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Improving Patient Outcomes Through Data
Community Health Center Association of Mississippi Annual Conference
July 30 – August 2, 2019
CONFIDENTIAL
This file contains information that is confidential to Azara Healthcare, LLCDo not view, copy, distribute, or disclose without prior consent.
Introductions
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Emily HolzmanClient Success Specialist
Christopher NealVP National Accounts
Agenda
1 DRVS Overview: Chris Neal
2 Evaluating Performance on Quality Measures
3 Improving Outcomes Daily: Patient Visit Planning
4 Data Transparency
5 Payer Integration and EHR Plugin
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OVERVIEW AND IMPLEMENTATIONAzara DRVS Overview
Our History Large investment via formal partnership
with Mass League (MA PCA) Specialty in large scale data reporting
& analytics for safety net providersCustomers and Patients Data on 28 million+ patients Over 340 FQHC’s live Key Relationships 20 PCA’s 15 Networks 31 StatesFocus on Community Health Set up specifically to deliver DRVS to the
Community Health marketplace using a Software as a Service (SaaS) model
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Azara Healthcare Overview
Data Goes Beyond the Health Center
HIE/RHIO
NY State DRVS Deployment
Health Centers and DRVS
Visit Planning
Practice Transformation
Quality Improvement
Population Health
Total Cost of Care
PCMH/PCHH Certification & Reporting
Compliance (UDS, MU, QUARR…)
Payment Reform
Care Transitions/Care Coordination
Benchmarking
Grant Monitoring & Reporting
State specific data delivery (DPH/DOH)
PCA’s and Health Centers utilize Azara in a wide variety of capacities
Bedford Stuyvesant Health Center13,700 Patients, 38,500 Encounters, 8 Sites
Goals for Data Usage Improve Hypertension control (BP < 140/90) measured at
57%
Results Root Cause Analysis Performed – Corrective Action
PSDA Put in Place Hypertension control improved to 64% over 4 month
period
Tiburcio Vasquez Health Center25,700 Patients, 87,000 Encounters, 15 Sites
Goals for Data Usage Utilize Visit Planning to optimize treatment for patients,
address care gaps and improve overall care quality
Results 56% improvement in Depression Screening 47% improvement in Adult Weight Screening and Follow‐up 7% improvement in Blood Pressure < 140/90 34% improvement in Tobacco Assessment and Cessation
Implementation Process Overview
ContractingPre
Implementation Meeting
Connectivity/Data Access
Kickoff Meeting
Measure and Data Validation Production/ Go Live Training Adoption
2‐4 weeks1 Hour
Phone Call 4‐6 Hours OnSite
4‐6 weeks of weekly 1 hour meetings and outside meeting work
Weekend Go Live and 2 weeks Post
Production Validation
4 Hours OnSite
8 Learning Sessions over 8‐ 10 weeks
Overview of DRVS Functionality
Monitoring Measure PerformanceEvaluation and Improvement
Value Based Care
Services(patientvolume)
Payment
Value Based CareA healthcare delivery model in which providers are paid based on patient health outcomes.
https://catalyst.nejm.org/what‐is‐value‐based‐healthcare/
Evaluate Reporting Requirements
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DiabetesA1c
BP Control
DiabetesA1c
BP Control
HTNBP Control
HTNBP Control
ObesityChild and Adult Weight Screening, & Follow up
ObesityChild and Adult Weight Screening, & Follow up
Cancer ScreeningCervical,
Breast, Colon
Cancer ScreeningCervical,
Breast, Colon
Sweet Spot
Build a Measure Matrix
Determine your organizational priorities. Update Excel Template with CHCs measures.
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Monitor Performance Scorecards provide a quick performance snapshot for a group of measures at an organization.– Measure
– Numerator– Result (%)– Exclusions
– Target (%)– Denominator
– Performance Indicator– Baseline Performance / Change
Share Results Choose display options on scorecards to easily compare performance across providers, locations, service lines, etc. and facilitate sharing
Create custom scorecards with focus measures
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Close Care Gaps Outreach to patients to close care gaps
– Shows each individual patient's compliance with the measures present on the scorecard and the number of care gaps per patient.
– Displays one patient per row with clinical quality measure gaps identified in the columns.
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Monitoring Measure Trends Compare different groups’ performance to spot outliers
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Tell a Story of Improvement Use dashboards to tell the story of your center’s efforts
– Display data in a variety of graphical formats– Share high‐level information with stakeholders – Track trends across populations
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Filter Capabilities
Filters available on all reports, dashboards, and registries to hone in on specific populations– Compare performance amongst patient groups
– Configure specialized outreach lists for support services
– Identify performance gaps
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Patient Visit PlanningMaximizing Daily Care Delivery
Data Foundation for “Sharing the Care”
REACTIVE
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PROACTIVEData and Reporting
Team members use population management reports, and
enabling services.
Visit PlanningTeam uses report to chase missing data & prepare for team
huddle.
HuddleHigh
Risk/Cost/Need Patients?
Other services needed?
Point of CareNursing uses Visit Planning report as action list standard
chronic and preventative care.
Outreach and Missed
OpportunitiesRegistry reports for recent patients who missed intervention.
Care Team Powered by Data
What is a Visit Planning Report?
An efficient, electronic “to do” list of alerts and other data for patients with upcoming appointments.
