

Hospital Service

contracting

PHM Cost

accounting system

Risk modeling and

Incentives analysis

Example Vendors:

Advisory Board

COMPASS tools

Optum One

Allscripts EPSI

Verisk

Patient portal

Self-service

mHealth

Telemedicine –

home monitoring

Customer portal

Outreach

Education

Example Vendors:

MedSeek

CernerHealth

(IQHealth)

WellCentive

Insignia PAM

MDLive

Epic MyChart



Once IT requirements are known, a multi-year roadmap for implementation can be created.

An

aly

tics

Core

S

yste

ms

Year 1 Year 2 Year 3 Year 4

DSS7 Upgrade:

Business Objects

Dashboards

HCAHPS

Clinical Dashboard

Allscripts Data Integration

Intranet Analytic Portal

Advanced Analytics: Claims, Benchmarks

Benchmarks

UMR Claims

EMPI Implementation

Continued EMR Optimization

Enterprise EMR Implementation Other EMR Integration?

Cro

ss C

on

tin

uum

Bill Pay (Client) Patient Portal – PHR/Wellness Self-Schedule and Reg

Case Management/Registry

Longitudinal Client HIE Physician Portal

E-Visits

Community MPI Integration of Independent EMR to HIE

Member

Engage

Physician

Engage

Community

Engage


Questions?

?

?


Stacy [email protected]

Gregg [email protected]

Mark Van Kooy, MDAssociate Principal, Clinical Transformation and Performance [email protected]

Tom Graf, MDNational Director of Population Health [email protected]

Melissa McCainDirector, Clinical Transformation Practice Leader [email protected]

Mark Werner, MD National Director of Clinical [email protected]

Anneliese GerlandEngagement Manager, Accountable Care Solutions Practice [email protected]

Gregory Maddrey Director, Accountable Care Solutions Practice Leader [email protected]

Cindy [email protected]

For More Information

Visit us at www.chartis.com/populationhealthmanagement.com











New Thought Leadership

Visit us online at www.chartis.com/insights.

population health management · analytics and analytic vendors lack data warehouse foundation for...

Documents