2. Brian Yeaman, MD, Chief Executive Officer, Yeaman+Associates Rodolfo Alvarez del Castillo, MD, Chief Medical Officer, Yeaman+Associates New Technology Initiatives for Care Coordination

4. “ A story has its purpose and its path. It must be told correctly for it to be understood”. Marcus Sedgwick, Author

5. Our patients deserve better Hand-offs

6. Not for-profit Board of Health Systems Managed Service Organization Improving provider handoffs Transition of care services Network of Networks Sustainable Health Information Organization

10. Background Office of the National Coordinator for Health Information Technology. Foster the advancement of a nationwide network able to support health information exchange (HIE) and interoperability. Improve long-term and post-acute care transitions. $1.7 million awarded to grant recipients. Oklahoma was among those endowed.

11. Preventive and proactive – Care-pathways. – Clinical Decisions Support tools. – Transitions of Care Protocols.

12. Activate Every Provider Level – CNA, CMA, LPN, RN, NP, PA, PCP, and more. – Care coordination. – Reducing hospital visits. – Unnecessary admissions. – Avoidable re-admissions.

13. The “Need to Know” message A “Need to Know” message Developed by clinicians and governance members Standardized Communication Tool Embedded in EHR Direct Ready HIE Data Contribution Ready at Transfer

14. TOKEN Results Transfers Absolute Reduction for 6 Month Pilot: 89% (6/56) Cost Savings Estimate for Acute Care RAC: 1.36M (5 facilities 6 months) 30 Day Re-Admissions: 33% Reduction 30 Day Return to ED: 71% Reduction

15. Average Page Length of Interventions: 1 page Reduction in Psychotropic Meds: 29% Average Facility Star Rating Pre-Intervention (5 Facilities): 2.0 Average Facility Star Rating Post-Intervention: 4.2 Average Increase in Facility Bonus Reimbursement: $26,000 per 100 beds

16. **Cedar Creek Set a State Record for Fewest TAGS in a QIS Survey** Patient Satisfaction: Baseline 62% Post Intervention 97% Meaningful Use Compliance: HIE, Direct, Transitions of Care Summaries.

18. Oklahoma Network of Networks eHealthExchange Coordinated Care Oklahoma Nationally Certified Leading with Care Equality on advanced connections for analytics Network of Networks CCO Connected to: KHIN- Kansas North Texas HIE MyHealth-TBD upon technical validation Passed legal VA- in progress DaVita- in progress

19. “An ounce of prevention is worth more than a million pounds of cure” David Agus, MD.

20. Health Information Exchange in tornado alley

21. “You don’t know what you don’t know” HIE driven by clinical use-case: ED Visit/ New Admission Discharge Coordination Specialist Referral Medication Reconciliation New or Return Patient

22. HIE acting on prescribing issues First State to require Pharmacies to submit controlled substance data to PDMP at the point of sale since January 2012 ONC and SAMHSA PDMP Pilot, live since February 2013 Model leverages HIE to deliver information to providers with immediate “one-click” access through EHRS Real time data from Pharmacy.

23. CCO App Store Advanced Directives- MyDirectives Referrals- Centralized Direct Hub- MU2 Chronic Condition Practice Extension Patient Portal Analytics- LightBeam Population Health Condition Specific Analytics PQRS HEDIS Patient Risk Scores Ability to combine claims data and clinical data

24. “In the end, it's not the years in your life that count. It's the life in your years.” Abraham Lincoln.

25. The art and science of asking questions is the source of all knowledge. Thomas Berger, Author