With each patient rehospitalization, thousands of dollars are spent on additional care and the risk of patients getting sicker or suffering preventable setbacks grows.

THE PROBLEM

There is high-quality, peer-reviewed evidence for what works for these high-risk patients, but not many physician practices are able to get it right. This isn't because it's impossible, but because it requires precision teamwork and a choreographed response to deliver what patients need.

An analysis of reports from MEDLINE, EMBASE, Web of Science and the Cochrane Library showed that patients require many interventions, not just one, during their transitions from hospital to home in order to have the best chance of avoiding readmission.

PROPOSAL

Chicago-based Oak Street Health says its core objective is to keep patients happy, healthy and out of the hospital. That, of course, means preventing avoidable hospitalizations – and especially avoidable readmissions.

To help toward that goal, Oak Street Health developed a proprietary inpatient review application within its application suite called Canopy to prevent rehospitalization for patients.

Canopy integrates 1,300 data fields across several platforms, including EHR, inbound/outbound calls, CMS, CRM, utilization management and care management. It also integrates with external data platforms like eligibility, revenue, claims, Rx and provider charts to track patients from hospital to home and better personalize their post-hospitalization care.

The Inpatient Review app in its Canopy suite guides teams through evidence-based interventions that consensus shows improves outcomes. This is the foundation of Oak Street Health's transitions-in-care process that provides patients the highest quality of care from hospital to home and every facility in between, the provider organization stated.

In this process, the responsibilities of transition nurses include, but aren't limited to: updating the Inpatient Review app daily based on discussions with the patient, hospital staff and/or facility EHR; maintaining up-to-date discharge planning information; scheduling post-discharge visits; requesting discharge summaries from facility and completing post-discharge calls; driving referrals to house call nurse practitioner if appropriate; and facilitating medication therapy management by pharmacist.

The Inpatient Review app serves as a virtual roundtable where care teams meet to discuss their highest risk patients. It's the venue for communication and includes all the relevant information to deliver evidence-based support.

MARKETPLACE

There are many health IT vendors in the market that offer decision support systems. These include Automated Clinical Guidelines, Chadis, Information Builders, LogicNets, MCG, medCPU, National Decision Support Company, Pepid, PointRight, Semedy AG, Stanson Health, Talis Clinical and Wolters Kluwer.

MEETING THE CHALLENGE

"Our approach is innovative because most primary care physicians don't have the processes to pull and manage this data, and therefore aren't able to meaningfully intervene in the care of their patients," said Drew Crenshaw, senior vice president of population health at Oak Street Health.

"Even primary care physicians in a closed-loop hospital system where the inpatient and outpatient setting share an electronic health records system don't have such sophisticated tools that are designed to help the provider make thoughtful decisions," Crenshaw added.

However, by developing Canopy and the Inpatient Review app, Oak Street Health is able to deliver evidence-based care at scale that results in measurably better outcomes, he added. The fixed process is a closed loop made of four stages.

First, the system measures patient data. The census pulls from a variety of sources, such as plan lists or authorization feeds, and local teams can manually add admissions as they occur.

"Our approach is innovative because most primary care physicians don't have the processes to pull and manage this data, and therefore aren't able to meaningfully intervene in the care of their patients."

Drew Crenshaw, Oak Street Health

Second, the system analyzes the data and leverages insights from the care team. The data is scrubbed and sorted to maintain consistent fields for diagnosis, site and length of stay. From there, alerts are programmed for patients with cases that are high-risk or out of network.

Third, the system communicates with the care team and/or the patient. The app automatically notifies the team every day of new census and status. Team members can manually add or revise information to ensure data is accurate and comprehensive.

And fourth, staff act on all this rich information. The care team logs into Canopy every day to view their patients' profiles and monitor their health updates. From there, users can work with other team members to better personalize post-hospitalization experiences and care.

"Once Canopy was developed, we rapidly scaled it across all Oak Street Health centers in three states in one month," Crenshaw said. "We were able to operate at this speed with our common single-sign-on platform that allows teams to quickly incorporate new tools from the platform into their daily routines."

Today, Canopy is a tool that's used throughout all of Oak Street Health's 40 centers. The next iteration of the tool will include evidence-based risk stratification tools to identify patients who need additional scrutiny and support, as they are at highest risk for readmission.

RESULTS

Since the development and launch of the Inpatient Review app, Oak Street Health has seen a 26 percent reduction in risk-adjusted rehospitalization, Crenshaw reported. This illustrates the integral role technology plays in supporting the consistent delivery of evidence-based care to complex, chronically ill patients in multiple care settings, he added.

"All Oak Street Health centers have access to the Canopy Inpatient Review app, and more than 100 employees across the organization regularly use it to coordinate care for admitted patients," he said. "On average, employees log into the tool 3.3 times a day, and 85 percent of employees would recommend it to a colleague. The app captures and tracks 22 percent more hospitalization events than what is reported through payer census files."

Canopy ensures Oak Street Health patients are getting the patient-centered, evidence-based care they require, regardless of where they go for inpatient services or which Oak Street Health team member they spoke with last, Crenshaw explained.

"Canopy is an example of the type of platform that value-based models of the future will need to deliver evidence-based care in a complex care ecosystem," he said. "It integrates all available data and simplifies the process for care teams to keep patients happy, healthy and out of the hospital."

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

KLAS released its latest report on population health management vendors this time focusing on how well vendors did when it comes to partnering and guidance helping healthcare providers make the transition to value-based care.

