Filling The Care Management Tool Box


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.

 

 

[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.

 

Where to Focus on Improving Chronic Disease Care


Post by Deb Leyva


Account Executive, Caradigm

Strategies for chronic disease management have to evolve because of the enormous increase in patient volume that’s expected. CMS statistics cited in this article project that the number of total people covered by Medicare will jump from 55.3 million in 2015 to 80 million by 2030.[1] Today, about 69 percent of Medicare patients have two or more chronic conditions.[2] Faced with an aging and co-morbid population, health practitioners are being pressed to identify the right strategies to prevent chronic disease and lower costs.

The challenge is knowing where to focus initial efforts. Many organizations are continuing to experiment in accountable care, however the overwhelming majority have found it difficult to lower the cost of care for a defined population. To explore this topic further, I thought it would be helpful to revisit this article by the Centers for Disease Control and Prevention (CDC) that listed four domains that providers should think about when seeking to improve chronic disease care.

Domain 1: Epidemiology and Surveillance: Gather, analyze, and disseminate data and information and conduct evaluation to inform, prioritize, deliver, and monitor programs and population health.

Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors (statewide in schools and childcare, worksites, and communities).

Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services in order to prevent disease, detect diseases early, and reduce or eliminate risk factors and mitigate or manage complications.

Domain 4: Strategies to improve community-clinical linkages ensuring that communities support and clinics refer patients to programs that improve management of chronic conditions. Such interventions ensure those with or at high risk for chronic diseases have access to quality community resources to best manage their conditions or disease risk.

To encapsulate these domains, the CDC is recommending care that is preventive, coordinated and engages patients. Also heavily implied in the domains is the idea that new health IT infrastructure is needed to support these changes. While I believe that these recommendations are fundamentally sound, they are broad and don’t specify where providers should focus.

Many of Caradigm’s customers choose to start with improving care coordination because of its central importance to driving population health. The importance is highlighted further because care coordination impacts all of the CDC Domains. For example, the ability to aggregate and share data (Domain 1) should be part and parcel of care coordination improvement efforts. So should increasing the use of preventive care (Domain 3) as well as the linkage with community-based organizations (Domain 4). Improving patient engagement (Domain 2) for co-morbid patients typically needs to be led by care managers through high-touch efforts involving a team of clinicians, family members and friends.

In my role with Caradigm as a customer account manager, I can tell you that it’s amazing to be in the room with a customer that has reached a consensus on their top population health priorities. For example, they may lay out the four or five specific care management workflows they want to improve first. Defining clear goals and a path to achieve them is a huge achievement in of itself. There’s no question that changing how an organization cares for the chronically ill is a long-term and highly iterative pursuit. No one has all the answers today, but focusing your efforts gives you a better chance to drive initial results and build momentum for your overall population health strategy.

[1] Sullivan, Tom. Chronic care management: Is the $50 billion market more hype than reality? HealthcareIT News. April 26, 2016.

[2] Lochner, Kimberly A ScD and Cox, Christine S, MA. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Originally published: http://www.cdc.gov/pcd/issues/2013/12_0137.htm

Time to Value in Population Health


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

The stakes are high when it comes to population health as improved patient outcomes and long-term financial success are on the table. By now, most providers recognize the need to evolve. They must participate in new value-based programs, collaborate with other providers, and tailor workflows to support the changes. Implementing these changes is not easy! It takes significant amounts of time and resources from across the organization. When it comes to acquiring health IT tools to support population health, it often takes providers 9-12 months to evaluate the myriad of available solutions. I don’t blame providers for wanting immediate results after spending so much time investigating population health tools.

One of the key reasons why Caradigm formed its Care Transformation Team is to help customers achieve fast time to value following the acquisition of solutions. Our team serves as a sounding board for our customers who are making the shift to value-based care. We find that some organizations have been engaging in population health initiatives for years and are more mature in their processes while others can benefit from additional support. We tailor our approach to each customer’s strategic vision because it’s not one size fits all. The uniqueness of each organization has to be respected as we seek to identify common best practices and turn them into consistent processes.

I believe that all organizations should seek quick wins soon after acquiring population health technology. They are critical to building positive momentum for workflow transformation. The following are a few suggestions to consider when trying to achieve fast time to value in population health.

