Clinical Integration, Network Development,
Physician-Hospital Organization, ACO:
Ask the Same Question…
To HIE or not to HIE?
St. Vincent’s Health Partners, Inc.
Dr. Michael G. Hunt
CMO/CMIO
Bridgeport, CT 06606
203-275-0201
michael.hunt@stvincentshealthpartners.org
http://stvincentshealthpartners.org/
 A PHO
is a legal entity generally formed by
physicians and one or more hospitals with the
intention of negotiating contracts with payers and
sharing in the financial rewards of controlling costs
while delivering high-quality care.
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“Physicians working together systematically, with or
without other organizations or professionals, to
improve their collective ability to deliver high
quality, safe, and valued care to their patients and
communities”.
Alice Gosfield, J.D.
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An active and ongoing program to evaluate and modify
practice patterns by the network’s physician participants and
create a high degree of interdependence and cooperation
among the physicians to control costs and ensure quality.
This may include:
 Establishing mechanisms to monitor and control utilization of health care
services that are designed to control costs and assure quality of care
 Selectively choosing network physicians who are likely to further these
efficiency objectives
 The significant investment of capital, both monetary and human, in the
necessary infrastructure and capability to realize the claimed efficiencies
SOURCE: FTC/DOJ - Statements of Antitrust Enforcement Policy - 1996
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Harold Miller: How to Create Accountable Care Organizations 2009
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SVHP
Hospital
Member(s)
Hospitals
Skilled Nursing
Facilities / Rehab /
HHC
Physician
Members
PCPs
Specialists
1 Flagship Hospital – St. Vincent’s Medical Center
370 Providers (Physicians, PAs, APRNs)
52 offices
> 40 specialties
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
Service
Provision of medical care from a provider/facility directly to
the patient
Managing all elements of individual patient care

Management
Population Health
Defining the operational roles of care coordination
 Enterprise level
Defining the operational role of case management
 Facility level
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 Participate in Care Coordination services across the clinically integrated
network while utilizing existing case management services in the hospital,
ambulatory, ED, urgent care centers and SNF’s by identifying the additional
Care Coordination needs and develop processes across the continuum for a
seamless transition of care.
 SVHP Playbook
 Identified more than 140 care transitions and established baseline
requirements for data portability
 Details quality metrics agnostic to Payer
 Reference for Care Guidelines – Preventative and disease management
 Organizational polices and plans
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
Goal:
Meet Patient Needs and Preferences in Delivery of High-Quality,
High-Value Care
Bridging the gaps between:
 Primary Care
 Specialty Care
 Inpatient
 Mental Health Services
 Long-Term Care
 Medical History
 Test Results
 Home Care
 Informal Caregivers
 Patient/Family Education and
Support
 Medications/Pharmacy, and
 Community Resources
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Legacy Data from disparate Practice Management
Systems
 Data

Hospital(s)
Laboratory
Local and national companies
Insurance
Patient specific (EMR)
Imaging
Pharmacy
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
Optimize preventive and chronic disease management
 Primary and specialty care
 Reduce variations of care

Care Coordination
 Focus the right treatment at the right time for the patient


Identify and develop cost-effective management strategies
Support initiatives
 Patient Centered Medical Homes
 Participation with ACO
 Maximize reimbursement
 P4P, PQRS, etc.
 Achieve clinical integration and physician adoption

Share Data
 Between professionals and institutions
 With the patient
 Public transparency
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Membership value to participate
 Priorities of membership
 Respect clinical workflow

Just another tool not well utilized

Cost and Budget
Limited financial resources

Quality and performance demonstration
Use of available data
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
Data types
Labs not based on LOINC
 Need for mapping between organizations
Data receptivity
 Format
 HL7
 CCD
 Flat file
Patient transition and patient-specific information transfer
 Intramember patient communication
 Extrainstitution patient communication
 Competing priorities between stakeholders
 Technology

System oriented versus independent members
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
If you do not measure it, you cannot improve it.

IT is the backbone of the CI network's value proposition and is critical
to improving coordination and connectivity between providers of care.

Today the industry is inundated with tools to assist with monitoring and
reporting the care provided to a patient.
 Two types of data sharing sources
 Health records
 patient registries
 repository that holds clinical information specific to a disease, disease process, implant,
drug, etc
 Sources
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
physician office
Hospital
ancillary care facility
ambulatory care facility
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Component
Definition
Method of Measurement
Process
Manner to ensure that
care is given
Clinical pathways
Readmissions
Rate of preventive testing
Infrastructure
Facilities, personnel and
equipment used in the
healing process
Patient satisfaction survey
Outcome
Results of patient care
Complications
Cost of care
Length of hospital stay
mortality
Morbidity
Disease-specific function
tools
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
Inpatient
Readmission rates
Medication reconciliation
Care Coordination

