Session #21
Key Principles and Approaches to PHM
Greg Spencer, MD
Chief Medical &
Chief Medical
Information Officer,
Crystal Run
Healthcare
Dr. Greg Spencer is the Chief Medical Officer and Chief Clinical
Information Officer at Crystal Run Healthcare. He graduated from the
Medical College of Wisconsin and completed residency training in
Internal Medicine at Wilford Hall US Air Force Medical Center in San
Antonio, TX, where he was chief resident and assistant director of the
Internal Medicine Residency program and attained the rank of major. He
is board certified in Internal Medicine and a Fellow of the American
College of Physicians.
Sreekanth Chaguturu, MD
Vice President for Population
Health Management, Partners
HealthCare
Dr. Sreekanth Chaguturu is Vice President for Population
Health Management at Partners HealthCare. He provides
clinical oversight to population health management clinical
programs, assists in management of clinical relationships
for risk contracts with commercial and government payers,
as well as oversight for Partners’ self-insured health plan.
In these roles, he leads the assessment and development
of information technology and analytic solutions to support
population
health
programs.
Dr. Chaguturu is also an Instructor in Internal Medicine at
the Harvard Medical School and an attending physician at
Massachusetts General Hospital.
David A. Burton, MD
Former Chairman and CEO,
Health Catalyst, Former
Senior Executive,
Intermountain Healthcare
Dr. David A. Burton is the former Executive Chairman and
CEO of Health Catalyst, and currently serves as a Senior
Vice President, future product strategy. Before his first
retirement, Dr. Burton served in a variety of executive
positions in his 23-year career at Intermountain
Healthcare, including founding Intermountain’s managed
care plans and serving as a Senior Vice President and
member of the Executive Committee. He holds an MD
from Columbia University, did residency training in internal
medicine at Massachusetts General Hospital and was
board certified in Emergency Medicine.
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Poll Questions (1-3)
Does your organization sponsor or participate in a population health management/shared
accountability initiative (e.g., ACO or commercial)
a.
Yes
b.
No
c.
Not sure
d.
Not applicable
What percent of your patients are covered by your organization’s population health/shared
accountability initiative?
a)
Less than 5%
b)
5-10%
c)
More than 10%
d)
No idea
e)
Not applicable
In your opinion, how successful has your organization’s population health/shared
accountability initiative been to date?
a)
Not at all successful
b)
Slightly successful
c)
Somewhat successful
d)
Successful
e)
Very successful
f)
Unsure or not applicable
Gregory Spencer MD FACP
Chief Medical Officer
Crystal Run Healthcare
Our Approach
• Triple Aim as an organizational outline
 Better care, better health, lower cost
• Analytics: multisource, scalable platform
• Provider involvement
• Care managers, CARETEAM, Telehealth
• Monitor the data
4
NY Healthcare Environment
• Massive consolidation and mergers
• Bankruptcies
• Larger systems and groups
• Optum
• Venture capital
• Mostly unmanaged
• Urgent care centers and retail medicine
6
Crystal Run Healthcare
 Physician owned MSG in NY State,
founded 1996
 300+ providers, 20 locations
 Joint Venture ASC, Urgent Care,
Diagnostic Imaging, Sleep Center,
High Complexity Lab, Pathology
 Early adopter EHR (NextGen®) 1999
 Accredited by Joint Commission 2006
 Level 3 NCQA PCMH Recognition
2009, 2012
Crystal Run Healthcare ACO
• Single entity ACO
• April 2012: MSSP participant
• December 2012: NCQA ACO Accreditation
• 35,000 commercial lives at risk
• MSSP
 11,000 attributed beneficiaries
 82% primary care services within ACO
8
Business Intelligence Past
• Initially BI = business only, reports
• Quality, safety measures and clinical performance
later
• Basic tools: SQL, SSRS, Excel
• Manual and time consuming
• Report generation > analysis
• Lack of scalability and extensibility
• Mostly tabular / numeric
9
Dashboards
10
Business Intelligence Now
• Central EDW- many sources, fewer joins
• Scalable
• More analysis, less reporting
• Self-service and drill down
• Consume and deliver information
• Visual
11
12
Basic System Needs
• Common integrative platform
 Pull together disparate data
• Cost: claims where available, internal costs
• A way to implement change
• “Leakage” and network
 Where are patients going, are needs being met?
