© 2015 The Chartis Group, LLC All Rights Reserved
17 November 2015
Webcast Session Four:
Creating and Deploying Powerful Information through
Technology and Analytics
Population Health Management: Advancing Your Position in the Journey
to Value-Based Care
© 2015 The Chartis Group, LLC All Rights Reserved 2
Welcome and Introductions
Stacy [email protected]
Gregg [email protected]
Mark Van Kooy, MDAssociate Principal, Clinical Transformation and Performance [email protected]
Tom Graf, MDNational Director of Population Health [email protected]
© 2015 The Chartis Group, LLC All Rights Reserved 3
About The Chartis Group
Our mission is to materially
improve the delivery of
healthcare in the world.
Strategic and Economic Planning
Accountable Care Solutions
Clinical Transformation
Informatics and Technology
ProfessionalsWorking In:
~250
The Chartis Group is a national
advisory services firm dedicated to
the healthcare industry.
The firm is comprised of highly
experienced senior healthcare
professionals and consultants who
apply a deep knowledge of
healthcare economics, markets,
clinical models, technology and
organizational dynamics to help
clients achieve unequaled results.
© 2015 The Chartis Group, LLC All Rights Reserved 4
Today’s Discussion
Discuss how organizations are developing and
implementing a technology and analytics plan that reflects
their population health management (PHM) ambitions
Explore the evolving field of tools and technologies
being developed by vendors to support care management,
patient engagement and other PHM activities
Share how organizations are integrating data from
disparate sources and converting the information
into actionable intelligence to manage the health of
populations and engage patients
Highlight data management structures and data
governance standards providers are developing to
create the foundation for their PHM platforms
5© 2015 The Chartis Group, LLC All Rights Reserved
An Integrated, Iterative Approach
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Big Questions Surround Development of PHM IT Capabilities
Healthcare IT executives cite population health and analytics as high priority investments for value based
care, but obstacles exist.
Breakdown of Top IT PrioritiesPercentage of Senior IT Leaders Who
Ranked Given Topic as a Top Priorityn = 70
Biggest Obstacles to Adopting Analytics
Percentage of Senior IT Leaders Who Ranked
Given Topic as a Key Challenge n = 70
Source: Health Catalyst Survey (2014): https://www.healthcatalyst.com/news/analytics-outweighs-accountable-care-population-health-icd-10-as-an-it-priority-say-health-system-execs/
0 20 40 60
Consolidation-Related Initiatives
AccountableCare/Shared Risk
ICD-10
Population Health
Analytics
0 20 40 60
Confusion in the market aboutanalytics and analytic vendors
Lack data warehouse foundation forrobust analytics infrastructure
EMR rollout consuming time andresources
Lack of funding
Lack of expertise and/or resources
7© 2015 The Chartis Group, LLC All Rights Reserved
Creating and Deploying Powerful Information
Rigorously Assessing PHM IT Capabilities
Developing a Comprehensive yet Flexible Investment Roadmap
Clarifying Our PHM Aspirations
Crafting a multi-year investment and development plan that accounts for a
rapidly evolving technology landscape and changes in PHM priorities
Evaluating the IT platform’s ability to integrate data from disparate sources,
stratify patient populations and translate information into actionable insight
Defining the organization’s strategic priorities and goals before investing
significant time and resources into the IT platform
Today’s discussion will focus on three key principles.
8© 2015 The Chartis Group, LLC All Rights Reserved
Creating and Deploying Powerful Information
Rigorously Assessing PHM IT Capabilities
Developing a Comprehensive yet Flexible Investment Roadmap
Crafting a multi-year investment and development plan that accounts for a
rapidly evolving technology landscape and changes in PHM priorities
Evaluating the IT platform’s ability to integrate data from disparate sources,
stratify patient populations and translate information into actionable insight
Clarifying Our PHM Aspirations
Defining the organization’s strategic priorities and goals before investing
significant time and resources into the IT platform
9© 2015 The Chartis Group, LLC All Rights Reserved
Use the health system’s strategic priorities to create business requirements and IT requirements.
