NextGen® Population Health

“The Game Changer”

May 14, 2014

Industry dynamics driving population health management

Presented by Elise Freedman, MBA

Senior Market Manager, Business Development

Population Health is hot!

Everyone says they have a population health solution….Really?

If it was that easy….

And population health is defined differently depending on who is using the term

NextGen Population Health

• Helps providers to deliver the most appropriate preventative care and intervention

based on the patient’s condition, risk and severity of illness …. across the entire

patient panel.

• An automated and targeted patient outreach and engagement solution

• (“Set it and Forget it!”)

• Fully integrated with NextGen EHR, PM, Patient Portal and Dashboard

• Helps healthcare providers improve:

• Patients health

• Quality of care

• Practice productivity/efficiency

• Financial outcomes

Population Health is very “Popular”

Core objectives of population health management

Deliver better care in lower cost settings• Reduce avoidable ER visits and hospitalizations

• Reduce hospital readmissions

• Significantly improve patient health outcomes

Financial Benefits• Maximize financial return for value-based care

• Reimbursement preventative care

• Payment for “non‐visit” contact

• Negotiate better risk sharing terms with payers

Dynamics driving need for population health management

• US healthcare system ― fragmented care, unsustainable costs

• Increasing chronic disease and comorbid conditions, • obesity, heart disease and diabetes

• Baby boomers (born between 1946 and 1964) extremely high utilizers especially end of life care

• Approximately 10,000 Americans turn 65 every day

• 40.3 million people age 65 or older in 2010; by 2050 projected 88.5 million; 8 in 10 seniors suffer from at least one chronic condition

• About 25 percent of seniors are obese

• 20 percent have diabetes

• 70 percent have heart disease

• Projected physician shortage

• Patient non-compliance with treatment• Transition to coordinated, collaborative, integrated, value-based• New diagnostic/treatment available to improve chronic conditions

How providers get paid is changing

Payer trends • Started with CMS quality incentive programs, now

commercial payers on board with performance-based

payment models (because Medicare is going broke, had to

do something)

• Patient Centered Medical Home (PCMH) and practices �implementing Accountable Care (ACO) programs

• Paying per member/per month (pm/pm) care

management fees and gain sharing revenue for

lowering healthcare costs • Payers are buying physician groups and launching

physician group practices, IPAs

CMS

But the clincher is: Responsibility for patients’ health is shifting to providers

• The onus for managing, improving and

reporting the health of patients is shifting to

providers, particularly primary care physicians

• Reporting on these outcomes will impact how

and how much they get paid

• Regardless of whether or not your patients are:

• Compliant

• Non-compliant

• Chronically ill

• Sick short term

My Patients’ Health

“Your patient your responsibility”

The impact of patient noncompliance

• Non-compliance accounts for:- 11% of all hospital admissions

- 40% of nursing home admissions

- 20% prescriptions never filled

- 30% prescriptions never refilled

• Contact with doctors and hospitals is sporadic/infrequent

• Problems are not addressed until patient is in crisis

• 2020, 25% of the American population will have multiple chronic conditions

Source: Wu, S., & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. In RAND Corporation.

The prevalence of chronic diseases has created a national health care crisis

Six "unhealthy truths" about chronic disease in the United States:• 1 Chronic diseases are the No. 1 cause of death and disability in the U.S.

• 2 Treating patients with chronic diseases accounts for 75 percent of the

nation's health care spending (75% of $2.8 trillion!)

• 3 Two-thirds of the increase in health care spending is due to increased

prevalence of treated chronic disease

• 4 The doubling of obesity between 1987 and today accounts for 20 to 30

percent of the rise in health care spending

• 5 The vast majority of cases of chronic disease could be better prevented

or managed

• 6 Many Americans are unaware of the extent chronic diseases could be

better prevented or managed

Many chronic diseases can be prevented with lifestyle and behavioral changes

• Modifiable behaviors that cause illness, suffering, and early death related to chronic diseases

• lack of physical activity

• poor nutrition

• tobacco use

• excessive alcohol consumption

Blame is not a factor possible reasons for patient non-compliance

• Language barriers (including regional semantics)

• Example: (Diabetes vs Sugar)

• Socio-economic conditions

• Unwillingness to follow treatment

• Lack of understanding treatment instructions

• Insufficient provider follow-up

What else is going on with my patients?Patient's personal life and circumstances could be

contributing to their poor health and non-compliance

What percent of your patient population looks like this?

Very Healthy

What percent of your patient population looks like this?

