ACO = HIE + Analytics

Martin SizemoreDirector, Healthcare Strategy

About Perficient

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Perficient is a leading information technology consulting firm serving clients

throughout North America.

We help clients implement business-driven technology solutions that integrate

business processes, improve worker productivity, increase customer loyalty and

create a more agile enterprise to better respond to new business opportunities.

Perficient Profile

Founded in 1997 Public, NASDAQ: PRFT 2012 revenue guidance of ~$327 million Major market locations throughout North America

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San Jose, Southern California, St. Louis and Toronto

Global delivery centers in China, Europe and India ~2,000 colleagues Dedicated solution practices ~85% repeat business rate Alliance partnerships with major technology vendors Multiple vendor/industry technology and growth

awards

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Our Solutions Expertise & Services

Business Solutions• Business Intelligence• Business Process Management• Customer Experience and CRM• Enterprise Performance Management• Enterprise Resource Planning• Experience Design (XD)• Management Consulting

Technology Solutions• Business Integration/SOA• Cloud Services• Commerce• Content Management• Custom Application Development• Education• Information Management• Mobile Platforms• Platform Integration• Portal & Social

Our Speaker

Martin Sizemore• Principal, Healthcare Strategic Advisory Services • A healthcare strategist, senior consultant and a trusted

C-level advisor for healthcare organizations including both payers and providers

• Specializes in clinical data warehousing, clinical data models and healthcare business intelligence for improving operational efficiencies and clinical outcomes.

• A TOGAF certified enterprise architect with specialized skills in enterprise application integration and service oriented architecture.

Agenda

• Accountable Care Organizations (ACO)• Definition, key components• ACO: Definition of success• ACO HIE requirements – use cases• HIE Current and Emerging views• ACOs require more than EHRs• Challenges to widespread ACO adoption• ACO = HIE + Analytics – Architecture• What are the typical use cases?• Summary

Accountable Care Organization Defined

• A healthcare delivery system whose members share responsibility, financial risk and a common goal to improve healthcare delivery and the overall health status for a given population.

• Acts collaboratively to coordinate patient care across the continuum and share both the payment and responsibility for quality of care for the covered patients.

• Paid a specified amount for the population it manages, rather than a per transaction fee. ACOs can be incented if their quality and patient satisfaction scores are higher than expected; they can also receive decreased reimbursement if scores are lower than expected.

* HIMSS ACO FAQ, www.himss.org

Key Components of an ACO

• Patient‐centered medical homes• Primary care physicians• Specialists• Minimum of one hospital• Ancillary providers• Minimum of 5,000 Medicare beneficiaries (for Medicare

demonstration funding)• Care coordination ability and mechanisms to support• Payer partnerships with reimbursement based on quality,

efficiencies and patient satisfaction

*Source: Article by Stephen M. Shortell and Lawrence P. Casalino

Emerging ACO Models ‐ Governance

Model Characteristics Current ExamplesIntegrated delivery systems/networks(IDN)

• Own hospitals, physician practices, perhaps an insurance plan.

• Aligned financial incentives.• E-health records, team-based care.

• Geisinger Health System• Group Health Cooperative of Puget Sound• Kaiser Permanente• Summa Health System

Multispecialtygroup practices(MSGP)

• Usually own or have strong affiliation with a hospital.

• Contracts with multiple health plans. • History of physician leadership. • Mechanisms for coordinated clinical care.

• Cleveland Clinic• Marshfield Clinic• Billings Clinic• Virginia Mason Clinic

Physician-hospitalorganizations(PHO)

• Nonemployee medical staff.• Function like multispecialty group practices.• Reorganize care delivery for cost-

effectiveness.

• Greater Newport Physicians (partners with Hoag)• St. Vincent Healthcare in Billings• Methodist LeBonheur Healthcare• Kettering Health Network

Independent Practice Associations

• Independent physician practices that jointly contract with health plans

• Active in practice redesign, quality improvement.

• Atrius Health (eastern Massachusetts)• Hill Physicians Group (southern California)• Monarch HealthCare (southern California)

Virtual Physician Organizations

• Small, independent physician practices, often in rural areas.

• Led by individual physicians, local medical foundation, or state Medicaid agency.

• Structure that provides leadership, infrastructure, resources

• Community Care of North Carolina• Grand Junction (Colorado)• North Dakota Cooperative Network

Performance Measurement in ACOs

Patient

CURRENT SYSTEM ACO SYSTEM

ACO

Patient

Performance Measurement exclusively at the individual/group level promotes fragmentation of care and an emphasis on encounter optimization as opposed to carrying a longitudinal view.

Measurement at the ACO level, across the team, promotes an emphasis on care coordination and taking a long-term, holistic view of wellness.