Clarifying Our PHM Aspirations
• Redesign care models to ensure
we provide high value triple aim
outcomes• Redesign network and payer strategies
and contracts
• Build a centralized PHM function
• Meaningfully engage target individuals
in managing their health
Strategic
Priorities
Strategic
Priorities
IT
Requirements
Business
Requirements
#1
#2
#3
• Analytics/Business Intelligence infrastructure (repositories,
warehouse, and presentation tools)
• Aggregation capabilities and tools for operational, financial, service,
quality, and other data required to support metrics
• Care management infrastructure and tools that support care team by providing
patient panels, worklists, alerts, prompts, and communication tools• Chronic disease management and health maintenance tools
• Tools for risk stratification, modeling, and analysis
• Understand sources of clinical variation and
utilize evidence-based pathways to deliver
highly reliable care
• Evidence-based pathways/alerts, including real-time,
point-of-care interventions for care gaps
• Embed disciplined approach to transition and patient
progression planning
• Common quality/outcomes measures, and ability
to monitor and report on measures
• Ability to monitor and report on variations
10© 2015 The Chartis Group, LLC All Rights Reserved
Participant Poll
Does your organization have a well-developed,
enterprise-wide PHM strategy?
29%
71%
Yes
No
11© 2015 The Chartis Group, LLC All Rights Reserved
When strategy or business requirements are vague, IT can determine which capabilities are
needed.
Clarifying Our PHM Aspirations
12© 2015 The Chartis Group, LLC All Rights Reserved
Creating and Deploying Powerful Information
Developing a Comprehensive yet Flexible Investment Roadmap
Crafting a multi-year investment and development plan that accounts for a
rapidly evolving technology landscape and changes in PHM priorities
Rigorously Assessing PHM IT Capabilities
Developing a Comprehensive yet Flexible Investment Roadmap
Clarifying Our PHM Aspirations
Crafting a multi-year investment and development plan that accounts for a
rapidly evolving technology landscape and changes in PHM priorities
Evaluating the IT platform’s ability to integrate data from disparate sources,
stratify patient populations and translate information into actionable insight
Defining the organization’s strategic priorities and goals before investing
significant time and resources into the IT platform
13© 2015 The Chartis Group, LLC All Rights Reserved
Rigorously Assessing Population Health IT Capabilities
Having defined the strategic priorities for the population health IT platform, the next step entails
conducting an in-depth assessment of capabilities and gaps across core competency areas.
Competency Definition
1. Data Sharing,
Governance,
and Standards
Data sharing and use agreements in place; Data governance policies and oversight structure in
place to ensure common data architecture, management, and data use cases
2. Data Aggregation
and IntegrationConsolidated data repositories to support integrated analytics needs; extraction, normalization, and
transformation of data from claims, clinical and financial systems
3. Innovation and
New TechnologyDefined processes and capabilities to assess new technology to support business innovation and
make proactive decisions
4. Patient Attribution, and
Risk StratificationAbility to identify and attribute individuals within a defined population and stratify defined
populations based on risk
5. Operational Analytics and
Performance ManagementSystems in place to measure, collect, track, and analyze quality, cost, and utilization data across the
care continuum
6. Decision Support and
Team CommunicationAdoption of toolsets and expertise to convert data and information into shared knowledge that is
communicated across care teams support clinical, financial, and operational decision making
7. Financial Management Processes and tools to support PMPM cost accounting, value-based payments, shared savings
accounting and distribution
8. Patient and Member
EngagementTools and capabilities to actively engage members in care management and health and wellness
activities
14© 2015 The Chartis Group, LLC All Rights Reserved
Competency #1:Data Sharing, Governance, and Standards
Rigorously Assessing PHM IT Capabilities
Conduct an in-depth gap analysis of IT capabilities across core competency areas.
Do not take on more than you can. Start with key areas that will generate the most value.
Develop and socialize use cases
Create a multi-year PHM data strategy and align the organization’s data management capabilities
Sharing, Governance and Standards = Data ManagementIt is an EVOLUTION and a journey.