WHY IT MATTERS

Hospitals will not achieve population health success with just technology, of course, and KLAS noted that getting to value-based reimbursement will also require partnering and guidance from your tech vendors.

“Some vendors have risen to the challenge, while others have faltered following acquisitions or efforts to scale,” researchers wrote in the new report, Population Health Management, Part 1 - Partnering and guidance: The X Factors to PHM success. 

THE KLAS RANKINGS 

KLAS uses metrics to measure a vendor’s ability to partner with healthcare providers that include strong executive relationships or proactive support, as well as high-quality tech and strong integration.

The firm based its separate ranking for guidance as “going above and beyond partnering,” and also providing strategy, value-based reimbursement contracting, product optimization and ongoing performance assessment.

In terms of overall score, which includes both the partnering and the guidance categories, here is how the vendors fared.

• HealthEC - 93
• Health Catalyst - 87.9
• Arcadia - 87.7
• Enli - 87.4
• Epic - 86.3
• Lightbeam - 85.7
• SPH Analytics - 85.5
• Optum - 82.5
• i2i Population Health - 81.7
• IBM Watson Phytel - 80.7
• Cerner - 79.4
• Allscripts - 70.8
• Philips Wellcentive - 70.7
• Athenahealth - 69.4

“HealthEC, Health Catalyst, Arcadia, Enli, Epic and Lightbeam are the vendors who deliver well in both areas,” KLAS explained in the report. “Over the last year, several other vendors have seen significant decline in overall customer satisfaction.”

KLAS pointed specifically to Philips Wellcentive, NextGen Healthcare, Allscripts and athenahealth as struggling to meet customer’s needs.

THE BIGGER TREND

In a mid-December report, Frost & Sullivan found that PHM vendors are adding artificial intelligence and machine learning for predictive disease modeling, automated risk stratification and capabilities to identify populations that could benefit from precision interventions.

Health systems including UPMC, meanwhile, are harnessing such tools to balance population health and precision medicine.

Princeton Healthcare is using population health tools to decrease post-acute care expenses by 12 percent and inpatient utilization by 5 percent in its value-based care initiatives.  

Robert Wood Johnson and NYU Langone are each enhancing their respective population health programs with platform innovations and workflow changes to reach their goals.  

ON THE RECORD

“In evolving markets like population health management, provider organizations need vendors who excel at partnering and who are also agile and strategic enough to guide customers through the market’s evolution,” said KLAS researchers. 

Twitter: @SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Healthcare IT News is a HIMSS Media publication. 

Livongo announced on Friday that Lee Shapiro is its new chief financial officer. Shapiro is the former president of Allscripts, the EHR vendor Livongo founder Glen Tullman served as CEO of before starting the digital health company.

WHY IT MATTERS

Shapiro is stepping into the CFO post on the heels of Livongo revealing that former Cerner President Zane Burke is it’s new CEO and Dr. Jennifer Schneider was promoted to President. Amid those executive moves, Glen Tullman, founder and CEO until Burke joined, became executive chairman.

Shapiro, who was president of Allscripts from 2001-2012, has been a board member of Livongo since the beginning. He also served as a member of the audit committees of member of the audit committee of Medidata Solutions and Tivity Health.

He and Tullman also cofounded the $100 million early stage healthcare investment fund known as 7wireVentures.

THE BIGGER PICTURE

Instituting a new executive team is part of an ongoing effort to move out its roots as a digital health startup focused on helping people with diabetes and into other chronic conditions as part of what the company calls Applied Health Signals.

Back at Health 2.0, for instance, the company announced the availability of a cellular-enabled blood pressure monitor people with hypertension can use to get real-time feedback, he said.

“The future of healthcare is not about big software systems in hospitals,” Tullman told Healthcare IT News at the time. “That’s important but healthcare today is about how we empower people with chronic conditions, how we empower those people with software and technology to make it easier to be happier and healthier.” 

ON THE RECORD

Ahead of today’s announcement, Tullman explained: “We hired Zane Burke as Chief Executive Officer, promoted Dr. Jennifer Schneider to President, and named Lee Shapiro Chief Financial Officer to take this company to the next level. With 135 million people living with chronic conditions in the United States today, we still have a lot of room to grow.” 

Shapiro's appointment to CFO will be effective in Feburary, 2019. 

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com 

Healthcare IT News is a HIMSS Media publication. 

HIMSS has honored California Correctional Health Care Services with its 2018 Davies Community Award of Excellence, recognizing the provider organization's efforts in using health IT to reduce hospitalizations for high-risk patients.

Ten years ago, California Correctional Health Care Services was buried in paper. Tens of thousands of inches of healthcare records were spread out across the state at more than 30 institutions – as well as a more than 150,000 square foot warehouse archive. The patient population reached numbers of more than 125,000 individuals, with approximately 600 new arrivals every week and roughly 11,000 transfers monthly.

Inappropriate patient placement

These paper records were unwieldy and sometimes lost during transfers. Many processes were person-dependent, and healthcare risks were not considered appropriately during placement. Placing vulnerable, clinically complex patients in inappropriate locations was identified as a frequent contributor to potentially avoidable adverse health outcomes.

With the appointment of Federal Receiver J. Clark Kelso, California Correctional introduced a new clinical classification system in 2009. This process established healthcare factors to consider when housing individuals and introduced the concept of a "basic" versus "intermediate" care institution.