Outpatient
Preventive Health
 Wellness exams
 Immunizations
 Mammograms/pap smears
Chronic disease
 Diabetes
 CHF
 Asthma/COPD
 Acute and Chronic Care Management
Measures
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









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

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Appropriate testing for children with pharyngitis
Appropriate treatment for children with URI
Appropriate antibiotic treatment for acute bronchitis
New episode of depression: acute phase treatment
New episode of depression: continued treatment
AMI: persistence of beta-blocker treatment after a heart attack
CAD: ACE inhibitor/ARB therapy
Complete lipid profile for patients with CV conditions
Heart failure (HF) : beta-blocker therapy
PDC: for HTN (ACEI or ARB)
PDC: for cholesterol (Statins)
Diabetes: eye exam
Diabetes: hemoglobin A1c testing
Diabetes: lipid profile
Diabetes: urine protein screening
PDC: oral diabetes
Annual monitoring on persistent medications: ACE/ARB
Annual monitoring on persistent medications: anticonvulsants
Annual monitoring on persistent medications: digoxin
Annual monitoring on persistent medications: diuretics
Arthritis: disease modifying therapy in rheumatoid arthritis
Osteoporosis management in women who had a fracture
Use of appropriate medications for asthma

 Preventive Care Measures
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
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Breast cancer screening
Cervical cancer screening
Childhood immunization status: MMR
Childhood immunization status: VZV
Chlamydia screening in women
Glaucoma screening in older adults
Adolescent well visits: 12-21 years
Well-child visits in the first 15 months of life
Well-child visits: 3-11 years
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
Inpatient
Length of Stay
Antibiotic usage
Blood products/transfusions
Readmission rate

Outpatient
Inappropriate ER use
Inappropriate advanced radiology
Costs pmpm for ED, Pharmacy, inpatient, outpatient, radiology

Ambulatory Sensitive Conditions
ER and Inpatient
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McKesson Population Manager – Population Management
McKesson Risk Manager – Risk Management/Value Based
Contracting
Clinical Informatics Systems – EHR/EMR/PMS/HIE/Pharmacy/Lab
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Data Sources
Clinical Lab
Partners
.CSV Results File
Upload
HL7 Interface Results Feed
Quest
Diagnostics
Secure File Transfer Protocol (SFTP)
Claims Feed
Practice Management System Claims
Data
MSG - SVMC
UCC – SVMC
Goldfarb Ranno & Assoc.
Allergy & Asthma Care, LLC
Pulmonary & Internal Medicine
Primary Care of Shelton
Endocrine Associates, LLC
Ehrlich Bariatrics
Opthalmic Consultants of
Connecticut
Family Podiatry Center
Dr. Reuvin Rudich
Dr. R. Levin & Dr. L. Fliegelman
McKesson Population Manager –
SaaS/Cloud
Physician Quality Reporting
Point of Care Technology
(Future)
Physician Offices
&
PHO Hospital Partner
Physician Hospital Organization
(PHO)
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Data Type
Source
Primary Practice Mgmt /
Billing System(s)
At each practice and not centralized.
Clinical Events
EMR systems.
Providers
Multiple sources. One provider could be in more than one source. TaxID & NPI’s are available for each provider (mid-levels too).
Lab
Hospital, Quest, Labcorp, CLP, POC labs
Radiology
Inpatient & Outpatient, may be different sources. POC radiology.
Pharmacy
Possibly Surescripts.
Processed Claims
Claims from insurers.
Other
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
Data sources include:
 Demographic, ICD-9, CPT, CPT-2
from Practice Management Systems
 Prescription history from Surescripts
 HIEs
 Lab results from hospital, local labs,
LabCorp, Quest
 EMRs
 Hospital
 State sources (Immunization Registry)
 Survey Data
 Payers
 Data entered on-line
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
Every night, registry processing runs automatically:
PCP Assignment
Registry Assignment
Responsible Provider
Medical Exclusions
Registry Purge
Compliance Calculation
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Payer
Medical
& Rx
Claims
Membership
Eligibility
Providers
Hierarchies
DCGs
ETGs
EBM Connect
Data
Sentinel
Rhapsody
Data Mart
Data
Entered
On line
EMR, HIE
Data
Lab
Results
Patient & Population Risk
Management:
Predictive Models
Risk Stratification
Episodes of Care
Management
Quality Rules
Benchmarks
P4P Rules
Formulary
FDB
HEDIS & STAR
Management
MPI
Attribution
Organization
Hierarchy
Pharmacy Mgt
Workflow Engine
MD Attribution &
Correction Workflows
Capitation Management
PMPM & Utilization
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Across the continuum of care: inpatient, outpatient and pharmacy
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Attribution
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

American Hospital Association’s Center for Healthcare
Governance
Lakeshore Health Network Case Study, 2013
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