What is it comprised of? Why is it important? What do you need?
Business intelligence strategy
Data governance
Standardized supporting
technology tools
The right data should be aligned with the
right metrics
Collaboration ensures data is shared
appropriately and the right people are
engaged
The program should be cost effective
with the right amount of resources and
support
Current state assessment -
technology, operations and
organizational structure
Establish a true governing model and
process
Align that model with your PHM
strategy
Staff and resource appropriately
15© 2015 The Chartis Group, LLC All Rights Reserved
Competency #1:Data Sharing, Governance and Standards
Rigorously Assessing PHM IT Capabilities
PEOPLE, POLICIES, TECHNOLOGY ADOPTION
PR
OD
UC
TIV
ITY
& Q
UA
LIT
Y
RIS
K
& W
AS
TE
Level 1:Local data;
no governance
Level 2:Pooling resources;
enterprise data points
Level 3:Collective vision;
Improving process and structure
Level 4:Predictive modeling;
Data-driven organization
Foundational Aspirational Proficient Transformed
HIGH
HIGH
LOW
LOW
Data in Spreadsheets
Dept. Data Experts
Enterprise Data Warehouse
Dept. Dashboards
Enterprise Analytics
Real-time Analytics
Data DrivenLeadership
Enterprise Chartered
Governance Closed Loop Analytics
Predictive Modeling
Standardized Reporting
Conflicting Data
Leadership
Awareness &
Initial Governance
Structure
Descriptive
Analytics
Data Management Maturity Model
Before making complex data management decisions, assess the maturity of your organization.
16© 2015 The Chartis Group, LLC All Rights Reserved
Competency #1:Data Sharing, Governance, and Standards
Rigorously Assessing PHM IT Capabilities
The following example highlights one leading health system’s approach to structuring its BI and
governance models to support population health and other strategic priorities.
Enterprise Data Governance (EDG) Facilitation• Led by Clinical Quality or Performance Lead
• Staffed by Director of EDG and Data Governance Facilitators
• Defines standards, policies, and roles related to EDG
• Ensures metric and data element definition, integrity,
standardization, and transparency
Data Steward Data Steward Data Steward
Enterprise Steering Committee• Confirms BI Strategy
• Resolves escalated issues
BI and EDG Subcommittee• Prioritizes analytics and improvement project request
• Approves EDG decisions (standards, processes, etc.)
• Provides oversight for the teams
Business Intelligence (BI) Strategy• Led by Head of Corporate Strategy
• Staffed by a VP of BI and Performance Management and
project manager(s)
• Ensures accountability (appropriate goals and progress)
• Provides consultation (translation of strategy to goals)
• Identifies and communicates overall direction of BI
Business Intelligence Strategy
(PHM strategy is a critical input)
Enterprise Data Governance
Clinical Advisory Committee• Analyzes clinical project
requests and makes
recommendations to the
Subcommittee
As-Needed Data
Governance Teams• Facilitated by EDG facilitator
• Membership is temporary and
depends on the issue
• Focus groups will be able to
address a lot of these issues
BI Triage Group• Facilitated by BI PM
• All the leads from the “verticals”
• Assesses feasibility of requests
for BI and EDG Subcommittee
• Fosters collaboration
Clinical and Business Stakeholders (data requestors)
and Data Analysts (data manipulators)
17© 2015 The Chartis Group, LLC All Rights Reserved
Rigorously Assessing PHM IT Capabilities
Key Considerations
Increasingly diverse
and robust data sets
needed from
traditional and non-
traditional sources
Increasing emphasis
on real-time
integration and
aggregation
Challenges with
attribution and
authenticity, coupled
with data
normalization
Security and storage,
especially for “data in
the cloud”
Significant work, “Buy
versus Build”
Competency #2:Data Aggregation and Integration
The need to manage diverse populations across care settings and over extended periods of time
elevates the importance of data aggregation.
