Building an Effective Population Health Team: Stepping towards

the Triple AimAmy M. Sitapati, M.D.

Chief Medical Information Officer of Population HealthClinical Professor Department of MedicineUniversity of California San Diego Health

2

UC San Diego Health

AGENDA• The triple aim as it pertains to Population

Health• Roles, Team, Oversight and Governance• Scaling for value in the MACRA era• Continuous cohesion – gluing together

programs and resources

Culture, Incentives, Leadership, Management, Business Model,

Structure – Tackling local problems to build outcomes, operations, and

infrastructure

Image: Sandiego.org

Operational

Reporting Application

4

Working Towards the Triple AIM-Improving

www.ihi.org

• Identifying At-Risk Patents: highest risk for poor outcomes

• Decision Support Tools: Predicting Risk, Identifying Care Gaps, and Prioritizing Decisions

• Reducing Provider Overload: highlighting salient data

• Point of Care Trials: eligibility at the point of care

• Living Clinical Guidelines: sound practice evolving to accommodate new clinical knowledge

• Insights in Dirty Data: use large data sets to impede findings

S. Klein and M. Hostetter: The Commonwealth Fund, Sept 2013 

5 J. Collins, Good to Great

POP Health Tools

The Learning Healthcare System MEETS Good to Great!

• Care Management (Outreach Navigator)• Risk Acuity (Predict Risk)• Provider Decision Support (Disease Based Print Group)• Patient Centered Goals (Include Patients in their Care

MyChart)• Performance Review and Accountability (Dashboard)

6

Making Population Health Work:

Data Driven Decision

s

Patient Engage

Provider Decision Support

Multi‐Disc. Team Care

RN Protocols

High Risk Program

Sophisticated HealthMaintenance

Smart/DynamicOrder Sets

Print GroupsSummary

Radar

Benchmarking

Gap Analysis

Call Lists

Televox

EMMI (in progress)

Bulk message and order

Registry based chronic disease management

Risk assessment

Slicer Dicer

Business Objects

IntegratedExternal Data

The STORY of our Journey Includes:

Sisters Jewel Thief Superheroes!Image: Pinterest

Population Health Team

Our Visionis to deliver outstanding population health through innovative use of the electronic health record

Our Mission is to create a healthier population through:· Actionable patient registries · Operational reporting for patient care and coordination· Tools that help patients and providers achieve health goals· Population-based performance measurement and quality improvement

39 Active Patient Registries (10/16):

Active PatientsWellness by age (3)Primary Care

AnticoagulationCardiovascularChronic KidneyDiabetesHeart FailureHypertensionHIVObesityPre‐DiabetesSleep Apnea

EmergencyInpatientTotal Joint

AnthemHealthNetMolina, etc.

12 Thousand Patient Messages 2nd quarter 2016

More Efficient and Direct Care Delivery

• Develop Operational Teams that can implement change with accountability and governance

12

“who” Two Core Concepts for PEOPLE:

• Technical Teams should be cross-fit and diversely functional responsive to the operational needs

Governance “who decides”

Partial Overview of Governance“who decides”

PRIME Executive

PRIME Steering

Workgroups

ACO/RISK Executive

ACO Steering

Workgroups

CIN Executive

CIN Steering

Workgroups

Medical Group Quality

Division based QM & Managed Care Teams

Quality Council(Operations)

Physician Led ChampsBy domain area

UCI/UCSD Executive

Workgroup Steering

Workgroups

IS Clinical Council (Coming Soon)

Physician Informatics

Workgroups

Information Services Executive (IS)

Health Care Reform

0123456

Level

Level

16

Work on the right projectsConsider a matrix scoring

Average registry or risk score might take $50-100k

Level Patient #Healthcare worker # FTE Safety Quality/Value

Incentive/Risk ($)

1 <100 <50 Minimal Harm <5% or <25th % <1 k2 101‐1,000 50‐200 Mild Harm 5‐10% or 50th 1‐10 k3 1,001‐10,000 201‐500 Moderate Harm 11‐15% or 75th 10k‐100 k4 10,001‐100,000 501‐1,000 Significant Harm 16‐20% or 80th 100,k‐ 1 m5 >100,000 >1,000 Catastrophic >20% or 90th % >1m

Try to prioritize projects“what matters”

Scaling for Value with Forward Vision

PRIME P4P PQRS ACO & MSSP

Other

GE healthcare

Developing the Organizational Teams to Deliver better Care

18

Utilize Successful Change Model8 Stages of Change, Kotter

Establish Urgency

Create a Guiding Coalition

Develop a Vision and Strategy

Communicate the Change 

Vision

Empower a Broad based 

Coalition

Generate Short Term Wins

Consolidate Gains & Produce More 

Change

Anchor the New Approach in the 

Culture John Kotter, Leading Change.Harvard Business Review Press. 2012

20

Operational: Supersize the Stakeholders:

expert to front line

A. Division Lead MD: Endo/MetabolicB. Primary Care Lead MDC. Managed Care RND. Pre‐diabetes stakeholder/sE. PharmDF. Diabetes EducatorsG. Patients/MyChart

Diabetes Educators

Pharmacists

Superheroes! Develop technical teams that excel.

