Analytics to Action

2013 Institute for Quality Leadership

Annual Conference

September 2013

Analytics to Action

How to Stay Ahead of the Cost Curve

Analytics to Action

Wendy Oberdick, MD

Family Medicine Board Certified

Joined HMG November 2010

Medical Director

HMG Patient-Centered Medical Home

HMG Value Based Operations

Co-Medical Director

ACO - Qualuable Medical Professionals

Analytics to Action

Jason Tipton, MBA

Joined HMG July 2012

Director of Informatics

HMG Decision Support

HMG Analytics

Chair of Data Aggregation & Analytics

ACO - Qualuable Medical Professionals

4

5

6

The correct answer is:

Open the refrigerator, put in the

giraffe and close the door.

This question tests whether you tend to do

things simple or in an overly complicated way.

7

8

The wrong answer is:

Open the refrigerator, put in the

elephant and close the door.

This question tests your ability to think

through the repercussions of your actions.

The correct answer is:

Open the refrigerator, take out the

giraffe, put in the elephant and close

the door.

9

10

This question tests your memory.

The correct answer is:

The elephant. The Elephant

is in the refrigerator.

11

O.K., even if you didn’t

answer the first three

questions correctly you

still have one more

chance to show your

abilities.

12

13

Correct answer:

You swim across. All the

crocodiles are attending the

Animal Meeting.

This question tests whether you

learn quickly from your mistakes.

14

Analysis:

Approximately 90% of adults

tested get all the questions wrong.

But when Kindergarten students

were tested, they answered several

questions correctly.

What did we learn?

Analytics to Action

How to Stay Ahead of the

Cost Curve

Analytics to Action

Holston Medical Group - Overview

Established in 1977

Multispecialty, physician-owned group

8 principle sites

150 primary care physicians, specialists and mid-

level providers

200K patient population

Analytics to Action

Analytics to Action

Core Belief: In the changing world of Healthcare, organizations that can stay

ahead of the curve will succeed. The problems arise in identifying the curve,

understanding what that means, identifying the changes that must take

place, deploying the resources to make the change and measuring if the

change is successful.

One of the first questions we at HMG had to ask ourselves is “Can we get there from here?”

The obvious answer was “NO”.

“Insanity: doing the same thing over and over again and expecting different results. &

Without changing our patterns of thought, we will not be able to solve the problems that we created with our current patterns of thought.” Albert Einstein

Analytics to Action Paradigm Shift

Definition of an Organizational Paradigm Shift:

Fundamental change in an organization’s view of how things work .

Analytics to Action Audience Interactive Activity #1

Questions to answer

Who (or what) is driving your organization?

Do you “do” data?

What data is more important: Clinical or Financial?

Are you more data reactive or data proactive?

This determines where you are in the curve.

Who (or what) determines the majority of your encounters?

Do you control the direction of your organization?

Analytics to Action Paradigm Shift

Goal – Answer the following 4 questions

Do you know your population?

Have you developed your assets?

Does your workflow support performance?

Can you measure your compliance?

Analytics to Action

How to Stay Ahead of the Cost

Curve

Do you know your

population?

Have you developed

your assets?

Does your workflow support

performance?

Can you measure

your compliance?

Analytics to Action

Do you know your

population?

Step 1

At HMG we looked at 3 determining factors for our population: Population Demographics vs. Population Characteristics Population Risk Levels (i.e. population stratification by chronic conditions) Population by Contract

Commercial Medicare Advantage Medicare/Medicaid

Analytics to Action

Do you really know

your population?

Analytics to Action Population Demographics:

Approx 500,000 people in the region (3% growth rate)

Median Age of 44 20% over 65 20% under 18

94% of the population is Caucasian Gender: 55% Female, 45% Male Median Income $25,194 17% below the poverty line

24.9% under 18 13% over 65

Employment: Private – 82% Government – 10% Self-employed – 8%

Population Characteristics:

70% Urban, 30% Rural Majority do not leave area where

they were born. 98.4% drive to work

Independent Small town USA attitude 25% have a college education 18% have less than GED Employment: 50/50 split between

white & blue collar. Life Expectancy – 75.4 years Factors of Death:

19% Tobacco Use 14% Diet/Activity 5% Alcohol

VS

Population Risk Stratification by Chronic Condition

STEPS • Identify a list of specific

conditions to apply to patient population

• Identify a specific timeframe to query population

• Get a distinct count of how many conditions each patient has diagnosed in history