• Lean
 Waste reduction, everywhere
13
How we chose our EDW
• Our bias: controlled by us
• Avoiding “black boxes”
• Prior healthcare experience
• Modern technology
• Established track record
• Teach us how to fish
14
Crystal Run EDW Roadmap
Improving the patient experience
• Web Portal
• Care Managers
• Shadow Coaching
• Choosing Wisely
• Practicing Excellence
16
Variation Reduction
• Specialty and division sponsored
 Best practice review
 Buy-in at the physician level
• Provider projects
 Innovation contest
• National: Choosing Wisely
• Improved access - backfill and market share
17
Variation Reduction
Variation Reduction Improves Access
• 41,823 fewer visits
• 30,206 more patients
• “Created” 12 physicians
Reducing Pharmaceutical Costs
PEG Filgrastrim cost per patient before and after
breast cancer pathway
Total cost difference
(equalized as cost per patient treated)
PEG-filgrastim use in Breast cancer patients
2012 pre-pathway
2013 post-pathway
791 patients
817 patients
$595,920
$368,160
TOTAL COST
SAVINGS
$227, 760
Summary
• Triple Aim, core values as a guide
• Unified analytics platform that integrates disparate
systems is required
• Quality, safety and performance programs that are
tracked
• Physician involvement, variation reduction
• Patient experience
• Leakage, where and why
• Systematically find and reduce waste
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Sreekanth Chagaturu, MD
Medical Director for Population Health Management
Partners HealthCare
Chapter 2: Innovations in
Population Health Management
Sree Chaguturu, MD
Vice President, Population Health Management,
Partners Health Care
September, 2014
Division of Population Health Management
My goals for today
• Describe Massachusetts health reform efforts
• Provide overview of Partners Healthcare
• Review select programs
25
Patient Protection and Affordable Care Act
My fair city…
Chapter 58 of the Acts of 2006: An Act
Providing Access to Affordable, Quality,
Accountable Health Care
Increasing health care spend in Mass crowded
out all other areas
2
Health care reform part two
Who We Are: Partners HealthCare
Teaching Hospitals
Community Hospitals
Non Acute Care
Mental Health Care
Community Provider
Network
31
• Massachusetts General Hospital
• Brigham and Women’s Hospital
• Newton Wellesley Hospital
• North Shore Medical Center
• Martha’s Vineyard and Nantucket Hospitals
• Spaulding Rehabilitation Network
• McLean Hospital
• Partners Community Health Care
• Community Health Centers
Partners HealthCare across eastern
Massachusetts
McLean
NewtonWellesley
Salem &
Shaughnessy
Kaplan
Union
Spaulding
MGH
BWH
Faulkner
Partners Acute Hospitals
Partners Specialty Hospitals
Towns With PCHI Primary Care
Care Physician Practices
Partners Home Care Branches
RHCI
32
What we do
Our Employees
• ~60K employees – the largest non-government employer in the
state
• ~13K are MDs, RNs and direct care givers
• ~5K are primarily involved in research
Our Patients
• ~1.6M ambulatory visits
• ~168K discharges
• ~4K licensed beds
• ~$205M investment in community benefits
Teaching
• 28 residency programs provide training to ~1,400 residents
• ~$ 167M investment in teaching
Clinical Research
• ~$1.6B in academic/research revenue
• ~2,800 paid researchers (MDs & PhDs)
Partners currently covers over 500,000 lives in an
accountable care contract
1
Medicare
2
Commercial
•Example:
Pioneer ACO
•Example:
Alternative
Quality
Contract
•Covered
lives: ~350K
•Covered
lives: ~74k
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3
Medicaid
•Example:
NHP
•Covered
lives: ~30k
4
Self Insured
•Example:
Partners
Plus
•Covered
lives: ~100k
Partners is implementing over a dozen PHM Programs
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Primary Care
•Patient Centered Medical Home (PCMH)
•High risk care management (palliative care)
•Mental health integration
•Virtual visits
Specialty Care
•Active referral management (eConsults/curbsides)
•Virtual visits
• Procedural decision support (appropriateness)
•Patient reported outcomes
•Episodes of care (bundles)
Care Continuum
•SNF care improvement (network/waiver/SNFist)
•Home care innovation (mobile
observation/telemonitoring)
•Urgent care
Patient Engagement
•Shared decision making
•Customized decision aids and educational materials
Infrastructure
•Single EHR platform with advanced decision support
•Data warehouse, analytics, performance metrics
And why these programs?