18© 2015 The Chartis Group, LLC All Rights Reserved
Rigorously Assessing Population Health IT Capabilities
• High Intensity / High Touch
• Leverage AMH high-risk care
managers with integrated specialty
care capabilities for intensive clinical
management
• Moderate Intensity
• Actively manage via primary care-
based advanced medical homes
• Promote access to full array of virtual
care options and self-management tools
• Low Intensity / Low Touch
• Ensure access to online self-
management tools and virtual care for
episodic needs
• Promote utilization of customized
digital platform to guide and inform
decision making regarding healthcare
and well-being
Parents with newborns
“Weekend warriors”
Tech-savvy, high-touch
professional
Teen
athletes
ESRD
Diabetics requiring
social support
Patients with
epilepsy
Patients with
depression
Pre-diabetics
Trans-plant
SPMI1Frail
elderly
Socially isolated, chron. ill members
1 Serious and persistent mental illness.
Cancer
Competency #4:Population Definition, Patient Attribution, and Risk Stratification
In assessing an patient identification and stratification capabilities, it is critical to understand the
competencies that advanced PHM practitioners have developed.
Early Identification Stratification
Clinical Risk / Social Determinants /
Engagement Preference
Clinical Model Characteristics
Members stratified
at enrollment and
continuously through
the care process
19© 2015 The Chartis Group, LLC All Rights Reserved
Rigorously Assessing Population Health IT Capabilities
Evolution of Decision Support and Team Communication Capabilities
Value to
Population
Health
Enterprise
Sophistication of Decision Support Tools
Emerging
Expanding
Advanced
• Alerts & reminders
embedded in clinical
information systems
• Care mgmt. tools in use in
isolated care settings
• Integrated communication
platform with basic
functionality
• Support teams embedded in
select areas
• Care mgmt. capabilities
accessible in all care
settings
• Workflow engines support
clinical protocol adherence
• Communication and alerts
targeted by team member
and role
• Fully integrated
communication platform
with comprehensive
functionality
• Real-time decision support
presented in an end-user
optimized configuration
• Patient preferences
integrated into learning
databases
• Care mgmt. system
incorporates data entered
by patients, community
partners
• Continuous performance
evaluation and improvement
program refining the
platform
Competency #6:Decision Support and Team Communication
In assessing patient identification, stratification, and support capabilities, it is critical to
understand the capabilities that advanced systems have developed.
20© 2015 The Chartis Group, LLC All Rights Reserved
Rigorously Assessing Population Health IT Capabilities
Increase interaction with
patients at all stages of
health
Improve care outcomes
and effectiveness by
creating continuous care
systems
Change patient behavior
with clear and targeted
information and meaningful,
real-time interactions with
the clinicians
Improve efficiency by
delivering care in more cost-
effective settings and
enhancing care system
responsiveness
Drive patient loyalty by
strengthening the
connection between the
patient and their physician
and other caregivers
Aspirations for Patient
Engagement
Technology Platform
New
Access
Modalities
Retail Access
Points
Traditional
Access
Points
Community-Based
Access Points
Virtualized
Access Points
Patient Portal
Telemedicine
Consults
E-Visits
Video Visits
School/Work-Based
Clinics
Community Health
AgentsHospitals
Physician offices
Skilled Nursing
Facilities
Stand-alone
Kiosks
Urgent Care
Centers
Retail Clinics
Competency #8:Patient and Member Engagement
In developing their patient engagement capabilities, providers need to focus on creating tools
and processes that support informed decision-making and can influence patient behavior.
21© 2015 The Chartis Group, LLC All Rights Reserved
Creating and Deploying Powerful Information
?