While this was a step in the right direction, the person-dependent, paper process left risk levels too broadly defined and was not often accurate or up to date. There were frequent discrepancies between reported risk and actual risk, whether due to missed relevant clinical information, incorrect interpretation of clinical risk rules, or a failure to update the clinical risk as new clinical information became available.

Significant staff time was dedicated to identify, update and communicate healthcare factors pertinent to the appropriate patient placement.

In order to address the challenges with a person-dependent paper process, California Correctional set out to leverage available data sources and information technologies to automate the clinical rules for a risk stratification system.

This system would provide timely, actionable information for those involved in the process of housing patients and provide near real-time performance reports to track progress, with a goal of improving placement of clinically high-risk patients.

From paper to electronic

While California Correctional began the multi-year journey to shift business practices from paper to electronic, the organization also looked to automate the clinical risk tracking system.

To accomplish this upgrade, California Correctional leveraged multiple available data sources, developed a structured data warehouse, and created daily automated jobs to update and communicate the clinical risk for all patients to their custodial colleagues who used this information, in part, to inform appropriate housing.

The organization used a change management strategy that included training of clinical and correctional staff and developed decision support tools to aid end users in the new process. California Correctional also reported performance for placement of high-risk patients to a subset of institutions identified as having access to an expanded set of healthcare services, including closer proximity to tertiary care centers.

As a result, California Correctional improved the appropriate placement of high-risk patients by nearly 20 percent, which led to improved accuracy of reported risk for individual patients, improved consistency in assigned risk between similar patients, and improved transparency of a patient's risk factor determinants – all while eliminating paper forms and person-dependency.

The organization was able to achieve a reduction in potentially avoidable hospitalizations for high-risk patients from 70.9 per 1,000 patients in June 2015 to 43.5 per 1,000 patients in December 2017.

Administratively, the automated clinical risk classification system has saved more than $2 million in the first three years of its implementation by eliminating the need for licensed clinicians to complete paper records.

"Quality patient care is the principal function of any healthcare organization, regardless of the patient population," said J. Clark Kelso, receiver over medical care for the California prison system. "Incorporating information technology solutions to leverage healthcare data is imperative to make informed decisions and improve organizational performance."

California Correctional Health Care Services will be recognized during HIMSS19, February 11-15 in Orlando, Florida.

Also at HIMSS19, California Department of Corrections and Rehabilitation Chief of Quality Management and Informatics John Rekart will show how analytics can help boost the success of EHR go-lives in an educational session entitled “Analytics-Based EHRs Implementation: Improved Outcomes,” scheduled for Thursday, February 14, from 11:30 a.m. to 12:30 p.m. in room W308A.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

HIMSS and the Cleveland Clinic are now accepting speaking proposals for the 10th annual Empathy & Innovation Summit, the world’s largest, independent conference devoted to improving the patient experience. This year the clinic is partnering with HIMSS to explore more deeply how healthcare is extending empathy into an increasingly digital environment.

The deadline to submit a presentation proposal is 5 p.m. EST on January 25. Priority is given to peer-to-peer, experiential learning and case studies from healthcare payer and provider organizations. The summit will take place in Cleveland on May 13-15.

As the Empathy & Innovation Summit moves into its 10th year, the Cleveland Clinic and HIMSS are proud to announce an exciting new partnership around this annual event. This year’s theme, "Looking Back, Leaping Forward," will explore the evolution of the patient experience movement, examining how major influencers from the past decade will incite big innovations in the future of care.

The 10th anniversary sets the stage for the new partnership and offers a valuable opportunity to enhance the focus on technology and more deeply explore how healthcare is extending empathy in an increasingly digital environment.
 
In addition to the main conference on May 14-15, HIMSS will present two preconference symposium on May 13. One will address the consumerism of healthcare; the other will explore “smarter care” or to how to maximize your existing technology more effectively to provide a better experience to underserved and high-risk populations.
 
Click here for more information and to submit a proposal for the main conference and the pre-conference symposiums.

Northland District Health Board (DHB), which is based in Whangarei and covering the northernmost part of the North Island in New Zealand, has launched a web-based interactive version of the Health Needs Assessment (HNA).

DHBs must produce an HNA report every 5–7 years as a way of monitoring the health and wellbeing of the population, as well as their need for health services. The reports are typically published as lengthy paper-based or PDF documents.

Former Northland DHB clinician Juliet Rumball-Smith was instrumental in driving the development of an online HNA, which is intended to make the data easier to access and understand by anyone.

Research associate Edith Bennett and data scientist Shameer Sathar at Northland DHB’s Health Intelligence Hub built the tool in-house using open-source software such as Python and Django.

“There’s a lot of data already published, but it’s quite hard to access or understand, so we thought why not create an application where people can access information themselves and with interpretation already there,” Bennett says.

“We can also update it as data becomes available, such as the Census 2018 data which will be published soon.”

A survey completed with stakeholders before the new tool was published found that 86 per cent of respondents said the web-based format improved their ability to access the data.

Sathar says future plans include making the tool more mobile compatible.

“We’re also hoping to use it beyond the HNA by having forecasting and projections data available,” says Bennett.

“Our real aim is to get a one-stop-shop for people to go to look for population health data specific to Northland.”

A version of this article first appeared on eHealthnews.nz.

A recent survey of leading institutions revealed that one of the top five reasons healthcare providers (HCPs) have struggled to expand home-based monitoring as part of their population health management programs is an inability to provide technology service and support at scale.