Plan early to achieve early success – establishing metrics and what quick wins look like prior to technology implementation provides a huge leg up in achieving them. Our team often collaborates with providers before contract signing to help clarify goals and expectations, and then align technology to them.

Define top value propositions – in addition to meeting specific metrics, population health tools can also deliver other types of value to end user clinicians. For example, the reduction of inefficiency or frustrating pain points for clinicians brings tremendous value to organizations and can be realized immediately. It’s important to document what the pain points and value propositions are in order to recognize that value.

Consider starting with care management – care management tools offer one of the quickest paths to value in population health because they can help remove numerous workflow inefficiencies that are impeding providers today. These can be items like having to hunt for data from multiple sources, having to manually generate care plans, or even being unaware when a patient is admitted to the ED. Care management solutions also give providers flexibility in where to start as they can begin by improving how they manage patients in a particular program, by disease category, or by focusing on a particular area of care management such as improving transitions of care.

While the road to population health can be long, organizations can achieve significant victories along the way. In fact, achieving those smaller wins should be celebrated as care transformation takes many small steps in the right direction. If you’d like to discuss how Caradigm can help you achieve quick time to value in population health, then please reach out to us here.

Healthcare’s Cybersecurity Mandate


Post by Mike Willingham


Vice President of Quality Assurance and Regulatory Affairs, Caradigm

The mandate for healthcare information security is clear. Our industry has to raise the bar. We are reminded of this by the constant stream of breaches affecting healthcare providers such as the recent incidents impacting 21st Century Oncology and Hollywood Presbyterian Medical Center. Industry reports like this one from the Ponemon Institute state that healthcare organizations face cyberattacks every month and are still struggling to find effective strategies to keep systems secure.

One of the core vulnerabilities facing healthcare is identity and access risk as that most healthcare organizations have vulnerabilities, but don’t realize their security strategies are insufficient. With frequent industry consolidation and the emergence of population health, information security is becoming increasingly more challenging to manage. Data is now being shared from a multitude of applications with both employed and non-employed physicians. Managing this risk is further complicated because it has multiple layers. You have to consider elevated privileges, remote and mobile access, multi-factor authentication, and balance these concerns with providing efficient access. While single-sign on (SSO) tools are often looked upon as the first line of defense in controlling identity and access risk, providers need additional capabilities because the threat landscape has evolved. Providers need to assume that insiders and outsiders with malicious intent are attempting to gain unauthorized access.

In order to reduce this risk, providers need greater visibility so that they can be more diligent. This entails a major shift in philosophy to a more proactive strategy that is constantly managing credentials and access rather than just reacting. The key to succeeding with this approach is to leverage automation. With the exploding number of applications and clinicians that must be managed, security teams must use tools that can automate manual security related processes. Here are a few examples of how automation can help manage risk:

  • Provisioning and de-provisioning processes, which provides consistency in the process, saves IT many hours of work and prevents errors
  • User, entitlements and behavior data can be brought together in a single view so you have all the information you need to take action
  • A governance, risk and compliance (GRC) dashboard can be set up with analytics to monitor and proactively manage risk efficiently (e.g. an orphaned accounts report)
  • Real-time alerting can identify a potential incident as it happens to minimize damage
  • Remediation can be simplified so that access can be removed or suspended in just a couple of clicks

Given the increased threats we face, healthcare needs to change its approach to security and privacy. Ultimately, the key is greater due diligence, day in and day out. If we use tools that help us accomplish this, then we give ourselves the best chance to win this battle. For additional information security best practices, you can download FierceHealth IT’s special report: Data Security in the Information-Sharing Age. You can also reach out to us here if you would like more information about Caradigm’s solutions that can help.

 

Nine Notes from NAACOS16


Post by Scott McLeod


Director of Product Marketing, Caradigm

I was recently at the Spring Conference of the National Association of ACOs (NAACOS) in Baltimore, and attended nearly a dozen sessions. Given the continued challenges many accountable care organizations (ACOs) have had in achieving shared savings, the biannual NAACOS events are excellent opportunities to hear from leading ACOs from around the country. In listening to the speakers as well as conversing with other attendees, I came away with nine key observations.

