HealthInfoNet Project Summary, Conclusions and Next Steps Maine State Innovation Model Test Grant September 28, 2016 HealthInfoNets SIM Objectives 1. Provide Maine patients with access to their statewide HIE record leveraging Blue Button standards in a 12-month pilot. 2. Provide real-time notifications from the HIE to MaineCare when MaineCare members are admitted or discharged from inpatient and emergency room settings. 3. MaineCare Analytics Dashboard: a) Provide a Dashboard from the HIE enabling MaineCare to clinically monitor members health care utilization and outcomes at the population and individual level. b) Develop and deploy real-time discrete data feeds for MaineCare claims and prescription data to HIN for HIE and Analytics inclusion 4. Provide HIT and HIE adoption reimbursements (1.4 million) to up to 20 Behavioral Health provider sites/organizations. 5. Provide HIE access to Behavioral Health providers. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
2 HIE Blue Button Pilot @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 3 Patient Portal Blue Button HIE Access Overview Objective: Provide Maine patients with access to their statewide HIE record leveraging the Blue Button standards promoted by the Office of the National Coordinator for HIT (ONC). HIN will conduct a 12Month Pilot with a provider organization to make the patient chart available via a certified EHR Portal administered by the pilot site. Hypothesis: If HIN creates the technical solution to provide patients with direct access to their state-wide HIE record Continuity of Care Document (CCD) via their local provider's Patient Portal; patients will access their CCD to better engage in their care. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
4 Patient Portal HIE Blue Button SIM Impact SIM Pillar supported: Engage People and Communities SIM CORE Metrics impacted: Patient Experience/Engagement, Fragmented Care Objective impact: This 12 month objective completed in July 2015 was the first State effort to get patients access to their comprehensive health record managed by the HIE. This effort allowed over 500 Eastern Maine Health System patients to access their HIE record via their local community providers health record portal. The patient cohort found value in having ready access to their statewide record. It serves as a model whereby the HIE can support the objectives of health providers to give patients ready access to their medical information and to empower them to be more involved in their medical decision making. Sustainability cost: Variable costs dependent on the provider-based EHR systems. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
5 EMHS Patient Portal HIE Blue Button @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 6 Data Collection Methods The project team collected qualitative and quantitative data to gauge consumer understanding and engagement with the Blue Button technology through: Number of CCD downloads 5 question pop-up survey at time of download Practice patient advocacy groups Practice staff involved with the project 5 question patient email survey @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 7
EMHS Pilot Statistics Initial pilot cohort: 760 active myEMHShealth portal users Across 3 primary care practices: EMMC Internal Medicine, Husson EMMC Family Medicine, Brewer SVH Family Care, Pittsfield EMHS Results Total number of downloads: 546 patients Total number of pop-up survey results: 169 Total number of email survey results: 421 @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 8 Key Lessons Learned 1. Patient call volume to HIN with questions was low 2. HIN CCD format and presentation using Blue Button is easy for patients to understand 3. Confusion for patients: their local portal vs. HIN data
HINs relationship to the provider can be confusing but is an opportunity to expand patient portal access and utilization 4. Having web-based access to the statewide record is positive; convenient; covers you on short notice & emergencies while traveling 5. Patients want access to their doctors notes 6. More specified data structure standards are needed @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 9 Blue Button Conclusions The pilot was a success; with the opportunity patients will use the HealthInfoNet Blue Button technology when the market is ready HIN can provide a technical solution for patient access using the Blue Button-Patient Health Record strategy Patients want more access to their health information than the current access provides Patients want to view their health record information with a interactive web-based product in addition to downloading their information Portal access is fragmented; patients want one place to access
all of their records Overall patients need more education about health information technology and Maines health information exchange @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 10 HIE Notifications @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 11 HIE Notifications Overview Objective: Provide real-time notifications from the HIE to MaineCare and health system Care Managers when MaineCare members are admitted or discharged from inpatient and emergency room settings across all provider organizations connected to the HIE. Hypothesis:
If HIN can release, build, and deliver real-time ADT & document notifications to MaineCare Care Management staff; MaineCare will have increased their data resources and thereby add efficiencies in staff workflows that will improve the desired results related to appropriate member ED/Admissions utilization. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 12 HIE Notifications - SIM Impact SIM Pillars supported: Strengthen Primary Care, Centralize Data & Analysis SIM CORE metrics impact: ED Utilization, Readmissions, Fragmented Care Objective impact: HIN provides near real-time notifications for MaineCare patients presenting in Emergency Department and Inpatient settings. MaineCare Care Management and provider organizations connected to the HIE receive emails continuously. This service actively supports near-real time tracking and member intervention with MaineCare Members and is used to specifically support the current paperbased ED diversion initiative. HIN expanded the project and its interfaces to include ED admission chief complaint information. All hospitals are sending chief complaint to HIN. For Year 4/No Cost Extension, HIN will be expanding notifications to include ED
and Inpatient admissions. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 13 HIE Notification Conclusions HealthInfoNets notification service provides 4 unique values to healthcare reform efforts in Maine: 1. The HIE is uniquely capable to automate near real-time notifications about MaineCare member utilization of ED and inpatient admissions. 2. The HIE offers a centralized statewide solution which brings efficiency to the workflow and process. 3. The HIE offers the automated identification of members who are over utilizing specific services by MaineCares custom definition (ED/inpatient, etc.) By automating the identification of members, Care Managers can spend more time intervening and collaboration with primary care providers, health homes etc. to impact behavior and member experience of the health care delivery system. 4. The HIE is the only current solution to automate in near real-time the delivery of discharge documentation for ED and inpatient events of care for members. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
14 Clinical + Claims Analytics to Support Care Management of MaineCare Patients @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 15 MaineCare Analytics Objective: Provide a Clinical Analytics Dashboard to MaineCare and clinicians from the HIE enabling care managers to monitor MaineCare Members health care utilization and outcomes at the population and individual level Develop and deploy real-time discrete data feeds for MaineCare medical and prescription claims data to the HIE and HIN Analytics platform Hypothesis: If HIN has access to MaineCare claims files, HIN can build an interactive analytics dashboard that presents clinical HIE and claims data to care managers. This dashboard can be used by clinical teams and DHHS to support/inform policy and program activities addressing utilization,
member outcomes, and improving care management and prescription medication workflows Merging Medicaid Claims and HIE data results in significant improvement in risk scoring/stratification If HIN has access to MaineCare Claims files, HIN will be able to integrate discrete MaineCare medical and prescription claims data into the Clinical Portal @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 16 MaineCare Analytics SIM Impact SIM Pillar supported: Centralize Data and Analysis SIM CORE metrics impact: Pediatric/Adolescent Care, Mental Health, Obesity, Diabetes Care, ED Utilization, Readmissions, Imaging, Fragmented Care, and overall cost utilization reduction goals
Objective impact: This objective supports MaineCare and clinician access to near real-time information by narrowing the focus for proactive risk management for members that are at identified for: 1. Being high-cost 2. High risk for incidence of inpatient and emergency department events of care 3. For actively developing key chronic illnesses The risk models, developed using the HIE clinical data and claims data from MaineCare allows access to actionable risk-information that care managers and clinicians otherwise wouldnt have. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 17
Medicaid Claims + Clinical Data = Improved Risk Scores Through a SIM grant, HIN Tested the hypothesis that: Merging Medicaid Claims and HIE data resulted in significant improvement in risk scoring/stratification For most models the addition of claims data improved the risk scores Better sensitivity at the higher risk bin levels Better c-statistics (0.64-0.9) Better r-squared statistics Key data available in the Claims data and not in the EHR data were shown as key features for several models Mental health diagnosis codes: Mood Disorders, Anxiety Disorders, CPT codes Medication claims Claims diagnosis codes filling the EHR diagnosis gaps (~40-50% EHR encounters missing some diagnosis codes) @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 18 Case Study: St. Joseph Healthcare Healthcare system in Bangor, Maine
