Monday_Medical Homes_ Hanekom.pptx

Using Clinical Data for Medical
Homes – Lessons Learned
Dr. David Hanekom, M.D., F.A.C.P., C.M.P.E.,
Chief Medical Officer
Challenges in data quality
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Fragmentation
Quality
Access
Normalization
Reconciliation
Interoperability
Robust hybrid data improves
outcomes
Building a PCMH
Re-define the role of the Health Plan
Re-imagine the health delivery system
Transform the payment system
Design & deploy enabling technology
Collaboratively re-design health care
Measure, report, share
Copyright © 2012 MDdatacor — Confidential
What Physicians Demand from a Population
Management Portal
“Principles of Acceptance”
I will accept your tool for use in my clinical
practice if:
1. 
2. 
3. 
4. 
5. 
I know it will help me practice better medicine
I can see and measure the positive impact on my
patients
I can trust and verify the information and results
delivered by the tool
It will allow me to safely delegate duties to my team
without compromising clinical care
I can see comparative and benchmark data to allow
me to compare my results with that achieved by my
colleagues
What Physicians demand from a Population
Management Portal
“Principles of Acceptance”
6.
I can spend more quality time with my patients and
not be financially penalized for doing so
7. It will reduce my paperwork and administrative duties
8.  It is affordable, user friendly and compatible with my
practice workflow
9.  I do not have to buy another electronic system
10.  I do not have to replace or upgrade my current system
Core Components of a Population
Management Solution
Reporting Solution
Administrator
Focused
Care Coordination
Solution
Care Plan
Clinician
Focused
Coordinated
Communication
Registry Solution
Risk-Focused
Patient-Centric
Meaningful Population Health
Reporting at Point-of-Care
•  Patient-Centric and Actionable
•  Identification of Evidence-Based care
opportunity
•  Reconciled across data sources
•  Targeted for clinically meaningful application
•  Risk Adjusted to identify future resource
needs
•  Meaningful benchmarking
Population Management Reports
Patient Care Summary
Clinician Comparison Report
Care Opportunity Report
Population Resource Use –
Impact of Data Integration
Total Health
Care Costs
Drug
Utilization
Laboratory
Testing
Primary
Care Visits
Pre‐Program Period A ‐ 1 Pre‐Program Program Post‐Program Post‐Program Post‐Program Post‐Program Period A+1 Period A+2 Period A+2 Start Period A Period A Clinical quality improvement—
PCMH in North Dakota
2009
2013
Improvement
Cervical cancer screening
34%
54%
+59%
Breast cancer screening
33%
63%
+91%
Colon cancer screening
18%
48%
+167%
Optimal diabetes care
7%
22%
+214%
Optimal vascular care
8%
29%
+263%
Hypertension control
61%
74%
+13%
LDL-cholesterol control in
CAD
66%
70%
+6%
LDL-cholesterol control in
DM
61%
64%
+5%
*Statewide PCMH enrolled patients
PCMH influence on Diabetes
Care
•  4% reduction in diabetes-related ER use
•  21% reduction in diabetes-related inpatient
admissions
•  42% reduction in diabetic coma
admissions
•  6.5% reduction in use of non-PCMH MD
E&M services
•  Net ROI of 5.0 for diabetes-related costs
North Dakota Population Level Event
Reduction
4 year intervention period (2009-2012)
N=360,000 Members
Major Risk Factor
Hypertension
Smoking
Hypercholesterolemia
Diabetes
Coronary Artery Disease
Population Level
Risk Factor Control
Blood Pressure < 140/90
mmHg (78%)
Tobacco Free (62%)
LDL-Cholesterol < 100mg/dl
(62%(
HBA1C < 8% (77%)
Antiplatelet Agent Use (70%)
* AP DRG Events/10,000 Members; CPT Procedures
Institutional Event
Rate & Procedure
Reduction 2008 v.
2012*
Intracranial hemorrhage -50%
Asthma -41%
Acute MI -40%
Angina Pectoris with CAD
-57%
Hypertension -31%
Heart Failure -31%
PTCA without AMI -60%
PTCA with AMI -10%
Elective CABG -54%
Emergent CABG -40%
Diabetes +14%
Key Lessons Learned
•  Collaborative leadership from providers
and payers essential to success
•  Payment innovation in support of
population health and improved outcomes
•  Technology foundation that is nondisruptive to provider & payer technology
legacy systems
•  Patient-Centric focus on quality and
improved outcomes