1) Difficulty: ACOs in general, are working hard to be successful, but that success is hard to come by. Comments I heard confirmed the statistic that only about a quarter of ACOs achieved shared savings. Due to this difficulty, there appears to be an increased appetite for tools that can increase the likelihood of success.

2) Uncertainty: There remains a great deal of uncertainty about value-based care—even among the winners. I spoke with a physician from one of the most successful Medicare Shared Savings Program (MSSP) ACOs, but he admitted that to some degree, they “didn’t know how they did it.”  This uncertainty affects decisions to continue in programs or engage in new ones, and also affects IT investment decisions. Providers must weigh the size of any IT investment against the possible return.

3) Benchmarking: As any shared savings are based on the comparison of actual utilization against the Centers for Medicare and Medicaid Services (CMS) established benchmark, there is strong interest in the methodologies CMS uses to establish the benchmark, e.g. historical v. regional fees, and the process for “rebasing” those benchmarks over time.  There is also interest in analytics solutions that can help (1) determine whether or not to participate in a specific program based on the benchmark, and (2) help manage their network of providers against the benchmarks for programs in which they participate.

4) What’s Next:  Organizations are considering participation in CMS’ Next-Generation ACO (NGACO) program.  While it provides some advantages for home health, telemedicine and skilled-nursing facility (SNF) waivers, it also comes with two-sided risk (i.e. greater potential upside but the addition of downside risk). Given the difficulty and uncertainty noted above, organizations are proceeding very cautiously and trying to garner as much information as possible before deciding.

5) Bundled Antipathy:  There is a level of antipathy among ACOs for awardees in BPCI (Bundled Payment for Care Improvement).  This antipathy results from the fact that CMS does not want to double-count (and double-credit) savings realized. Any savings realized for beneficiaries that qualify for bundled-payment services are credited to the BPCI entity and deducted from the potential shared savings of the ACO.  This is true even if the beneficiary is a member of the ACO. There is some feeling of unfairness as the ACO is responsible for a beneficiary’s utilization over the entire year while the BPCI entity only has to manage utilization during the length of the episode of care.

6) Variability of PAC: Whether for bundled payments or MSSP, several presenters called out the wide range of costs in post-acute care, and cited it as a big opportunity for cost management. This recent Wall Street Journal article also discusses the same issue of variability of costs.

7) Survival of the Fittest: While providing quality care to patients is always central to a provider’s mission, competing within their market is also on their minds. Strategies and initiatives adopted are business decisions that include the goal of capturing market share from competitors.

8) Diversification: The advice to the audience from a panel of large, mostly successful ACOs was to nurture other sources of revenue until the hoped-for shared savings were realized. This includes continuation of fee-for-service (FFS) business, participation in the episode-based BPCI, etc.  There was evidence of one-off agreements with large employers for a specific bundle or set of services.  As the industry makes its shift to value-based reimbursement, I expect we’ll see lots of different activities (though headed in the same direction) rather than a unified strategy.

9) Patient Care vs. Population Health:  Although ACOs are participating in a variety of value-based initiatives, the language of presenters and participants tended to focus on the quality care of patients more than managing the health of populations.  This may be a reflection that many of the speakers were physicians, but it seems that there remains a mindset around individuals rather than populations.

As fast as healthcare has been evolving recently, I look forward to tracking these and other trends over the course of the year. I hope to circle back to them during the Fall 2016 NAACOS event to see if they have changed.

Population Health and “The Wire”


Post by David Lee


Product Marketing Manager, Caradigm

NPR recently published this in-depth article about the challenges of healthcare for Baltimore’s lower income residents. After reading it, it’s hard for me not to think of The Wire, the HBO series that received acclaim for its authentic portrayal of Baltimore’s deep rooted social challenges. I think healthcare is another issue that David Simon, the show’s creator, could have explored as the core premise of the series is the interconnected nature of the city’s struggles – poverty, crime, policing, race relations, politics and the education system. There is a quote from a character on the show that has become emblematic of this theme that also applies to how healthcare has been recently shifting to population health:

“All the pieces matter.” — Detective Lester Freamon to Detective Roland Pryzbylewski, The Wire