112 bed acute care community hospital Primary care and specialty physician practices 24,000 covered lives Partner with FQHC Participates in several ACOs Medicare shared savings
Medicaid Commercials Using real-time predictive risk scores (Calculated with HIE + MaineCare Data) to manage patients daily @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 19 Workflow: Acute to Ambulatory Patient Risk Management Post discharge, St. Josephs PCP patients are handed off to ambulatory care manager for follow up. Patient risk scores drive post-discharge care plan. Discharged to St. Joes PCP
Dis ch arg ed t oc om mu n it y PC P @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution St. Josephs Ambulatory Patients
Community At Large 20 St. Joseph Healthcare Results Compared to the state-adjusted rates 15.0% 9.5% reduction in emergency room visits reduction in 30-day ED return rate 4.2% 13.0% reduction in admissions reduction in 30-day readmissions 12.1%
5.0% reduction in inpatient days reduction in cost per person @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 21 MaineCare Analytics Conclusions 1.Integration of monthly MaineCare pharmacy claims into the HIE medication history list is critical for care management and medication reconciliation for clinicians across the state for all MaineCare members Reduces fragmentation of care across multiple prescribers and emergency rooms Improves the quality of medication reconciliation Reduces medication error and medication redundancies resulting in lower overall costs and improved outcomes 2.Providing future risk prediction information of ED, inpatient admissions, and highcost MaineCare members: Supports early intervention care management to prevent cost Improves communications and coordination between MaineCare and providers
May result in more accurate caseload and forecasting as MaineCare enters into risk-based contracts Supports improved outcomes for members 3.There are additional provider-centric use-cases (utilization risk, disease prediction) that will be tested in SIM Year 4 NCE. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 22 Behavioral Health Objectives @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 23 Behavioral Health HIT Reimbursement Objective: Provide HIT and HIE adoption reimbursements ($1.4 Million/$70,000 each) to up to 20 Behavioral Health
provider sites/organizations. Hypothesis: If BH organizations in Maine have access to funding reimbursements to support EHR interoperability improvements and HIE connection, they will choose to invest in their EHR and participate in Maines statewide HIE. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 24 BH HIT Reimbursement SIM Impact SIM Pillars supported: (from SIM Strategic Framework): Integrate Physical and Behavioral Health, ED Utilization, Fragmented Care SIM CORE Metrics impact: (from SIM Core Metrics): Fragmented Care, Mental Health, Diabetes Care
Objective impact: This objective supports community-based mental health providers in adopting heath information technologies (HIT) that support clinical integration of all services that a patient/consumer is receiving (mental health and physical health). EHRs and HIE interfacing costs are being supported under this objective in order to make sure that clinicians in these locations have the right information on the right patient at the right time. The funds that are being provided to each of the 20 organizations involved are being used to support staff time, contractors, licenses and support fees related to their adoption of HIT tools that are both interoperable (can support HIE) and can measure quality of care delivered. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 25 Behavioral Health HIE Goals 1. Implement connections between 20 BH organizations and the Health Information Exchange Train BH staff to leverage EHR and HIE services Document and share Data Informed workflows for patient care
improvement Build data interfaces and go live with initial data available from each BH organization 2. Support quality improvement aimed at reducing ED Utilization and measure impact (Observational Analysis) @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 26 Behavioral Health HIE SIM Impact SIM Pillars supported: Integrate Physical & Behavioral Health, Centralize Data & Analysis, Engage People & Communities SIM CORE metrics impact: Fragmented Care, Mental Health, Diabetes Care, ED Utilization, Readmission, Imaging, Fragmented Care Objective impact: All 20 BH organizations have access to their patients statewide health records and are actively using the tools within their care coordination workflows to improve coordinate care regarding the physical health issues of their patients. 13 BH organizations are live with sharing mental health records to benefit the general practitioners, specialists and hospitals. The remaining 7 are working to complete the data integration process through SIM Year 4 NCE.
