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 = The Swiss Army Knife of the ACO

CCMR General Features• Accessibility • Usability

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

Demo Analytics

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

THANK YOU!

RCCO

Petaluma

Santa Rosa

RCH

John

Canova, MD

AllianceAlexander Valley

West County

Clinic Ole

Coastal

Contact Information:

Danielle Oryn DO MPH

doryn@rchc.net

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