Doing the Impossible—Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured COUNTY OF ORANGE HEALTH CARE AGENCY 2007 National

Doing the Impossible—Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured

COUNTY OF ORANGEHEALTH CARE AGENCY

2007 National Congress on the Un and Under-Insured

Hank FanbergManager of Research & Development


Dan Castillo, MHA, FACMPE, CHEProgram Administrator

Technology and the Uninsured: Increasing Access and Coordinating Care


Today’s Objectives

• To share with you how two different types of healthcare organizations are utilizing technology in their efforts to serve the underserved.

– What a Provider System is currently doing– What a Public Health (Payor) System is

currently doing


• We will demonstrate the different technology applications that have been implemented and how they support our respective initiatives.

• We will share with you the outcomes of our efforts and how leveraging technology has not only made our respective systems more efficient but how it has enhanced the patient’s quality of life.

Today’s Objectives (cont.)


• The Provider Perspective– Hank Fanberg – CHRISTUS Health

• The Public Health (Payor) Perspective– Dan Castillo – Orange County Health Care

Agency

Today’s Objectives (cont.)


Our Healing Ministry


• CHRISTUS Health background

• Market Statistics re: un and under insureds

• Programmatic Approach to Care

• Technology Tools to Accomplish

PRESENTATION GUIDE


Our Vision What We Are Striving To do.

• Strengthen current ministries and expand into new locations and services

• Implement innovative approaches to caring for the whole person

• Increase access to health care for the poor and underserved through advocacy and other initiatives

• Make significant contributions to creating healthy communities

• Create a work environment filled with hope, dignity and mutual respect


• In 1866, Texas was faced with illness, disease and poverty of staggering proportions.

• Galveston Bishop Claude M. Dubuis turned to his native France and issued a plea to Religious Sisters for assistance

• Three Sisters answered the Bishop’s call, Mother Blandine, Sister Ange, and Sister Joseph

Our Legacy


• The Sisters arrived in Galveston in October 1866 and founded the Congregation of the Sisters of Charity of the Incarnate Word.

• In 1887 the Sisters opened the state’s first Catholic hospital in Galveston, Charity Hospital.

• Mother Madeline, Sister Agnes and Sister Pierre traveled from Galveston to San Antonio in 1869

• Within months, the Sisters established Santa Rosa Infirmary in San Antonio.

Our Legacy



• 40 hospitals and other health care ministries in more than 70 communities

• Dozens of other health services in Texas, Louisiana, Arkansas, Utah, Oklahoma and Mexico

• Approximately 27,000 employees

• More than 8,000 staffed beds

Cont’d

Facts and Figures - Today


Uninsured in Texas and Louisiana – Demographics

• Texas leads nation in uninsured; Louisiana is third (2005)

• Majority are:

- Working families with low and moderate incomes

- Young adults age 19-34

- Disproportionately Hispanic and African-American

- Legal, US residents• Health care coverage is not available from employer or

is unaffordable

Sources: Health Policy Institute; The Access Project


0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%45.00%50.00%

LA TX

Per

cen

t o

f P

op

ula

tio

n

Medicaid/CHIP Uninsured

Uninsured and Underinsured in Texas and Louisiana, 2005


CHRISTUS Direction

Comprehensive strategiesto address the symptoms and underlying causes of

health problems.

From To

Community collaboratives that mobilize and build upon existing community assets.

Focus on high cost, ER-based charity care to treat illnesses that

Could have been prevented.

Proprietary approachesto planning andimplementation.


Three Pronged Approach

Uninsured Population

Manage Care• Identify high risk

patients• Manage Lifestyle• Navigate the System

Manage Acute Care• Develop clinical pathways/

supply chain management• Implement strategic pricing• Implement communication

plan

Provide Access to Care• Identify/establish

medical homes• Identify/develop other

building blocks


Current Building Blocks

CareManagement

Enrollment

ReferralsSystem

DurableMedicalGoods

PharmaceuticalsAccess

Wellness &Prevention

Medical Home

DiagnosticService

DiseaseManagement


Admission

Prepare for treatment & discharge

Medical or surgical

treatment

Discharge to home and/or

aftercare

CommunityCollaboration

Enrollment

ReferralsSystem

DurableMedicalGoods

PharmaceuticalsAccess

Wellness &Prevention

Medical Home

DiagnosticService

DiseaseManagement

CareManagement

ExpandedInsuranceCoverage

Dental HealthMental Health

Comprehensive Integrated Care


• Technology: – variety of tools that fit the need

• Touch: – Community Health Workers

Success Requires Tech and Touch


• People who are residents of underserved communities who are uniquely knowledgeable about their neighbors’ needs

