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Leveraging Payer Datato Jumpstart RHIOs
David St.ClairChairman & CEOMEDecision, Inc.
March 7, 2005
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Agenda
• Our Vantage Point• The RHIO Market• Leveraging Payer Data• Collaborative Care Management
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MEDecision’s Vantage Point
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MEDecision’s Position• We are the software leader in Collaborative Care Management.
– Collaborative Care Management enables all members of a Patient’s Care Team to share information about the Patient’s history and status, combined with clinical “best practice”, to improve the quality of care and outcomes.
– MEDecision focuses on health care Payers and the emerging Regional Health Information Organizations (RHIOs) as principal customers.
– MEDecision’s Integrated Medical Management (IMM) solution set is the most comprehensive, functionally integrated and adaptable suite of products in production today.
• We create “Actionable Intelligence” for the health care system.– MEDecision provides authorized stakeholders with access to the new
Payer-based Health Record (PBHR) in a flexible and responsive care management environment to accelerate decisions, automate processes and adjudicate clinical requests on the spot.
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MEDecision’s Position
• Today, we have a more than 60 Payer customers nationally, managing care for 42 million people.– 15% of top 433 MCOs, 1 out of every 6 insured Americans;– 21 of the BlueCross BlueShield Plans;– Significant pockets of managed Medicaid business;
• Collaborative Care Management is most likely in markets with progressive Payers that represent a significant portion of each physician’s practice.– We have market-dominant Payers in more than 30 markets.
• The bridge from the Payer space has been iEXCHANGE® Web. – In production or being implemented in half of the markets.
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MEDecision’s Position
iEXCHANGE MarketsiEXCHANGE Penetration
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The RHIO Market
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The RHIO Market
• Hundreds of initiatives springing up nationally.– Predominantly well-intentioned, but under-funded…– Lots of excitement, but having difficulty focusing…
• Challenges are daunting for every group.– “Without proven models, how can we raise money?” – “What services and capabilities should the network provide?”– “What technologies should we assemble, and how can we support them?”– “How can we minimize or eliminate first-mover disadvantages?”
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The RHIO Market
• High-level Steps to Start a RHIO– Create a Collaborative environment for constituents.– Set Reasonable expectations and schedules.
» Plan for the Success of early adopters and investors.» Link the “Investment-Value-Investment-Value-Investment-Value” chain.» Prepare the ground for future growth.
– Enroll the regional market leaders as Leaders.» Innovation requires a “leap of faith” mentality, but with very small cliffs!» Be willing to praise commitment publicly – it’s an early ROI for Leaders!
– Take Action!» Small trust-building steps today are much more valuable than bigger successes years
from now, and early, small mistakes will likely not be fatal!» Remember the concept: “Speed to Value”
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The RHIO Market
• What is the “First-Mover Disadvantage”?– The Network Effect: the value of a network grows exponentially as the
number of nodes increases.– Therefore, the early adopters risk receiving no real value for their connections
to a RHIO, as no other user likely has data to share about their patients…
So, what should be the first step?
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Leveraging Payer Data
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Patient Data Sources
Lab Care MgmtClaimsPharmacy
• Today, a tremendous amount of Payer data is available for clinical summarization and analysis.
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Patient Data Sources
SO
AP
Lab
Images Fam. Hx
Care MgmtClaimsPharmacy
Encounter
OTC
Exercise
HRA
• However, other electronic data about Patients are distributed inmultiple repositories.
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Patient Data Sources
PHREMR
PBHR
• Three primary systems are used to integrate and store Patient Data.
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Patient Data Sources
PHREMR
PBHR
Electronic Health Record
“EHR”
• Our challenge is to intelligently “weave” these primary sources of Patient data together.
EHR = PBHR + EMR + PHR!
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“RHIO”
“EHR”
Uses for Woven Record
Consumer Decision Support
Clinician Decision Support
Care Management Support
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Uses for Woven Record
• The EHR becomes the source data for:– Patient-centric Risk Assessment & Predictive Modeling.– Comparison to Evidence-based Medicine treatment plans and identification of
“Treatment Opportunities.”– Populating care management systems in Payer, Provider and Disease
Management organizations.– Public Health and Surveillance programs.– Clinical research with unidentified records and data.
• The PBHR is the first step to the EHR, and it’s moving into production in Provider settings today!– Has years of experience in Disease Management organizations.
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Collaborative Care Management
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The Emerging Opportunity• The market for Electronic Health Records (EHR) is exploding, and
Payers can become “infomediaries” to help create Regional data exchanges.– 2nd generation analytics to create the Payer-Based Health Record through a
“data weaving” process;– Evidence-Based Medicine and predictive modeling capabilities to identify
Treatment Opportunities (“gaps in care”) in Patient Clinical Summaries;– Multi-Payer connectivity solutions and a Service Oriented Architecture to
efficiently deliver Payers’ data to the point of care.• The goal is to fully integrate all care management functions across
the entirety of the “Care Team.”– Payers, Disease Management vendors and multiple Providers.
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ASP/RHIO
xEHR
The Future of the PBHR
Users of Clinical Data Sources of Clinical Data
MIDRiEXCHANGE Web
PBHR/PCS
PRAV
xEHR
xEHR
xEHR
xEHRs
xEHRs
xEHRs
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DM Services Company
Collaborative Disease Mgmt.
Payer Systems
ASP/RHIO
Diabetes
CO
PD
Asthm
a
Behavioral
Coaching
Diabetes
CH
FC
HF
Behavioral
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DM Services Company
Collaborative Care Mgmt.
Customer Systems
ASP/RHIO
Diabetes
CO
PD
Asthm
a
Behavioral
Coaching
CH
FC
HF
Behavioral
iEXCHANGE® Web
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Questions?
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Thank You!