1

Healthcare Division

2019 NJAMHAA AnnualConference Workshop 1DPractice Transformation, Data and Reporting:

Maximizing Technology to Improve Health Outcomes

April 15, 2019

2

Introductions

Sarah BalzanoDirector

Garden Practice Transformation Network & Measures Management Department, NJII

Van LySenior Director

New Jersey Health Information Network (NJHIN)

3

Agenda

➔ Practice Transformation Strategies

➔ Value of Becoming Interoperable

➔ Data Collection to Guide Clinical

Interventions & Payment Opportunities

➔ Health Information Exchange (HIE) & Health

Information Network (HIN)

➔ Closing

44

Practice Transformation Strategies

4

5

GPTN Community

6

New Jersey Clinicians

Legend:

Blue – Primary Care Providers

Red – Specialty Providers

● Cluster of providers in specific pockets of New

Jersey

● The number within the circle indicates how

many clinicians are located in the area.

7

GPTN NJ Clinician Roster

Specialty Number of Active Clinicians

Pediatrics 378

Family Medicine 253

Internal Medicine 220

Radiology 211

Obstetrics/gynecology 153

Anesthesiology 118

Gastroenterology 116

Psychiatry 94

General Surgery 89

Neurology 78

Social Work 71

Podiatry 62

Nephrology 57

Cardiology 56

Ophthalmology 53

** Less than 50 Clinician Specialties: 65

2,779 Active NJ Clinicians

• 871 Primary Care• 1,908 Specialist

80 Unique Specialty Types

Top 15 Specialty Types

8

What is Transformation?

9

Evidence Based Interventions

10

GPTN Progress to Date

11

Reducing Unnecessary Hospitalizations

Key Interventions to Produce Results

● Receiving ADT reports

● Connecting to the NJHIN

● Care team members are designated to identify

and provide care coordination to high risk

patients

● Practice makes use of ROI calculator to determine

potential revenue

● Alignment with MIPs incentives and improvement

activities

● Shared Decision making/ ASK ME 3/ Ottawa SDM

Tool

● CMS QRUR report for risk stratification

● Referrals to community resources and closing the

referral loop

● Patient & Family Engagement

# of Contributing Practices Commitment

Actual # Admissions 891

Baseline # Admissions 2,159

# Reduced Readmission 1,268

Through January of 2018, 160 of our exemplary practices have provided:

● 12923 transitional care management services.

● 6375 readmissions have been avoided, meeting 16.5% of NJII’s

commitment to this initiative.

12

Cost Savings

TCM $ 15,776,613.32

HbA1c $ 4,119,637.06

High BP $ 12,072,923.06

Total Cost of Care $ 77,803,629.82

Total $ 109,772,803.26

13

Phase Progression with Key Milestones

14

Phase Movement

15

Patient and Family Engagement Metrics

51 Practiceshave all 6 PFE Metrics implemented

• Active e-tool

• Patient Activation

• Health Literacy Survey

• Shared Decision Making

• Medication Management

• Support for Patient & Family Voices

231 Clinicians and 28 Specialty Types

Specialty Type(cont.) Count of Clinicians

Midwifery 5

Pathology 4

Rheumatology 4

Interventional Radiology 2

Orthopedics 2

Endocrinology 2

Pediatric Neurology 2

General Surgery 2

Pediatric Surgery 1

Allergy/Immunology 1

General Practice 1

Cardiovascular Medicine 1

Infectious Disease 1

Specialty Type Count of Clinicians

Radiology 36

Internal Medicine 26

Gastroenterology 18

Psychiatry 17

Family Medicine 15

Otolaryngology 15

Pulmonary disease 15

Obstetrics/gynecology 13

Audiology 11

Nephrology 10

Podiatry 8

Pediatrics 7

Cardiology 6

Oncology 6

16

Care Plus New Jersey

CarePlus New Jersey is a non-profit organization, providing

comprehensive, recovery-focused integrated primary and metal care and substance abuse rehabilitation services.

