1

Kings Fund Masterclass:

Closing Session – IT and Analytics

2

Objectives

• Understand importance of IT and digital health as key enabler for

PHM

• Develop understanding of critical role that data occupies throughout

PHM lifecycle

• Discuss key elements of IT infrastructure required to support PHM

• Describe Montefiore’s experience and approach to implementing and

integrating key IT solutions as part of its overall IT strategy

• Develop understanding of the pervasiveness of data and analytics as

part of PHM

3

Whole Person

Care Model

• Integrated Medical / Behavioral Health

• Supportive social and ancillary care coordination

• Episodic and Longitudinal Care Management

Clinical

Programs

• Focused clinical care designed to treat advanced

needs

• Cancer, Renal, Cardiac, Respiratory, Transplant, etc.

Network Care

Setting

• Acute care

• Sub-acute and post-acute care

• Transitions to home

Enabling

Technology

• Seamlessly connect providers, patients and

caregivers

• Consumer-centric platforms to improve

patient experience

PHM Foundational Architecture - Revisited

IT solutions will accelerate connectivity and transition to patient-centered care

4Member ProviderClinical Claims

Enterprise Electronic Health Record (EHR)

Healthy Planet PHM and Care Management

Analytics

EDW

IT and Digital Health Enablement at Montefiore

Automation

Layer

• Focused around patient,

not disease or condition

• Standardized processes

across programs

Consolidated

technology platform

Risk Programs

NextGenACO

Other Value-Based

Programs

• Health Homes

• Managed LTC

• Medicare Adv.

• Shared Savings

(Commercial)

• DSRIP

Identify & Prioritize

Enroll

Assess

(Baseline and ongoing)

Develop Personalized

Care Plans

Stratify into Programs

Monitor & Update Care Plans until Discharge

Consumer Engagement Tools

No single system is comprehensive

but Epic EHR offers opportunities to

achieve significant scalability and

standardization

5

IT and Digital Health Enablement at Montefiore

Core

Applications

Data

Inte

gra

tion L

ayer

Care

Management

Patient /

Caregiver

Engagement

Enterprise Electronic Health Record (EHR)

Network

Management

Utilization

ManagementTelehealth

Epic hospital data

exchange

Non-Epic hospital data

exchange

External Provider connectivity

Independent

MDs

Behavioral

Health

FQHCsCBOs

Member ProviderClinical

Business IntelligencePredictive Analytics

Performance/ Quality

Dashboards

AnalyticsOperational /

Regulatory Reporting

Claims

Data

Warehouse

EDW

6

Identify & Prioritize

Enroll

Assess

Develop Personalized Care Plans

Stratify into Programs

Monitor &

Update Care

Plans until

Discharge

• Dynamic assessment

functionality with branching

logic and decision algorithms• Robust data model to

accommodate structured

care plan with problems,

goals and interventions

• User access for multi-

disciplinary team across

continuum of care

Digital Health Enablement

Robust IT support required to enable seamless care coordination and task management

Patient

Primary CareProvider,

PCMH

• Analytical toolsets to predict, identify

and prioritize high utilizers of care

• Automated case creation and

enrollment into longitudinal or

episodic care coordination

• Automated surveillance and

management dashboards to

inform ongoing resource intensity

7

CMO

An evolving landscape of digital health technologies

Community-

Based

Organizations

(CBOs)

Integration of data and workflows across disparate entities remains significant challenge

Clinical

Delivery

Network

Patient Portals

Enterprise Data Warehouse

Tele-Health

Analytics

Care Management

EMR

8

CMO

Pushing boundaries with leading-edge IT solutions

Community-

Based

Organizations

(CBOs)

Incremental “point” solutions offer specialized functions to enhance core Epic EHR

Clinical

Delivery

Network

Technology Goals and Objectives

Diabetic Retinopathy Screening • Leveraging advanced medical equipment for screening & Ophthalmology follow-up

Population Health Management

Analytics Toolkit (3M)

• Real time analytical tools to alert PCPs and care managers about patient status, gaps in care, prioritized care

management workflow

Patient Engagement• Comprehensive member outreach tool leveraging integrated voice response (IVR), live calls and multi-media

messaging

Chronic Kidney Disease / ESRD

management

• Comprehensive patient identification, workflow and artificial intelligence platform for CKD, transplant, dialysis and

ESRD management

Telehealth for remote behavioral

health therapy

• Smartphone app, interactive voice response and videoconferencing tools to maximize resources and improve

between visit care

Community-based organization

(CBO) directory / referrals

• Enables ability to locate CBOs to match the needs of our patients (age, location, time of day)

9

Data and Analytics

10

Data and Integration Layer

Integration Layer

Data Sources Data AnalyticsData Integration,

Transport and Portals

• MMI/EMPI

• Data from any EHR

• Claims & payer

data

• CMS data

• Cost data

• Patient satisfaction

data (Press Ganey,

NRC)

• Medication

management/PBM

• Constellation:

Platform for

aggregating data

• Aggregation of:

CINs, ACOs,

Super-CINs

• Hadoop cluster for

large data sets

• Connectors for

local data

distribution

• Care Everywhere

• Community Connect:

PlanLink, CareLink,

HealthyLink

• Happy Together

• Web-deployed

longitudinal plan of care

• Quality dashboards

• Care manager web

portal to complete care

gaps

• Community-based

organizations (CBOs)

Epic hospital data

exchange

Non-Epic hospital data

exchange

External Provider

connectivity

Independent

MDs

Behavioral

Health

FQHCsCBOs

Care

Management

Patient /

Caregiver

Engagement

Enterprise Electronic Health Record (EHR)

Network

Management

Utilization

ManagementTelehealth

Member ProviderClinical

Business IntelligencePredictive Analytics

Performance/ Quality

Dashboards

Operational /

Regulatory Reporting

Claims

EDW

3M

11

Population Health Management Toolkit

• Access and EHR Integration to 3M’s 360MD-Patient Insights Technology

o Real time tools to alert PCPs and care managers about patient status, gaps in

care, prioritized care management workflow

o Coding Alerts with reports ad analytics

• Patient Identification and Risk Stratification criteria (CRGs)

• Service classification and preventable event identification (DRG, APG, PFP)

• Predictive analytics and intervention optimization (PHN, EHN, PPV, PPC)

• Care Manager and Care Team Roles Optimization

• Physician and Office Staff Engagement Resources

• Patient Engagement Strategies and Mobile support

• Quality and Cost Outcomes Measurement, Reporting and incentives (VIS)

12

13

Revenue

Management

Sample: HCC coding to classify appropriate patient intensity to support

appropriate revenue capture for Medicare Advantage and Exchange populations.

• Review patients with undocumented chronic diagnosis

• See patients historical diagnoses

3MSM 360eMD Patient Insights

14

Monthly Executive and Operational Dashboards

Capacity and

Throughput

Workflow Compliance

Data Quality

Legend• Monthly refresh enables benchmarking

• Macro and micro trend identification

• Proactive and predictive management