EpicCare AmbulatoryEpic Inpatient

MyChartCadence

Healthy Planet

ClarityCrystalReporting WorkbenchRadarCaboodle/Star

Span the Clinical and Reporting Department/s

Physician Led: CMIO Population HealthClinical Analyst, Registry Reporting AnalystReporting Analyst, CIN Reporting Analyst

Clinical Systems  Reporting

Blended Teams: constant evolution

Model “Swiss Cheese” –Integrated Pop Health Team

Population Health

Patient Portal /Ambulatory/HM

Managed Care/Care 

Coordination

Dashboard & Reporting

Registry & Operational Reporting

Integrated Data Warehouse

Building an Olympic TeamNeed good structure!

Using version of Agile Scrum Methodology to share work

2 week SPRINT: Starts Fridays

(QOF)Finish line and Start line for

projects

FINISH LINE: 10 min demo of DONE each

analyst

START LINE: 1 hour of Project Planning

28

A Shared active work board for project work –SWIM LANES for active work

• 2012: Registry: shared with inpatient Report writer duties and HIV clinic had a demonstration project then expanded to ambulatory report writer

• End of 2014/2015: Approval for 2 new resources & Core team constructed, some turnover, Dr. Sitapati appointed

• Mar 2015: Pop Health 22 week install

• Jan 2016: ACO – 2 resources

• Fall 2016: Working on UCI – our instance of Epic – no new

• Summer 2017: CIN Pop Health solution in Epic

29

Team evolved from little…

2012 2014 2016

ACO

2015

Team Launched

2 new resources

2017

CIN EpicRegistry UCI

Sisters: Find new collaborators and partners

UC San Diego Clinically Integrated Network

Jewel Thief! Seek experts that you wouldn’t usually partner with

Leverage robust Research Infrastructure including-OMOP-Data Harmonization Experience

-Relationships

32

Challenges: Lots of Work! Needs

prioritization, vision, and strategy!training,

project management, right sizing,

organizational structure with growth, talent,

lexicons,clinical and technical

overlap

Value in patient outcomes:

UCSD Medical Group 2013 – 2015 Performance/Cost

2013

2014

2015

PQRS2015 Results

34

PQRS2015 Results

35

PQRS GPRO Measures 2014 Rate 2015 Rate YoY Change

IVD User of Aspirin 87.43% 83.39% -4.04%

CAD-7 ACE or ARB Therapy 85.17% 84.03% -1.14%

HTN-2 Controlling High Blood Pressure 63.67% 62.79% -0.88%

PREV-12 Screening for Clinical Depression and Follow-Up Plan 22.83% 22.15% -0.68%

DM-2 A1c >9% Poor Control 11.59% 11.04% -0.55%

PREV-10 Tobacco Use Screening and Cessation Intervention 94.14% 94.29% 0.15%

PREV-5 Breast Cancer Screening 75.25% 75.82% 0.57%

PREV-7 Influenza Immunization 71.50% 72.21% 0.71%

CARE-2 Screening for Future Fall Risk 98% 99.51% 1.46%

PREV-9 BMI screening and follow-up plan 53.09% 55.14% 2.05%

HF Beta-Blocker Therapy for LVSD 94.67% 97.75% 3.08%

PREV-8 Pneumonia Vaccination 77.36% 81.37% 4.01%

PREV-6 Colorectal Cancer Screening 58.52% 65.63% 7.11%

PREV-11 Screening for High Blood Pressure and Follow-up Documented 26.43% 38.50% 12.07%

CARE-3 Documentation of Current Medications in the Medical Record n/a 81.33% N/A

DM-7 Diabetes Eye Exam n/a 50.33% NEW

MH-1 Depression at Twelve Months n/a 23.53% NEW

36

Clinical Domain Score 37.39/100

P4P MY2015 Clinical Results

Achieved Some Quality

Points

Achieved Some Quality

Points

Achieved Max Quality Points

Achieved Max Quality Points

Measure Name MY2014 75th Percentile

MY2014 95th Percentile

MY2014 Rate

MY2015 Rate

YoY Delta

Chlamydia Screening: All Ages (16-24) 64.01% 72.76% 78.21% 77.66% -0.55%Diabetes Care: HbA1c Control < 7.0% 41.80% 51.72% 49.75% 52.18% 2.43%Diabetes Care: Medical Attention for Nephropathy 90.91% 94.22% 94.07% 96.43% 2.36%Optimal Diabetes Care--Combination 32.17% 40.80% 47.12% 49.21% 2.09%Diabetes Care: HbA1c Poor Control > 9.0% 23.42% 15.45% 13.34% 10.12% -3.22%Colorectal Cancer Screening: Ages 50-75 73.72% 79.97% 79.48% 79.15% -0.33%Diabetes Care: HbA1c Control < 8.0% 64.53% 73.89% 72.98% 69.84% -3.14%Breast Cancer Screening: Ages 52-74 84.18% 88.91% 83.84% 86.50% 2.66%Human Papillomavirus Vaccine for Male Adolescents 21.72% 29.26% 15.38% 22.22% 6.84%Evidence-Based Cervical Cancer Screening - Appropriately Screened: All Ages (24-65, 67+) 63.64% 85.58% 70.51% 71.35% 0.84%