11Providers

49Sites

52LCSW

3Outpatient

Centers

10Residential

Facilities

7Community

Offices

Approximately 9261 patients serviced last year

17

Care Plus Interventions

• Risk Stratification

• Patient Attribution

• Quality Measure Collection & Improvement

• MIPS reporting

• Ask Me 3

• Aunt Berta

• NJ 211

• Transitional Care Management

• Chronic Care Management

• Patient Satisfaction Surveys

• Opioid Initiative

• Comprehensive Quality

Improvement meetings every month

18

Care Plus HIN Project

Went Live in January 2019 with the HIN

• Care Plus’ main focus is improving quality and

safety of patient care by reducing errors and

duplication of services

• Encourage the sharing of data

• Alerts of Transitions of Care

• Improving patient success rates in transitions of

care

• Improves public health reporting and monitoring

• Facilitates efficient deployment of emerging

technology and health care services

• Provides a basic level of interoperability among

electronic health records (EHRs) maintained by

individual physicians and organizations

• Reduces health related costs

1919

Value of Becoming Interoperable

19

20

Definition(s) of Interoperable

The Office of National Coordinator (ONC) defines interoperability as:

“The ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the user.”1

1 https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf2 https://www.himss.org/library/interoperability-standards/what-is-interoperability

Healthcare Information & Management Systems

Society (HIMSS) defines interoperability as:

“...is the ability of different information systems, devices or applications to connect, in a coordinated manner, within and across organizational boundaries to access, exchange and cooperatively use data amongst stakeholders, with the goal of optimizing the health of individuals and populations.”2

21

The Office of the National Coordinator (ONC)

https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf

State HIEs and Meaningful Use Stage 1 Begins

Blue Button and the

Direct Project is

launched to send health

information securely

over the Internet

2010 - 2011

HITECH Act Passed

16% of hospitals and

21% of providers adopt

basic electronic health

records

2009

● Stark exception and anti-kickback safe harbor enacted

● National Health Information Network develops protocols for exchange

● Certification Commission for Health Information Technology (CCHIT) starts

2005 - 2008

National Coordinator for Health IT Created

Created via Executive

Order 13335 and

published the Decade of

Health IT: Delivering

Consumer-centric and

Information-rich

Healthcare

2004 2012 - 2015

● The Consolidated Clinical Document Architecture (CDA) is created

● Carequality, a public-private collaborative, is formed

● 80% of hospitals are on EHR

● Additional State HIE Cooperative Agreement funds are awarded

● 2015, NJHIN is created

2015 - 2024

● Expand data sources and users in the interoperable health IT ecosystem to improve health and lower costs.

● Achieve nationwide interoperability to enable a learning health system, with the person at the center of a

system that can continuously improve care, public health, and science through real-time data access.

22

Value Roadmap

https://www.healthit.gov/sites/default/files/hie-interoperability/nationwide-interoperability-roadmap-final-version-1.0.pdf

23

Health On-the-Go

2424

Data Collection to Guide Clinical Interventions & Payment Opportunities

24

2525

“ Empowering Providers to Understand

and Use their Data

25

26

Improvement Performance by Specialty:Controlling High Blood Pressure

Specialty Average of Improvement

Mental/Behavioral Health 48.93%

Pediatric Endocrinology 39.77%

Vascular Surgery 26.65%

Neurology 16.85%

Pediatric Neurology 16.55%

Plastic & Reconstructive Surgery 14.17%

Neurosurgery 13.82%

Gastroenterology 13.55%

Podiatry 9.74%

Dermatology 8.54%

Internal Medicine 6.19%

Family Medicine 5.24%

Nephrology 4.63%

Endocrinology 2.61%

Allergy/Immunology 2.54%

Otolaryngology 2.48%

Cardiology 1.99%

Radiation Oncology 1.58%

Psychiatry 0.98%

Physical Medicine & Rehabilitation 0.25%

Cardiovascular Medicine 0.16%

158 Practices

Interventions

● Measuring BP - Positioning

● Device Accuracy

● Correct size cuff

● Enrolling in Target BP

● Correct documentation within

the EMR

● Ask Me 3

27

CPC Behavioral Health

11Providers

7NJ Locations

4Counseling Centers

1Special Education

Schools

8,000

Approximate # of Clients

seen in 2018

2

# of Monthly QI

Meetings

3

# of Patient Advisory

Board Meetings in 2018

28

CPC Behavioral Health CPC Behavioral Healthcare provides high quality and evidence based services for mental health,

substance use and special education through an integrated system of care design to promote

wellness, recovery and productive lives for children, adults and families in New Jersey.

Patient and Family Engagement:

● Bi Directional Patient Portal

● Shared Decision Making

● Patient Activation Measures

● Health Literacy

● Patient Satisfaction Surveys

● Patient On Advisory Councils

Opioid Initiative:

● Patients Sign Opiate

Medication Contract

● Registered for NJ

Prescription Monitoring

Programs

● Integrated Physical and Mental Health Care Coordination

● Run Charts for continuous data monitoring

● Community Resources

● Phase 5

● Ask Me 3 actively implemented

● Connected to HIE

GPTN Coach Interventions

Set Aims Use Data to Drive

Care Achieve Progress on

AimsAchieve benchmark

Status

Thrive as a business via pay for value

approaches

• 15 physician's/3 Locations/patient panel 6568• Provide Youth Programs like Children's Mobile Response and Stabilization Services, and In – Home Therapy Services• PACT program reducing ER and Hospital admits• Provide Adult Programs like Supportive Housing , Supported Employment , Integrated Case Management Services

29

30

Consumer Satisfaction Results

Approximately 300 consumers completed the Mental

Health Statistics Improvement ProgramConsumer Satisfaction Survey FY 2018.