• Apply logic based on how many conditions are diagnosed as to risk level associated with each patient

Chronic Condition

% of Prevalence in

Total Population

HTN 34.6%

Diabetes 18.2%

Depression 17.6%

Asthma 14.0%

CAD 5.5%

COPD 4.6%

Osteoporosis 3.8%

AFIB 2.0%

Gout 1.7%

Kidney Dysfunction 1.7%

Pneumonia 1.7%

CHF 1.6%

Osteoarthritis 1.2%

Stroke 0.9%

ASCVD 0.8%

MI 0.1%

Schizophrenia 0.1%

Population Risk Stratification by Chronic Condition

• This process allowed for immediate action on Level 3 patients • Since the Level 3 patients are a small segment of the population, a manual

chart review on each patient was performed to identify care gaps and needs. • Level 2 patients are actioned by those with the highest chronic count

including Hypertension and Diabetes.

Population by Contract

Analytics to Action Lessons learned from Population Analysis:

Patient outreach needs to be local where trust can cultivated between doctor and patient.

Outreach needs to be simple and consistent.

High risk patients, regardless of insurance, need to be addressed repeatedly with higher level of care.

Chronic Conditions of Hypertension, Diabetes and COPD need a more dedicated focus and plan of action.

Patient’s behavior needs to change to more proactive approach where a hospital admit is not the 1st step in their medical care.

Analytics to Action

One of the next questions we at Holston had to ask

ourselves is “Where do we focus first?”

The obvious answer was “Where we can make a difference.”

“When eating an elephant, take one bite at a time. 4 star Army General Creighton Abrams

Analytics to Action

Who (or what) determines the majority of your encounters? BEFORE – uncontrolled patient flow with complete

seasonal variance AFTER – structured patient flow driven by care

models and decreasing seasonal variance

Are you data reactive or data proactive?

BEFORE – data reactive and dependent on payor format

AFTER – data proactive and building independent care models to decrease cost and improve quality

Who (or what) is driving your organization?

BEFORE – no one = retail business model AFTER – internal Data Mining to identify target

patient groupings

Analytics to Action

Have you

developed your assets?

Step 2

What resources are needed to affect the level of change desired?

Analytics to Action

Audience Interactive Activity #2

Questions to answer

Who (or what) are the top 3 focus points of your organization?

What do you measure?

What do you repeat?

How do you determine your organization’s needs and match resources ?

Analytics to Action Scope Iceberg Typical Action Typical Roles

Events – what we see happening

Tip React & Respond Firefighter, Impatient leaders

Trends – what has been happening

Just under the surface

Anticipate, Plan and Prepare

Architect, Contemporary Leader

Structure – why is it happening, how and what is the thinking that created it

At the Core Design, Create, Reengineer,

Innovate

Planner, Innovator, Designer, Servant Leader

Analytics to Action

Resource Preparation

Visualize the End Product

Asset Evaluation

Determine Change “agents”

“Low Hanging Fruit” first

Driver Diagram

Coordina onofCare

IncreasePa entCompliance

DecreaseHighCostSpend

ImprovePopula onWellness

AIM PrimaryDrivers SecondaryDrivers Interven ons

ClinicalWorkflows

StrategicOutreach

Predic veAnaly cs

TeamAc va on

ConvenientAccess

InformedDecisions

AccurateCarePlans

SOPs

Ac onLists

Pa entStra fica on

Educa on

ExtendedServiceLines

Team-basedCare

PerformanceImprovement

Transi onofCare

Diagram1–DriverDiagram

HMG Needs:

Improved technology to identify needs and

improve patient care.

Improved technology to measure success

and reduce cost.

Services to address high risk population

needs.

Analytics to Action

Analytics to Action

Diagram'8'–'Subcontrac1ng'Management'and'Procurement'System'Model'

HMG IT Landscape EMR: Allscripts Enterprise

Practice Management: GE Centricity (changing to Allscripts PM in 2014 1st Qtr.)

Data Mining & Analytics Tools: Humedica MinedShare

Precision BI by Origin Healthcare

OnePartner ATAC datacenter

www.onepartnerhie.com

Tier 3 Data Center

Health Information Exchange

Population Health Tool Sets

dbMotion

EHR Agent

Collaborate Engine

Performance Clinical Systems

Quire

Diagram11–HITImplementa onPlanModelDiagram

Professional Health Information & Analytics Exchange

One Partner Architecture Professional Health Information & Analytics Exchange

Quire – Population

Management

• Population Management Intelligence Tool

• Applies artificial analytics intelligence and queries to extract actionable health information from unstructured text in medical records.

