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2011 Annual Report
A Community Approach to Putting Patients First
2011 was an incredible year of discovery, development and acceleration for the
Colorado Beacon Consortium. CBC staff, participating providers and community
partners accomplished tremendous progress toward our shared vision of a high
performing, socially equitable, Western Colorado medical neighborhood. We are
very pleased to provide an overview of the strides we’ve made in the areas of
Technology, Practice Transformation and Measurement. More importantly, we are
pleased to share the experiences of our team members, of participating providers,
and the direct impact of their work upon patients in our community. Ultimately, it is
the human capital we develop and the human connections we make that will sustain
a patient-centered, system of care – long after our Cooperative Agreement with the Office of the
National Coordinator ends in March 2013.
Like many of our colleagues in the Beacon Community Program throughout the nation, and in countless
other communities like them, we grappled throughout 2011 with the challenges entailed in integrating
data from multiple sources and powerful new technologies in team-based, comprehensive primary care
settings. We recognize, however, that technology has limited utility unless it can positively impact
patient experience and support behavior change at the point of care. In addition to the development of
a health information exchange infrastructure that can deploy new tools, CBC is focused upon the
development of new skills and ongoing supports for comprehensive primary care within our community.
Our efforts are reflected in numerous measures, including progress toward Meaningful Use.
Practice Transformation
During the past twelve months, the CBC
Practice Transformation initiative grew from a
handful of “early adopting” practices, working
with a newly formed team of CBC Quality
Improvement Advisors on initial process
mapping and target setting exercises – to a
broad-based Learning Collaborative that
includes fifty (50) primary care sites, working in
successive cohorts throughout our seven
county region. These practices vary
significantly in scale, scope and organization,
from large FQHCs and residency programs to
RHCs and small, private practices. They serve
over 155,000 patients (nearly 1/2 of the entire
population within the region), who are now
receiving clinical interventions predicated upon
Patrick Gordon
Program Director

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the three-part aim of better quality, better health and lower costs. Further, while these practices are
operating on no fewer than sixteen (16) different EHR platforms, they have uniformly embraced specific
quality improvement targets that are measured actively through a balanced array of metrics – most of
which are adopted directly from the Clinical Quality Measures (CQM) established within the final
Meaningful Use regulations. CBC has intentionally leveraged Meaningful Use to align focus, learning,
incentives and improvement within our Western Colorado demonstration.
2011 Milestones Achieved
Working with their dedicated Quality Improvement Advisors, practices participating in the CBC Learning
collaborative achieved several important milestones and objective results during 2011. A high-level
summary is provided below, with greater detail available in Appendix B.
Milestone Description / Elements Status Metrics
Pre-Work Phase
Practices complete four (4) introductory pre-
work learning modules, with online and in-
practice support from QIA team members to
prepare them for entry to the CBC Learning
Collaborative
Teamwork;
The Patient-Centered Registry;
Practice Narratives and
Storyboarding;
Making the Most of Measures.
Pre-Work
Complete for All
Cohorts
100%
(50 of 50 Practices)
Learning Collaboratives
Participation in quarterly, multi-cohort
workshops and with other practices, CBC
advisors and faculty.
Provider and Patient;
Experience Sharing
Successes and Failures;
Barrier Busting and Innovation;
Measures Reporting.
Cohorts 1, 2, 3
participating.
Cohort 4
commences at
the 1/13/12
Learning
Collaborative
70%
(35 of 50 Practices)
CBC Curriculum Complete
Practices complete the entire CBC Change
Package curriculum and quarterly Learning
Collaborative meetings, and “graduate” from
the initial phase of the program.
Physicians and staff “graduate”
and join faculty and leadership
teams;
Practices participate selectively
in CBC “web and action”
follow-ons and “capstone”
projects (e.g., Archimedes’
IndiGO
®
pilot);
$10k per practice, private
financial incentive from Rocky
Mountain Health Plans fully
awarded;
Maintenance of Certification
Credit Awarded via CBC
Accreditation from national
Family Medicine (ABFM),
Internal Medicine (ABIM) or
Pediatric (ABP) boards.
Cohort 1
Graduates at
CBC’s 1/13/12
Learning
Collaborative
30% (15 of 50
Practices);
MOC Credit
awarded to 24
Practices (68
physicians, 29
credit hours);
$150,000 in full
private
incentives
earned;
2 Practices
Joined IndiGO
pilot, 3 add’l
practices in pre-
pilot
assessment.