IT departments are being asked to take on roles that stretch them beyond their comfort zone. Some say IT organizations’ sole purpose is to “keep the lights on” within the brick and mortar facilities. They profess that IT’s role does not include supporting computer devices that patients use as part of their enrollment in a home-based monitoring program.

For a moment, let’s agree... The number one job of the HCP’s IT organization is the management and functional maintenance of IT infrastructure within the health system, including externally facing applications such as patient portals. However, for most, supporting devices provisioned to patients for at-home use is beyond their scope and capacity.

Yet, the business of healthcare is changing, and IT must keep up with the demands brought on by these changes. When asked to assist in the onboarding of home-based monitoring, IT should have the confidence and ready state strategy to meet the needs of their population health and community outreach departments.

“We must consider factors beyond those related to the traditional healthcare system,” says Dr. Chris Gibbons, Chief Health Innovation Adviser, Federal Communications Commission, and CEO and Founder, The Greystone Group, Inc.

Like many, Dr. Gibbons views these nontraditional factors as only becoming more important as healthcare becomes more mobile, ambulatory, home and community based, personalized, and patient/consumer oriented. He explains that if we wish to enhance patient engagement, as is generally advocated by many, than the need for comprehensively servicing and supporting patients’ participation is vital.

The reality is when IT departments are managing day-to-day routine tasks, like tech refreshes, security audits, and provisioning user accounts and access privileges, they may struggle to participate in the strategic decision-making process that will add to their business’s bottom line. This can stifle the innovative potential of an increasingly vital department, which given the way tech advances, no business can afford.

In 2018, Ipsos Research conducted telemedicine qualitative interviews. A consistent response amongst those hospital payers who were interviewed was related to administrative burden: “Hospitals don’t want to sign up for the big administrative burden of collecting and using the data without a clear plan or support system.”

This sentiment extends to their IT organizations. As a program administrator, there are a few tactics you can take to address these challenges up front, and successfully align your stakeholders.

Getting off to a good start

When adopting a home-based monitoring program, there are a few tactics you can employ to prevent similar challenges from stifling your ability to launch and grow your initiative (and keep you on your IT team’s good side). Kick start your program with a deployment model that addresses the need to:

1. Reduce routine endpoint management tasks

2. Ease budget concerns

3. Tighten up security

4. Get a handle on device management

5. Establish reliable disposal processes

6. Deploy a timely and responsive break/fix model

7. Seek a trusted IT service partner

This is not all the work of the IT department. Not at all. Population health and community outreach teams need to think about and communicate a vision, not just a compromising list of demands. Work together to establish criteria for the selection of a third-party service provider and look for partners who understand health consumer behavior.

Technology placed in the home setting may not have the same controls or structure that are in place in the confines of a clinical setting. You’ll want to think about how your healthcare consumers will be interacting with the devices and the health system from outside of your clinics. Most institutions want smart, simplified computing solutions that are easily deployed, tracked and supported.

What is your vision?

Taking the time to brainstorm and prioritize the optimal technology-enabled solutions and services scenario for your patient population will serve you well, because you’ll be better positioned to say what’s truly needed. For instance, consider the following:

• What if you could easily add or remove managed patient enrollees and enrolled devices?
• How might managed oversight of enrolled patients and devices yield better insights and opportunities for early intervention?
• Continuous improvement is a must, and as a result, programs often change course. What if you could request and default application deployment and updates easily and without hesitation?
• How convenient might it be to have the ability to move requested apps from a healthcare consumer’s Device App Catalog?
• Downtime is not an option for devices being deployed for remote monitoring. Imagine the confidence and trust built between you and your patients when devices are monitored. What would it mean to you, your patients and their personal caregivers to know you will all be notified when a device health issue is detected?

Imagine the benefit of shifting device investments from the CAPEX side of the ledger to the OPEX side. We all know that CFOs are mindful of many factors when determining expenditures, and each year brings new considerations—this will help keep your program more financially predictable and thus more financially manageable. This is also a really nice way to stay in line with reimbursement caps.

For more on remote patient management, visit hp.com/go/healthcare. Continue the conversation at HP’s booth #3741 at HIMSS19.

A new report this month from the Bipartisan Policy Center explores the reasons for – and remedies to – the fact that mental and behavioral health data are so poorly integrated with clinical information in electronic health records.

WHY IT MATTERS
Some 45 million Americans have some form of mental illness, the Bipartisan Policy Center points out, and there's been an increase in deaths due to substance abuse and suicide in recent years. The ongoing opioid crisis is only exacerbating the challenges associated with getting patients the healthcare they need.

A decades-old federal statute known as 42 CFR Part 2 aimed to protect patient privacy by keeping substance use disorder separate from clinical records. It was well-meaning, but the rule prevents physicians from getting a complete view of their patients.

Add to this the fact that mental and behavioral health providers were left out of the federal EHR Incentive Program that spurred uptake of EHRs at hospitals and practices a decade ago.

There are numerous other hurdles too, related to insurance, administrative barriers, workforce challenges and more.

The new report aims to "identify barriers to integration caused by federal policy, to identify policy options to mitigate or remove those barriers, and, through policy changes, to advance evidence-based treatment for mental health in the United States."

Among its suggestions: Congress should enable use of HITECH funding to incentivize uptake of EHRs for mental and behavioral health provides, and HHS should clarify rules around HIPAA and data sharing.

