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Session 79 - How Accountable Care Organizations Can
Harness the Power of Health Data and Analytics
Farzad Mostashari, CEO, Aledade, Inc.
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Agenda • Overview of Accountable Care Competencies for Independent Physicians
– Practice Perspective – The Role of Health Data and Analytics
• 5 Key Competencies
– Quality Measurement and Improvement – Managing Attribution and Risk – Managing High Risk Patients – Transitions of Care/Emergency and Inpatient Utilization – Referral Management
• Data to Support Population Health
– Getting Practice Data – Getting HIE/Community Data – Quality Reporting and Practice Workflow
• Q&A
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Learning Objectives • Identify and address key challenges to harnessing health data and
analytics to support independent doctors focused on population health • Demonstrate potential of health data and analytics at point of care • Assess current landscape and potential for accountable care, especially for
independent physicians
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To Succeed in Accountable Care • Prevent Panel Churn • Measure and Improve Quality • Avoid preventable emergency room visits • Cut readmissions and post-acute days • Reduce acute episodes for high risk patients • Target high-value referrals
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Practice Perspective
For those in small independent practices, sometimes our world feels like this
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”Interop”- From Sneakernet to Live Data
Manual Data Extracts EHR Vendor Integration ”Connector” Agent
CCDA Claims(837) Appointments(SIU) Raw Data
Lightweight Data Normalization/Standardization
Data Consumed by Analytics and Apps
sftp (30)
vpn (21)
DIRECT (1)
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The Role of Data and Analytics Transformed into Action Example Annual Wellness Visits Patients prioritized on key factors: Drawing on multiple data sources:
- Time since last primary care physician visit
- Potential for under-coded chronic conditions
- Potential to benefit from care coordination
- Upcoming appointments scheduled
- Claims reports (practice)
- Upcoming appointment list (practice)
- ADT feeds (hospital)
- Medicare patient list (practice)
- CCD from EHR (practice)
- Monthly claims reports (CMS, starting 2015)
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Panel Churn–Managing Attribution and Risk Workflow Competencies • Patient Outreach and Recall • Patient call lists • Appropriate risk coding • Wellness Visit EHR workflow
Data and Analytics Needs • Patient diagnoses • Practice claims and/or CCDA • Risk stratification • Coding opportunities • Patient prioritization
Challenges • Getting data • EHR optimization • Shifting schedule capacity focus
Annual Wellness Visits with Aledade Intervention
Data are for Aledade Delaware and Primary Care ACOs. AWV is number of Medicare AWV claims; AWV payments is total Medicare payments for AWV Claims. Source: Medicare Claim and Claim Line Feed data.
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Quality Improvement/Measurement Workflow Competencies • Capture clinical quality measures
• ID and mitigate care gaps
• Care management for high risk
• Provider training
Data and Analytics Needs • Clinical data interfaces at practice
level
• Terminology mapping
• Data normalization
Challenges • Workflow adherence
• Vendor CCDA limitations
• Integration speed and costs
• Workflow integration ACO->EHR
Pneumococcal Vaccination with Aledade Intervention
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Reduce Acute Episodes for High Risk Patients
Workflow Competencies • ID and monitor chronic patients
• Dedicated chronic care management
• ID increasing spend
• Comprehensive care plan
Data and Analytics Needs • Cohorting
• Risk scoring
• Event Surveillance
• 360 Claims Feed
• ADT Feeds
Challenges • Practice resources to provide care
management
• Hospital Data Feeds
• Tracking CCM time
• Shared care plans
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TOC – Cut Readmissions and Post-Acute Days
Workflow Competencies • Patient Outreach and Recall
• Tracking TCM Visits
• Convincing some patients to come in
Data and Analytics Needs • ADT Hospital Feeds
• App for notifications
Challenges • Getting data
• TCM Workflow Tools
0%
5%
10%
15%
20%
25%
30%
35%
1 2 3 4
Rea
dmis
sion
(%)
Patient Risk Category (Predictive Model)
No TCM With TCM
Aledade Transitional Care Management Impacts 30-day Readmissions (n=3,274 Medicare Discharges)
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Avoid Preventable Emergency Room Visits Workflow Competencies • Schedule Access
• Provider Availability
• Patient Outreach
Data and Analytics Needs • ADT Hospital Feeds
• % ED Visits During Office Hours
Challenges • Practice Change
• Patient Education
Preventable ED%
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Target High Value Referrals Workflow Competencies • ID Preferred providers
• Provider Availability
• Patient Education
Data and Analytics Needs • Cost, Utilization, and Quality Data
for downstream providers
Challenges • Determining quality, tiering
• Getting commercial cost data
• Availability of alternatives
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Clinical Data Integration (C-CDA)
Support C-CDA Manual Batch Export Less than 1/3 of EHR vendors provide practice staff the ability to export in bulk C-CDA XML data portability documents at the point of care
Support Outbound C-CDA Automation Only 2/3 of EHR vendors have the capability to generate and transmit C-CDA documents after a visit without manual intervention from the provider
3 Year Median Cost of Ownership Based on 11 representative vendors, the median 3 year total cost of ownership of a C-CDA interface is $7,500 for a 3 provider practice. Costs range from $200 to as much as $58,000 per vendor.
28% 68% $7,500
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Clinical Data Availability
High Availability • Problem List
• Medications
• Allergies
• Tobacco Use
• Vitals
• Immunizations
Frequently Unavailable • Diagnostic imaging / surgical
procedure orders and results • Lab results with LOINC codes • Health Maintenance
Documentation
Extremely Low Availability • Preventive Screenings (Fall Risk
and Depression Screens)
• Counseling and Patient Education
• Specialty Referrals
Key clinical data for population health management aren’t always available in a structured format with the C-CDA interface
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HIEs and ADT Alerts
States where community-based HIEs are offering ADT alerting services
9 of these HIEs can provide ADT alerts in near real time (w/in 1 hour of the event)
2 can provide ADT alerts from all hospitals in the state
Percentage of ED visits with alerts when a patient panel is used for matching v. provider NPI Providers receive alerts on a greater proportion of ED visits when ADT data is matched on patient demographics rather than provider NPI
Most common patient panel demographics requested by HIEs: • DOB • First and last name • Gender • Address • Phone • SSN • Medicare ID
Cost per patient per month for ADT panels Matching ADT feeds with patient panels often incurs a fee for each person on the panel
Before ambulatory providers may receive alerts, most HIEs also require them to become HIE participants, which often involves separate fees
11 of 11 87% v. 63% $0-$.12
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Practice EHR/PM Integration
The Good • Best (and worst)
experiences with VARs • On premise often easier to
implement than cloud vendors
• Shortest implementation=3 weeks
• Using 3rd party agent works
The Bad • Typically 6-9 months from
first contact through contracting to go-live with dedicated project management.
The Ugly
29 Vendors, ~115 Practices
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• Farzad Mostashari, MD [email protected] @farzad_MD • Edwin Miller, MBA [email protected] • Paul Kleeberg, MD [email protected]