Technologies Needed to Support the Payer, Provider and Patient Associated with New Care and Payment Models

(current and future)

April 12, 2015

Paul Oates, FHIMS Senior Enterprise Architect

Cigna DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest Paul Oates Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Collaborative Accountable Care

What is Cigna Doing?

• There are now 114 Cigna Collaborative Care arrangements with large physician groups in 28 states.

• These programs encompass:

– More than 1.2 million commercial customers

– 48,000+ doctors, including:

• 23,000+ primary care physicians

• 25,000+ specialists

http://newsroom.cigna.com/KnowledgeCenter/ACO/

Results

Capabilities to Support New Reimbursement Models

Connectivity Data Aggregation Analytics Care Coordination

Multiple channels to connect workflows using transmission standards (e.g. HL7)

Def

initi

on A set of tools that

allows clinical and administrative data from many sources to be translated and stored in the usable format

Actionable information and reports to assess performance against triple aim targets

Workflow tools that will allow a care plan to be shared across multiple entities and share work tasks across the continuum

Cha

lleng

es In spite of HITECH

and MU, still very difficult and not repeatable. Movement to private HIE patterns

Difficult to aggregate claim/admin and clinical info accurately

Variety: - MA vs. Commercial - Quality vs. Cost/Util Content: - Risk adjustment - Measures

Few standards or capabilities that enable task sharing across stakeholders

State of the art 2015: telephone and email

EMR: opportunity to step up

Customer Engagement

Tools that offer transparency to customers’ clinical data and care plan as well as tools to help with education and engagement

Digital revolution is both a blessing and a curse, because of the number of options. Customer control is nascent. But it’s coming!

Mgmt. Services

Services provided to enable successful risk management

Changing process is hard, sometimes need 3rd party help or trusted relationships And Diffculty of divvying results

Network

Benefits

Administrative and Risk Platforms

Process Change

Note – Courtesy of Cigna

% Consumers saying “Sure, I’d do that” to new access and care venues that today generate big provider revenues

At home

1. PwC’s Health Research Institute survey of 1,000 U.S. adults representing a cross section of population by age, gender, income and geography – 12/2013

59%

Strep test

$150M

Wound care

$796M 49% 55%

Photo for dermatologist

$358M

42%

Urinalysis test with phone

$694M

44%

ECG with phone

$2.9B

43%

Pacemaker evaluation

$110M

37%

Chemotherapy

$3.3B

26%

Dialysis administration

$1.9B

34%

MRI

$11.6B

Retail clinic Via smartphone

Lessons Learned

• It’s all about data • Process and measures change is hard: being happy without heads

in beds • Don’t forget there is a customer that will eventually dictate • Partners – it takes a village • Test and learn – work our way up a maturity curve • A full technology suite is very expensive, but not as expensive as

failed assessment of risk • EMR role is point of care data collection and task management.

Open up integration to enable this.

Technologies Needed to Support the Payer, Provider and Patient Associated with New Care and Payment Models

(current and future)

April 12, 2015

S. Shafiq Rab, M.D., MPH Vice President and Chief

Information Officer DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest S.Shafiq Rab, MD, MPH Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Hackensack University Medical Center • Nonprofit teaching and research hospital in NJ

• 1,727 beds, nearly 10,000 employees and 3,359

credentialed physicians.

• U.S. News & World Report - #1 hospital in New

Jersey and Top four New York metro area

• Healthgrades®

• America’s Best 100 Hospitals in 10 areas – most in

the nation

• America's 50 Best Hospitals™ for seven years in a

row

• Distinguished Hospital Award for Clinical

Excellence™ 11 years in a row

• Leapfrog

• Top Hospital

• Joint Commission

• 19 Gold Seals of Approval™ most in the country.