"A major integration barrier in a coordinated care setting is the inability to easily share patient information between providers," researchers from the Bipartisan Policy Center write. "Providers are allowed to share information only with elaborate contractual agreements, which creates barriers for care coordination, an essential component of successful integration."

Another major barrier is the "lack of information sharing, spurred by privacy concerns, which has limited the adoption of electronic health records by mental health and SUD providers."

While the HITECH Act earmarked "billions of dollars in subsidies for medical providers to purchase and maintain electronic health records," it didn't make those incentives available to mental health and substance abuse disorder providers. As a result, "while the adoption of electronic health records has increased among other healthcare providers and entities, adoption by mental health and SUD providers has lagged."

THE LARGER TREND
As long ago as 2011, leaders on Capitol Hill such as Sen. Sheldon Whitehouse, D-Rhode Island, were looking to remedy HITECH's oversight of behavioral health providers and extend eligibility for meaningful use money their way.

More recently, both the House and the Senate have supported bipartisan bills designed to incentivize adoption of EHRs by psychologists, psychiatric hospitals, community mental health centers and others.

"Electronic records help doctors and other providers make better decisions about their patients’ care," said Whitehouse in a May 2018 statement touting the senate passage of a newer bill, his Improving Access to Behavioral Health Information Technology Act. "Americans who receive substance abuse and mental health treatment should benefit from that technology, too."

ON THE RECORD
"The history and structure of the mental health system has resulted in payment and policy silos and a host of agencies and providers that, while committed to quality care for people with mental illness, have significant interest in changes to the status quo," wrote researchers in the report.

"Integration of services financed at the federal level will require collaboration among traditional mental health providers, public health departments, states, health plans, and federal government agencies that have not traditionally been required to work together and may not have aligned interests.

"In addition to political and jurisdictional concerns associated with some of the options, many will require increased federal spending. BPC has typically sought to identify savings or additional revenues to avoid policies that add to the federal deficit. This will need to be considered as policymakers weigh options."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

Healthcare IT News is a HIMSS Media publication. 

There are lots of ways to analyze data for better quality outcomes and improved pop health – and there are also many types of data that can be analyzed.

At HIMSS19 next week, Kevin Gormley, principal data scientist at The MITRE Corporation, along with his colleague Dawn Heisey-Grove, principal epidemiologist at MITRE, will show how tapping into multiple sources of data from specific communities can help detect at-risk patient populations and target needed interventions.

By probing risk factor estimates and heat maps of higher-risk geographic locations, providers and public health officials can detect certain health patterns that might have been previously overlooked. But putting that data to work requires that certain hurdles be overcome – especially with regard to access and aggregation of vastly different and often very siloed data types: state or county information, census block group, postal code, etc.

A new open source tool aims to help address some of the biggest challenges for communities and health organization hoping to leverage multiple data sources at once. Called Simulated Multivariate Adaptive Regression Technique, or SMART Scatter, the technology allows easier access to local administrative data for the development of pop health models.

In Orlando, Gormley and Heisey-Grove will discuss how various different datasets can inform public health policy, surveillance and intervention; explain how partnerships between local government and the the private sector can boost the success of those efforts, and show how heat maps can be leveraged to improved population health health management.

In advance of HIMSS19, Gormley answered a few questions about SMART Scatter tool for Healthcare IT News.

Q. What is SMART Scatter and how does it work?

A. SMART Scatter integrates data from different sources stored at different geographic levels (e.g., county, ZIP code, census block group, and household). Before SMART Scatter, analyses could only be conducted with data at the same geographic level. SMART Scatter increases the amount of data that can be used in a single analysis thus enabling estimates that help public health decision makers better evaluate the implications of certain policies. Our tool captures valuable information from each data source (e.g., correlations between variables, distributions of variables such as income) and uses all the available data sources for each household (its respective census block group, ZIP code, county, etc.).

Q. What are some of the ways it's helping improve public health, surveillance and intervention? What challenges does it solve?

A. Our community partner confirmed that the heat map of domestic violence hot spots fit their public health experience. Knowing that the model is accurate, we are shifting this year to building a public health policy simulation infrastructure that evaluates public health intervention policies applied to community or communities. Based on their experience and expertise, public health staff could use the model to simulate the effects of interventions they predict will be most impactful within targeted portions of a community (e.g., school districts). Our tool will estimate impacts for different policy interventions, enabling public health staff to confirm their strategies and consider refinements.

Q. Are some other specific use cases that could be promising besides the ones that will discussed at HIMSS19?

A. Our current model is based on incidents of domestic violence, but other conditions could be simulated similarly if their risks can be modeled at the geographic level. For example, residents close to wooded areas may be at greater risk of tick-borne illnesses, people living near sources of air pollution (factories, highways, etc.) may be at higher risk of asthma, or those who live in "food deserts" may be more susceptible to obesity.

Q. What are the specific geographic data that are most useful here?

A. What is most useful is combining multiple local data sources that a county or community already have access to with Census data, which are publicly available.

Q. Beyond public health and safety, do you feel that this is a tool that has great promise for larger population health management challenges, esp. as health systems grapple with value-based reimbursement?

A. SMART Scatter has the potential to estimate the social determinants of health and other risk factors for communities. As healthcare organizations consider how to control costs while improving care, there are many aspects related to social determinants of health and access to care that could be modeled with SMART Scatter. Access to transportation, for example, is an ongoing challenge for patients travelling to appointments. In the future, perhaps SMART Scatter could be coupled with patient rosters to estimate how public transportation could be modified or supplemented to improve access to care, or to better understand community needs around transportation. Another example is among clinicians who are treating patients with obesity; they may wish to better understand the community assets around the patient’s home or place of employment, and SMART Scatter, with its ability to leverage data from multiple sources, could be a tool to facilitate that view.