Dr. Marcia Cort, chief medical officer of the non-profit Total Health Care, states in the article that “Baltimore City is in a health crisis.” The life expectancy of residents in the impoverished Sandtown neighborhood is 69.7 years old, which is the same as in poverty-stricken North Korea. Also according to the article, “residents of the ZIP code including Sandtown accounted for the city’s second-highest per-capita rate of diabetes-related hospital cases in 2011, the second-highest rate of psychiatric cases, the sixth-highest rate of heart and circulatory cases and the second-highest rate of injury and poisoning cases. Asthma, HIV infection and drug use are common.”[1]

Over the years, some residents have developed a mistrust of healthcare due to challenges in access and because of negative outcomes experienced resulting from a lack of coordinated and preventive care. A Baltimore resident, Robert Peace, described how he developed a recurring bone infection after undergoing a surgical procedure. Likely due to receiving minimal follow-up care, the infection grew worse, became extremely painful and resulted in five additional surgeries being required in 18 months. Today, Robert has permanently impaired mobility.

Dr. Jay Perman, pediatric gastroenterologist and president of the University of Maryland, Baltimore stated in the article that clinicians have to accept responsibility for patients outside the walls of the hospital. “As a profession, as an industry, we have not sufficiently appreciated, let alone done something about, the impact of social determinants. Guys like me and gals like me can easily say, ‘I made the correct diagnosis. I wrote a proper prescription. I’m done.’ What I say to my students is, if you think you’re done — if ‘done’ means the patient is going to get better — you’re fooling yourself.” To the credit of health systems in the area, they acknowledge that there have been shortcomings in how care was delivered and are implementing improvements. These efforts include a new focus on preventing readmissions, new investment in care coordinators, primary care and post-discharge management.

Although the social challenges Baltimore faces have been ingrained for many years, healthcare is the one for which there may be the clearest path to lasting improvement – via population health. Population health as an approach recognizes that health systems must care for patients outside the walls of the hospital using a multi-disciplinary team. An expanded care team can include friends, family members and social organizations (e.g. assistance with transportation, meals, paying for prescriptions, etc.). It can involve multiple health systems collaborating in the care of patients even though the health systems are in reality competitors. It also recognizes the need for innovation in technology such as a longitudinal patient record shared across all providers, analytics, and workflow tools that can help care teams manage a high volume of patients efficiently.

I would theorize that more than any other factor, it was the shortcomings of the fee-for-service model that contributed the most to the poor outcomes experienced by Sandtown residents. Population health offers a real strategy for change. More than cost efficiency, which is often the most commonly mentioned driver of population health, improved outcomes is the most compelling reason for population health. I am hopeful that health systems like those in Baltimore will continue to invest more and scale their population health initiatives with a sense of urgency. If they can successfully transform to become more patient-centric and improve the health of the people they serve, they will be able to rebuild the trust of the community. That accomplishment would be truly worthy of a television series.

[1] Hancock, Jay. In Freddie Gray’s Baltimore, The Best Medical Care Is Nearby But Elusive. NPR.org, 2.15.16. originally published at http://www.npr.org/sections/health-shots/2016/02/15/466550095/in-freddie-grays-baltimore-the-best-medical-care-is-nearby-but-elusive

Progressing with Population Health and Big Data


Post by Neal Singh


Chief Executive Officer, Caradigm

Last year, I wrote this blog post about the great potential of big data to drive innovation in healthcare. With the rapid progress organizations are making with their population health strategies, I thought it would be a good time to revisit this topic because of its importance to the industry. To be honest, healthcare organizations are still in the early adoption phases of big data.  Only a few organizations are dealing with petabytes of data, which is typically the threshold people think of when it comes to big data. However, I do see significant progress. Big data is in the process of transitioning from a research-oriented activity to a main stream agenda item that enables multiple population health scenarios. Let’s explore why.