• Population Management Activities:

• Identification of pre-diabetics

• Risk stratification of patients with multiple indications

• Highlighting patients who would benefit from a new standard of care

HMG has developed 2 program services that are designed to

improve patient centered quality for High Risk patients at a

reduced cost - Alternative Outreach Services (AOS) and

the Extensivist Clinic (e-clinic).

These services offer non-traditional opportunities for patients

to be taken care of in an outpatient setting and have patient

care and convenience at the core of their design.

Analytics to Action

Alternative Outreach Services

(AOS) –

Utilizes Nurse Practioners and

Providers

Reaches out to provide full

service healthcare for highest risk

patients

Proactively treats high risk

patients in facilities, at home and

includes end-of-life transitions

Analytics to Action

Extensivist Clinic –

Transitional high acuity care clinic

Care team includes:

ICCAs

C3s

Infusion services support

“Extends the walls” to stage appropriate care plan strategy

Analytics to Action

Analytics to Action

Does your workflow support

performance?

Step 3

Are your processes built to succeed?

Analytics to Action

Audience Interactive Activity #3

Questions to answer

How do you engage providers and support teams to determine and develop workflow?

Do you use “just in time” tools?

Do you develop performance support mechanisms?

How do you measure the change going forward that you determine is necessary and then effect?

• Primary Care Physician

• Specialists

• Hospitalists

• Transitional Care Team

• Extensivist Clinic

• Adopting “best practice”

• Performance Potential

Analytics to Action

Building a functional team:

Load%%%%%Drive%

&/or

PCS

Patient

Eval

Compliance

Hospital

Facility

Home Care

Acute Observation

Infusion Center/Post

discharge clinic

HMG Extensivist

Office Clinics & Urgent Care

The Master Plan (Table of Pathways)

• Pathway 1 (Pre-Emptive Care): Patient of Primary Care office, Urgent Care facility, or other non-hospital facilities – Provider assesses need for

Extensivist program for patient.

• Pathway 2 (Ex-Post Facto Care): Patient discharged from Hospital with plan of care orders for Extensivist program

Menu for Services

• Infusion Clinic

• Laboratory

• Pharmacy Services

• Radiology

• Respiratory Services

• Physical Therapy/Wound Care

• Same Day Consultative Services

• AOS (Alternative Outreach Services)

Patient Workflow

Coordina onofCareServices

Load%%%%%Drive%

&/or

PCS

Patient

Eval

Compliance

Load%%%%%Drive

Patient

Eval

Compliance

Diagram12–CapacityforMonitoringandMeasurementofOutpa entClinicalServicesModelDiagram

PROCESS RESOURCEACTION

PEOPLE

LOCATION

SYSTEM

TIMELINE

Alternative7Outreach7Services7(AOS)7Initiative7I>Chart

PROCESS PROCESS PROCESS PROCESS PROCESS

Identify7Patient7List

Decision7Support

Admin

PBI

Quarterly

Load%%%%%EHR%

&/or

PCS

Schedule7Patient7Visit

C37Facility7

Facility7"Home"

PM

1>27weeks

Patient

Eval

Patient7Facility7"Home"Visit

C3Nursing7SupportProviderBack

Facility7"Home"

M>Modal

EHR

1207min

Follow7

UP

+7

CPOE

Patient7Action7Items

C3Nursing7SupportProviderBackCodersAncillaryDiagnosticRehab

Facility7"Home"

Symphony

EHR

PM

1>27days1>27weeks

Compliance

Cohort7Capture7Reporting

Decision7SupportOps

Admin

PM

PBI

Humedica

Quire

Symphony

4>67weeks

Humedica

PM

Facility

Humedica

Symphony

AOS Workflow

AOS will encompass Nursing Home, Assisted Living, and Home Visits.

Each of these three types of visits will require an individual mapped process.

All orders written or verbal will be faxed to a C3 fax line.

Hospital Coordinators

- Receives copy of face sheet from NH and Assisted Living facilities

- Update insurance information/demographics in Centricity - Build the patient account in Symphony/Centricity

- Place the patient under the appropriate tab (AOS/Prep)

- Bill all charges for all facilities.

- Bill all flu vaccines administered.

- Bill CMN for all providers. - Any call changes or scheduling assistance with be coordinated with Beverly

Shull.