Q. Any other thoughts for those interested in learning more?

A. SMART Scatter is representative of the type of innovation that can be realized from research collaborations – in this case between county public health staff, university researchers (Virginia Tech), and MITRE. We are careful to always recognize these indicators do not suggest that a single individual is at greater risk. Rather, these SMART Scatter estimates show risk potentials within small populations, possibly within a few blocks or a ZIP code.

Kevin Gormley and Dawn Heisey-Grove's presentation, "Leveraging Local Data for Public Health with “SMART Scatter" is scheduled for Wednesday, February 13, from 11:30 a.m. to 12:30 p.m. in room W206A.

Providence St. Joseph Health has launched a new population health company, Ayin Health Solutions.

WHY IT MATTERS

PSJH said the new venture will aim to help organizations “maintain stability in a shifting healthcare market,” and it will do so by offering services that can help organizations keep costs down, improve care and ease into population health management. Headquartered in Portland, Oregon, Ayin’s offerings will include a pharmacy benefits management service, risk evaluation tools, comprehensive reporting and employee health benefits service.

Value-based competition is getting tougher, and providers are looking for a competitive edge that calls for more customized population health management programs, according to a new study by Frost & Sullivan. Traditional PHM solutions that focus on high-cost patient populations are giving way to more holistic and evidence-based approaches that cover both high-risk and at-risk patients. Providers want to focus on preventive care and target patients as consumers.

Many population health technologies are evolving to provide a more granular understanding of a patients' social determinants, giving providers greater insight into how to approach care, according to Matt Hawkins, CEO of Waystar, a cloud-based revenue cycle management company.

ON THE RECORD

“These are tumultuous times for the healthcare industry and organizations are eager for proven strategies and solutions that will stabilize their business and guide their shift toward a new standard of care,” said Dr. Rhonda Medows, CEO of Ayin Health Solutions and president of Population Health at Providence St. Joseph Health. 

Diana Manos is a Washington, D.C.-area freelance writer specializing in healthcare, wellness and technology.

Twitter: @Diana_Manos
Email the writer: dnewsprovider@gmail.com

Today, in advance of HIMSS19, Lightbeam Health Solutions is debuting Lightbeam 3.0, a new and what it labels improved population health management platform.

"Version 3.0 represents the full end-to-end nature of population health management that we've always been working toward," said Jorge Miranda, executive vice president at Lightbeam Health Solutions. "This release focuses on extending capabilities and ease of use for managing high-risk, high-cost populations."

New integration, dashboard and user interface

Version 3.0 includes a new data integration service, provider insights chart, KPI dashboard, referral management module and user interface design, in addition to enhancements of existing Medicare Advantage and hierarchical condition category analytics.

"We developed it based not just on what we're seeing in the market, but also from extensive client feedback and beta testing, especially with our ACO and Medicare Advantage clients," Miranda explained.

"Because these two types or organizations are on the leading edge of shared- and downside-risk contracting, they have unique insights into what it takes to really engage physicians and the organization as a whole in succeeding under shared- and full-risk models," he said.

Notably, Version 3.0 includes new analytical views that leverage predictive analytics and the vendor's proprietary "ability to impact" score to manage larger populations in downside risk, he added.

Two other key technology aspects of Version 3.0 are fully integrated referral management capabilities and the clinical integration data service, which the vendor calls clinically integrated network-as-a-service.

"Providers can't afford to lose track of patients in the shuffle of referrals, and patients should not have to suffer being caught between two providers whose systems aren't interoperable," Miranda said. "Just as important, providers can't be expected to wait on EHR and other vendors to solve the interoperability problem – they need solutions right now to ensure they can extract value from the technology in which they've already invested millions and, in some cases, hundreds of millions of dollars."

Trends to discuss at HIMSS19

It will be focused on a few health IT trends at the conference, including payer/provider collaboration and social determinants of health integrated with analytics, AI and machine learning.

When it comes to payers and providers collaborating, whether it's through mergers and acquisitions, new partnership models, or entirely new whole-cloth initiatives, Lightbeam said it is seeing insurers push for the wellness of their patients through preventive, proactive care delivery.

"As value-based care and downside-risk continue to gain steam, integrated solutions to support these delivery models will only become more important."

Jorge Miranda, Lightbeam Health Solutions

"As value-based care and downside-risk continue to gain steam, integrated solutions to support these delivery models will only become more important," Miranda said. "Deploying solutions that inform and impact provider behavior at the point of care is key for aligning behaviors across payers and providers. To ensure a sustainable approach, payers and providers must have a common platform that enables them to 'speak the same language' and exchange information seamlessly."

Then there is the integration of social determinants of health with analytics, artificial intelligence and machine learning, he added, noting that the importance of bringing together these aspects of healthcare is sometimes lost in the buzz surrounding them as individual topics.

"If not correctly defined and developed at the application level, they can become untethered to clinical realities and documented research from medical societies, which of course means providers will be less likely to adopt and champion them," he said. "AI is not a doctor or simply a set of rules. True AI for healthcare is a model based on clinical standards that can leverage data beyond the EHR, empowering providers and organizations to deliver high-quality care."