Population health is driving the data explosion

Whether healthcare organizations are ready for big data or not, many are faced with exploding amounts of data at their disposal as they embark on new population health strategies. Within a single health system, it is not unusual to have several hundred IT systems and applications in the portfolio, and to have 50-75 that are actually exchanging data. Population health often requires a better understanding of your patient population, utilization, costs, quality, and chronic conditions across multiple systems and or with many partner organizations. This likely involves extending beyond your EMR to other disparate EMRs and IT systems outside your enterprise. Therefore, one needs to aggregate, normalize and share clinical, operational and financial data from many IT systems across the community—including EMRs, billing systems, payers, pharmacy systems, labs, and HIEs. Also consider that today, most of the data sets in the industry tend to be structured. We are now beginning to see early use of unstructured data (i.e. clinician notes), which can contain highly valuable patient information (e.g. ejection fraction for patients with congestive heart failure). Additionally, I see increasing interest in other new data sets such as consumer, genomic, demographic and social data (e.g. fitness devices, purchasing history, Twitter, Facebook) integrated into scenarios for population health. There is no end in sight for the growth of data in healthcare, which I find incredibly exciting because of the ability to draw new value from it.

The mechanics of big data are being established

In order to realize the full value of their data, organizations have been establishing the mechanics of how that data needs to be aggregated, transformed and stored. It’s important to have the right population health data platform in place that can automate numerous processes, or else big data efforts can struggle to get off the ground. Healthcare organizations leading the way in big data have been adopting data platforms for healthcare that have the following capabilities:

  • Automated data ingestion from any originating source in any format in real-time that has existing pre-defined configurations or parsers for a variety of data formats, e.g. HL7, CCD and CCLF, and unstructured.
  • Automated transformation of data regardless if data is in different terminology code sets or structures that includes semantic mapping for code conversion and pre-built tooling that facilitates normalization and deduping of data from pre-defined and custom sources.
  • Automated modeling of data that uses pre-defined healthcare entities that can accommodate most clinical and claims data as well as custom entities to accommodate customer-specific data.
  • Open data sharing APIs that provide untethered read and write access with source systems and the ability to share data with analytics and self-service reporting solutions.
  • Role-based security with auditing.

Initial population health scenarios are being explored

The scenarios for big data are limitless and I believe that one day they will expand to untapped data sources such as social media, consumer purchasing, and even things like smart clothing. Until that day arrives, big data can still have a significant impact on how you manage a population at an aggregate as well an individual level. Here are a few initial scenarios that organizations are already exploring today:

  • Build and share a true longitudinal patient record to see all relevant patient data (e.g. labs, pharmacy, claims, analytics) that covers the full continuum of care.
  • Employ predictive models (i.e. risk stratification), which are especially effective with large data sets so that you can focus your resources where they will have the greatest impact.
  • Expand the scope of your analytics to new areas such as measuring the quality and financial performance of individual clinicians as well as overall organizational financial and utilization analytics.

It’s fantastic to see that healthcare is innovating through big data and population health. The organizations that have built their infrastructure strategically should be in great position to keep refining what they’re doing today while scaling and building new use cases. If you’d like to discuss how Caradigm can help with your big data strategies, then leave us a note here.

 

HIMSS16 Trends: The Maturation of Population Health


Post by Scott McLeod


Director of Product Marketing, Caradigm

The educational sessions at HIMSS16 serve as a barometer of the progress of population health management as a priority for healthcare organizations.

This year, after three days of attending sessions, I note four key themes—

1) Current economic realities are driving new strategies

The changing market is not just a distant-future consideration. Payment reform from CMS and private payers is already occurring and will accelerate. Local markets—in which healthcare organizations must compete—face shifting roles and demands of employers and consumers. In one local market, a reported 75% of payments are tied to risk contract. Facing the fact that maintaining the status quo is not sustainable in the long term, organizations are setting new strategic directions that balance external forces and internal capabilities to achieve success under commercial and Medicare programs.

2) Collaboration is key

Healthcare organizations must work with others to realize the revenue under value-based reimbursement. This includes building relationships with non-contracted physicians and other (often competing) organizations to form accountable care organizations, clinically integrated networks or performing provider systems to provide the geographic coverage required for an assigned population. In addition, organizations are changing their relationships with employers and payers to seek win-win contractual arrangements that improve the quality of care for patients served and manage the costs for all stakeholders.

