“The Role of Electronic Health Records and Health Information

Technology in Medical Home Development”

A. John Blair, III, MD

CEO, MedAllies

Hudson Valley Initiative

Infrastructure EMR HIE

Transformation Ambulatory Community

TransparencyRe-Imbursement RedesignEvaluation

EHR

2008 CCHIT CertificationNYeC Requirements

HIE

Interoperability CCD

Reporting Quality Public Health

Ambulatory Transformation

MassProTransforMedCommunity Care of North Carolina

MassPro

NCQA PPC-PCMH PPC1: Access and Communication PPC2: Patient Tracking and Registry Functions PPC3: Care Management PPC4: Patient Self-Management Support PPC5: Electronic Prescribing PPC6: Test Tracking PPC7: Referral Tracking PPC8: Performance Reporting and Improvement PPC9: Advanced Electronic Communication

MassPro

Process for Redesign Develop operational vision and goals Define redesign teams Develop workflow list Document current state Analyze Redesign Implement

MassPro

Team Development

Large practices

Small practices

MassPro

Functional Workflow DiagramPatient flow

Me

dic

al A

sst

Ph

ysic

ian

Fro

nt

De

sk

MassPro

Outside consultation Develop protocols and education Develop in-office workflow Develop tracking and outreach plan

MassPro

Outside Consultation

Ph

ysic

ian

Adm

in

Ass

ista

nt

Create referral order:- Consulting physician- Reason for visit- Due date

Patient visit

Pre-authorization

Consult report

received

Report scanned

Report associated with referral order

Report reviewed

Consultation required?

Yes

Send supporting

medical documentation

Scheduling assistance

Sign-off completes order

Access to Care & Information

• Health care for all

• Same-day appointments

• After-hours access coverage

• Lab results highly accessible

• Online patient services

• e-Visits

• Group visits

Practice Management• Disciplined financial management• Cost-Benefit decision-making• Revenue enhancement• Optimized coding & billing• Personnel/HR management• Facilities management• Optimized office design/redesign• Change management

Practice Services

• Comprehensive care

for both acute and chronic conditions

• Prevention screening and services

• Surgical procedures

• Ancillary therapeutic & support services

• Ancillary diagnostic services

Care Management

• Population management

• Wellness promotion

• Disease prevention

• Chronic disease management

• Care coordination

• Patient engagement and education

• Leverages automated technologies

Continuity of Care Services

• Community-based services• Collaborative relationships

Hospital care

Behavioral health care

Maternity care

Specialist care

Pharmacy

Physical Therapy

Case Management

Practice-Based Care Team

• Provider leadership

• Shared mission and vision

• Effective communication

• Task designation by skill set

• Nurse Practitioner / Physician Assistant

• Patient participation

• Family involvement options

Quality and Safety

• Evidence-based best practices

• Medication management

• Patient satisfaction feedback

• Clinical outcomes analysis

• Quality improvement

• Risk management

• Regulatory compliance

Health Information Technology

• Electronic medical record

• Electronic orders and reporting

• Electronic prescribing

• Evidence-based decision support

• Population management registry

• Practice Web site

• Patient portal

TransforMed

Practice FacilitationFacilitation teamPractice EngagementCollaborative MeetingsDissemination and Sustainability StrategyList servesWebinars

TransforMed

Regular conference calls Regular Reports to practices and

sponsoring institutions Kick off event Practice PCMH evaluation with pre-work

and site visit Formal report on practice status and

opportunities

TransforMed

Development of project lists and timelines

Regular, continuous engagement of practices

Periodic collaborative meetings Early work focusing on leadership,

change management and team work – creating a culture for change and success

Community Care of North Carolina

Implementing Best PracticesImplementing Disease ManagementManaging High-Risk PatientsManaging High-Cost PatientsBuilding Accountability

Community Transformation

Care CoordinationProvider to Provider

Referral Consultation

Inpatient to Outpatient Inpatient Discharge ED Discharge

Transparency

Claims DataClinical DataNCQA PPC-PCMH recognition

Quality Reporting

Community Information Services

Aggregator

Measures Patient Data

Summary Measures

EHRs Payers

PayersProviders

Reimbursement Reform

EmployersPayerNY State EmployeesProviders

Physicians Hospitals

Quality Comittee

Provider/Payer ConsortiumQuality MeasuresData SourcesAttribution MethodologyPayment Components