Slide courtesy of Oracle

ACOs from the Patient’s Perspective

Patient

CURRENT SYSTEM ACO SYSTEM

Payer

ACO

Patient

Payer

Volume & IntensityRewarded

Care Coordination

Care CoordinationShared Savings

Quality Metrics& Cost Savings

Slide courtesy of Oracle

ACO: Definition of Success

Experience of Care

Per Capita Costs

Population Health Metrics:

• QUEST outcomes• Select HEDIS metrics• Health status – SF12• Mortality rates

Metrics:• Total medical PMPM• Total Medical Trend• Total Rx PMPM• Admissions/1000• Readmission rate

Metrics:• Patient satisfaction• PAM Scores (Patient Activation

Measures)

Improving triple aim™ population outcomes

* The term triple aim is a trademark of the Institute for Healthcare Improvement

Healthcare Business Intelligence will be the key to success in managing to these

metrics

Health Information Exchange (HIE)

• Extension of EMRs• Integration or

Interoperability role

• Primarily data push or pull

• Struggles with financial viability

• Shifting from state-level efforts to private HIEs

• Key element in the integration and coordination of care

HIE: Current View

Rx Claims

Medical Claims

Remote monitoring

Environmental

Social /economic

Lifestyle / behavioral

HRA

Bio-metrics

Labs

Demographics

HealthInformation

Exchange

Focus: Data collection and

Integration

Rx Claims

MedicalClaims

RemoteMonitoring

EnvironmentalFactors

Social /Economic

Lifestyle /Behavioral

HealthAssessments

Biometrics

Labs

Demographics

HIE: Emerging ACO View

Financial Performance

Clinical Performance

Risk / predictive modeling

Care plan design

Care plan deployment

Interventions

Quality Reporting

Risk Management

HealthInformation

ExchangeFocus: Population

Health Analysisand tracking

Financial Performance(vs. paid claims

ClinicalPerformance

Risk / PredictiveModeling

Care PlanDesign Care Plan

Deployment

Interventions

QualityReporting

RiskManagement

ACOs Require Far More Than EHRs

Requirements– Predictive modeling– Registries– EHR interfaces– Reminder systems– Claims and clinical data

warehouses– Episode of care analysis

systems– Specifications for integrated

claims and clinical databases– Patient portal options– Health information

exchanges

Data Sources for Mining– Medical records– Clinical outcomes data– Patient billing systems– Payer data– Quality measures

abstracts– Charge master– Physician, payer, service

line utilization data– Infection surveillance

data– Labor, productivity and

throughput records– Adverse drug events

Challenges to Widespread ACO Adoption

• Silos lead to a disconnected business and IT infrastructure• Islands of computing create inefficiencies and underutilized

assets• Missing or competing data standards, limited interoperability• Struggle with regulatory compliance, volume of information,

data integrity and security• Resource constraints and difficulty managing

complexity/change• Volume of data points and quality measures, in widely

dispersed locations• Limited use among providers

Meaningful Use Stage 2 and 3 to the rescue!

ACO: High-Level Architecture

ACO Performance Management will be the key to success

HIEs Require Document Sharing (XDS)

• First Register and Store Documents from providers

• Providers Retrieve Documents:

– Find Patient– Then Locate Documents– Then Retrieve

Document

• Supports centralized, federated and hybrid data models

• HIM facilitates installation and coordination of XDS components

ORACLE HIM QUERY AND RESPONSE PROCESS

Patient Lookup

Documents Associated with Patient

Select Patient

Select Individual record/ Document

Extract full data set/ document

Potential Matches

Requestor/ESB OHMPI Registry Repository

Display Record Set

Query XDS.b Registry

Display record headers, store pointers

Query XDS.b Repository

Displayed Detailed result(s)

Oracle Health Sciences Information Manager (HIM)

Slide courtesy of Oracle

Oracle Health Sciences Information Manager

EXALOGIC Oracle Hardware Servers & Storage EXADATA

DM

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all &

Inte

rnet

Oracle Portals and ApplicationsConsumers Clinicians Administrators Consent Mobility Empowerment

Oracle Identity & Access ManagementSSO User Provisioning LDAP

Oracle Desktop VirtualizationCaregiver Mobility

Oracle Databases, Clusters & Enterprise ManagerEnterprise Linux Solaris Containers Oracle VM Database Encryption

Oracle HIE Architecture

Oracle Health Sciences Information Gateway Oracle Business Process Management Suite

ESB BPEL Business Process Manager Process Analysis

Fixed Web Service Orchestration

Data Center AdapterCONNECT/Direct

DMZ GatewayCONNECT

Web Service Orchestration

Adaptive Web Service Design & Orchestration

Dat

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nter

Fire

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Oracle Sun Ray Thin Client

FeaturesHealth Policy MonitorHealth Policy EngineHealth Record Locator Public Key Directory