HIN rolled out the new mental health opt-in consent model with each organization and active opt-in participation continues to climb with over 5,000 patients opted-in to date. For patients, this initiative supports their ability to choose to share their mental health information with all of their providers. @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 27 BH Connections as of August 2016 75 Site Locations Accessing HIE 13 of 20 Live with Data Sharing 1. Aroostook Mental Health Center 2. Assistance Plus 3.
Charlotte White Center 4. Cornerstone Behavioral Healthcare 5. Crisis & Counseling Centers 6. Julie Racine, NP 7. Maine Behavioral Health Organization 8. Northeast Occupational Exchange 9.
OHI 10. Pathways (Providence) 11. Restorative Health 12. Sweetser 13. United Cerebral Palsy @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 28 BH Staff Active HIE Access May 2015 - August 2016 250 226 219 217 205 200
200 228 227 185 150 112 100 77 70 54 48 50 60 54
28 10 0 ay M 15 13 ne Ju ly Ju 13 15 16
16 17 20 r r r r y st ar be be be be gu u o u m m m
t n TotalA BH Orgs. Accessing e e HIN cPortal e Ja Oc pt e ov e D N S Linear (Active BH-HIN Users) 20 ry ua r
b Fe 20 20 il ch pr ar A M Active @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 20 20 20 ay
M ne Ju ly Ju BH-HIN Users 20 st gu u A 29 Population Impact May 2015- August 2016 Patient Records Accessed by Behavioral Health Staff Patient Records Accessed by Behavioral Health Staff
1849 1500 1053 1000 871 419 203 0 633 609 500 ay une M J 314
y e h ly st ril er ry er er er ry Ju ugu mb tob mb mb ua rua arc Ap Ma Jun M e ce Jan eb A pte Oc v e o F D N Se @2016 HealthInfoNet (HIN) All Rights Reserved HIN
Proprietary Not for Redistribution ly st Ju ugu A 30 Data Informed Workflows Documented 1. Targeted Care Management Services 2. Hospital Discharge Planning 3. Comprehensive Transitional Care; Post ED and Hospital Follow up 4. Identification and Coordination with Clients Care Team 5. Medication Reconciliation 6. Client Engagement and Education; Using the Clients HIE record 7. Intervention with Client Following a Medical Event while Waiting for Reports from Medical Providers 8. Assessment of Accuracy of SMI Diagnosis vs. Medical Diagnosis with Medical Provider 9. Identification of Gaps / Overuse of Medical Care 10.Location of Missing Clients @2016 HealthInfoNet (HIN) All Rights Reserved HIN
Proprietary Not for Redistribution 31 Value of HIE in Managing Mental Illness and Chronic Disease Reduce fragmentation with medical community Mitigate medical issues that contribute to Mental Illness Identify prescriptions, both unknown and duplicated Provide a safety net, locate clients and intervene Provide integrated BH intervention to address medical issues and reduce unnecessary ED visits Able to replace hours spent in getting permission to view a clients record to provide care for clients Able to relieve stress and anxiety around medical care @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 32 BH Quality Project Goals January-July 2016 1. Implement real-time notifications for ED/hospital admissions to intervene with clients with a history of 2 or more ED visits within
a 6 month period 2. Access the HIN Portal to coordinate care with both the client & medical community 3. Leverage Data Informed workflows with all organizations and convene monthly learning community to share lessons learned 4. Measure change in ED utilization at the end of 6 month period (Observational Analysis) @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 33 MaineCare BH Quality Project Observational Analysis Overview Hypothesis Integrated care interventions that include medical record data and real-time notifications will reduce ED utilization for patients Patients chosen for inclusion based on 2 or more ED visits in the 6 month pre-intervention period A list of 800+ patients was provided to the 18 BH organizations to determine appropriateness for intervention A observation panel of 443 patients were selected by the 18
BH organizations participating @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 34 Observational Analysis Results (Preliminary) @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 35 HIE Portal Views of Cohort Patients Portal views increased in the post-intervention period, mostly by users from behavioral health facilities @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
