1. NextGen® Population Health
“The Game Changer”
May 14, 2014

2. Industry dynamics driving population health management
Presented by Elise Freedman, MBA Senior Market Manager, Business Development

3. 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

4. Population Health is very “Popular”

5. 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

6. 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
The A challenging national
economy, chronic disease, and an aging population combine to place
a tremendous strain on the system. As the new diagnostic and treatment options have been introduced at an
accelerated rate.
In response to this convergence of economic stress, chronic disease,
comorbidity, an aging population, and medical innovation, the
population health management (PHM) model is evolving to effectively
manage patients across the continuum of health and care by delivering
appropriate intervention according to patient risk and disease severity.
PHM has grown in prominence and practice, particularly as recent
federal healthcare reform efforts stimulate the public and private sectors
to adopt models of reimbursement and care delivery that rely upon
PHM to bend down the cost curve and improve care.
Today, the healthcare system is transitioning from an inefficient, volume based,
fee-for-service model to a coordinated, integrated, and value based
paradigm for which PHM is ideally suited.

7. 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
American medical association practice management center
Chapter 14: Evolving compensation methodologies for
employed physicians in an era of changing clinical
practice, reimbursement and health reform
Elias N. Matsakis, Esq., Rod St. Clair, M.D., John L. Bender, M.D.

8. “Your patient  your responsibility”
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”
Along with that the onus for managing the health of all patients, compliant and non-compliant, chronic, sick or well is shifting to the providers across the care continuum….
That is what MU , PCMH and Accountable Care is all about!

9. 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
We all are aware Patient non-compliance to follow-up visits and medication adherence impacts the bottom line as well as patient care.
Some quick facts: Non-compliance accounts for 11% of all hospital admissions and 40% of nursing home admissions; Up to 20% of all prescriptions written by physicians are never filled; 30% of prescriptions are never refilled. Patient non-compliance is costly to everyone.
Patient non-compliance to follow-up visits and medication adherence negatively impacts patient health and health care costs across the health care continuum.
Source: Wu, S., & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. In RAND Corporation.

10. 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

11. 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
Page last reviewed: August 13, 2012
Page last updated: August 13, 2012
Content source: National Center for Chronic Disease Prevention and Health Promotion

12. 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

13. What percent of your patient population looks like this?
Very Healthy

14. What percent of your patient population looks like this?
Mostly Healthy

15. What percent of your patient population looks like this?
Not so good
Where does this guy go when he goes into cardiac arrest?
When do you think he last saw a doctor for a check-up?

16. 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?
Even relatively healthy people need to follow directions. Population health management applies to all patients.

17. Population Health as it relates to NextGen Care Coordination

18. 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

19. NextGen Population Health generates reports that track and analyze performance
Physicians and practice administrators can produce analytical reports on CQM performance as well as detailed patient reports identifying treatment opportunities within the patient population
Outreach communication reports that can be scheduled for delivery
Graphical reports to measure performance of outreach program

20. 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
HQM is NextGen for reporting CQM’s and Objectives for Primarily for Meaningful Use but used for other reporting
Data Warehouse collects and stores non-PHI clinical data to produce summary and detail reports using specific program rules
Automated calculations are performed in an aggregate format which can be used for
attestation/reporting depending on year
HQM reporting eliminates the need for Claims reporting and G-Codes
Benchmarking against other NG clients

21. 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

22. 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
Need graphic from creative

23. 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 goals
Population Health
Analytics

24. 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
Our goals for the care coordination series
Are to provide improve quality & patient safety to avoid re-admissions or unnessary hospitalization
To increase staff efficiency by providing a central location where care planning & documentation can occur
To provide greater focus on patient’s goals & expected outcomes by establishing clear and organization steps and interventions for them to follow
By providing the ability to fully document the patients care plans, it will improve patient compliance and provide for improved communication.

25. 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 s
text messages
Patient communications documented by various categories and filtered to show all or selected data

26. 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

27. 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

28. Proactive Patient Engagement
Before I move on the demo, I would like to show few screen shots to give you flavor of our application and point out how we address the 3 challenges that we discussed in the beginning.

