Becker's Hospital Review

42 Health IT Goal: To develop an application suite that combines 'intelligent' clinical as- sessment and care planning, real time notification and data analysis to maxi- mize the quality and efficiency of care for risk populations. Solution: Working closely with Care Solutions, North Shore LIJ's care man- agement organization, the system created The Care Tool, customized to sup- port the unique workflows associated with management of high risk popula- tions. The tools features include clinical outreach, medication reconciliation, evidence based care planning, risk stratification, performance tracking and outcomes analysis. The Care Tool can be configured to conform to the spe- cific requirements of multiple risk programs, all of which are accessible from a single user interface. Integration with the health system HIE was enabled by InterSystems HealthShare, an informatics platform, which provides real time notification for acute events such as ED visits and readmission. The Care Tool is also used by the clinical call center, where data sharing and collabora- tion is essential for the swift resolution clinical issues. Outcome: The Care Tool was piloted to manage cardiac, orthopedic and stroke cohorts for Medicare's Bundled Payment Care Initiative (BPCI). For the year to date, North Shore-LIJ has seen a 6 percent reduction in cardiac valve replacement patient readmissions, between a 10 percent and 28 percent increase in surgical patients discharged home instead of a nursing facility, a 56 percent increase in patient use of in-network home care, and overall im- proved infection control, readmissions and patient satisfaction rates. 7. Northwestern Medicine and Northwestern Medical Group (Chicago) Integrating home/self blood pressure readings, 24 hour ambulatory blood pres- sure readings, and office blood pressure readings through the EHR Goal: To optimize hypertension control by making actionable information about blood pressure more readily available to primary care physicians. Solution: Northwestern Medicine developed the Expanded Hypertension Data Flowsheet, an EHR-based tool that presents a more accurate picture of a pa- tients true blood pressure by integrating patient blood pressures from home, ambulatory and office settings for physician viewing for any patient, any time, so physicians wouldn't miss diagnosing or appropriately managing hyperten- sive patients. The tool is created from existing EHR functions, meaning the cost of the tool was negligible, and using the tool does not interrupt workflow. Outcome: By giving physicians actionable blood pressure data while they are seeing patients, Northwestern Medicine's physicians are better able to con- trol hypertension, seeing a 7 percent gain in hypertension control rates in six months at their primary testing site in Evanston. Preliminary pilots were suc- cessful enough that the innovation will be rolled out across all primary care offices system-wide. In addition, Northwestern Medicine has also integrated this data into the recently implemented PopulationManager at its prototyp- ing site in Evanston, a tool that lists each physician's chronic care patients and whether each patient is at disease-management targets, allowing real-time viewing of the effects of different treatment strategies. With time they hope to roll out PopulationManager across the system as well. 8. Partners HealthCare (Boston) Asking surgeons: Is that procedure really appropriate for your patient? Goal: To clinically and financially optimize preoperative planning for high-cost surgical cases, both goals in line with Partners' position as a Pioneer ACO. Solution: Partners implemented a procedure order entry decision-support system, Q-Guide, co-developed by QPID Health and Massachusetts General Hospital, to help physicians determine whether prescribed procedures are truly an optimal fit for that patient. The system draws upon the individual health data of each patient as well as published evidence-based guideline to calculate patient-specific risks and "appropriateness" scores and creates a customized consent form. Q-Guide can use information from both struc- tured data and unstructured fields (such as visit notes). Outcome: Improved shared decision-making among physicians and pa- tients, who are able to better understand the risk they assume with surgical procedures, has led to higher levels of appropriate procedures at MGH than in the literature. The provider order entry process is now used for eight sur- gical procedures, has been used over 3,400 times and will be expanded to 16 conditions and 45 procedures that are high-cost, high-volume, or both. 9. Rochester (N.Y.) Regional Health System-Unity Health System, Rochester, N.Y. Conquering diabetes through longitudinal patient records Goal: To bridge four EHRs and create a single-record view of 3,000 diabetes patients to improve their care. Solution: Led by its CIO, CMO and CMIO, the system applied for a grant from New York State and engaged a group of internal and external stakehold- ers to build a solution rooted in patient-centered medical home philosophies: the Community Diabetes Collaborative. The program is built on a public- private health information exchange, which uses Allscripts dbMotion tech- nology to interoperate with four EHRs in use as well as with the information systems of outside providers. It accesses data from labs, other hospitals and community-physician EMRs via effective connectivity with the Rochester RHIO as well. The CDC includes patient engagement tools, a data warehouse for collection of population data and glucose management tools. Outcome: Transitions in care and out-of-hospital care improved for the sys- tem's diabetes patients. Through the HIE, patient information became more readily available within Unity and for outside providers, improving care co- ordination and referrals management. In addition, added decision support and performance management tools streamlined the treatment process of diabetic patients. Unity was also able to replicate the process for patients with other types of chronic disease, further extending the population health ben- efits of the program. 10. St. Vincent's Healthcare Partners (Bridgeport, Conn.) Using tech to implement a "playbook" of minimum data-sharing for care transitions Goal: To monitor care transitions by instituting a mandatory data-sharing minimum among the physician-hospital organization's providers for nearly all types of care transitions. Solution: St. Vincent's implemented information platforms from McKesson to actively facilitate its "playbook," which mandates the minimum dataset that must be shared among members of the healthcare team during more than 140 different types of care transitions, automating the patient transfer safely and efficiently. Outcome: As a result of platform implementation of the playbook, the orga- nization has applied best practice interventions which has decreased the risk for every patient, experienced less patient loss to out-of-network groups, bet- ter quality metric management, and more appropriate utilization of ambula- tory care. The use of the system also attuned individual practices within the PHO to modifications in patient care that could be accomplished in pursuit of the triple aim. 11. Tenet Health System, Lakewood (Calif.) IPA & Premier ACO Investing in case management to improve quality in advance of ACO membership Goal: To improve population health management in advance of applying to CMS' Shared Savings Program, following its relationship with the pay-for- performance program since 2005. Solution: In 2010, the physician group did an infrastructure assessment of its ability to manage patients' population health in advance of joining the Medi- care Shared Savings Program. In accordance with a consultant's guidance, the group selected ZirMed for its case management needs. Outcome: After adopting ZirMed, the group built a customized clinical inte- gration platform to keep track of the specific quality measures that are part of the MSSP program, many of which evaluate practice success in managing population health. As a result, the ACO's MSSP quality scores have increased 12 percent. n

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