Mostly Healthy

What percent of your patient population looks like this?

Where does this guy go when he goes into cardiac arrest?When do you think he last saw a doctor for a check-up?

Not so good

Then, there’s everyone else…

• When’s the last time you had a preventative screening on time?• How many doctor’s appointments did you cancel this year

because you were too busy?• Do you always take your medications as prescribed?• Do you stop taking medication when you start feeling better?• Do you eat properly? • Exercise regularly? • Get enough sleep?

www.shamedog.com

Population Health as it relates to NextGen Care Coordination

You can’t measure what you don’t track

• P4P programs (PCMH/ACO) earn incentive payments for programs such PQRS, Bridge to Excellence (BTE) and MU

• Practices must track and monitor the health status of their entire patient population

• Providers are responsible for documenting and reporting outreach efforts

Bottom line:

You can’t get paid on what you don’t report

NextGen Population Health generates reports that track and analyze performance

• Outreach communication reports that can be

scheduled for delivery• Graphical reports to measure performance

of outreach program

Physicians and practice administrators can produce analytical reports

on CQM performance as well as detailed patient reports identifying

treatment opportunities within the patient population

NextGen Health Quality Measures (HQM) collects EHR data organized by patient encounter

• Produces summary and detail outcomes results per program rules

• Performs automated calculation, tracking and reporting

• Extracts new clinical data

• Provides useable reports to provide insight and performance metrics at a practice, provider and patient level

• Enables clients to receive incentive for performance

• Automatically submits CQM reports for MU Compliance

Integrated NextGen solutions in a single platform bringing it all together

CCO Phase1 integrates and optimizes NextGen products in our Ambulatory EHR and EPM

• Patient Registry (new!)• Population Health• Patient Portal• NextGen Share• Dashboard• KBM

Tools for comprehensive provider-driven population health management

CCO Phase 2 provides a complete, vendor-agnostic solution leveraging Mirth products by providing:

• Comprehensive care management and

collaborative chronic disease management• Central Data Repository and Data exchange• Population health activation• Advanced “cohort” analytics and risk modeling

Advanced data analytics identify treatment opportunities and report those outcomes

• Ultimately, providers will need to predict

which patients are likely to get sick to

minimize future costs • Data driven workflows manage care

plans, track events, and schedule

appointments and reminders.• Patient engagement tools that enable

patient participating in their healthcare

goalsAnalytics

Population Health

NextGen care coordination goals

• Improve care quality and patient safety for decreased

hospitalizations and re-admittance• Increase staff efficiency by reducing time required to

develop care plan• Greater focus on patient goals and expected outcomes • Establishes clear, organized and specific interventions to

improve patient care• Improved patient compliance with their prescribed care

plans through automated communications and clinical

decision support

Care coordination workflow

• Identify care team members and define roles

• Enter, review and modify referral information

• Identify barriers to care:

• patient disabilities and limitations

• other issues impacting patients ability to comply with care plan

• Review and modify current care plan and track progress

• Log and review all patient-related communications, including:

• phone calls

• emails

• text messages

• Patient communications documented by various categories

and filtered to show all or selected data

Manage the shared care plan

• Standardized care plan accessible to and modifiable by

designated providers, case managers and caregivers

• Customized to patient needs: • Health maintenance

• Chronic care management

• Complex cases

• Advanced directives

• Includes patient directed goals • Patient preferences and directives

• Planned provider and patient interventions

• Barriers to care

Templates that advance PCMH & Collaborative Care

Enhanced care

coordination templates

provide efficient and

reliable care

coordination among

multiple providers to

provide safer and more

effective healthcare

Proactive Patient Engagement

Proactive instead of Reactive

• Today you see patients when they are sick or due for an appointment

• They call you to make an appointment

As we shift from volume-based to value-based care, providers need to focus on:• Proactive patient engagement for preventative care

• Keeping patients from falling through the cracks

• Quality reporting for an ever-increasing volume of measures and mandates

Really important NextGen Population Health differentiators

Fully integrated with NextGen • EHR

• EPM

• Patient Portal

• Dashboard

• No interfaces required!

But wait…there’s more!

