Session 79 - How Accountable Care Organizations Can

Harness the Power of Health Data and Analytics

Farzad Mostashari, CEO, Aledade, Inc.

Agenda • Overview of Accountable Care Competencies for Independent Physicians

– Practice Perspective – The Role of Health Data and Analytics

• 5 Key Competencies

– Quality Measurement and Improvement – Managing Attribution and Risk – Managing High Risk Patients – Transitions of Care/Emergency and Inpatient Utilization – Referral Management

• Data to Support Population Health

– Getting Practice Data – Getting HIE/Community Data – Quality Reporting and Practice Workflow

• Q&A

Learning Objectives • Identify and address key challenges to harnessing health data and

analytics to support independent doctors focused on population health • Demonstrate potential of health data and analytics at point of care • Assess current landscape and potential for accountable care, especially for

independent physicians

To Succeed in Accountable Care • Prevent Panel Churn • Measure and Improve Quality • Avoid preventable emergency room visits • Cut readmissions and post-acute days • Reduce acute episodes for high risk patients • Target high-value referrals

Practice Perspective

For those in small independent practices, sometimes our world feels like this

”Interop”- From Sneakernet to Live Data

Manual Data Extracts EHR Vendor Integration ”Connector” Agent

CCDA Claims(837) Appointments(SIU) Raw Data

Lightweight Data Normalization/Standardization

Data Consumed by Analytics and Apps

sftp (30)

vpn (21)

DIRECT (1)

The Role of Data and Analytics Transformed into Action Example Annual Wellness Visits Patients prioritized on key factors: Drawing on multiple data sources:

- Time since last primary care physician visit

- Potential for under-coded chronic conditions

- Potential to benefit from care coordination

- Upcoming appointments scheduled

- Claims reports (practice)

- Upcoming appointment list (practice)

- ADT feeds (hospital)

- Medicare patient list (practice)

- CCD from EHR (practice)

- Monthly claims reports (CMS, starting 2015)

Panel Churn–Managing Attribution and Risk Workflow Competencies • Patient Outreach and Recall • Patient call lists • Appropriate risk coding • Wellness Visit EHR workflow

Data and Analytics Needs • Patient diagnoses • Practice claims and/or CCDA • Risk stratification • Coding opportunities • Patient prioritization

Challenges • Getting data • EHR optimization • Shifting schedule capacity focus

Annual Wellness Visits with Aledade Intervention

Data are for Aledade Delaware and Primary Care ACOs. AWV is number of Medicare AWV claims; AWV payments is total Medicare payments for AWV Claims. Source: Medicare Claim and Claim Line Feed data.

Quality Improvement/Measurement Workflow Competencies • Capture clinical quality measures

• ID and mitigate care gaps

• Care management for high risk

• Provider training

Data and Analytics Needs • Clinical data interfaces at practice

level

• Terminology mapping

• Data normalization

Challenges • Workflow adherence

• Vendor CCDA limitations

• Integration speed and costs

• Workflow integration ACO->EHR

Pneumococcal Vaccination with Aledade Intervention

Reduce Acute Episodes for High Risk Patients

Workflow Competencies • ID and monitor chronic patients

• Dedicated chronic care management

• ID increasing spend

• Comprehensive care plan

Data and Analytics Needs • Cohorting

• Risk scoring

• Event Surveillance

• 360 Claims Feed

• ADT Feeds

Challenges • Practice resources to provide care

management

• Hospital Data Feeds

• Tracking CCM time

• Shared care plans

TOC – Cut Readmissions and Post-Acute Days

Workflow Competencies • Patient Outreach and Recall

• Tracking TCM Visits

• Convincing some patients to come in

Data and Analytics Needs • ADT Hospital Feeds

• App for notifications

Challenges • Getting data

• TCM Workflow Tools

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15%

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30%

35%

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(%)

Patient Risk Category (Predictive Model)

No TCM With TCM

Aledade Transitional Care Management Impacts 30-day Readmissions (n=3,274 Medicare Discharges)

Avoid Preventable Emergency Room Visits Workflow Competencies • Schedule Access

• Provider Availability

• Patient Outreach

Data and Analytics Needs • ADT Hospital Feeds

• % ED Visits During Office Hours

Challenges • Practice Change

• Patient Education

Preventable ED%

Target High Value Referrals Workflow Competencies • ID Preferred providers

• Provider Availability

• Patient Education

Data and Analytics Needs • Cost, Utilization, and Quality Data

for downstream providers

Challenges • Determining quality, tiering

• Getting commercial cost data

• Availability of alternatives

Clinical Data Integration (C-CDA)

Support C-CDA Manual Batch Export Less than 1/3 of EHR vendors provide practice staff the ability to export in bulk C-CDA XML data portability documents at the point of care

Support Outbound C-CDA Automation Only 2/3 of EHR vendors have the capability to generate and transmit C-CDA documents after a visit without manual intervention from the provider

3 Year Median Cost of Ownership Based on 11 representative vendors, the median 3 year total cost of ownership of a C-CDA interface is $7,500 for a 3 provider practice. Costs range from $200 to as much as $58,000 per vendor.

28% 68% $7,500

Clinical Data Availability

High Availability • Problem List

• Medications

• Allergies

• Tobacco Use

• Vitals

• Immunizations

Frequently Unavailable • Diagnostic imaging / surgical

procedure orders and results • Lab results with LOINC codes • Health Maintenance

Documentation

Extremely Low Availability • Preventive Screenings (Fall Risk

and Depression Screens)

• Counseling and Patient Education

• Specialty Referrals

Key clinical data for population health management aren’t always available in a structured format with the C-CDA interface

HIEs and ADT Alerts

States where community-based HIEs are offering ADT alerting services

9 of these HIEs can provide ADT alerts in near real time (w/in 1 hour of the event)

2 can provide ADT alerts from all hospitals in the state

Percentage of ED visits with alerts when a patient panel is used for matching v. provider NPI Providers receive alerts on a greater proportion of ED visits when ADT data is matched on patient demographics rather than provider NPI

Most common patient panel demographics requested by HIEs: • DOB • First and last name • Gender • Address • Phone • SSN • Medicare ID

Cost per patient per month for ADT panels Matching ADT feeds with patient panels often incurs a fee for each person on the panel

Before ambulatory providers may receive alerts, most HIEs also require them to become HIE participants, which often involves separate fees

11 of 11 87% v. 63% $0-$.12

Practice EHR/PM Integration

The Good • Best (and worst)

experiences with VARs • On premise often easier to

implement than cloud vendors

• Shortest implementation=3 weeks

• Using 3rd party agent works

The Bad • Typically 6-9 months from

first contact through contracting to go-live with dedicated project management.

The Ugly

29 Vendors, ~115 Practices

• Farzad Mostashari, MD farzad@aledade.com @farzad_MD • Edwin Miller, MBA edwin@aledade.com • Paul Kleeberg, MD pkleeberg@aledade.com