iHT² Health IT Summit Atlanta 2014 - Case Study "Carilion Clinic’s Journey with Population Health Management and Health IT" with Stephen Morgan, M.D., SVP, CMIO, Carilion Clinic
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Stephen Morgan, M.D. Senior Vice President, Chief Medical Information Officer Carilion Clinic iHT2 case studies and presentations illustrate challenges, successes and various factors in the outcomes of numerous types of health IT implementations. They are interactive and dynamic sessions providing opportunity for dialogue, debate and exchanging ideas and best practices. This session will be presented by a thought leader in the provider, payer or government space.
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iHT² Health IT Summit Atlanta 2014 - Case Study "Carilion Clinic’s Journey with Population Health Management and Health IT" with Stephen Morgan, M.D., SVP, CMIO, Carilion Clinic
- 1. 1 Carilion Clinic’s Journey with Population Health Management and Health IT April 16, 2014 Stephen A. Morgan, M.D. Chief Medical Information Officer Senior Vice President Carilion Clinic
- 2. 22 Greetings from Western Virginia
- 3. 3
- 4. 44 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
- 5. 5 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
- 6. 6 Building Blocks of our Success • Physician leadership • Technology • EHR – Epic • Data Analytics – Premier , IBM , Verisk • Patient Engagement • Partnerships • Payers – Aetna • Service Providers • Provider Engagement
- 7. 77 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
- 9. 9 Our National Spend Average Healthcare Spending per Capita,1980–2009 Adjusted for differences in cost of living Source: OECD Health Data 2011 (June 2011). Dollars THE COMMONWEALTH FUND
- 10. 10 •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?
- 11. 11 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
- 12. 12 Majority of Cost is from Chronic Conditions
- 13. 1313 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
- 14. 1414 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
- 15. 1515 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
- 16. 1616 Key Considerations • Able to manage risk • Integration • Engaged physician leadership • Culture shift • Effective HIT and data management • Time to change – pace
- 17. 17
- 18. 1818 Our Strategic Path Since 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
- 19. 1919 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
- 21. 21 Carilion Clinic: PCMH Today Total 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
- 22. 22 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
- 23. 2323 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
- 24. 2424 System PHM Initiatives 24 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, psychosoci al 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
- 25. 25 System PHM Initiatives Program 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
- 27. 2727 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
- 29. 29 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
- 30. 3030 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
- 31. 3131 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
- 32. 32 HEALTHCARE IT AND ACCOUNTABLE CARE
- 33. 3333 “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
- 34. 3434 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
- 35. 35 Ambulatory Care Inpatient Care Skilled Nursing Home Health Remote Care Ancillary Care Transitions of Care-Patient Engagement Data Claims Data HIE Visibility Attributed Population • Gaps in Care • Risk Stratification • Predictive Models • QM & Outcomes
- 36. 3636 Healthcare IT and ACOs The 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
- 38. 38
- 39. 39 Bridging the gap between home, hospital , office and beyond… Telemedicine
- 42. 4242 High Risk Patients for Re-admission
- 43. 4343 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 PCPNAME MEMBER_ALT_I D MEMBER_NAME HBA1C LDL_C NEPHROPATHY Measurement_Peri od_Members 7000000CARILION 0001000002 7 LAZO, M.D., ROBERT L. 8565173911 CAROL WHITAKER 1 1 1 1 7000000CARILION 0001000002 7 LAZO, M.D., ROBERT L. 8728319211 NANCY STAMPER 1 1 0 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8320176601 DEXTER SLUSHER 1 1 0 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8334701741 HAWTHORNE STUART 1 1 1 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8347362421 INA MARTIN 1 1 0 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8355332541 DOROTHY BOLT 0 1 0 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8495612601 SIDNEY WEBB 1 1 0 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8529433351 SHIRLEY CONNER 1 1 1 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8571966511 CURTIS TURNER 1 1 1 1 7000000CARILION 0001000010 4 HORNEY, M.D., WAYNE D. 8592308431 CURTIS TURNER 1 1 0 1
- 44. 4444 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.
- 45. 45 TRANSPARENT DATA DELIVERY TO PROVIDERS
- 46. 4747
- 47. 48
- 48. 49
- 49. 505050
- 51. 52 PAYOR DATA
- 52. 5353 ED Frequent Flyers ER Visits % of Total Abdominal 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
- 54. 55 ENTERPRISE DATA WAREHOUSE AND ADVANCED ANALYTICS Putting it all together
- 55. 5656 Enterprise Data Warehouse Claims Data Aetna Employee Group, ACO (Wholehealth) Claims Lab Rx Eligibility TMG Medicare Advantage Claims CMS Medicare Shared Savings SAP/ Business Objects Enterprise EPIC EMR Operational Database (Cache) QNTX Medicare HMO (Majesticare) Other Plans - TBD CLAIMS/Plan Data Sources CARILION CLINIC NIG HTLY ETL ETL Clarity Relational Database Cloud-Based/ASP services Temporary Claims Staging Database Care Conerns/Gaps, Risk Stratification Data Population Advisor Premier/Verisk Web-based User Interface Enterprise Data Warehouse EPIC EMR
- 58. 5959 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
- 59. 6060 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
- 60. 6161 Carilion Patient Centered Medical Home Outcomes Comparative Clinical Performance Measures: 2009-2012 Q-4 2009 Q-2 2012 Percent Change (%) 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."
- 61. 6363 0 200 400 600 800 1000 1200 1400 3.8 4.4 4.7 5 5.3 5.6 5.9 6.2 6.5 6.8 7.1 7.4 7.7 8 8.3 8.6 8.9 9.2 9.5 9.8 10.1 10.4 10.7 11 11.3 11.6 11.9 12.2 12.5 12.8 13.1 13.4 13.7 14 14.3 14.6 14.9 15.2 15.5 15.8 16.1 16.4 17.1 17.6 18.3 DistributionofFCM&IM Patients'LastA1CValue March2012 - Feburary2013 Median = 6.8 Average = 7.3 N = 23,473 patients with type 2 DM
- 62. 64 SUMMARY
- 63. 6565 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
- 64. 66 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?)