meeting 6 brownsville regional campus. agenda brownsville regional campus school of public health 1....

Meeting 6

Brownsville Regional Campus

Agenda

Brownsville Regional CampusSchool of Public Health

1. Members and Architecture Overview2. RGVRegistry Project and RGVHIE Update3. Wellcentive Use Cases and Data Needs4. Su Clinica: Technical Implementation Lessons Learned5. Su Clinica: How Su Clinica will use Wellcentive6. Salud y Vida: Technical Implementation Lessons Learned7. Salud y Vida: How Salud y Vida will use Wellcentive

1. Members and Architecture Overview


Name Organization ContactSusan Fisher-Hoch UTHealth [email protected] Moal UTHealth [email protected] Vatcheva UTHealth [email protected] Reininger UTHealth (Salud y Vida) [email protected] Mitchell-Bennett UTHealth (Salud y Vida) [email protected] Sprague Wellcentive [email protected] Presas Su Clinica [email protected] Alpert Brownsville Community Health Center [email protected] Rock Valley Baptist Health System [email protected] Paez Valley Baptist Health System [email protected] Sheila Magoon Buena Vida y Salud [email protected]

Name Organization ContactAndrew Lombardo RGVHIE [email protected] Martinez RGVHIE [email protected] Lee RGVHIE [email protected] Bender UTHealth [email protected] Christina Lawson Wellcentive [email protected]


Advisory Team

Action Team

The Registry Review Architecture


• Summary:• Action Team works with Workgroups

• Per need basis: every week to every three weeks

• Progress presented to Advisory Team• Advisory Team provides feedback• Advisory Team provides advice

• UTHealth Workgroup analyzes data• Data quality suggestions

Complete architecture document located on The Registry Review wiki (https://theregistryreview.wikispaces.com/file/detail/The-Registry-Review_Architecture_3-31-2015.pdf)

The Registry Review Presentations



The Registry Review Presentation Goals



The Registry Review Wiki


• Wiki Page: • URL: http://theregistryreview.wikispaces.com/

• Content:• Currently:• Support Documentation• Meeting Documentation• Education Page • Discussion Page

http://theregistryreview.wikispaces.com/



2. RGVRegistry Project and RGVHIE Update


Technical Connection Status


100% complete

100% complete

90% complete

95% complete

50% complete

Initiating

Chronic Disease Registry DSRIP Needs and Strategy1. Identify disease status and risk of uncontrolled status

• Disease status: Controlled, Marginal, Not Controlled• Risk of uncontrolled status: (High → Low)• UTHealth revising list of alerts and reports• The Registry Review & Short-Term Provider Panel to review

2. Use registry to assist providers in diabetes management• Identify follow-up need• Referral to management resources• UTHealth revising list of alerts and reports• The Registry Review & Short-Term Provider Panel to review

3. Track patient admission and discharge across facilities• Identify high-utilizers• UTHealth, Valley Baptist, STHS: Strategies for using/displaying hospital data• Criteria for identifying patients that need intervention


Training Plan1. User Access

• Wellcentive user access, initiatives, and HIPAA overview2. Secure Messaging

• How to send messages in Wellcentive• Sending patient charts identified and de-identified

3. Referral Workflow• Hands-on referral workflow for external facilities, like TTBH and RGSC

4. Creating and Using Alerts• Process of creating and using alerts in Wellcentive

5. Creating and Using Reports• Process of creating and using reports in Wellcentive

• Training for Advisory Team?


Presentation in D.C. on June 4th


• Office of the National Coordinator for Health IT• Meaningful Use; forefront of administration’s health IT efforts

• Association of State and Territorial Health Officials• National nonprofit organization representing public health agencies in the U.S.

• National Association of City and County Health Officials• Represents 2,700 local health departments across the United States.

• Present the disease registry project and other programs in the RGV• Advertise the health efforts and positive impact of efforts in the RGV to

national agencies and organizations for future growth.

Next Steps1. Duplicate Patient Management

• Near patient-matches merging process

2. Alert/Report Excel list with descriptions• PCMH, MU, NQF, disease registry, etc.

3. Data Quality Reports• Recommendations to facilities

4. Comprehensive Data Availability Report• Listing of all reportable data being captured in Wellcentive by facility

5. Patient intervention by participating facilities• Quantifiable patient impact: Need 500 diabetic patient interventions

(outreach, management, referral) by September 30, 2015



3. Wellcentive Use Cases and Data Needs


User Access Venn Diagram

Su Clinica

SYV: SPH

Tropical TexasSYV: MHP

Aggregate, De-Identified Population Reports

Cameron County DHHS

Brownsville City Health

Department

Community Statistics: Grants, Initiatives, etc.


