“The Role of Electronic Health Records and Health Information Technology in Medical Home Development” A. John Blair, III, MD CEO, MedAllies

Hudson Valley Initiative  Infrastructure  EMR  HIE  Transformation  Ambulatory  Community  Transparency  Re-Imbursement Redesign  Evaluation

EHR  2008 CCHIT Certification  NYeC Requirements

HIE  Interoperability  CCD  Reporting  Quality  Public Health

Ambulatory Transformation  MassPro  TransforMed  Community Care of North Carolina

MassPro  NCQA PPC-PCMH  PPC1: Access and Communication  PPC2: Patient Tracking and Registry Functions  PPC3: Care Management  PPC4: Patient Self-Management Support  PPC5: Electronic Prescribing  PPC6: Test Tracking  PPC7: Referral Tracking  PPC8: Performance Reporting and Improvement  PPC9: Advanced Electronic Communication

MassPro  Process for Redesign  Develop operational vision and goals  Define redesign teams  Develop workflow list  Document current state  Analyze  Redesign  Implement

MassPro  Team Development  Large practices  Small practices

MassPro  Functional Workflow Diagram

MassPro  Outside consultation  Develop protocols and education  Develop in-office workflow  Develop tracking and outreach plan

MassPro

Access to Care & Information Health care for all Same-day appointments After-hours access coverage Lab results highly accessible Online patient services e-Visits Group visits Practice Management Disciplined financial management Cost-Benefit decision-making Revenue enhancement Optimized coding & billing Personnel/HR management Facilities management Optimized office design/redesign Change management Practice Services Comprehensive care for both acute and chronic conditions Prevention screening and services Surgical procedures Ancillary therapeutic & support services Ancillary diagnostic services Care Management Population management Wellness promotion Disease prevention Chronic disease management Care coordination Patient engagement and education Leverages automated technologies Continuity of Care Services Community-based services Collaborative relationships Hospital care Behavioral health care Maternity care Specialist care Pharmacy Physical Therapy Case Management Practice-Based Care Team Provider leadership Shared mission and vision Effective communication Task designation by skill set Nurse Practitioner / Physician Assistant Patient participation Family involvement options Quality and Safety Evidence-based best practices Medication management Patient satisfaction feedback Clinical outcomes analysis Quality improvement Risk management Regulatory compliance Health Information Technology Electronic medical record Electronic orders and reporting Electronic prescribing Evidence-based decision support Population management registry Practice Web site Patient portal

TransforMed  Practice Facilitation  Facilitation team  Practice Engagement  Collaborative Meetings  Dissemination and Sustainability Strategy  List serves  Webinars

TransforMed  Regular conference calls  Regular Reports to practices and sponsoring institutions  Kick off event  Practice PCMH evaluation with pre-work and site visit  Formal report on practice status and opportunities

TransforMed  Development of project lists and timelines  Regular, continuous engagement of practices  Periodic collaborative meetings  Early work focusing on leadership, change management and team work – creating a culture for change and success

Community Care of North Carolina  Implementing Best Practices  Implementing Disease Management  Managing High-Risk Patients  Managing High-Cost Patients  Building Accountability

Community Transformation  Care Coordination  Provider to Provider  Referral  Consultation  Inpatient to Outpatient  Inpatient Discharge  ED Discharge

Transparency  Claims Data  Clinical Data  NCQA PPC-PCMH recognition

Quality Reporting Community Information Services Aggregator Measures Patient Data Summary Measures EHRs Payers Providers

Reimbursement Reform  Employers  Payer  NY State Employees  Providers  Physicians  Hospitals

Quality Comittee  Provider/Payer Consortium  Quality Measures  Data Sources  Attribution Methodology  Payment Components  FFS  Care Coordination Fee  Outcomes Measures  Payment Frequency and Timing

22 Evaluation  To determine the effects of implementing the Patient-Centered Medical Home in the Hudson Valley on:  Health care quality  Health care cost  Patient experience

The Setting: Hudson Valley  8 suburban and rural counties north of NYC  55% of practices have ≤5 physicians  National leader in ambulatory adoption of health information technology (health IT)  Excellent track record in community transformation  Hudson Valley Health Information Exchange (HVHIE) has been operating for 7 years, making it one of the longest running and most successful clinical data exchanges in the country

Distinguishing Features  Large scale  6 health plans that comprise 74% of the commercial market  Aetna  Empire Blue Cross Blue Shield  Empire Plan (United HealthCare)  MVP  Capital District Physicians’ Health Plan  Hudson Health Plan  1200 physicians and 1 million pati ents

Distinguishing Features  Informative study design  Separates medical home from EHRs and pay- for-performance (P4P)  Unique financial incentive model  Lump sum payment after implementation

Methods  Design: Prospective cohort study with concurrent controls  Intervention: Physicians receive $10,000 each after they reach NCQA Level II medical home  Timing: Implementation getting underway  Participants:  All primary care physicians who are members of the Taconic IPA (N = 1200)

Methods  Participants (cont’d.):  A sample of their patients in medical home and control practices  Baseline: N = 300 medical home control  Follow-up: N = 300 medical home control

Study Groups for Physicians NChart Type P4PMedical Home Group 1600PaperNo Group 2150PaperYesNo Group 3100EHRNo Group 4100EHRYesNo Group 5250EHRYes

Measurements  Health care quality  10 HEDIS measures  Aggregated across 6 health plans  Each year for 4 years ( )  Health care utilization  18 utilization measures aggregated across 6 health plans, each year for same 4 years  Inpatient, outpatient and emergency department, thus essentially all utilization

Measurements  Patient experience  Telephone survey based on CG-CAHPS (with additional questions from the CMWF International Health Policy Survey and ACES), in 2009 and 2011

Overview of Analysis  For quality and cost:  Using generalized estimation equations, comparisons between study groups and across time, adjusting for physician characteristics and case mix  For patient experience:  Adhering to CG-CAHPS guidelines, comparisons between study groups and across time, adjusting for patient demographics and co-morbidities

Products  Hudson Valley experience with medical home transformation  Total and incremental effects (compared to EHRs and P4P) of medical home transformation on quality  Total and incremental effects (compared to EHRs and P4P) of medical home transformation on cost  Effect of the medical home transformation on the patient experience

Contribution  Determine the clinical and economic value of the Patient-Centered Medical Home  Using a fairly unique payment model  Measured magnitude of cost savings can inform future incentive programs  Determine the incremental quality and economic value of the Patient-Centered Medical Home beyond that of EHRs and P4P  Comparison critical to inform community activities nationwide

Contribution  Maximize reliability and generalizability of effect size estimates  6 health plans, 1200 physicians and 1 million patients

Priority Focus on Discharge Transitions  Medicare 30 day readmit rate 17.6% (MedPar)  Estimated 3/4ths avoidable  Employed GHS physician readmit rate 17%  Case Mgr phone contact all discharges hrs  Assess transition status, concerns, review plan  Medication reconciliation  Confirm or make f/u appointments  PCP discharge follow up visit 4-7 days

Decreasing Readmissions Over 25% reduction Jan-OctYTD 2006 to 2007

Acute Admission Impacts  Lewisburg Acute Admits/1000  Jan-Oct07YTD  Lewistown Acute Admits/1000  Jan-Oct07 YTD  Employed Admits/1000  Jan-Oct06 YTD  Jan-Oct07 YTD % Reduction 22% Reduction

Medical Home: Care Cost Trend Medical Home PMPM down 2% vs Network PMPM up 6%

Thank you for your time! A. John Blair, III, MD CEO, MedAllies, Inc.