• Care Managers by many different names– Health Promoter– Family Health Care Advisor– Natural Caregiver– Promotora– Resource Mother

Community Health Workers


CHRISTUS Spohn Kleberg – Preliminary Results (12-06)

A study of 77 chronically ill clients during the first 6 months of intervention by CHWs

Utilization Impact• 52 of 77 had no ED visits or admissions• 49 ED visits by 25 patients• 28 admissions by 20 patients

Financial Impact (6 months)• $123,329 in net savings for ED & Acute Care• Costs of $35,152• Return on investment (ROI) $3.80 per $1 invested in the

Kleberg CHW program


Patient Specific Results

• 22 year old Caucasian female– Diabetic

– ED as primary care site

– Admitted to ICU ~ 6 weeks for acidkerotosis

• Community Health Worker + Home Monitoring– No admissions 11 months

– 3 ED visits

– $215,000 cost avoidance


Home Monitoring Device


What Technology building Blocks Are Needed?

• Clinical Systems

• Communications Systems

• Financial Systems


Map the technology to the Need

NEED SOLUTION

Enrollment Financial Eligibility & Enrollment

Medical Home Clinical/ Comm EMR/PHR

Wellness Clinical PHR, on line

Diagnostics & Disease Mgmt

Clinical Home Monitoring

Referrals Communications Portals

Medications Clinical ePrescribing

Data Analytics Data base Oracle SQL


What Technology building Blocks Are Needed?

• Clinical Systems– Shared electronic medial record – Community Wide Master Patient Index– Vital sign monitoring device in the home

• Communications Systems– Secure network for accessing and sharing– Web based access and applications

• Financial Systems– Eligibility verification

• Strong Authentication– Positive patient identification and verification


CDA document-based network

EMR

PM-paper

chart

RIS/dictation

LIS

eRx/paper

HL7|^v2 data

HL7|^v2 text

text

HL7|^v2

text DICOM

paper NCPDP

• EHR

• V-EHR

• PHR

• Patient Portal

• Physician Portal

• Health Record Bank

• All transform to CDA

• View the complete record

• No loss in computable semantics


HIE InfrastructureCLINIC / HEALTH CENTER

Clinics / Health CentersCloverleaf® Secure Object Client

HOSPITAL

HospitalsCloverleaf® Secure Object Client

Leverage existing Quovadx Infrastructure

Patient Directory

Member DataLinkage Data

Audit Data

HIE Infrastructure

Cloverleaf® Integration Services Identity Services

SDKServices

Web ServicesJava APIC++ API

Initiate Engine

Identity RulesComparison

AlgorithmSecurity &

Access Control

I nitiate™ EnterpriseViewer

Initiate™ Auditor

Protocol Services

TCP/IP (S) SOAPSMTP POP3LU 3

LU6.2 APPC

FileFilesetFTP(S)

HTTP(S) MQ (MQSeries)

JMSMS MQUPoC

PDL Async (RS232)

Message Services

HL7 V2.xHL7 V3.

X12 HIPAANCPDPCeRxXML

UN/EDIFACT Fixed Length

Variable LengthHierarchical

Record Length

Monitoring Services

Network MonitorGlobal MonitorEngine Stats

AuditingEngine Logging

Messages LoggingSystem Alerts

Message Alerts

SecurityServices

Secure Messenger SSL

Basic SecuritySecurity Server

(Advanced)Audit Tracking /

ReportsUser Auth. (x509)Entity Auth. (x509) Access Control List

(ACL)

IHBServices

Web Services Security (WSS 1.0)