• Magnet®

• First hospital in New Jersey and second in the

nation

Hackensack Physician Hospital Alliance ACO – Started in March 2012 • Partnership between Hackensack University Medical Center and ~120

Affiliated, Independent Community Providers

• Fee For Value Contracts

• MSSP ACO – Achieved Shared Savings in PY1 - $10.75M

• Blue Cross ACO

• Aetna Medicare Advantage

• Adding Three More Contracts

• Care Coordination Strategy

• Inpatient Navigators

• Ambulatory Care Coordinators

• MA’s/Transition Assistants

• NCQA Certified ACO

Hackensack University Health Network

Allspire Health Partners

• 7 Health Systems with 25 hospitals

• Health Systems remain separate entities

• Combined revenue of $10.5 billion

• Largest health care consortium in the

country

• Focus on population health and group

purchasing

• Service area of more than 9 million

people

• $7 million invested to form alliance

Merger with Meridian – Hackensack Meridian Health

• “Committed to implementing

innovative models of care”

• “Garrett said the success of the two

ACO’s provides evidence of their

commitment to transforming health

care”

• “We are in the minority in the country

of ACOs that have actually worked.”

• “We are both trying to develop

significant infrastructures for

population health”

Capabilities to Support New Reimbursement Models

Note – Courtesy of Cigna

Capabilities to Support New Reimbursement Models at Hackensack University Medical Center

Note – Courtesy of Cigna

Capabilities to Support New Reimbursement Models at Hackensack University Medical Center

1) Patients are Number One and Are the Center of All Efforts!

2) We have a passion for what we do

3) Doctors truly believe that we can impact healthcare outcomes

4) We Believe in Patient Participation and Patient Engagement Including Patient Family

5) The Care Model / Payment model is important but the Patient and the outcomes come First

The HackensackUMC Main Ingredients (Recipe) - What we Care About

The HackensackUMC Recipe

1) Less Days in Acute Care Setting

2) Less Days in Skilled Nursing Facility

3) Patient Adherence to Medication Regiment and PCP visit schedule

4) Engaging Patients to Understand Their Own Symptomology and their Care options

5) Active Care Coordination Tools and Active Care Coordination TEAM

The HackensackUMC Mix Using the ingredients above:

1) We Enable Providers and Patients to Work together as a TEAM 2) We Tighten Integration Across The Entire Continuum of Care 3) We Create a Unified View of the Patient and Their Care 4) We Manage the Actions That Improve Outcomes and Reduce Costs 5) Interconnect all aspects of the patient’s care via integrated interoperability

a. Using the technologies and tools below to achieve standardization i. PCMH Certified Practices ii. Practices with ONC Certified EHRs iii.Standard Order sets iv. Standard Care plans v. Standard Protocols (HL7 & FHIR)

Inpatient EHR

Ambulatory EHR

Interface Engine

Private HIE

Public HIE

Integrated Lab Results Nursing Homes

Ambulatory EHR (Community)

Active Care Coordination Tools

Management Tools

Analytics Tools

Tablets & Mobile Devices HealthKit

Risk Stratification Tools

HackensackUMC has been ahead of

the curve by strategically planning

and preparing for the new and

emerging care models for many

years

The HackensackUMC Gravy

Technology Lessons Learned from Setting Up IT Infrastructure for ACOs and other “Fee For Value” Initiatives • Need to have one platform to manage all “Fee For Value” Initiatives and agreement on Care

Coordination Workflow Goals – Need commitment to “Active Care Coordination” – Currently at 4

contracts and growing

• Need to have a “Unified Coordination Plan” agreed to by all Fee For Value Participants across the

Continuum of Care

• Need to Engage Patients in Their Own Care

• Data from Claims Based Analytics is too late to be effective in provider workflow

• Lack of IT infrastructure between ecosystem providers (e.g. Transition of Care)

• Many physicians are in the process of changing EHRs or don’t have an MU 2 certified EHR

• Not all EHRs can generate an automated CCD or C-CDA

• Most EHRs do not have all the fields for ACO and other “Fee For Value” Quality Metrics (e.g. Falls

Risk, Depression Screen)

• Tasks generated within EHRs are not Care Coordination workflow across the Care Continuum

• Currently need both a Private Health Information Exchange (HIE) and a Regional Health Information

Exchange (HIE)

• Need to Implement FHIR