Healthcare Master Person Index

Healthcare Transaction Base

SOA-based IntegrationsOther SOA Service Endpoints

Healthcare AnalyticsEHA: HDWF-- HDM – ORA -- PSCA

Message-based SupportHealth Sciences Integration Engine

Web Service Registries

PKI Security CertificateAuthorities

Other HealthInformationOrganizations’ Web Services & Secure Health Email

Standardized“Front Door” HIETransactions

Slide courtesy of Oracle

DM

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all &

Inte

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Solving CIO Worries by Providing an Internet “buffer” to PHI data sources

Dat

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nter

Fire

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Web Service Registries

PKI Security CertificateAuthorities

Other HealthInformationOrganizations’ Web Services & Secure Health Email

End Users

DMZProxy Servers

Cloud Computing Data Center

Firewall Penetrations Multiple Internal and back channel

PHI Data Sources

Standardized“Front Door” HIETransactions

Edge Servers for EHR UsersDesktop Virtualization

Edge Servers for the Health Information Internet Cloud

Electronic Health Record System(s)

Edge Servers supports Secure, Controlled Health Information Exchange of PHI to and from the EHR System(s)

Prepared for the future of consumer-oriented healthcare and wellness management

Slide courtesy of Oracle

Oracle HIE “Edge-Server” Architecture

De-identified

Client Opt In/Out

Organizationor Patient Consent

HL7, CCD, EDI, PHR, Batch,

Web Services

Research(Evidence-Based

Medicine)

Structured Data

Longitudinal Record

Analytics

Claims

Clinical

Wellness

Satisfaction

Raw Data

IdentifyPredictPreventInterveneMeasure

Personalized Health Plan VP of

PopulationHealthMgmt

Home Health Assistant

Primary Care Physician

Health Coach

Device

People

Clinic

Hospital

Payer

Person

Applications

ACO/HIE as a Population Health Platform

HIE

Advanced Analytics

DataTransformation

and Normalization

Master Patient IndexVocabularies

Master Data Mgmt

Enhancing knowledge translation and the adoption of evidence-based practice

Read byQxMed

Why Build This Level of Technical Architecture?

• Move from retrospective reporting to predictive modeling of population health to manage risk and share savings

• Create the data analytics necessary to move to evidence-based medicine and modeling of outcomes, meet coming demand of healthcare consumer analytics

• Predictive modeling provides an objective assessment of a patient’s future illness burden and associated health costs based upon their historical conditions as captured through claims and clinical information – key to ACO success!

– It is a method for prioritizing members for population health management and care management and stratifying them based upon their morbidity burden and financial risk

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ACO = HIE + Analytics Summary

Benchmarking Outcome AnalysisACO Analytics and Management

Population HealthManagement

Spend Analysis

Value Based PricingClaims Adjudication

Value Analysis

Quality

Labor Supply OptimizationSupply Chain Optimization

Waste and Harm

Operations ManagementOptimization

Efficiency & Effectiveness Analysis

Disease Management

Practitioner Profiling & Quality HEDIS 2010 (select measures)

Savings OpportunitiesHarm Avoidance

Safety Pharmacy Analysis AHRQ

Harm AvoidanceAlerting

Actuarial Analysis

Claims HandlingClaims Adjudication

P4PPatient SatisfactionPerformance Improvement

HIE + Analytics: What are typical use cases?

Use Cases Use Cases

Determine and model total cost of care across all settings (acute, ambulatory, home care) by population or individual

ID risk to patients by looking at environmental factors e.g. asthma, flu breakout

Care coordination New age case management (CRM for patients)

Match payer and provider data-verify rollout of preventative programs

ID labor savings. Correlate staffing to predicted demand/activity

Meds Mgmt./Reconciliation/Med Therapy Mgt./Prescription fill compliance

Physician attribution and/or care team – quality outcomes – patient satisfaction

Analyze population health levels based on various grouping (geo, facility, provider, etc.)

Monitor and track (real time) compliance to regulatory and/or clinical guidelines across settings

Understand resource utilizing productivity, throughput and access

Chronic care cost modeling to support payments and allocation

Evaluate readmission across continuum Support transitions of care through transfer of data

Resource planning/physician profitability (contract management, preferences, outcomes

Aggregate and manage data across all care settings (cost, care)

Support all 65 ACO measures, not just the initial 33 Comparative Effectiveness / waste reduction

Monitor/track patients experience beyond HCAPS (coordinate w/workforce, predict experience)

Creation of new evidence base for guidelines

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Thank You / Questions?