Wellcentive Use Cases and Data Needs

1. Undiagnosed Diabetes Mellitus• Self-reported diabetes: 13.7% (CCHC)• Objectively measured diabetes: 30.7% (CCHC)

2. Pre-Diabetes Mellitus• 30% of the population (CCHC)

3. At-risk for Diabetes Mellitus• Obesity, CHF, family history of diabetes

4. Complications of Diabetes Mellitus• Uncontrolled diabetes• At risk for uncontrolled diabetes• “Frequent flyers” to hospitals

For Providers & Care Managers (Identified Data):


Wellcentive Use Cases and Data Needs

1. Salud y Vida (only participants enrolled)• Chronic care management program

2. Project Echo (only participants enrolled)• MD Anderson cervical cancer project with Su Clinica

3. Medication Therapy Management (only participants enrolled)• Sí Texas: Starting with Salud y Vida, expanding to referrals from outside

For Support Programs for Provision of Care (Identified Data):

1. Public Health Facilities• Cameron County Health and Human Services Department• Brownsville City Health Department

2. Population studies• Needs assessments, grant proposals, initiative development & feedback

For Research (De-identified, Aggregate Data):


4. Su Clinica: Technical Implementation Lessons Learned


Su Clinica: Technical Implementation Lessons Learned1. Long implementation: ~4.5 months2. Sending all data for analytics • Ended up using a custom CCDA• The vendor had difficulties getting it started

• HIE opt-out workflow is in the process of being created• The PCP field used in house differed from the one used

by the CCD which created a workflow change. 3. Initial trigger for the CCD was the signed visit• Labs were not initially included if the visit was signed

before the electronic lab came in.4. Historical data challenging to send• Based on active patients• Waiting for increase in bandwidth


5. Su Clinica: How Su Clinica will use Wellcentive


Su Clinica: How Su Clinica will use Wellcentive

• Care Managers as main users• May have physicians use tool eventually

• Diabetes Registry• Diabetes status of all locations • Controlled, Marginal, Not Controlled

• Patients that need follow-up• Care manager test reminder

• Patients with high, medium, low risk of diabetes uncontrolled status


Su Clinica: How Su Clinica will use Wellcentive

• Patient-Centered Medical Home• Secure Messaging• Salud y Vida Feedback• Referrals to other organizations• Alerts based on survey results• Salud y Vida Engagement based on DSME


6. Salud y Vida: Technical Implementation Lessons Learned


Salud y Vida: Technical Implementation Lessons Learned

1. Long implementation• ~6 months

2. Custom interface• Export from ScoreMD (Chronicle) to Wellcentive

3. Figuring out what was needed in Wellcentive• Data needed from ScoreMD (Chronicle)

4. Difficult to enable users to only use one application• Chronicle is useful for DSME class management• Wellcentive is useful for aggregated information and alerts/reports

based on aggregated information


7. Salud y Vida: How Salud y Vidawill use Wellcentive


Salud y Vida: How Salud y Vida will use Wellcentive

• Aggregate data on patients in Salud y Vida• Will help to reduce unnecessary tests

• Alerts/Reports to manage patients• Based on aggregate data

• Secure messaging with other organizations• Can communicate securely, and de-identify patient

charts, if necessary• Referrals to external organizations• Referrals auditable from a central, secure source

Questions/Follow up/Next Meeting• Questions/comments:

• How can we make these meetings better?• Format, members, topics, perspectives, etc.

• Follow-up:• Compiled, condensed chronic disease status and control risk literature will be sent to

Advisory Team for edits and comments with The Registry Review Meeting 6 minutes• Johnny to follow up with Henry (Su Clinica), Emily (BCHC), Mary (RGSC), Dr. Magoon

(BVYS), Maria (SYV), and Peggy (RGVHIE) for provider panel physicians and care managers• Any other follow-up?

• Next Meeting:• June 23 from 2:00 – 3:00 pm CST• Method for identifying high-utilizers by UTHealth, STHS, Valley Baptist, RGVHIE• UTHealth, RGVHIE, and Wellcentive to present data quality methods• Any other proposed topics?


Thank you!

Brownsville Regional Campus


PowerPoint and meeting items located on The Registry Review wiki:http://theregistryreview.wikispaces.com/The+Registry+Review+Meeting+Documentation

meeting 6 brownsville regional campus. agenda brownsville regional campus school of public health 1....

Documents

rev slide

wellcentive slide

registry review wiki

complete initiating

advisory team advisory

salud y vida

feedback advisory team

wiki content