ESB Adaptor*ServiceMix Adaptor*Hydra SDO Adaptor*

DatabaseServices

Recovery DbaseError Dbase

Transformation Services

ParsingTranslation

Routing

Implementation Serivces

Patient LookupPatient Update

Patient Registration

IHEServices

PIX/PDQ v2 & v3ATNA

XDS DOC SRC/ CONSUMER

PWPBPPC

XDS-SD

Custom Patient Lookup / Update PortalEMPI Face Sheet

Patient Care Home AssignmentEMPI Patient Lookup

Patient Compliance Review

EMPI – Patient Lookup Portal

eRX Translation Services

EMR/eRx/CPOEHL7 - NCPDP SCRIPT

Health Interoperability Solutions

Medication History Services

Medication Safety Directive

RxHub MEDS

Financial Interoperability

Revenue ManagementDirect & Hub

transaction support

MD Office Connectivity

Secure object ClientCloverleaf® Gateway

Clinical Terminology Service

3M Data DictionaryStandardized terminology

* Current 2007 Development plan

Physicians


• Divert inappropriate care from ED – By using home monitoring devices and Community Health Workers

for support• Provide a medical home with electronic linkages to entire care

team– Virtual PHR using grid technology

• Establish a community wide referral network– Web site, in early development

• Collect de-identified data for analytics– Not yet robust enough

• Identified the major components to implement and integrate – much more work to be done

OUTCOMES TO DATE AND FUTURE NEEDS


Still Building Infrastructure

• Evaluating social networking model (i.e. Face Book) for sharing and notifications

• Standardizing terminology across multiple systems• Integrating eligibility and financial systems with

clinic systems• Continue to develop the virtual EMR• Continue to improve communication and

collaboration tools• Continue to automate as much as possible


Summary

• The Need drives the technology– Not the other way around

• Technology by itself is insufficient– But it is necessary

• Underlying Foundation is the Medical Home– Requires sharing of information



2007 National Congress on the Un and Under-InsuredDan Castillo, Medical Services Initiative Administrator


About Orange County MSI

• Orange County’s state mandated indigent program

• Serves as the County’s safety net program for the underserved

• Operates without the benefit of a County controlled healthcare delivery system– Public-private partnership– No County-Employed Physicians– No County-Run Hospital system

• Annual enrollment of 25,000 patients• $87 million annual budget


By the Numbers

• 22 hospitals reporting admit and discharge data– Over 10,000 ER admits electronically

reported– Over 3,000 hospital stay notifications

• 14 Community Clinics connected• Over 200 ER Physicians connected• Over 200 Primary Care Physicians

connected• Over 500 Pharmacies connected


By the Numbers (cont.)

• Over 5,000 eligibility checks per month by provider network

• Over 10,000 ER Queries in 12 Months

• Over 2,000 ER Physician notes submitted

• Over 700 e-Referrals to Community Clinics


e-fficiencies Result in Cost Savings

• Reduction of inappropriate ER utilization by 11% over the last quarter

• Hospital cost savings per re-admitted patient is $2,000

• Duplicate prescription cost savings per patient per year is $600 (avoidable)

• Diagnostic and ancillary cost savings is $130 per patient per year

• Improved quality of care:– PRICELE$$


• Medical Home linkage (over 12,000 patients assigned)

• Reduction in prescription errors• Increased continuity of care• Increased access to timely care• Improved outcomes• Increased patient satisfaction

The Bottom Line…Improving Care


• Manual enrollment process with “paper” record keeping

• More likely to wait over 45 days for eligibility determination

• Limited medical home linkage• Less likely to have a regular source of care • Lack of clinical information at the point of

care• More likely to report they have not received

needed care

The Dark Ages


• Standardized paperless enrollment• 30% reduction in eligibility staff• Patient eligibility wait times decreased to less

than 30 days• Balancing Stakeholder ROI with quality patient

care– Enhanced Physician and Clinic

reimbursement through P4P• Increased ability to monitor and manage

program costs– Addressed through Case Management

enrollment, patient outreach, and consultation with Medical Homes.

Health IT Renaissance


The four pillars to our technology initiative:

1. Electronic Eligibility Determination & Enrollment2. Hospital Census Notification and Tracking3. ER Connect4. Clinic Connect

With these technologies, MSI is the most technologically progressive Safety Net Programin the State.