With other PH vendors…• Patient receives an alert to schedule appointment for a mammogram

• When patient calls to schedule the appointment, reception pulls up the patient chart but

there is no info in the patient record regarding the alert and why the patient is calling

• But…NextGen is fully integrated so all patient info is integrated within the workflow, The

receptionist will have all information about the alert sent for each patient contacted

NextGen integration no interfaces required

• NextGen Practice Management and NextGen

Ambulatory EHR streamline workflow

• Display outcomes performance in NextGen

Dashboard

• Creates alerts on patient chart with triggering event

• Alert cleared when appointment is kept

• Chart notes added in Practice Management with

reasons for outreach

• Follow-up documentation goes directly into EHR

• Evidence-based quality measures leveraged using

NextGen Health Quality Measures (HQM)

• Data mining capability within PM and EHR

“Set it and Forget it”

– While you are away on vacation…

– 2,500 automated flu shot reminders have just been sent from your

NextGen® Ambulatory EHR to a targeted group of patients

– During the week, 50 patients schedule their flu shots

Pre-programed notifications are

automatically sent to your patients

Target patients for follow-up and preventative care

• Hypertensive patients for blood pressure control

• Diabetic patients with A1C levels greater than seven

• Women age 55, who require pap smears and mammograms in May

• Men, age 60 who require prostate exams in September

Patient engagement outreach channels

• Phone & Interactive Voice Response (IVR)• Text Message• Email• Patient Portal• Mobile & Remote Monitoring Integration

Program alerts using a stratified approach

• These alerts have been automatically programmed in your NextGen EHR

• As these patients schedule appointments, all encounters are

documented and tracked in your EHR

• You can generate reports as you need them

Congratulations…!!!

You have just met an important Meaningful Use 2 requirement

• Reminders: “Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care”

• Secure Messaging: “Use secure electronic messaging to communicate with patients on relevant health information for 5% “

The patient profiler for simple stratification

• Diabetic patients with A1C greater than 7

• Women age 50, require pap smear and mammograms in May

The patient profiler for more complex stratification

Identify male patients age 40 who have:

• Diabetes with history of high A1C

• High blood pressure and Hyperlipidemia with high total cholesterol and LDL

• No foot or eye exam for last 6 months and

• No booking for next 2 months

ROI, NextGen client Infinity Primary Care

Expected Revenue Projection

• Reminders sent: 10,000 per month (calculated on full provider participation)

• Roughly three patients contacted for each provider per day

• % Patient of patients responded: Between 20 – 45%; average of 33%

• Approximate revenue per visit: $95

• Generating one additional visit per day for each provider

• Additional Annual Revenue: $3,420,000

Infinity Primary Care success story

Patrick Stevenson Director of IT

• 30% Average response rate• 3 Patients contacted daily per provider • 10,000 patient reminders monthly

“NextGen Population Health fills an important gap

between patient communication and patient health

management. In the past, we would dedicate hours of staff

time attempting to contact a small percentage of patients.

Now, we use a stratified approach to engage our at-risk

patients with a single click. NextGen Population Health

has improved the way we care for our patients.”

ROI roughly ½ million $ additional annual revenue

Activity and Variables Annual Projections

• Number of providers 32

• Number of patients reached at 200/month/provider 76,800

• Response Rate 33%

• Potential Appointments 25,344

• Number of additional appointments (from previous year) Capacity for 3 additional patients per week

4,992

• Average profit (stated as income) per visit $95.

• Average profit for all new visits $474,240

Coming soon….

Data Integration &

Analytics

• Integration with Payer

data (CCLF)• Integration with third-

party Risk Stratification

(Statictical and

Predictive modeling)

tools• Dashboards:

• Chronic Condition• Payer Analysis

Care Coordination

• Enhance care

coordination workflows in

NextGen EHR with

population health data

(outreach & gaps in care)• Actionable Patient

Registry with Referral

Management

Patient Engagement

• Enhance patient

communication methods• Gather survey and

remote monitoring data

from patients

A B C

Ready to take a deeper dive?

We will now demonstrate how easy NextGen Population Health is to use

Kim Root will now show you various features and functionality

Let’s see NextGen Population Health in Action

Live Demo presented by

Kim Root

NextGen Application Specialist

NextGen Population Health results Healthier clinical and financial outcomes

• Outreach communications is the first step in managing chronic conditions

• Increase revenue from additional patient encounters and treatment opportunities

• Improves patients engagement which is essential to meet health reform requirements

• Augments EHR to meet ACO, PCMH, and MU2 criteria

Questions?

NextGen Population Health Resources

• Population Health web page• Watch for future monthly population health webinars

demos• White paper• Demo• Video• Brochure• Contact your sales representative• Request a live demo

efreedman@nextgen.comswilliamson@nextgen.com

Thank You !