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Through the power of a collaborative learning process, and with the support of trusted, onsite practice
advisors who are backed up with substantial data analysis, quality measurement and population health
expertise provided by Rocky Mountain Health Plans, practice teams within the CBC have taken
advantage of an opportunity develop the internal competencies and external connections (with
colleagues in other practices and among specialty, hospital, payer and employer organizations
throughout their local medical neighborhoods) that are required to deliver comprehensive primary care.
Practice Stories
Physician leaders and their supporting teams have begun to recognize the power of targeted, data-
driven improvement goals and system design processes upon the care they deliver to patients. Below is
a sampling of practice feedback from around the CBC Region:
When we started doing depression screening on our diabetics, we had a doctor who wasn’t thrilled. A
few days later, after a Beacon team meeting, he complimented the team because he identified a
patient who was depressed as a result of the process. He said he never would have picked up on the
fact that the patient was depressed without the screen. - Greg Reicks, DO, Foresight Family
Physicians, Grand Junction CO
We have come a long way in six months. Our team has built a registry that has helped
us understand areas in which we can improve our patient care and satisfaction. Our staff
is more engaged in preventive medicine. Our front office has taken on more duties,
including depression screening and recalls, which has resulted in positive changes for our
staff and patients. We now understand why we implemented a registry….A patient thanked us for doing the
depression screen because she was meaning to talk to someone about how she was feeling. - Terry Moss, COO
and Cathie Hren, PAC / CDE Diabetic Educator, Western Valley Family Practice, Fruita CO
Our most recent aim is obesity/weight management. We’ve had multiple quality improvement
meetings exploring root causes and management. “DC” is a 60+ year old female with obesity,
hypertension, and osteoarthritis. Having just PDSA’d obesity, I sent more time discussing causes
and approaches to her weight problem. She began to journal her dietary intake, bought a calorie
counting book and increased her activity. She has successfully lost weight for 3 months in a row.
She is visibly thinner and at her two-month follow-up, I told her she was a “star.” She replied, “I’ve never been a
star at anything.” She continues to lose weight and appears to be empowered and motivated to manage her
health as never before. I am hoping to be able to reduce her medications soon. Enrolling in the Beacon Consortium
has resulted in a weekly QI meeting in my office. This emphasis is resulting in better patient care – Lars Stangbye
MD, Montrose CO
Prior to Beacon, our office maintained the “status quo”. Due to busy schedules, months could go by
without a staff meeting. Implementing Beacon caused us to meet more often, inspired
communication and positive changes. Staff have taken on additional responsibilities and have risen
to the task. The care we provide to our patients has improved. We improved the efficiency of our
practice with process mapping. – Mindy Miller, MD, Montrose CO

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Alison
Leifert
A New Workforce for a New Delivery System
A transformed health care system requires a transformed workforce and new infrastructure, with a mix
of different knowledge and skills. The CBC Quality Improvement Advisors have worked closely with
Western Colorado practices to support care process re-engineering, dissemination of best practices,
team-based care, continuous quality improvement, the extraction and use of data to support an
integrated system. As fundamental as these skill sets are to an efficient, patient-oriented clinical
practice, they are not the exclusive domain of licensed clinical staff. None of the Quality Improvement
Advisors working within the CBC region have clinical training or credentials from a state licensing board.
Nor did the staff undergo years of formal education in process design or quality improvement prior to
deployment in the field. Rather, they joined the CBC team based upon their own aptitudes, interests
and commitment to the community, and undertook a rapid-cycle learning process with brief, intense
orientation and guidance from experts in quality improvement, design and organizational development.
Moreover, as additional members joined the team, they shadowed and studied with established
advisors, learning from champions and quality improvement teams within the practices themselves –
thereby demonstrating the capacity for self-sustainment.
Each member of the team has shared his or her journey, breakthroughs and perspectives on the impact
of their work with Beacon practices in brief video testimonials:
Now that the QIA team has established itself, a capacity for continuous learning, and an integral
relationship with CBC participating providers, it will be invaluable for ongoing work in the community –
to support the adoption of new tools, prioritized interventions and resource allocation. During the
remainder of the Beacon Cooperative Agreement with ONC, the QIAs will support additional cohorts of
practices in the completion of the CBC transformation curriculum; ongoing Web & Action learning
Ali Sanchez
Brooke Thomas
John
Bailey
Cathie Nicholson Candice Talkington