C3

- Receives a patient list for each facility daily from NH and Assisted Living. - Assigns each provider their patient list daily.

- Receives all home health certificates and coordinates provider approval

- Receives death certificates from Vickie Belcher and will get provider

signatures and return to Hospital Coordinator.

- Receives phones calls/faxes with various reports throughout the day and insures that providers are notified and that documents are scanned into the

patients EMR.

- Home visits are to be coordinated through Brittany in which she will place

under Home visit tab and schedule with patient

Symphony

- Nursing Homes/Assisted Livings will send a face sheet of patients needing to be seen by AOS Team to Cheryl George/Brittany Eichmann

- Cheryl will build the account in Symphony and Centricity.

- Verification of Insurance

- Cheryl will place patient under appropriate facility

Nursing Homes

Holston Manor

Brookhaven

Nova

Assisted Living

Crown Cypress

Elmcroft

Emeritus

Preston Place I Preston Place II

Village at Allandale

Home Visits

Triaged and scheduled by C3 Once scheduled, the patient will be placed under that appropriate tab with

provider assignment in the patient detail screen.

Once patient has been seen/treated at home, the provider will complete their

checklist and will assign to the C3 for 48 hour phone call and continued

education.

At the completion of visit, the 30 day, 60 day, 90 days alerts will be set.

AWV’s will be tract in Symphony

Symphony Clinical Scenario

Nursing Home Visit Types New/Established Initial Nursing Facility Visit

New/Established Subsequent Nursing Facility Visit (will have a drop down for 30/60/90

day follow-up)

Nursing Facility Discharge (at end of checklist, red light that will have option to select greater or less than 30 minutes.)

Annual Nursing Facility Assessment (AWV)

Assisted Living Visit Types New Assisted Living Visit

Established Assisted Living Visit

Home Visit

New Home Visit Established Home Visit

!!!!!!!Import!

List!

for

Action!!

Medication

?s

Pharm&D

Compliance!

&

31+!d

claim

2013 Initiative

Transitional Management Services Medicare Patient in Transition – facility to home

•Established patient requiring moderate or high complexity decision making •Service period – 29 days from day of discharge

• Billing not submitted til day 30 • Can not be readmitted during timeframe

•Both F2F and non F2F services required • F2F – first visit - is not billed separately • Communication within 2 days of discharge

• Telephonic, electronic or direct contact • Communication F2F

• within 7-14 calendar days of discharge • If more than 1 required, bill separately

• Non F2F services • Aspects of care • Communication with Home Health • Education on Self Management • Med Adherence & management

•Med Rec required and must occur no later than F2F visit

2013 Initiative

Transitional Management Services (cont.) Medicare Patient in Transition – facility to home

•Documentation requirements • Date/ timing of post discharge communication (within 2 days) • Date of F2F • Complexity of Decision Making

•Only 1 provider can bill • Claims paid on the first received by the payer

•Codes • 99495

• 2 day communication with patient/ caregiver • Moderate complexity decision making + • F2F within 14 calendar days • Estimated Medicare allowable based on 2012 RFS = $142.96

• 99496 • 2 day communication with patient/ caregiver • High complexity decision making • F2F within 7 calendar days • Estimated Medicare allowable based on 2012 RFS = $231.11

Analytics to Action

Can you

measure your compliance?

Without measuring performance, how do you know if you are succeeding?

Step 4

Analytics to Action

Audience Interactive Activity #4

Questions to answer

How do you reward providers, support teams and patients?

Do you use a “carrot” ?

Do you use a “stick” ?

How do you measure success and facilitate sustained compliance that drives effectiveness?

HMG Population Quality Measures

Hospital Admits – all populations

Transition of Care – all populations

Extensivist – Prevented Hospital Admits

Primary Care visits – all populations

HCC coding – all populations

Wellness programs – Medicare & Medicare Advantage populations

Total Medical Cost – Commercial, Medicare Advantage and MSSP

populations.