QuestionsRigorously Assessing PHM IT Capabilities
Evaluating the IT platform’s ability to integrate data from disparate sources,
stratify patient populations and translate information into actionable insight
22© 2015 The Chartis Group, LLC All Rights Reserved
Creating and Deploying Powerful Information
Rigorously Assessing PHM IT Capabilities
Developing a Comprehensive yet Flexible Investment Roadmap
Clarifying Our PHM Aspirations
Crafting a multi-year investment and development plan that accounts for a
rapidly evolving technology landscape and changes in PHM priorities
Evaluating the IT platform’s ability to integrate data from disparate sources,
stratify patient populations and translate information into actionable insight
Defining the organization’s strategic priorities and goals before investing
significant time and resources into the IT platform
23© 2015 The Chartis Group, LLC All Rights Reserved
Developing a Comprehensive yet Flexible Investment Roadmap
Multiple vendors offer multiple evolving products to satisfy IT requirements in the core
competency areas.
Data Aggregation
and Integration
to Support
Data Governance
Population Definition,
Patient Attribution,
and Risk Stratification
Operational Analytics
and Performance
Management and
External Reporting
Decision Support
and Team
Communication
Financial
Management
Patient and Member
Engagement
HIE/regional HIEs
Enterprise Master
Member Index
Transformation of
data from claims,
EMR, other
Rules engine
Integration engine
Example Vendors:
Orion
Allscripts/
DBMotion
Medicity
Intersystems
Physician and
Hospital Service
contracting
PHM partner
reimbursement
PHM Cost
accounting system
Risk modeling and
Incentives analysis
Example Vendors:
Advisory Board
COMPASS
Optum One
Allscripts EPSI
Verisk
Operational
performance tools
Physician
performance tools
EDW/data marts
Dashboards
Example Vendors:
Wellcentive
IBM Explorys
Medicity
Advisory Board
Crimson
General BI tools:
Business Objects,
Qlikview, Tableau
against EDW
Care management
Longitudinal care
plan
Care pathways,
interventions, goals
Alerts, notifications
Example Vendors:
Wellcentive
Allscripts/dbMotion
Caradigm
Lightbeam
IBM Phytel
Conifer
AthenaHealth
Physician and
Hospital Service
contracting
PHM Cost
accounting system
Risk modeling and
Incentives analysis
Example Vendors:
Advisory Board
COMPASS tools
Optum One
Allscripts EPSI
Verisk
Patient portal
Self-service
mHealth
Telemedicine –
home monitoring
Customer portal
Outreach
Education
Example Vendors:
MedSeek
CernerHealth
(IQHealth)
WellCentive
Insignia PAM
MDLive
Epic MyChart
24© 2015 The Chartis Group, LLC All Rights Reserved
Developing a Comprehensive yet Flexible Investment Roadmap
Once IT requirements are known, a multi-year roadmap for implementation can be created.
An
aly
tics
Core
S
yste
ms
Year 1 Year 2 Year 3 Year 4
DSS7 Upgrade:
Business Objects
Dashboards
HCAHPS
Clinical Dashboard
Allscripts Data Integration
Intranet Analytic Portal
Advanced Analytics: Claims, Benchmarks
Benchmarks
UMR Claims
EMPI Implementation
Continued EMR Optimization
Enterprise EMR Implementation Other EMR Integration?
Cro
ss C
on
tin
uum
Bill Pay (Client) Patient Portal – PHR/Wellness Self-Schedule and Reg
Case Management/Registry
Longitudinal Client HIE Physician Portal
E-Visits
Community MPI Integration of Independent EMR to HIE
Member
Engage
Physician
Engage
Community
Engage
25© 2015 The Chartis Group, LLC All Rights Reserved
Questions?
?
?
26© 2015 The Chartis Group, LLC All Rights Reserved
Stacy [email protected]
Gregg [email protected]
Mark Van Kooy, MDAssociate Principal, Clinical Transformation and Performance [email protected]
Tom Graf, MDNational Director of Population Health [email protected]
Melissa McCainDirector, Clinical Transformation Practice Leader [email protected]
Mark Werner, MD National Director of Clinical [email protected]
Anneliese GerlandEngagement Manager, Accountable Care Solutions Practice [email protected]
Gregory Maddrey Director, Accountable Care Solutions Practice Leader [email protected]
Cindy [email protected]
For More Information
Visit us at www.chartis.com/populationhealthmanagement.com
27© 2015 The Chartis Group, LLC All Rights Reserved
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