community health center association of mississippi annual ... · 15 networks 31 states focus on...

Improving Patient Outcomes Through Data

Community Health Center Association of Mississippi Annual Conference

July 30 – August 2, 2019

CONFIDENTIAL

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Introductions

3azarahealthcare.com

Emily HolzmanClient Success Specialist

[email protected]

Christopher NealVP National Accounts

[email protected]

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


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.


Monitoring Measure Trends Compare different groups’ performance to spot outliers

20Azara Proprietary & Confidential

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


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


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


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


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


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


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


Criteria for suspicious data ‐it is unlikely your center has patients

who are older than 120 years

Questionable Values | Detail List


Data Health | Lab Volume


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


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


Edit MappingsChange Mapped Value to Ignore/Archive when values do not match an appropriate category using the Pencil Icon.


Additional FunctionalityPayer Integration, Referrals, and Financial/Operations Reports

Referral Management

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Operations

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Payer Integration and EHR Plugin


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


NextGen Integration


Template can be launched from the template selection or as a link from another template

NextGen Integration


Example of embedded page within a NG template.

NextGen Integration


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

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