29. 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

30. 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

31. 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
Within a single system, NextGen ambulatory solutions to streamline client workflow, capturing and documenting all activity and communication for future reporting requirements.
Were able to do this by including chart notes to the practice management system to include reasons for out reach
We provide follow- up documentation directly into the EHR
We leverage evidenced based quality measures by using HQM
And of course we are able to data mine across the practice management and EHR products

32. Pre-programed notifications are automatically sent to your patients
“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
Back at the office…
2500 flu shot reminders are send from your NextGen EHR in a week and 50 patients are administered flu shots

33. 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
To begin with you can zero in patient for follow-up visits or preventive care e.g.
Hypertensive patients for blood pressure control
Diabetic patients with A1C greater than 7
Women age 55, who require pap smear and mammograms in May

34. Patient engagement outreach channels
Phone & Interactive Voice Response (IVR)
Text Message
Patient Portal
Mobile & Remote Monitoring Integration

35. 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
Leveraging technology
Meeting with high-risk patients is not the only way Reid Hospital approaches population health management. The hospital also uses an electronic population health tool from NextGen Healthcare to query which clinic patients have not had an annual wellness checkup and contact those patients to schedule visits. This allows the organization to reach out to low-risk and high-risk patients alike and transition them into proactive care. Additionally, Reid Hospital plans to use the tool to identify populations with chronic conditions for which regular interventions are known to improve quality and reduce the likelihood of patients becoming high-risk. For example, the technology will help the hospital track hemoglobin A1C measurements for diabetic patients and proactively alert patients when any anomalies are detected.
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% “

36. The patient profiler for simple stratification
Diabetic patients with A1C greater than 7
Women age 50, require pap smear and mammograms in May

37. 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

38. 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
To summarize the benefits of our first release here are few quotes from our clients who are using NextGen’s Population Health solution..

39. Infinity Primary Care success story
“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.”
30% Average response rate
3 Patients contacted daily per provider
10,000 patient reminders monthly
Patrick Stevenson
Director of IT
Pop health, anticipate increasing our revenue by several million dollars, Maybe we will have a diabetes clinic, AC1 that hasn’t been checked in the last month
Infinity Primary Care were one of the first clients to get mass adoption of the Patient Portal. Today they are doing the same with Population Health, using it in conjunction with EHR and Portal to proactively reach out to their patients. They say that it takes the randomness out of care management. In addition to improving care they anticipate greatly enhanced revenue for doing the right thing.
Amlitore network in SE michagan 13 location 55 dr and 80 residents
Involved with several quality initiatives including BCBS & NCQA’s PCMH & MU
Show AR, Dashboards outreach compliance dashboards
Need a way to manage quality care more efficiently
CEO allows us to target patients that have chronic disease hypertension CHF diabetes list goes on and on allowing us to change our approach to prevent and chronic care proactive instead of reactive
Starts with PP text message and notification to come into the office and laically to come into the office and takes the randomness and guess work out of follow up
Standardization is big to, documenting how many patient we contacted why, how much time we spend wich is nearly ZERO because everything is automated
Set it and forget it. With a a click of a few buttons you can contact 10,000 or more patients per month. Maybe we will have a diabetes clinic, AC1 that hasn’t been checked in the last month etc
We anticipate increasing our revenue by several million dollars.
Pop health helping us provide more timely and quality care

40. 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

41. Data Integration & Analytics
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
In the end we would like to share with you our plans to take the solution to next level….
We will be focusing on 3 key areas of population health management – Data Integration , Care Management & Patient Engagement
Under data integration :
We will be extending the population profiler across continuum of care by integrating with payers data and HIE in the community for collaborative care.
Once the data is available across the continuum we will be incorporating risk scoring and implementing care management workflow to manage high risk patients for better care and decrease cost. Along with this we will be integrating with the latest Dashboard from NextGen and BI reporting tools.
In parallel we are working on latest technologies to enhance patient engagement and reduce non-compliance e.g. mobile app for follow-up visit reminders and medication adherence. We are also looking into integrating with remote health monitoring devices to gather clinical data for alerts to providers and patients. A B C

42. 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
Its up to you to just dip your toe or take a deeper dive with fully automated outreach across your entire patient population.

43. Let’s see NextGen Population Health in Action
Live Demo presented by Kim Root NextGen Application Specialist

44. 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

45. Questions?
Before I move on the demo, I would like to show few screen shots to give you flavor of our application and point out how we address the 3 challenges that we discussed in the beginning.

46. 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

47. Thank You !