36
Primary Care
•Patient Centered Medical Home (PCMH)
•High
risk careteam
management
(palliative
Develop
based
care care)
•Mental health integration
•Virtual visits
Specialty Care
Promote
Medical
Neighborhood
•Active
referral
management
(eConsults/curbsides)
•Virtual visits
• Procedural decision support (appropriateness)
•Patient
reported outcomes
Demonstrate
value in procedures
•Episodes of care (bundles)
Care Continuum
•SNF care improvement (network/waiver/SNFist)
•Home care innovation (mobile
Reduce post acute variation
observation/telemonitoring)
•Urgent care
Patient Engagement
•Shared decision making
Empowerdecision
patients
in educational
their carematerials
•Customized
aids and
Infrastructure
•Single EHR platform with advanced decision support
Information -> Insight -> Action
•Data warehouse, analytics, performance metrics
Successful ACOs will use predictive analytics to
launch a high risk care management program
High risk patients - those at risk
of being high cost
Medically
Complex
Not
Chronically
Ill, Medically
Complex
Primary Care
37
Significant opportunity in integrating mental health services into
primary care
Primary
Care
Mental
Health
Mental Health Disorder
Key Elements
Chronic Condition
Examples [Current and Future]
Better identify patients
Increased screening
Better triage of patients
Patients
a support
Phone access
line withwith
referral
Better use of protocols
Better self-management
mental health
IMPACT for depression, SBIRT for substance
disorder have 40%
abuse
higher chronic
Online patient-directed
condition therapy
costs (iCBT)
Better access to services
Embedded mental health resources,
consulting psychiatrist
Better tracking outcomes
IT tools tracking longtitudinal progress,
Patient reported outcomes measurement
Primary Care
38
Virtual visits allow us to connect
nchronous
toVisits
patients in more convenient
ways (and avoids unnecessary
Synchronous
office visits)
nges between students and teachers ar e frequently enacted asynchr onously
ace conversations. This type of communication taking place at dif ferent times
learning, auction, and business web services. W ith RelayHealth, a pr ovider of
Practice is testing a tool that conducts asynchr onous exchanges between phy -
visits. V isits are available for about 100 non-ur gent symptoms and conditions
Models that allow people and
providers to connect in real time
tice. Patients login to the RelayHealth website and complete a r elevant online
Virtual Visit
Asynchronous
Models that deliver care to people
without requiring real-time interaction
nizational and financial support to enable virtual
Specialty Care
39
Patient Reported Outcome Measures are outcomes that matter
(and demonstrates value to market)

Direct collection of information from patients regarding symptoms, functional
status, and mental health.
Functional Status
Surgery
Tier 3: Sustainability
of Recovery
Tier 1: Health
status achieved
Tier 2: Process
of Recovery
time
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Specialty Care
We can improve a patient’s surgical journey
(and avoid unnecessary or unwanted surgeries)
PROMs PrOE (Procedure Decision Support)
Assess
Shared
PROs Appropriateness Decision
Criteria
Survey(s)
Making
Patient
with a
Surgical
Problem
Physician
Encounter
Possible
Need for
Procedure
PROMs
Personalized
Risk
(Consent Form)
Informed
Consent
PreSchedule
Procedure
OR
Testing
Short-term
Outcome
Measures
Long-term
Outcome
Measures
Procedure Recovery
Milford CE, Hutter MM, Lillemoe KD, Ferris TG. (2014). Optimizing appropriate use of procedures in an era of payment reform. Annals of Surgery 206(2): 202-204
Specialty Care
41
We target the most costly procedures
Nationally, these 7 procedures
account for $56.6 billion, or 55%
of the total costs of the 20 most
costly procedures in the US:
•
•
•
•
•
•
•
Spine fusion
Spine laminectomy
Knee arthroplasty
Hip replacement
PCI
CABG
Heart valve repair
Specialty Care
42
Ultimately, we have created a more efficient
prior authorization
Clinical
Office
Patient visits surgeon
and lumbar
laminectomy is
indicated
PrOE
completed
MGH
Admitting
Payer
Surgeon
schedules
procedure
Admin
faxes form
to admitting
Yes
Admin
knows
procedure
requires
PA?