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sessions; deployment of community registry; risk stratification and clinical decision support tools;
internal evaluation and communications initiatives. After the Beacon demonstration ends, Rocky
Mountain Health Plans will sustain and build upon the team as a community resource for all providers
and patients – without regard to coverage or network status.
Technology
Quality Health Network (QHN) has been helping western Colorado
providers improve quality of care through health information exchange
(HIE) since launching in 2005. Initially started as a community-based
effort in Mesa County, QHN now provides service to more than 600
western Colorado providers in a 40,000 square mile region. Providers
actively use QHN for the secure and timely exchange of clinical
information to support more effective care processes, improve patient
outcomes and reduce costs. The Colorado Beacon Consortium
demonstration has enabled QHN to accelerate progress on its roadmap for high-value interoperability,
data aggregation and application support services—with a core focus upon producing usable
information to clinicians at the point of care.
Provider Perspectives Across the Continuum – The Value of Community HIE
The Beacon roadmap for the development of QHN’s architecture and functionality is compelling.
However, substantial value is available within the exchange network today –in services that range from
“Virtual Health Record” functionality, in which community –wide patient information regarding a
patient’s status and history is available to clinicians upon demand, to highly efficient clinical data
exchange services that route admissions, lab, pharmacy and referral information across the entire
continuum of care. Hospitals, specialists and primary care providers all benefit from the availability of a
single, standardized channel of communication, which vastly reduces administrative burden, duplicative
utilization of services and the potential for error. Physicians within a wide variety of clinical settings and
specialties have derived tremendous value from QHN’s established exchange services, and share their
perspectives in their own words:
Dick Thompson, CEO
Quality Health Network

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Marc Lassaux
Technical Director, QHN
QHN’s Roadmap -- Sustainability Through Design
QHN understands that maximizing value and sustainability are
fundamentally questions of design. During 2011, QHN
advanced an elegant architecture for infrastructure that will
maximize value to a broad array of stakeholders within the
community it serves. The design incorporates traditional ‘best
of breed’ elements in the deployment of high-value
applications. However, QHN’s roadmap also focuses squarely
upon the importance of “community ownership” of data as an
invaluable asset, and the need to support a wide array of
functions, from clinical process and decision-making at the point of care, to broad-based population
health management, care coordination and cost-trend management functions that are imperative to
payers, employers and governments. This strategy consists in three major strategic focus areas:
1. Major Sources Development – Completion of data
interfacing, mapping and interoperability projects with hospital,
lab, pharmacy and payer participants in the exchange. The
availability of clinically-relevant data from multiple sources
though a single service significantly enhances adoption of
health information exchange among physicians and other
providers, which, in turn, increases the capacity and the value
of the services provided.
2. Data Platform Architecture – Development of a regional data platform, upon which data from major
clinical, administrative and patient reported sources can be aggregated and normalized discretely, and
returned timely at the point of care to support patient interactions, asynchronous planning and patient
interventions, as well as broader-based population health management, measurement, payment,
prioritization and evaluation functions.
3. Advanced Application Deployment – The aggregation of data, and the availability of a community-
wide interfacing and interoperability service, make it possible to deploy high-value applications on an
efficient basis. QHN is currently implementing an advanced, patient-centric registry application (The
Advisory Board Company’s Crimson Care Registry®), as well as a risk stratification and patient-facing
behavior change tool (Archimedes’ IndiGO®). QHN is also completing procurements for cost, utilization
and performance monitoring tools. Deployment of these sophisticated applications via health
Jane Foster, BSN, MS
Clinical Director, QHN

