Predictive Analytics: Real-world experiences of HIEs Transforming Themselves

Mark J. Jacobs, MHA, CPHIMSS CIO, Delaware Health Information Network

Becker's Hospital Review 3rd Annual Health IT + Revenue Cycle Conference

About DHIN

• All 10,000 physicians who order tests use DHIN • > 2.2 million unique patient records from all 50 states • > 14 million clinical results delivered annually • 100% of Delaware hospitals and three from Maryland

participate • Nearly 100 % of clinical results from Delaware Labs and >

95% of results from Delaware commercial radiology facilities delivered to DHIN

• Exchange ADT data from Maryland, New Jersey, Philadelphia, West Virginia

• > Practices send Ambulatory CCDs to DHIN from 23 different EHRs.

Innovative Solutions

• Community Health Record • Public Health Reporting • Event Notification System (ENS) • Clinical Image Viewing • Medication History • HISP – Direct Secure Email • Personal Health Record • Analytics • Clinical Gateway Services • DMOST • Other Business Solutions

HIE Value Stream

Logical Consolidated

Patient Record

Alerting (ENS)

Population

Health

Analytics

Decision Support

Community Health Record (Query)

Encounter Notification Service (ENS)

Analytic Reporting Community Gateway

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IE U

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Strength of Services used by Stakeholders

Distribution

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- • Secure Messaging • CCD Delivery • Results Delivery

HIEs Vary

• Services and functionality

• Costs

• Liability

• Data

Meaningful Comparisons

Outcomes from Use of Analytics

• Promotes measure evolution from utilization of CMS quality measures (e.g., MIPS, MSSP)

• Increases awareness for adoption of value-based payment models

• Exposes need for improvement of data collection for provider performance

• Moves healthcare towards transparency for consumers

Federated - HIE Value & ROI

• Patient Matching – MPI/RLS • Public Health Reporting • Query/Response • Repatriation • ED and EMS • Image Exchange • POLST • Next : patient registries, Trauma, ESRD and reporting to

the California Cancer Registry

Total potential community annual shared savings because of HIE participation: $19,737,950+

ED and EMS - SAFR

• 808 paramedics and EMTs trained and utilizing

• SD City EMS to UCSD's two emergency departments-s 4,082 in the last 90 days

• Currently evaluating length of stay (LOS) measures

• Morbidity and Mortality outcomes for both Trauma and ED patients

• Ancillary test ordering patterns

• Patterns of frequent utilizers of the 911

• Estimated a cost-saving of not having to prep & scan pre-hospital EMS reports and revenue reversals due to late/missing EMS documentation of nearly $230,000 annually

Strategic Focus

• Centralized HIE

• Longitudinal Health Record

• Improving the operations of health care delivery by having access to datan to deliver high quality and cost effective care to support payment reform and new payment models.

• Assisting stakeholders with better understanding and delivering informed care to patients. Assisting in the management of the risk on the populations stakeholders serve by focusing on the following:

• Data Access (& Acquisition)

• Data Use and Ability to take Action

• Maximizing Stakeholder ROI

• Payment Reform & Coordination

• Focused is on filling analytics void that any one organization couldn’t do on its own. • Use Case : Analytics reporting in Flint Michigan region on how many people have had abnormal Lead

blood levels. – real-time basis as new results from the various labs are being sent to GLHC. – Leverages historical lab data to in HIE to how things progressed. – A proactive view to the data so care delivery can be addressed right away.

• Use Case : ED Super-utilizers – Analytic reporting of people who have been to one of the 3 emergency departments in a community

5 times or more in the previous month. – ~ 50% of people in this category are going to all 3 EDs with another 25% going to 2. – 25% go back to the same ED which validates the value of having this cross-community view. – spawned the conversations in the community about who should be following up…health plan care

manager, PCMH care manager, hospital care manager, community care manager? Today, some of all of those are reaching out to the same people.

– With this data we can now have a better conversation about who is on point so we can spread the resources out and not over-bother the people we are trying to serve.

• Big push - change the way things are done in a community through actional analytics and alerting

Readmission Prediction Humans Don’t Predict Readmissions Well

(Journal of General Internal Medicine, 2011)

Tested five cohorts: Attending Physician

Resident Physician

Intern Physician

Case Manager

Bedside Nurse

None were good at making readmission predictions

“The inability of providers to predict readmissions goes

against our initial hypothesis that the providers’ experience

and interpretation of innumerable factors would

make them ideal candidates for this task.”

ENS Value Proposition for Hospitals

• JHCP has seen a lower hospital readmission rate in 30 days post discharge for their self-insured patients [CUSTOMER]t are seen in 7 days by their PCP, compared to those [CUSTOMER]t are not seen in 7 days. Because PCPs are notified in a timely manner about hospitalizations and thus get the scheduling process started sooner, patients are able to be seen within the 7 day window after discharge.

• Additionally, in 2013, JHCP’s Medicare readmission rate was 15.3%, which is lower [CUSTOMER]n the Maryland and national average.

• While ENS is not by any means the only factor, JHCP has had a number of successes [CUSTOMER]t can be attributed to ENS and its ability to immediately notify caregivers when, where, and why hospitalizations are occurring.

Readmissions for 2016 compared to CMS benchmark

Reduced ED visits leading to inpatient admissions

TOC Revenue for Employed and Affiliated Providers

• Ambulatory providers can capture Transitional Care Management (TCM) revenue for employed and affiliated providers. – CPT code (99495 and 99496) can be billed when a patient is

called within 48 of discharge and a office visit occurs within 7 to 14 days, depending on complexity.

• Encounter notifications are sent in real-time, or if preferred, a daily basis and include the most recent patient demographics, including contact numbers, allowing rapid follow-up scheduling.

• Billing TCM CPT codes represent a significant revenue opportunity but few providers bill for effectively, in large part because they don’t know about a hospitalization quickly enough

Focus on the High Risk

Low risk patients (0-5%)

High risk patients (>20%)

1

3

1

3

1

3 Readmission Distribution

Moderate risk (5-20%)

<5% 15-25%

Interventions that reduce the rate of readmission will have largest impact

among high risk patients

70-80% of readmissions

SHIEC - PCDH

Valley Hospital Medical Center, Predict/Envision Target

Estimated Annual Savings for Valley Hospital Med. Ctr.

Estimated Annual Savings for Valley Hospital Med. Ctr.

Thank You