Medical Expense Ratio – High Risk Patients & Medicare Advantage

populations

Medicare

Medicare Advantage

Commercial

20

40

60

80

100

120

140

Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13

Co

de

s B

ille

d p

er

Mo

nth

Transition of Care Codes billed by HMG in 2013 August Forecast

2013 2nd Qtr* 190 $1,938,000 $1,938,000

2013 3rd Qtr 194 $1,978,800 $3,916,800

2013 4th Qtr 198 $2,019,600 $5,936,400

2014 1st Qtr 202 $2,060,400 $7,996,800

2014 2nd Qtr 206 $2,101,200 $10,098,000

2014 3rd Qtr 210 $2,143,224 $12,241,224

2014 4th Qtr 214 $2,186,088 $14,427,312

2015 1st Qtr 219 $2,229,810 $16,657,123

2015 2nd Qtr 223 $2,274,406 $18,931,529

2015 3rd Qtr 227 $2,319,895 $21,251,424

2015 4th Qtr 232 $2,366,292 $23,617,716

2016 1st Qtr 237 $2,413,618 $26,031,335

2016 2nd Qtr 241 $2,461,891 $28,493,225

2016 3rd Qtr 246 $2,511,129 $31,004,354

2016 4th Qtr 251 $2,561,351 $33,565,705

2017 1st Qtr 256 $2,612,578 $36,178,283

*Actual performance

Extensivist

Program -

Forecast

Savings

Analysis thru

2017

Forecast

Prevented

Admits with

no program

expansion

Forecasted

Cost Savings

Generated

from

Prevented

Admits

Forecasted

Cumlative Cost

Savings

Generated from

Prevented

Admits

Extensivist

Population by

Insurance

% of

Population

Med Advantage 49%

Commercial 24%

Medicare 15%

Dual eligible 11%

Medicaid 1%

Extensivist Program Performance

Primary Care Visits

Population Risk Levels

Annual Wellness Process & Performance

Commercial 2013 Contract Performance

• 8.1% better than market in Total Medical Cost ($23/PMPM) • 3.2% better than market in Quality Performance

Market

Medicare Advantage 2013 Contract Performance

Performance Indications

High Risk Patients are increasingly being

seen in a Primary Care setting.

Appropriate coding is being documented.

Quality measures are improving.

Total Medical Cost is being driven down.

Hospital Admits continue to decline.

Analytics to Action

Conclusion - 4 Principle Transition Points

Analytics

Using Technology to enhance care and impact change

To Action

Clinical Integration & improving quality of care

How to Stay Ahead

Leading through change

Of the Cost Curve

Improving Operational Efficiency

How to Stay Ahead of the Cost

Curve

Do you know your

population?

Have you developed

your assets?

Does your workflow support

performance?

Can you measure

your compliance

?

Analytics USING TECHNOLOGY TO ENHANCE CARE

AND IMPACT CHANGE

Using data metrics to:

identify gaps in care, benchmark for organizational improvement

and build a foundation for population health analytics, allows

the development of predictive models that both identify cost drivers and facilitate wellness solutions via outreach, patient

engagement and workflow.

What we do today will not get us to tomorrow – we need an analytical & clinical transformation.

How to Stay Ahead of the Cost

Curve

Do you know your

population?

Have you developed

your assets?

Does your workflow support

performance?

Can you measure

your compliance

?

To Action CLINICAL

INTEGRATION & IMPROVING QUALITY

OF CARE

Predictive modeling involving disease burden, specifically chronic conditions that lend to hospitalizations, coupled

with development and implementation of standardized care

processes within a medical home model leads to total medical spend

reduction and improved quality metrics across multiple populations

and enables valued-based risk contractual arrangements.

Where we focus determines what we measure and repeat – we need to stratify patient need and

resource allocation.

How to Stay Ahead of the Cost

Curve

Do you know your

population?

Have you developed

your assets?

Does your workflow support

performance?

Can you measure

your compliance

?

How to Stay Ahead LEADING THROUGH

CHANGE

Identifying physician leadership and facilitating engagement is

what initially re-engineers the care team across the continuum.

How we engage providers and support teams determines how we develop workflow – we need to effect change with performance support to get ahead.

How to Stay Ahead of the Cost

Curve

Do you know your

population?

Have you developed

your assets?

Does your workflow support

performance?

Can you measure

your compliance

?

Of the Cost Curve - IMPROVING

OPERATIONAL EFFICIENCY

Transitioning from volume to value and aligning provider

compensation and support team financial incentives is the

foundation of moving from a productivity-based to a value-based model and successfully

fulfilling the obligations of risk-bearing contracts.

How we reward providers, support teams and patients determines the level of success we experience– we need to facilitate compliance to drive the effectiveness of the “triple aim”.

Why we do what we do….regardless of the waves or distance…

Analytics to Action

“I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.” Leonardo da Vinci

“Do or do not. There is no try” - Yoda

Now is the time to act, it is not too late.