31

Value Proposition to Payers

• First commercial contract established between NJII

network and a commercial payer in which GPTN

providers are eligible to join from NJ

• Process of negotiating Medicare Advantage contract

with a Payer in NJ

• Network of providers (PCN)

• NJII provides teach backs on revenue opportunities and

how to appeal to payers through quality improvement

initiatives using a data evidence approach from

Transformation work

• Providers educated on how transformation efforts lead

to cost reductions (key player in value based contracts)

• Coaches integrate Industry standards and benchmarks

(such as Stars and MIPS) into everyday conversations

with Providers

• KPI dashboards reflect industry standards and

benchmarks

• Hosting webinars based on payer opportunities

3232

Health Information Exchange (HIE) and Network (HIN)

32

33

What is the New Jersey Health Information Network?

34

What is the NJHIN?

Statewide Infrastructure for Health Data Exchange

• Created by the NJ Department of Health

• Managed by NJII

• Requirement for Charity Care Reimbursement

• Requirement for Delivery System Reform Incentive Payment (DSRIP)

Leverage Technology to Improve Health Outcomes and Lower Costs

Legal Framework Data Sharing• Data Use and Reciprocal Sharing Agreement (DURSA)

Governance

- Advisory Council

- Participating Members, or Trusted Data Sharing Organizations

- Committees for Compliance and Use Case Development

35

Statewide Connection

Health

Plans

Physicians

Specialty

Providers

Hospitals & Clinics

Patients

& Families

Lab tests &

XRAYs

Medications

Public Health

Insurance Companies

Physicians

Specialty Providers

Hospitals & Clinics

Patients & Families

Lab tests &

XRAYs

Medications

Public Health

Duplication of effort, waste, & expense

(N*(N-1)/2 connections)Shared Services

(N connections)

36

NJHIN Data Highway

37

Participating Organizations:

Bergen New Bridge Medical

Center

RWJBH

Jersey Health Connect*

Camden Coalition*

Healthy Greater Newark*

Trenton Health Team*

NJSHINE*

CentraState

HSX*

OneHealth New Jersey (MSNJ)*

Carepoint

St. Michael’s Medical Center

St. Clare’s Health System

* Indicates Multiple Organizations are represented by these HIEs

38

NJHIN Services / Use Cases

39

Service 1: Statewide ADT Notifications Use Case

Trusted Data Sharing

Organization

Trusted Data Sharing

Organization

Patient to Provider Attribution

Health

Provider

Directory

1) Patient goes to hospital which sends message to TDSO then to NJHIN

2) NJHIN checks patient-provider attribution and identifies providers

3) NJHIN retrieves contact and delivery preference for each

provider from Healthcare Provider Directory and Active Care

Relationship Service

4) Notifications routed to providers based on electronic address and preferences

Primary Care

Specialist

Care

Coordinator

Social Worker

Other Health Provider

Patient

40

ADT Notifications with Master Person Index and Common Key Service

Trusted Data

Sharing

Organization

Trusted Data

Sharing

Organization

Patient to Provider

Attribution

1) Jane admitted to hospital with MRN 19860122 and ADT initiated

2) ACRS enriches ADT message with Jane’s Common Key

Jane Doe

Jane Doe

MRN: 19860122

Specialist

Primary Care

Care

Coordinator

J Doe

MRN: 20100116

CK: 2FZ4UR79H

Jane Doe

MRN: 19360204

CK: 2FZ4UR79H

Jane Doe

MRN: 19980119

CK: 2FZ4UR79H

3) Jane is accurately and reliably linked to her Care Team

Health

Provider

Directory

Jane Doe

MRN: 19860122

CK: 2FZ4UR79H

41

Live Today and In Development

Live Today• Master Person Index

• Common Key Service

• ADT Notifications

• Health Provider Directory

• Active Care Relationship Service

In Development• Transitions of Care (CCD

Routing)

• Immunization Registry Query

• Immunization Registry Submission

• PMP Query

• Opioid Risk Factors

• CCDA Query/Retrieve

42

THANK YOU