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information exchange makes them much more functional and accessible than they otherwise would be –
particularly in primary care settings. Likewise, the breadth of impact and return on investment is
significantly greater than would be possible with fragmented data single platform dependencies.
2011 Milestones Achieved
Quality Health Network achieved several critical milestones in advancing its three part strategy for
success during 2011. A high-level summary is provided below.
Milestone
Description /
Elements Objective Status / Metrics
Major Data Sources
The acquisition of data from
critical sources across the
health care continuum is
critical to QHN’s value and
sustainability.
Hospital Facilities
Physician Groups
Lab, Radiology and
Other Sources
Payer Data
All hospitals are contracted,
w. interfaces completed or
underway;
Level 1- Independent EHR
platforms interfaced uni-
directionally for delivery
from QHN ;
Level 2- Limited EHR bi-
directional data exchange
w. QHN for progress notes;
Level 3 - Complete discrete,
bi-directional data exchange
with EHR platforms for
advanced applications;
Eligibility and claims data
produced regularly and
aggregated within HIE
100% - 12 of 12 hospitals
contracted / 58% - 7 of 12
hospitals interfaced;
10% - 75 of 740 ambulatory
care providers (Level 1);
33% - 247 or 740 ambulatory
care providers (Level 2):
6% - 50 or 740 ambulatory
care providers (Level 3);
1 payer (Rocky Mountain
Health Plans) exchanging
eligibility, claims and Rx data.
Colorado Medicaid and local
employer groups pending
(Pitkin County).
Regional Data
Platform
Participation in quarterly,
multi-cohort workshops and
with other practices, CBC
advisors and faculty.
Clinical, Administrative
and Patient-Reported
Data;
Aggregation and
normalized via HIE;
Delivered via HIE at
point of care and for
population-level
analytics
Procure and implement
Regional Health Data
Platform solution.
Procure and implement
Enhanced Master Patient
Index – Robust identity
management solutions.
RDHP RFP released and
evaluation process
completed. Contract and
implementation plan pending
1/27/12.
EMPI RFP released.
Evaluation process
underway. Contract and
implementation plan pending
1/27/12.

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Milestone
Description /
Elements Objective Status / Metrics
Advanced
Applications
Advanced technology
solutions deployed on
efficient, community-wide
QHN data platform.
Maximizes value of HIE to
diverse health care
marketplace; maximizes
access by providers and
patients to hi-value tools:
and maximizes impact upon
population health, risks and
costs.
Community-wide
population
management solution;
Risk stratification and
patient activation
support;
Cost, utilization and
performance
management analytics.
Best of breed, patient-
centered clinical registry
application w. certified
PQRS reporting support.
Superior predictive
modeling technology, w.
practice-based applications
and interactive, patient-
facing outputs.
Superior functionality for
utilization, diagnostic,
population, provider and
resource analysis,
sufficient to support
advance payer, employer
and ACO planning and
management functions.
Procurement complete.
Contract awarded for
Crimson Care Registry®.
Initial application availability
for practices by 3/31/12.
Procurement complete.
Contract awarded for
Archimedes’ IndiGO®.
Deployed in 1 CBC practice
w. 8,500 patients analyzed.
Deployments pending
3/31/12 in four additional
practices (FQHC, Residency
and private practice
settings) w. 45,000 add’l
patients.
Procurement complete.
Contract pending RDHP
outcome. RFP for RDHP
included bundled, but
severable, request for cost,
utilization and performance
management solutions.
Meaningful Use
In addition to participating in the Colorado Beacon Consortium demonstration as a sub-recipient, Quality
Health Network is also serving as a Regional Extension Center (REC) partner. QHN staff have worked
within the CBC counties, and throughout the entire Western Colorado region, to support the adoption,
deployment and demonstration of Meaningful Use among Eligible Professionals (EPs). Below is a status
summary and forecast of QHN’s progress with Beacon-region (EPs) allocated by CO-REC through the
formal milestones established by ONC:
REC Program Milestone QHN
Total
EPs Percentage
EPs contracted for REC services in the Beacon Region
270 273 99%
EPs that have achieved Milestone #2 in the Beacon Region
178 270 66%
EPs that will receive 2011 MU Incentive Payments in the Beacon Region
9 270 3%
EPs that will qualify and attest to MU by 2Q12 (includes 2011 attests.)
158 270 59%

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