“Need” Drove Technology


A streamlined and automated web-based enrollment and eligibility determination System.

• An immediate and automated way to screen and enroll applicants online

• Workflow approach promoting efficiencies in management oversight and processor accountability

Electronic Eligibility & Determination


• Collects daily census data electronically from hospital scheduled batch runs

• Uploads data automatically and provides the user with a current daily census report in a web-based environment

• Tracks and displays “Level of Care” and “Length of Stay” information

• Case Management linkage

Hospital Census Notification & Tracking


ER Connect

• Provides usable patient data at the “point of care”

• Facilitates communication between ER physicians

• Tracks patient’s utilization activity

• Reduces consumption of the community’s scarce healthcare resources


ER Connect – Patient History Tab


ER Connect – Prescriptions Tab


• It’s an innovative, technology-based, data communication platform, facilitating the use of available patient information.

• It allows Clinic Providers to access patient information with the goal of enhancing the health services both “at the point of care” and for ongoing care management purposes.

• It’s a patient flow management tool for those patients referred into the clinic.

Clinic Connect


Clinic Connect – Patient Referral Worklist


Clinic Connect – Patient Summary


Clinic Connect – Patient Encounter Documented


Data Accessed by

ERs

Lab Results

e-Referral

MSI Technology Schema

Refe

rrals

Pre

scriptio

n

s

Eligibility

Fiscal Intermediary

Claim

s Hist

ory

Case M

an

ag

em

en

t

Hos

pital

Act

ivity

Emergency Room

Medical Home

Medical Home


• End-user was included from the beginning– Community clinics and ED physicians created it!

• Early adoption by the hospital association• Proven return on investment

– Reduction in redundant procedures and prescriptions

– Reduction in delays and costs associated with enrollment

– Efficiency savings to us and our partnering hospitals from avoided tests

– Increased patient safety – Better continuity of care– Improved provider reimbursement

Critical Success Factors


• Additional funding from Federal Govt. (CI) • OCPRHIO – this is viewed as a potential

backbone for the RHIO in Orange County• Platform to expand Chronic Care

Management• Easily modified to support e-Referral

system providing access to over 5,000 specialists in OC

• Expansion to other public health sectors such as County Medicaid that manages ~350,000 lives.

Current and Future Opportunities


Closing Remarks

The MSI Program is now a proven leader in utilizing innovative

technologies within the County health sector


The Common End GoalTo Address the issues of serving the Underserved.

– How? – Technology supports Payor and Provider initiated programs.

– Why? – Increased accountability, enhanced efficiencies, and most of all improved the quality of patient care.

– Where? – Technology knows no boundaries. It allows our services to extend our reach across many underserved populations.

– When? – Now. Both organizations have presented today what is currently on the ground and operating in their respective regions.


CHRISTUS Objectives - Revisited• What has CHRISTUS Health, a Provider system,

done with technology?

– The medical home as the foundation – Share clinical information among providers

electronically – virtual EMR (grid)– Include touch with the tech– Continue to install and integrate the necessary

clinical, financial and communication systems


OC MSI Objectives – Revisited

• What has Orange County MSI, a Public Health Payor system, done with technology?

– Implemented an electronic enrollment system– Deployed an ER-based, patient history, query

system– Integrated an electronic referral system– Enhanced the linkage of unattached patients

with a Medical Home– Improved quality of care


Whether through a Provider System such as CHRISTUS Health or a Payor system such as Orange County MSI, technology has clearly improved the delivery of health care services, supported targeted patient programs, increased the ability to track and manage our transient population, and has more efficiently utilized our scarce health care resources.


Questions & Answers

Hank FanbergManager of Research & DevelopmentCHRISTUS HealthOffice – (504) 838-1550E-Mail – [email protected]

Dan Castillo, MHA, FACMPE, CHEAdministratorCounty of Orange – Medical Services InitiativeOffice – (714) 834-6249E-Mail – [email protected]

Documents

Doing the Impossible—Leveraging Technology to Reduce Costs and Improve the Quality of Care for the Uninsured COUNTY OF ORANGE HEALTH CARE AGENCY 2007 National