A. John Blair, III, MD CEO, MedAllies

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

2. Hudson Valley Initiative • Infrastructure • EMR • HIE • Transformation • Ambulatory • Community • Transparency • Re-Imbursement Redesign • Evaluation

3. EHR • 2008 CCHIT Certification • NYeC Requirements

4. HIE • Interoperability • CCD • Reporting • Quality • Public Health

5. Ambulatory Transformation • MassPro • TransforMed • Community Care of North Carolina

6. 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

7. MassPro • Process for Redesign • Develop operational vision and goals • Define redesign teams • Develop workflow list • Document current state • Analyze • Redesign • Implement

8. MassPro • Team Development • Large practices • Small practices

9. MassPro • Functional Workflow Diagram

10. MassPro • Outside consultation • Develop protocols and education • Develop in-office workflow • Develop tracking and outreach plan

11. MassPro

12. 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 • Health Information Technology • Electronic medical record • Electronic orders and reporting • Electronic prescribing • Evidence-based decision support • Population management registry • Practice Web site • Patient portal • Care Management • Population management • Wellness promotion • Disease prevention • Chronic disease management • Care coordination • Patient engagement and education • Leverages automated technologies • Quality and Safety • Evidence-based best practices • Medication management • Patient satisfaction feedback • Clinical outcomes analysis • Quality improvement • Risk management • Regulatory compliance • 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

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

14. 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

15. 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

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

17. Community Transformation • Care Coordination • Provider to Provider • Referral • Consultation • Inpatient to Outpatient • Inpatient Discharge • ED Discharge

18. Transparency • Claims Data • Clinical Data • NCQA PPC-PCMH recognition

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

20. Reimbursement Reform • Employers • Payer • NY State Employees • Providers • Physicians • Hospitals

21. 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

23. 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

24. 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 patients

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

26. 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)

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

28. Study Groups for Physicians

29. Measurements • Health care quality • 10 HEDIS measures • Aggregated across 6 health plans • Each year for 4 years (2007-2010) • 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

30. 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

31. 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

32. 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

33. 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

34. Contribution • Maximize reliability and generalizability of effect size estimates • 6 health plans, 1200 physicians and 1 million patients

35. 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 24-48 hrs • Assess transition status, concerns, review plan • Medication reconciliation • Confirm or make f/u appointments • PCP discharge follow up visit 4-7 days

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

37. Acute Admission Impacts • Lewisburg Acute Admits/1000 • Jan-Oct07YTD - 224 • Lewistown Acute Admits/1000 • Jan-Oct07 YTD - 273 • Employed Admits/1000 • Jan-Oct06 YTD - 295 • Jan-Oct07 YTD - 292 14% Reduction 22% Reduction

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

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