Sharing the Journey: Health IT Roadmap Exercise
In 2007, Dr. Don Berwick proposed a conceptual framework designed to improve the patient’s care experience, while at the same time reduce the cost of care and improve the health of populations of people, called the Triple Aim. There is recent discussion of expanding the Triple Aim to the Quadruple Aim, which incorporates the important aspect of improving the work life of clinicians and staff.
Community health centers have been leading the nation in addressing the health of the populations they serve. Today’s meeting is designed to focus on the journey toward the Quadruple Aim.
Many health centers are focused on developing and implementing population health management strategies within a reimbursement framework that still rewards volume. As health care delivery models are redesigned to fundamentally deliver care differently, health centers need a roadmap for the Health IT that will be needed to move from volume to value in order to achieve triple aim objectives (improving the health of the population, improving the experience and outcomes of the patient, and reducing the cost of care).
Throughout the day, as you hear the speakers and engage in the breakout sessions, we invite you to use the Roadmap to assess your health center’s Health IT capacity, including:
1)What is your Health IT capacity now?
2)Where does your Health IT capacity need to grow next?
3)What is your long-term vision for the Health IT capacity you will need in the future?
We will take a few breaks at different times throughout the day to take stock of where we are on our Health IT Journey.
Using the crayons, you can fill in the bubbles based on your assessment, from your personal point of view. At the end of the day, we’ll have time for you to get together with others from your health center to share your ideas and create a shared Roadmap.
RED =We’ve got this! We are satisfied with our Health IT in this area and do not plan to make any changes. We feel like we are using it well.
YELLOW = We have some Health IT capacity in this area. We may not be using it as well as we would like or may need additional functionality that our current systems just don’t provide.
BLUE = We are interested in progressing in this area in the near future or have already taken some steps. We may need additional Health IT or training soon to make progress.
GREEN = This in on our radar as a future priority. We would like to see future investment in this area.
Some areas of future focus are described briefly for your consideration. These are areas where HCCNs may be uniquely positioned to support coordinated investment and/or pilot opportunities.
Health Information Exchange (HIE) for Care Coordination: Participation with one of the state’s HIEs, such as the Indiana Health Information Exchange (IHIE) or Michiana Health Information Network (MHIN),can offer access to information about the care that is being provided outside of your health center through IHIE’s Care Web or MHIN’s Community View. (Supports PCMH CC 15-19, CC 20)
HIE for Population Health Management: HIE for population health management can include a number of things, like Bi-directional CHIRP exchange and Admissions, Discharge, or Transfers (ADT) alerts from IHIE or MHIN. (Supports PCMH CC 14)
Centralized Data Architecture:Participation in a centralized data warehouse for multiple health centers has become a cost-effective strategy to provide consistent reporting capabilities to multiple health centers and can serve as a basis for shared learning. Health centers who participate in Alternative Payment Models such as Accountable Care Organizations, need a data infrastructure to support decision-making, performance measurement and improvement.
Regular Peer Benchmarking: All health centers participate in annual Peer Benchmarking through UDS reporting. But, effective shared learning requires more frequent and regular peer benchmarking, both internally across providers and sites and across health centers.
Payer Attribution Matching: Medicaid Managed Care Entities (MCEs) assign patients to providers within health centers and provide files with attributed patients. These files, which come from multiple payers for multiple plans (e.g., Hoosier Healthwise and the Healthy Indiana Plan) in a variety of formats that are difficult to match to actual patients seen and provide little ability to organize for action. (Supports PCMH AC 14)
Claims Data for Cost & Value:Medicaid MCEs have access to claims data to assist in identification of high cost and high-risk patients who may be receiving suboptimal and uncoordinated care in the community. Access to claims data could provide health centers with a better understanding of the risks and needs of their highest cost patients, as well as demonstrate the value of effective primary care on total costs of care and utilization.
Social Determinants Data: Health centers collect data around core measures that are required as part of UDS reporting. Additional Social Determinants of Health (SDOH) can also be valuable to providing care management to vulnerable health center patients. (Supports PCMH KC02, KC07)
Risk Stratification:Applying a comprehensive risk-stratification process for the entire patient panel can support a health center’s effort to identify patients who are at high risk and prioritize their care management to prevent poor outcomes. (Supports PCMH CM 03)
Predictive Analytics:Predictive analytics is the branch of advanced analytics which is used to make predictions about unknown future events. Predictive analytics uses many techniques from data mining, statistics, modeling, machine learning, and artificial intelligence to analyze current data to make predictions about future. HCCNs with access to extensive data are beginning to utilize predictive analytics to predict risk or support operational improvement.