– Does the work MAs/ LPNs currently do manually, using EHR data and electronic calculation of alerts
– Displays basic demographics, active diagnoses, relevant risk factors and social determinants of health (SDOH)
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Ideal PVP Characteristics
Actionable data
Configurable‐ national standard evidence‐based but practices can adjust alerts to fit practice guidelines– A1c frequency or result range– Mammogram age‐ start at age practice prefers
Not just medical interventions‐ community health center‐specific process reminders like SOGI documentation
Displays overdue referrals for those with referral module
Ability to generate PVP for Same Day or Walk‐in patients
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The Azara Patient Visit Planning Report
EHR Planning Tools vs. the Azara PVP
Most EHRs have some kind of care gap, visit planning, or decision support tool, but few aggregate all the patients into a single list for easy huddling.
Efficient for pre‐planning work and making notes on one sheet
Focus only on the most important things/patients Patient Centered Medical Home (PCMH) requirement
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Customize Actionable Data
Configure alerts to show your care team the information they need to see, when they need to see it– Choose from over 100 clinical and administrative alerts– Adjust the display name, age range, lookback period, inclusion and exclusion criteria, and set Due Soon
reminder for editable alerts
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Create Provider Groups for PDSA Cycles
Compare pilot groups of providers to average center performance – Track specific interventions over time– Tell a compelling story of improvement
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Monitor Team Efficiency by Alert Closure Rates Track alert closure rates week over week
Use provider and location groupings to target interventions
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Data TransparencyTrust your data
Reporting Hierarchy in DRVS
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COMPLIANCE• UDS• Meaningful Use• PCMH, etc.
POPULATION MANAGEMENT • Registries,
Scorecards, Dashboards
• Patient Detail• Referrals
DAILY CARE DELIVERY
• Visit Planning• Care
Management Passport
Break down the details ‐from definition to mapping.
Deep Dive Approach to Validation and Tools in DRVS
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Understanding the Measure Definition
•Review the Info Snippet •Understand what values are in the Value Sets•Utilize the Measure Investigation Tool (MIT) for how it applies to a patient
Measure Investigation Tool
•Breaks down the Numerator / Denominator / Exclusion•Understand why in or out of each
Measure Performance Discrepancies
•Looking at the population•Measure Validation Workbook
Mapping and Data Accuracy
•Mapping Admin (the details on mapping)•Data Health – Questionable Values Dashboard•Data Health – Lab Volume Dashboard
Value Sets for Every Measure
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Check the different types of data that make up the measure.
Sort by Numerator, Denominator, or Exclusion to find the values you are seeking.
Measure Investigation Tool
The MIT displays how a patient qualifies for the numerator, denominator, or exclusion
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Data Health Reports
Monitor data entry errors on a weekly basis
Drill down to patient level detail to easily correct data entry issues in the EHR
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Data Health| Questionable Values Dashboard Displays suspicious data coming over from the EHR
Allows users to efficiently identify data entry errors
Focus in on large numbers
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Criteria for suspicious data ‐it is unlikely your center has patients
who are older than 120 years
Questionable Values | Detail List
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Data Health | Lab Volume
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Use to monitor fluctuations in lab data coming into DRVS
Mapping Administration
Review mapped and unmapped structured data elements in DRVS
Update incorrect or missing mappings in real time
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Review and manage how structured clinical data flows from the EHR to DRVS
Dynamically update mappings reflect changes at the health center
EHR to DRVS: Mapping
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Edit MappingsChange Mapped Value to Ignore/Archive when values do not match an appropriate category using the Pencil Icon.
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Additional FunctionalityPayer Integration, Referrals, and Financial/Operations Reports
Referral Management
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Operations
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Payer Integration and EHR Plugin
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Care Gap Reconciliation Report
EHR Plugin‐ The Vision
Enable health center care team members to access DRVS data/results from within their EHR at the point of care
What does this take?– Single sign‐on: Successfully logging into your EHR also allows access to DRVS– Interface to pass authentication (see above bullet) as well as patient identifier to DRVS from the EHR at the point of care
– Interface to pass back pertinent information about the patient back to the EHR Outstanding Care Gaps / PVP Alerts Open Referrals RAF / HCC Diagnosis opportunities
– Configuration to display DRVS information within the EHR via a web portal
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NextGen Integration
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Template can be launched from the template selection or as a link from another template
NextGen Integration
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Example of embedded page within a NG template.
NextGen Integration
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Example of an embedded page within a NG template.
Our Success is Measured by Your Success…
DRVS in Action
19% INCREASE in screening translates to approximately – $1.5 MILLION DOLLARS of savings to the Alaska health system – in just 10 MONTHS!
Breast Cancer Screening Trend
One team’s performance went from 9% to 86%
compliance and maintained it
One team’s performance went from 9% to 86%
compliance and maintained it
Depression Screening Alert Closure Measure
Using the Patient Visit Planning report, the DM A1C >9 and Untested
Improved 10% in one year
Using the Patient Visit Planning report, the DM A1C >9 and Untested
Improved 10% in one year
Diabetes Visit Planning
Client Success
Client Success
Lynn Community Health Center Recognized by CDC for achievement within Million Hearts Program
10% INCREASE in Hypertension Control
Greene County Health Care
17% INCREASE in Tobacco Screening and Cessation
Upper Great LakesFamily Health Center
23% IMPROVEMENT in Colorectal Cancer Screening
Client Success
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Improvement across the Network on all 6 UDS Measures of focus
AA
Questions?
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