36 ED Visit Days Claims Data CDR Data There was a 35%+ reduction in ED Visit Days for the cohort population in the post intervention period @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 37 Patients with ED Visit Days CDR Data Claims Data There was a 30%+ reduction in patients having ED visits in the post intervention period
@2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 38 Total ED Visit Rates Mean ED Visit Rate for All patients (HIE Data) Pre Intervention: 4.4 visits / 6 month period Post Intervention: 2.7 visits / 6 month period Mean ED Visit Rate for Patients with ED visits (HIE Data) Pre Intervention: 5.1 visits / 6 month period Post Intervention: 4.1 visits / 6 month period @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 39 ED Visit Charges During the post intervention period ED visit charges were $378,448 (46%)
less Note These figures do not include ancillary, pharmacy, consultant or facility charges. Claims Charge Data @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 40 All Medical Charges Total medical charges were $6,010,578 (34%) less in the postintervention period - Does not include pharmacy claims - See analysis caveats and limitations slide for discussion Claims Charge Data @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
41 Caveats and Analysis Limitations Sample bias: Patients were chosen by BHOs based on a comprehensive list Comment: While considered a bias in sampling, this may represent a policy means to engage health care organizations around a goal of health improvement Observational vs Controlled: There was no control group for this analysis. Conclusions are observational in nature Results may be attributed to intervention and/or other uncontrolled for factors Seasonality of behavior Sampling/Selection Patients already in a care management program; etc. Claims and Clinical Data Limitations: There is a big difference between claims and clinical data. Clinical data clear date and time but missing high risk data/encounters (MH/HIV) Claims time is not included: must go through a manual process to create claims encounters Claims Lag Since the analysis ended in July 2016, claims continue to run-out Costs are difficult to aggregate for ED based on Claims Consultants Facility Fees Ancillary services
Did not look at appropriate vs inappropriate use of the ED Data was not age or severity risk adjusted @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 42 Study Continuation Analysis will be continued in SIM Grant Year 4 Address claims lag Analyze paid data vs charge data Increase timeframe (look-back period and intervention period (12 month) Addition of control group/population Allowing SIM to understand the impact of policy change (e.g. BHH) and other factors Addition of pharmacy claims Review polypharmacy impact Review $ impact Analyze appropriate vs inappropriate ED utilization @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution
43 Behavioral Health Conclusions The cost of advanced EHR technology is significant, with financial support the BH community can participate in data sharing With access to real time medical data via HIE services, BH care teams are able to enhance their health home and intervene to improve patient experience, appropriate utilization, and reduce cost Data integration into workflow is resource intense for BHOs, but when coordinated and data informed the impact can be significant. Few BHOs have dedicated staff to care management and workflow optimization. DHHS will continue this work through SIM Year 4 Add new data elements to HIE BH Prior Authorizations Expand HIE access Fill in the gaps of the observational study Understand how to go after CMS 90/10 match funding $$ @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 44 Discussion Thank you!
Shaun T. Alfreds, Chief Operating Officer [email protected] Katie Sendze, Director of Client Services [email protected] @2016 HealthInfoNet (HIN) All Rights Reserved HIN Proprietary Not for Redistribution 45
Christopher Todd . Head of Unit. DG Regional and Urban Policy, European Commission. Conference on European added value of the Cohesion Policy in the regions. 21 November 2017. European Parliament. Results and rollout of the pilot project in Poland.
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