Population Management

1. Population Management David Dorr, MD, MS, FACMI Professor and Vice Chair, Informatics and Internal Medicine, OHSU

2. The Mission of Care Management Plus is to better understand how data, information, and knowledge can assist in transforming health for our most vulnerable patient populations. Identifying vulnerable people Risk stratification and segmentation Tailoring care to these needs Improving outcomes

3. Major topics … • What is population health and its relationship to informatics? • What are initiatives for population health? From a policy perspective, one entirely primary care focused : Comprehensive Primary Care Plus; others include Accountable Care Organizations, payment reforms away from volume to value • What are transformation needs ? And • What are informatics needs?

4. Population health • Determined by • Environment > • Lifestyle / behaviors > • Genetics ~ • Medical care • Public health – all of society, vs. a defined population • Management – how can health care assist in maximizing the health of a population • Payment changes • Quality improvement • Data-driven elements

5. CPC+ Overview • National advanced primary care medical home model • Aim: strengthen primary care through • regionally-based multi-payer payment reform, and • care delivery transformation • 2 tracks • 14 regions, 2688 practices • 5 years

6. Policy: Significant payment changes (PBPM) (PBPM)

7. CPC+ Oregon Region Track Breakdown Total Number of Practices Starting in 2017 • Payer Partners • AllCare Health, Inc. • ATRIO Health Plans • CareOregon • Eastern Oregon Coordinated Care Organization (EOCCO) • FamilyCare Health • Oregon Health Authority (Medicaid) • Moda Health Plan • PacificSource • PrimaryHealth of Josephine County • Providence Health Plan (PHP); • Providence Health Assurance (PHA) • Tuality Health Alliance (THA) • Umpqua Health • Western Oregon Advanced Health, LLC • Willamette Valley Community Health • Yamhill Community Care Organization, Inc. 156 Practices Organizational Structure Medicare SSP* Participation • 46 independent practices • 30 rural practices • 23 small practices • 100,549 Medicare FFS beneficiaries served 15% • 23 practices in existing Medicare SSP ACOs** *Shared Savings Program (SSP) **Accountable Care Organizations (ACOs) Practice information current as of January 2017. Subject to change.

8. CPC+ HIT needs • Risk stratification • Segmentation • Tailoring care • Care Plans • Incorporating social needs / determinants • Quality metrics • Alternative visits (e-Visits) Population health

9. Prediction of at risk, vulnerable populations 1-5% 5-10% 25-40% >50%

10. Risk prediction and scoring Hierarchical Condition Categories (HCC; CMS); DxCG; ACG; Charlson Comorbidity Score; etc. Algorithmic risk score Targeted services by risk category Adjudicated risk score Pure clinical intuition “Of your patients, who would you not be surprised if they ended up in the hospital / had a major health issue / died in the next year?”

11. Adjudication or Human Review is important for successful risk stratification at the point of care Figure 3a. Composite risk stratification perception by algorithm type From Ross et al, under review. Survey of 99 persons from 37 clinics engaged in risk stratification.

12. Identification of vulnerable people

13. Data and information sources: social and behavioral issues

14. Ideas for HIT enhancements / workflow for risk stratification The High Risk Patient List Report provides a means to track and enroll high risk patients. It also stores multiple risk calculations and what approaches have been used to address needs.

15. Population-based reminders • Make reports interactive • Prioritized • Population Reminders • As a task list

16. Generate summarized clinical information; Facilitate structured conversationsWilcox et al, Proc AMIA, 2009; Edwards, Dorr, Landon JAMA, 2017 Care planning / summarization Goals: What brings you joy? What matters in life? or Increase walking 5 times per week or A1c < 8.0% Goals: What brings you joy? What matters in life? Increase walking 5 times per week

17. CPC+ Clinical Quality Tracking and Reporting

18. Challenges with using Electronic Health Records for Quality Measurement and Improvement

19. Informatics and Health IT Challenges • Lack of perceived usefulness, lack of computer skill, system design flaws, lack of system interoperability, and incompatibility with clinical workflows are primary deterrents to the use of Health IT systems(1,2) • Exchanging health information effectively can provide significant care coordination and care management benefit, but is still a struggle at many sites (3) • Use of Health IT alone is not sufficient to improve quality but engaging organizational management can influence the effect health IT has on quality improvement initiatives (4) • Implementing a new system or changing an existing system will be met with resistance

20. Steps to grow Health IT expertise Your Vendor’s Training Certification, often for a variety of roles Champions Regular online and in-person training (see left – networking, informal communications) Experiential + Asking Questions CPC+ Connect Affinity groups HIT/EHR user groups HIT/EHR technical support HIT/EHR online repositories Local informatics folks (hospitals, academic centers) Try! Get Unstuck! General Informatics Training ONC HIT curricula : Free online courses and materials 10x10 courses (single online courses) : AMIA Formal programs (e.g., certificates -> PhDs) :

21. Future state • FHIR / APIs to build better functionalities (later today!) • Reduced lag times • Patient entered data – especially for outcomes • Analytics capabilities in the hands of users

22. Oregon Health & Science University Bhavaya Sachdeva Karri Garaventa Melanie Marzullo Jesse Wagner Raja Cholan Nicholas Colin Colleagues and Mentors Cherie Brunker, MD Adam Wilcox, PhD Bill Hersh, MD Paul Clayton, PhD Family Thank you! dorrd@ohsu.edu www.ohsu.edu/cmp