Personalizing the intervention to the individual is what drives behavior change; analytics can greatly augment the ability to identify and manage high-risk populations, he added.

Advice for healthcare CIOs

"EHRs provide a good source of truth regarding what happened in the past, but when it comes to predictive analytics and effective management of high-risk and high-cost populations, healthcare organizations need tools designed for prospective rather than retrospective analysis," said Miranda. "EHR and claims data just aren't enough, so tools designed with only those data sources in mind will never be up to the task."

CIOs and other leaders can start by developing a strategy based around the insights found in their patient-population data, EHR and available claims sources, he said. The strategy would include population health management, proactive wellness plans, risk-adjustment coding, post-acute care coordination, chronic-care management, referral-management optimization to address patient leakage, and automated care gap identification to improve quality outcomes.

"Although that's a heavy lift in and of itself, the truth is that's the new table stakes in healthcare," said Miranda. "So it's critical to quickly move to what is required to manage 'rising risk,' and reducing or eliminating future avoidable spend that erodes good performance in downside risk arrangements," he concluded.

Lightbeam Health Solutions will be in Booth 4370 at HIMSS19.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

Medfusion, the developer of patient connectivity technologies, is partnering with Healthdom, whose platform is focused on personalized preventive healthcare, to help its members more easily access and aggregate their digital health data.

The goal: Beef up patient data sets and provide the most complete patient view possible. Armed with those insights, Healthdom users can better identify potential health problems early on and improve their overall health outcomes.

WHY IT MATTERS
Healthdom’s digital platform reminds users to better manage their own care by undergoing various preventive health screenings at the appropriate times, based on each user’s specific DNA, age, gender, medical history and other factors.

Going forward, the platform will make use of Medfusion’s data service APIs, enabling its users to quickly import their patient medical records across providers and combine them with those others factors – helping deliver personalized and more comprehensive preventive care recommendations that can drive better patient results.

Medfusion’s network consists of more than 700,000 providers already mapped for data retrieval, with more than 53,000 active connections across 55 major electronic health record systems.

THE LARGER TREND
"Seeing companies like Healthdom use our Data Service APIs to drive real improvements in members’ health and care is inspiring," said Kimberly Labow, Medfusion CEO. "Empowering people to proactively use their health data is the realization of health IT’s promise."

Patients with online access to their health information who received timely alerts about gaps in care were more likely to get preventative tests and screenings than patients who didn't use such a service, according to a Kaiser Permanente study published in the American Journal of Preventative Medicine.

That said, the health and wellness market is flooded with tools for individuals seeking to better manage their own care – which can cause information overload. Some experts say aggregating disparate data and making the entire process as simple as possible are crucial elements to mass adoption by healthcare consumers.

ON THE RECORD
"Health IT has advanced so quickly that solutions which we couldn’t have even imagined just a few years ago, now exist," said Healthdom Business Development Director Robert Keehan in a statement. "Medfusion APIs are game-changing for us. Partnering with Medfusion will help us reach our goal of identifying potential health issues early enough to give members the best possible chance at positive outcomes."

Among the many analytics vendors in the exhibit hall at HIMSS19, here are new products from two companies that showed their technology at the global conference this week.

Mammography tech analytics

Hologic has launched Unifi Analytics, a business intelligence tool that allows healthcare facilities to manage their mammography devices, monitor technologist performance and prevent unanticipated downtime via predictive tube replacement technology.

Unifi Analytics tracks a facility’s installed base of mammography devices and provides statistical analysis of technology efficiency and technologist accuracy, allowing imaging centers to benchmark their performance against similar facilities, identify potential risks and challenges, and maximize device utilization, the company explained.

The web-based platform helps administrators make informed business decisions by providing actionable insights designed to optimize imaging center performance, the company added.

Using advanced machine intelligence, Unifi Analytics has the ability to predict tube failures before they occur, allowing facilities to avoid costly downtime, the company said. Additionally, predictive procedure volume and quality metrics reports notify facilities if they move off target, giving them the opportunity to make immediate adjustments and potentially stay on top of Mammography Quality Standards Act compliance issues before they arise, the company added.

Data collected through Unifi Analytics is distributed through secure, encrypted channels and is de-identified in accordance with HIPAA privacy rules; no personal health information is collected or shared, the company said.

Population health analytics

On another front, SPH Analytics, a healthcare analytics and population health management technology vendor, and Medecision, a vendor of integrated health platforms, announced a strategic partnership to help health plans improve the quality of care their members receive and lower related costs.

This partnership adds SPH Analytics’ Quality Measures system to Medecision’s Aerial platform, so care managers can quickly and easily identify, monitor and close care gaps, improving quality measures prior to regulatory submission, the companies said.

The system will be driven by SPH Analytics’ certified quality measure engine, which previews measure performance in advance of required Healthcare Effectiveness Data and Information Set (HEDIS) data submission so that health plans can drive early intervention and performance.

HEDIS is the measurement tool used by more than 90 percent of the nation’s health plans to evaluate their performance in terms of clinical quality and customer service, as established by the National Committee for Quality Assurance.

SPH Analytics is at HIMSS19 in booth 4679. Medecision is in booth MP4.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

The American Hospital Association (AHA) has launched its second annual innovation challenge to find sustainable scalable IT solutions for eliminating the social determinants that bring a community’s health down.