For example, Inova Health System and Aetna launched a joint venture to form a new health plan, Innovation Health, working together for improved care, cost and quality. Care coordinators steer members to appropriate programs and provide coaching. High-risk patients are enrolled in care management programs at post-acute facilities, and high-performing skilled nursing facilities (SNFs) are selected for inclusion on the network.

3) Results are starting to show

Population health initiatives seem to be more targeted and organizations are more specific about what they want to measure. The result is that—beyond reports of pilots and early steps—we are beginning to see tangible, positive results from these initiatives. The joint venture cited above has achieved a 17% reduction in the number of unnecessary hospital days after surgery, 15% fewer hospital admissions and 21% fewer hospital readmissions. As another example, Banner Health reported on the successes of its telehealth program: 20% reduction in length of stay, 45% reduction in hospitalizations and a 27% reduction in total cost of care.

4) Health Information Technology (HIT) is necessary for success

As the number of population health initiatives increases, and the number of at-risk lives grows, organizations recognize that HIT solutions are required to achieve the efficiency, effectiveness and scale that the programs demand. Successful organizations employ and rely upon solutions for data aggregation, risk stratification, analytics, interoperability and population health management. Staten Island PPS, for example, reports that each of its 11 DSRIP projects actively underway has unique HIT requirements for success including longitudinal patient records, predictive analytics and utilization management, telehealth and patient registries.

One other theme, that overlays the rest, became apparent during the educational sessions. The journey to population health management will continue, but the routes will change. What works today may or may not work tomorrow as the relationships among the different stakeholders shift.

Caradigm offers population health solutions that offer scalability and adaptability over time. You can have a discussion with a Caradigm representative by leaving a note here.

  1. “Value-Based Models: Two Successful Payer-Provider Approaches.” Clifford T. Fullerton, MD MSc and Mark Stauder. March 1, 2016.
  2. “Volume-based to Value-based Care at a Pioneer ACO.” Julie Reisetter, MS, RN. March 3, 2016.
  3. “Addressing the IT Challenges for a Startup DSRIP Program.” Joseph Conte, PhD(c). March 2, 2016.
  4. “Transformative Payment Models.” Jody White and Brian Sandager. March 1, 2016.

HIMSS16 Day 2: The Emergence of Care Transformation


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

I am so thrilled to be at HIMSS16 this year with my newly formed Care Transformation team that includes fellow clinicians, Natalie Benner and Ruth Light. It was also a pleasure to speak in the Population Health Knowledge Center and converse with a number of the attendees afterwards. Having recently moved from a product strategy role at Caradigm to my new position as the VP of Care Transformation, I am excited to be able to collaborate with providers and customers about their population health strategies even more this year. We all know population health requires more than just new technology solutions. The team of clinicians delivering care and how they deliver that care has to evolve as well. What makes it challenging for providers is that there’s no single “right” way to do it. Caradigm’s Care Transformation team was formed to help organizations find their optimal approach given their goals, strategies and resources. Below are a few questions that can be helpful to think about if you are interested in care transformation.

Who should be added to the care team?

As I alluded to above, there are many different ways to set up your care teams depending on your particular area of focus. Some providers partner closely with primary care physician groups and will share resources such as a social worker, behavioral health counselor or a non-clinical admin that helps clinicians work “top of license”. Others may focus on designing care transition teams that ensure effective handoffs between care settings. Community-based services such as transportation can also be a highly effective addition to care teams that can drive immediate results. Providers have had success reducing unnecessary ambulance and ED utilization for non-emergency situations simply by providing access to a taxi service.

How do we align different workflows?

It’s critical to think about care pathways as an end-to-end process. Ask yourself “How do they connect?” “How can we make processes consistent between them?” “How do we remain patient-centric?” After providers take initial steps in population health, often the next step in their journey is to map and align different workflows and teams. Providers need aligned goals, metrics and protocols across the spectrum. Silos between teams need to be removed to enable an efficient patient-centered approach to care.

Can we support different care settings?

Being able to provide effective care in different settings is also critical because patients often move between them (e.g. acute to post-acute, ambulatory to assisted living). For patients with no regular caregiver support, care may be best delivered in a long-term care or skilled nursing facility for which providers must have a plan. For other patients, a medical home with embedded services such as behavioral health and access to community-based services may be the right fit. Effective handoffs between care settings must be established to avoid gaps and lapses in access to services. Being able to communicate and share a plan of care across an interdisciplinary team is also essential for complex patients.