FFS Care Coordination Fee Outcomes Measures

Payment Frequency and Timing

22

Evaluation

To determine the effects of implementing the Patient-Centered Medical Home in the Hudson Valley on: Health care quality Health care cost Patient experience

The Setting: Hudson Valley

8 suburban and rural counties north of NYC55% of practices have ≤5 physiciansNational leader in ambulatory adoption of

health information technology (health IT) Excellent track record in community

transformation Hudson Valley Health Information Exchange

(HVHIE) has been operating for 7 years, making it one of the longest running and most successful clinical data exchanges in the country

Distinguishing Features

Large scale 6 health plans that comprise 74% of the

commercial market Aetna Empire Blue Cross Blue Shield Empire Plan (United HealthCare) MVP Capital District Physicians’ Health Plan Hudson Health Plan

1200 physicians and 1 million patients

Distinguishing Features

Informative study design Separates medical home from EHRs and pay-

for-performance (P4P) Unique financial incentive model

Lump sum payment after implementation

Methods

Design: Prospective cohort study with concurrent controls

Intervention: Physicians receive $10,000 each after they reach NCQA Level II medical home

Timing: Implementation getting underwayParticipants:

All primary care physicians who are members of the Taconic IPA (N = 1200)

Methods

Participants (cont’d.): A sample of their patients in medical home

and control practices Baseline: N = 300 medical home + 300 control Follow-up: N = 300 medical home + 300 control

Study Groups for Physicians

N Chart Type

P4P Medical Home

Group 1 600 Paper No No

Group 2 150 Paper Yes No

Group 3 100 EHR No No

Group 4 100 EHR Yes No

Group 5 250 EHR Yes Yes

Measurements

Health care quality 10 HEDIS measures Aggregated across 6 health plans Each year for 4 years (2007-2010)

Health care utilization 18 utilization measures aggregated across 6

health plans, each year for same 4 years Inpatient, outpatient and emergency

department, thus essentially all utilization

Measurements

Patient experience Telephone survey based on CG-CAHPS (with

additional questions from the CMWF International Health Policy Survey and ACES), in 2009 and 2011

Overview of Analysis

For quality and cost: Using generalized estimation equations,

comparisons between study groups and across time, adjusting for physician characteristics and case mix

For patient experience: Adhering to CG-CAHPS guidelines,

comparisons between study groups and across time, adjusting for patient demographics and co-morbidities

Products

Hudson Valley experience with medical home transformation

Total and incremental effects (compared to EHRs and P4P) of medical home transformation on quality

Total and incremental effects (compared to EHRs and P4P) of medical home transformation on cost

Effect of the medical home transformation on the patient experience

Contribution

Determine the clinical and economic value of the Patient-Centered Medical Home Using a fairly unique payment model Measured magnitude of cost savings can

inform future incentive programsDetermine the incremental quality and

economic value of the Patient-Centered Medical Home beyond that of EHRs and P4P Comparison critical to inform community

activities nationwide

Contribution

Maximize reliability and generalizability of effect size estimates 6 health plans, 1200 physicians and 1 million

patients

Priority Focus on Discharge Transitions

Medicare 30 day readmit rate 17.6% (MedPar) Estimated 3/4ths avoidable Employed GHS physician readmit rate 17%

Case Mgr phone contact all discharges 24-48 hrs Assess transition status, concerns, review plan Medication reconciliation Confirm or make f/u appointments

PCP discharge follow up visit 4-7 days

Decreasing Readmissions

Over 25% reduction Jan-OctYTD 2006 to 2007

01020304050607080

CY06 Oct07YTD

Rea

dm

its/

1000

Lewisburg Lewistown

Acute Admission Impacts

Lewisburg Acute Admits/1000 Jan-Oct07YTD - 224

Lewistown Acute Admits/1000 Jan-Oct07 YTD - 273

Employed Admits/1000 Jan-Oct06 YTD - 295 Jan-Oct07 YTD - 292

14% Reduction

22% Reduction

Medical Home: Care Cost Trend

Medical Home PMPM down 2% vs Network PMPM up 6%

560

580

600

620

640

660

680

CY 2006 CY 2007

Pre

-Rx A

llo

wed

PM

PM

.

Medical Home Non-Medical Home

Thank you for your time!

A. John Blair, III, MD

CEO, MedAllies, Inc.