WHY IT MATTERS

The challenge, as defined by AHA, is to focus on using technology “to influence positive cultural change and improve health outcomes, while increasing value and lowering costs.” Winners will be selected for how well they identify a defined target population, validate the need for improvement in the population through data, and for how well the proposed improvements fit, improves or complement current care strategies.  

Managing social determinants within population health is critical to improving outcomes, closing care gaps and lowering the cost curve, experts said, but getting there will require a new era of personalization, science and return on investment. 

THE LARGER TREND

Healthcare IT News owner HIMSS has predicted that this will be the year social determinants gain greater attention. In its new report, "2019 Healthcare Trends Forecast: The Beginning of a Consumer-Driven Reformation," HIMSS said that last year it became clear traditional healthcare alone won't bend the cost curve.

This year, companies and healthcare providers that focus on the social determinants of health and how to integrate mechanisms for providers to play a bigger role in triage, data-driven care, continuity of care and personalized action plans will find a more receptive environment, according to HIMSS.

ON THE RECORD

“Through this year’s Innovation Challenge, our goal is to improve living conditions of our most vulnerable populations by pushing the boundaries of today’s and tomorrow’s technologies,” said Jay Bhatt, senior vice president and chief medical officer at AHA.

WHAT ELSE TO KNOW

The competition, sponsored by First American Healthcare Finance, is open to all AHA members and their partners, and AHA is offering three prizes: $100,000, $25,000 and $15,000.

Submission requirements and application are available at aha.org/innovation-challenge. The deadline to submit applications is May 24, and winners will be announced at the AHA Leadership Summit in San Diego, July 25-27.

Diana Manos is a Washington, D.C.-area freelance writer specializing in healthcare, wellness and technology. 

Twitter: @Diana_Manos
Email the writer: dnewsprovider@gmail.com 

Healthcare IT News is a HIMSS Media publication. 

I went to HIMSS19 last week, like a whole lot of other people. As Healthcare IT News is a HIMSS Media publication, we actually start covering the conference well in advance and this time around that meant a first article way back in August, believe it or not, about the new HIMSS Circles communities.

Fast forward to late Friday before the Global Conference and word got out that the Office of Management and Budget finished work on the eagerly-anticipated information blocking rule — thereby signaling the possibility that it would bring the new rule to Orlando.

And while the rule dominated the discourse from the opening panel to Friday morning keynotes, plenty more happened at the show.

[Also: Our full HIMSS19 coverage]

Innovation and emerging technologies were all over the show floor, in fact, including artificial intelligence, blockchain, IoT and virtual reality wares.

Let’s take a look at the most important aspects of HIMSS19.

1. Health and Human Services dropped the long-awaited information blocking rule. HHS, along with CMS and ONC, delivered the proposed rule on Monday, which not only graced the cover of our first Show Daily but also set the stage for discussion during Tuesday’s opening keynote panel. That session featured CMS Administrator Seema Verma, HIMSS CEO Hal Wolf, as well as former feds Karen DeSalvo (national coordinator), Michael Leavitt (HHS Secretary) and Aneesh Chopra (US CTO). The overarching message from that group was that, particularly when it comes to FHIR and open APIs, the tide shifted and the private sector now needs to catch up to the government.

2. Speaking of FHIR … You’ve been hearing about its promise relative to interoperability for some time now but, beyond that, tech stalwarts such as IBM, Google and Microsoft are already viewing the specification as a gateway for AI and machine learning because it can be used as a foundational element when building tools that democratize data and AI. Quick status check on FHIR: In the weeks before HIMSS19, HL7 introduced FHIR 4, the first normative version and, in turn, offered a glimpse of what to expect of the forthcoming FHIR 5.

3. Doctor’s loathe their EHRs, right? Well, despite that being a sort of conventional wisdom, Epic Systems CEO Judy Faulkner countered the argument by saying that recent studies do not prove a correlation between EHRs and job dissatisfaction or burnout. Not everyone will agree but Faulkner said that KLAS research found “a lot of people who were satisfied with their job but didn't like the EHR. A lot of people who weren't satisfied with their job but did like (the EHR). And by far the smallest number was those who didn't like both.” Healthcare IT News Editor Mike Miliard’s wide-ranging Q&A with Faulkner also delved into her drive to keep working like Warren Buffett and speculation that Apple should acquire Epic, which she regarded as laughable. 

4. Emerging tech was everywhere. Exhibitors introduced new IoT tools, including sensors and wearables, some brought interoperability technologies, others showcased digital workspace and imaging wares, while telemedicine offerings were also on display. A number of cybersecurity products made their debut. Artificial intelligence gained traction, meanwhile, with health system Sutter unveiling AI tech of its own. And I cannot forget about blockchain for two reasons: the new blockchain products at HIMSS19, of course, as well as the question that arose about what’s really fueling the blockchain craze?

5. Premier CEO Susan DeVore, in her Friday morning keynote, delivered a clarion call. Healthcare as an industry has ‘a higher calling’ to fix our broken system — and she explained the five interrelated problems we need to solve to achieve success. “We have to do this,” DeVore said. “It’s the force that will give rise to the future we’re all working toward.”

I had to catch a flight before the closing session but my colleague Laura Lovett, Associate Editor at MobiHealthNews, was there and reported on the stories Not Impossible Labs founder Mick Ebeling shared about his inspiration in creating digital tools for helping an artist draw again, 3-D printed arms for Sudanese amputees, tech for helping people with hearing impairments experience music that also helps Parkinson’s patients steady their hand tremors. 

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

Healthcare IT News is a HIMSS Media publication.