How do we connect with the patient?

Every clinician that I speak with agrees that patient engagement is vital to improving health outcomes, but also agrees that it is extremely difficult. Even contacting a patient can be challenging because providers often have outdated contact info. In order to scale population health programs, providers need their patients to have “skin in the game” and participate in their own care. Providers might be able to create a registry of the most expensive patients, but it’s just as important to find out why they are the most expensive. For example, are they not taking their medications because they don’t have transportation, can’t afford them or are they confused by the different medications that have been prescribed by multiple specialists? Motivating patients and changing behavior is not easy, but it’s important to think about how it fits into the care team’s responsibilities and workflows.

How can technology help?

Coordinating care across the continuum is difficult because legacy health IT infrastructure was not designed to support risk-based care approaches. When I ask clinicians what do they need technology to help with, I hear a lot of common responses. They wish they had access to real-time lab info because while claims data is great, it is dated. Others tell me they wish they had integrated EMRs. They wish all providers could be connected so that everyone can have a true encounter and care summary even if it was out-of-network. Did a patient get admitted? Did a patient get discharged? Scaling population health according to patient risk-level is also another core challenge where technology can be extremely helpful, which is a topic that I’ll cover more in a future blog post. The truth is technology can help in a lot of areas, but how you sequence and scale that investment will depend on your particular organization.

These are the types of questions that I am so excited to help providers tackle this year. The Care Transformation team is in the Caradigm Booth #5427 this week at HIMSS having discussions with providers. If you miss us at HIMSS, you can reach out to us after by leaving a note here.

Vicki HIMSS16

It was an enjoyable experience presenting in the Population Health Knowledge Center

HIMSS16 Day 1: Seeking Interoperability in Population Health


Post by Neal Singh


Chief Executive Officer, Caradigm

The healthcare world assembled in Las Vegas with the kick-off of the Health Information Management Systems Society (HIMSS) Annual Conference. An issue that I expect to have many conversations about at HIMSS16 is the ongoing challenge of interoperability. Organizations engaging in population health continue to be frustrated by disparate information systems that result in outdated and incomplete patient information. This greatly hinders organizations’ ability to effectively coordinate care between providers in different settings, close gaps in care, and manage overall utilization and financial risk. The demand for interoperability has reached a crescendo as it is now a must-have in order to succeed with population health.

As I noted in this recent blog post about the Fast Healthcare Interoperability Resources (FHIR) standard, while FHIR is part of the discussion around interoperability, it is not a cure-all for all data challenges. An ideal solution starts with the foundation of an enterprise data warehouse (EDW) that can support a multitude of data standards and is designed specifically to model healthcare data and share it with other applications. This piece of the solution aggregates, normalizes and models your data, creating a rich data asset that can be used to drive action in any native or third-party application. True interoperability also requires bi-directional integration with any EMR in your community to enable the exchange of electronic care plans, care summaries, and other clinical data within the community.

There has not been an enterprise data platform like this in our industry, until now. At HIMSS16, Caradigm  announced Open Exchange, which works in conjunction with the Caradigm Intelligence Platform (CIP), an EDW for healthcare. The HIMSS ConCert certified solution is unique in our industry for its ability to enable interoperability of EHRs and other data source systems needed for population health. Caradigm is demonstrating its capabilities this week as part of the HIMSS16 Interoperability Showcase, which is the culmination of our participation in several collaboration events with other health IT solution providers.

We are extremely proud of our team’s efforts with Open Exchange and CIP that underscores Caradigm’s industry leadership in innovating healthcare data exchange. If you are attending HIMMS16, then we invite you to stop by the Caradigm booth #5427 or the Interoperability Showcase to discuss your interoperability needs and learn more about how Caradigm can help. Also, don’t miss my colleague, Vicki Harter, who is speaking tomorrow in the Population Health Knowledge Center about how providers can approach different value-based strategies in a presentation entitled – ACOs and CINs and DSRIP, oh my!

 

Neal Accepting HIMSS Award

I was very proud to accept Caradigm’s award for the HIMSS ConCert Certification of Open Exchange