Childhood Immunization Status: Combination 3 80.88% 89.57% 64.20% 71.93% 7.73%Asthma Medication Ratio: All Ages (5-64) 85.68% 96.09% 76.80% 80.29% 3.49%Diabetes Care: Two HbA1c Tests 64.41% 81.26% 61.78% 63.49% 1.71%Use of Imaging Studies for Low Back Pain 87.10% 91.89% 81.44% 82.22% 0.78%Avoidance of Antibiotic Treatment for Adults With Acute Bronchitis 63.83% 84.42% 60.61% 47.37% -

13.24%Annual Monitoring for Patients on Persistent Medications: Overall 87.93% 91.85% 82.93% 79.25% -3.68%Diabetes Care: Blood Pressure Control <140/90 mm Hg 70.16% 85.04% 71.17% 68.06% -3.11%Controlling Blood Pressure for Non-Diabetic People with Hypertension: Ages 18-85 66.06% 84.92% 73.13% 64.07% -9.06%Human Papillomavirus Vaccine for Female Adolescents 30.67% 39.31% 29.31% 28.57% -0.74%Immunizations for Adolescents: TD/Tdap 90.34% 93.92% 89.32% 88.07% -1.25%Proportion of Days Covered by Medications: RAS Antagonists 75.05% 80.74% 71.13% 70.70% -0.43%Proportion of Days Covered by Medications: Oral Diabetes Medications 69.83% 77.66% 61.12% 61.41% 0.29%Proportion of Days Covered by Medications: Statins 69.36% 76.23% 66.77% 66.78% 0.01%

37

MUHIT Domain Score 86.82/100

P4P MY2015 Patient Experience & Meaningful Use Results

Patient Experience Domain Score 25/100Measure Name

MY2014 75th

Percentile

MY2014 95th

Percentile

MY2014 Rate

MY2015 Rate YoY Delta

Doctor-Patient Interaction Composite 80.90% 84.67% 84.21% 81.30% -2.91%Coordination of Care Composite 63.38% 68.21% 68.35% 65.55% -2.80%Overall Ratings of Care Composite (Rating of Doctor & Rating of All Healthcare) 70.79% 75.30% 75.98% 73.21% -2.77%Health Promotion Composite (One-Year) 64.96% 71.52% 65.49% 59.46% -6.03%Office Staff Composite 72.92% 76.74% 74.85% 69.82% -5.03%Timely Care and Service Composite 59.96% 64.42% 55.55% 55.69% 0.14%

Measure Name MY2014 Rate MY2015 Rate YoY Deltae-Measure: Controlling High Blood Pressure 67.85% 58.10% -9.75%e-Measure: Controlling High Blood Pressure (Percent Reportable) 100.00% 90.91% -9.09%e-Measure: Screening for Clinical Depression and Follow-up 19.15% 3.57% -15.58%e-Measure: Screening for Clinical Depression and Follow-up (Percent Reportable) 100.00% 90.91% -9.09%Percent of Providers Paid Meaningful Use Incentive by Medi-Cal or CMS 97.65% 86.00% -11.65%

Achieved Some Quality

Points

Achieved Some Quality

Points

Achieved Max Quality Points

Achieved Max Quality Points

• Defining modifiable factors that occur before new EVENT OUTCOMES through chart review

• What do I predict?

38

RESEARCH PROJECT

Source: Healthcare Information and Management Systems Society (HIMSS) Conference 2014, Annual Conference and Exhibition

Active in healthcare system 

Disease/ risk factor recognition

Disease/ risk factor control

Disease/ risk factor treatment

CARE GAPS IN CVD RISK MANAGEMENT

Missing visitsMissing lab tests

Pill burdenCompliance

Tailoring Adequate dosing

New CVD events might be targeted by improving:

1. Failure to start treatment on diagnosed patients.

2. Under‐diagnosis of hypertensive, diabetic, and/or dyslipidemia patients

3. Achievement of LDL goal

4. Missing care visits and missing lab data

5. Facilitating workflow of clinicians at the right time

6. Improve continuity of care. 

Become by intersecting , with , and

PASSION

BEST in the world

Makes/Saves Money

J. Collins, Good to GreatA. Flynn et.al. Tell it Like it Seems 2015.42

15% Healthcare spend is waste

Aim for high quality

Our passion is to change patient lives

UC San Diego HealthAmy Sitapati, MDContact Phone: 858-249-0112Email: asitapati@ucsd.edu