danielle oryn do mph chief medical informatics officer redwood community care organization rcco 2 nd...
Post on 29-Dec-2015
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Danielle Oryn DO MPH
Chief Medical Informatics Officer
Redwood Community Care Organization
RCCO 2nd Quarter Summit 1
RCCO – DATA & ANALYTICS UPDATE: CUTTING THE CAKE
CCMR
CCMR Connector
Data Visualization
eHUB
Claims Data
LIS/RIS
EHR Vendor 2
EHR Vendor1
Nursing Home
eCW EMR
Hospital
Connector
L V Portal
Other EMRs
eMPI
Interoperability
Referrals
Referrals
JTN – Join the Network
eHX = Care Coordinator ConnectorPatient Stories• 72 yo Medi-Medi• COPD (on O2), DM, CHF,
HTN, CKD …• 23 Medications• 2 Medication allergies• Caregiver and Case
Manager• 7 ED visits and 3
hospitalizations
Complications of lack of information:• Given medication she had
previous reaction to.• Repeat studies already done as
outpatient• Unnecessary hospitalization• PCP does not know if patient is
d/c for f/u and medication reconciliation
eHX Features• Physician portal• Longitudinal patient record• Ability to import (eCW) structured records from other
organizations• Admit, Transfer, Discharge feed
eHX Consenting• All ACO patients will be
automatically in the system.
• All other patients need to be given the opportunity to opt out at the next appointment.
Care PlanningCase Managers• Inability to manage a
caseload within the system• Difficult to track
interventions• No risk scoring or acuity
scoring • Keeping of non-HIPAA compliant spreadsheets
• Silo of information• Lack of information to PCP• Missed opportunities for
intervention• Lack of clear system for
patient identification
Care Planning Features• Longitudinal record• Program enrollment• Monitor case load• Risk stratification (both ACG and custom)
Analytics• Two current systems are
difficult to program• Only work with eCW• No ability to see claims
data• Little ability to do risk
stratification• Getting data across the
system is close to impossible
• Difficult to make large population health changes
• Disparities amongst health center capability
Analytics Features• ACG Scoring – see resources on RCCO website• Data by organization>site>provider>PATIENT• Ability to see claims and clinical data side by side
CCMR Implementation Timeline• 5/1 – (1:30pm – 3:00pm) Fist CCMR Care Coordination
Module training for Health Center Key Contacts• 5/6 to 6/9 – Dashboard Training for RCCO – CCMR Team• June through August - Work with eCW CCIS consultant to
map, plan, train teams on Dashboard. Eight weeks of time have been purchased that may be used in intervals of two to four weeks
• July – Go live for first RCCO Health Center• July through September – Training and Go live for Health
Centers
CCMR – Implementation update• April 22 – RCCO obtained Medicare Claims Files and
upload to CCMR• May 7 – eCW and RCCO begin work to customize views
available within CCMR for initial analysis of ACO data.• May 12 – Preliminary data available to share with ACO
participating health centers. • April and ongoing – ACO participants connect EMRs to
CCMR through eHX tool. Once connected the health center will be able to view clinical data together with claims data.
eBO Reports available• Medicare Patient List – eBO report that generates a full
list of the organization’s Medicare beneficiaries with demographics and PCP. Note that this list includes all patients with Medicare rather than only those who are attributed to the ACO.
• ACO – Model for risk – This report generates a list of Medicare beneficiaries, number of current medications, and high risk conditions (COPD, CHF, CAD, DM).
• Data Sharing Preference – This report is used to track informing patients of the option to opt-out of data sharing.
Analysis of five eCW health centers
12%
16%
21%30%
22%
Total Medicare Patients
CHA
CHCO
PHC
SRCHC
WCHC
6%
8%
10%
15%
11%
50%
Total Medicare Patients
CHA
CHCO
PHC
SRCHC
WCHC
Grand Total
Other Medicare data available • Beneficiary Lists – Provided quarterly to RCCO. These
will be made available to each participating organization. The next one will be available mid-May.
• Benchmarking data – Provided to RCCO on an annual basis in March-April
• Patient experience measurement.
eCW New Structured Data• New structured data to meet the ACO 33 measure
requirements:• Guidebook / documentation is available on RCCO website• Training on data capture is coming very soon• Build for SRCHC, PHC, CHA and CHCO is complete. WCHC is
pending.
Obtaining Access to CCMR• 3-5 individuals from each RCCO provider organization to
start• Request form will be available online for more staff after
that
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