Admitting
calls clinic
to work
through PA
form
Potential savings:
• Current process:
o 4-5% denial rate,
Admitting denied
Admittingo <1% ultimately
checks for
checks for
Decision
form
• PrOE process:
form
submitted
to
o Produces same result
(<1%
Admitting
denial rate)
o Reduces administrative
burden
No
PrOE PA
form sent to
Admitting
Patient
undergoes
procedure
Admitting
submits PA
PA
reviewed
by third
party
Admitting
enters auth
# in
PATCOM
Denied
Authorization
Manually
submitted
to
appeal
Admitting
claim
PA is granted
without third
party review
Specialty Care
43
We can do a better job in helping our patients
understand their healthcare encounters….
Problem
Outcome
Redundant,
inconsistent, and
perishable
educational
encounters in
healthcare
Reduced provider
productivity and
patient
satisfaction
Patient Eng.
… by providing a non-perishable, personalized solution
to patient education
Problem
Redundant,
inconsistent, and
perishable
educational
encounters in
healthcare
Outcome
Solution
Improved provider
productivity and
patient
satisfaction
Providergenerated, videobased education
prescribed to
patients before,
during, and after
clinical
encounters.
Patient Eng.
We believe personalized nonperishable education will
improve outcomes and
satisfaction
• Series of short, singletopic videos featuring a
patient's own
healthcare provider.
• Improve provider
efficiency, increase
patient engagement,
and improve clinical
outcomes
46
Patient Eng.
Thank you! Thoughts or questions?
47
Appropriateness Results: Diagnostic Cath
Appropriateness Scores for Diagnostic
Catheterization by Month (all AUC Indications)
Appropriateness Scores for Diagnostic
Catheterization for Suspected CAD at MGH vs. NY
Cardiac Database*
100%
100%
90%
90%
80%
80%
70%
70%
60%
60%
50%
50%
40%
40%
30%
30%
20%
20%
Median hospital-level
inappropriateness rate
is 28.5%*
Rarely
Appropriate
Maybe
Appropriate
Appropriate
10%
10%
0%
0%
Aug
Sept
Oct
Nov
Dec
MGH
n=156
NY Cardiac Database
n=8986
*Hannan, EL, et al. Appropriateness of Diagnostic Catheterization for Suspected Coronary Artery Disease in New York State. CIRC INTERVENTIONS. January 28, 2014. 113.000741
PrOE: Inputs and outputs
INPUTS
OUTPUTS
PrOE Appropriateness tool
Appropriateness Indications
& Decision support
Prepopulated
data fields
(NLP
search)
LMR, OnCall
Internal
Performance
Dashboards
EMR
Appropriateness
Data Repository
EHR note created
RPM,
RPDR,
CDR,
EMPI
PCI, CABG,
Vascular,
Harris Joint
Procedure
Scheduling
Data
storage
Billing and
Prior
Authorization
Copy of
appropriateness
results placed in
LMR and CDR
Existing
registries
Public
Reporting
Measurement & analysis of
appropriateness and outcomes
inform guidelines and
indications in real-time
Data passback to
registries (Web service)
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Personalized
consent form
Analytic
Insights
Questions &
Answers
A
Session Feedback Survey
1. On a scale of 1-5, how satisfied were you overall with this session?
1)
2)
3)
4)
5)
Not at all satisfied
Somewhat satisfied
Moderately satisfied
Very satisfied
Extremely satisfied
2. What feedback or suggestions do you have?
3.
On a scale of 1-5, what level of interest would you have for
additional, continued learning on this topic (articles, webinars,
collaboration, training)?
1)
2)
3)
4)
5)
No interest
Some interest
Moderate interest
Very interested
Extremely interested
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Upcoming Keynote Sessions
2:20 PM – 3:10 PM
Location
23. Predictive and Suggestive Analytics
Dale Sanders
Senior Vice President, Health Catalyst
Main Ballroom
3:25 PM – 4:25 PM
24. From The Heart: Healthcare Transformation From India
To The Cayman Islands
Dale Sanders
Senior Vice President, Health Catalyst
Chandy Abraham, MD
Chief Executive Officer, Director of Medical Services
Health City, Cayman Islands
Gene Thompson, Health City Director, Director of
Thompson Development, Ltd.
4:15 PM – 4:45 PM
25. Closing Keynote
Dan Burton, Chief Executive Officer, Health Catalyst
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