patient care alerts integration into clinician workflow€¦ · realize full potential • pursue...

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Patient Care Alerts... Integration into

Clinician Workflow


1 Introductions

2 Alabama Landscape & Opportunity

3 Direct Messaging

4

5

Provider Feedback & Lessons Learned

Care Alerts & Current Status

Agenda


11,381 Network Providers • 4,085 PCPs (Including OB-GYN)

4,072 Primary Care Extenders (NP, PA)

Average PCP Clinic Size = 5 Physicians

90 Short-term, Acute Care Hospitals

Over 120 Unique Ambulatory EHRs

Alabama Landscape


Opportunity

Goal: Integrate actionable data into the provider’s EHR systems and workflow. New Measures: Readmission Rates & Medication Reconciliation Provider Feedback & Demand: Visibility when their patients utilize the hospital or the emergency room. Connectivity: Near real-time ADT messages from 46 of the 90 hospitals in Alabama, representing approximately 73% of the short-term acute care hospital beds. Member/PCP Attribution: Established processes to identify the appropriate provider-to-member healthcare relationship. EHR Adoption: 79% of physicians utilizing an MU Certified EHR system (Direct Message capability).*

*Office of the National Coordinator for Health IT (ONC)


Direct Messaging

5

Deliver Care Alerts to providers within their EHR workflow to trigger the appropriate follow-up care after a member utilizes an emergency room or is admitted/discharged from an inpatient facility.

• Began February 26, 2018

• 10 Unique EHR Systems

• 25 Clinics/50 Physicians


Direct Messaging


Actionable Message

ALERT: A patient attributed to you was discharged from the hospital. Remember to contact this patient within 2 days of discharge to schedule a follow-up appointment and to reconcile medication no later than 30 days post discharge. Once discharge medications are reconciled with the patient’s current medication list, document it in your electronic medical record system and submit CPT Category II code 1111F on a claim to confirm that medications have been documented and reconciled.


Do Care Alerts provide better visibility into

treatment your patients receive outside of

your practice?

Survey Results

NO 85%

15%

YES


Has your practice incorporated Care Alerts

into your office’s processes to follow-up

with patients?

0%

10%

20%

30%

40%

50%

60%

70%

80%

Yes No

Survey Results

Establishing a Process


Provider Feedback

…This is huge for continuity of care and medication reconciliation! …Information is helpful and allows us to follow up with the patient.

…I get these messages faster than what I get from the hospital.

…Other discharge notices would be useful to us as well.


Lessons Learned

Not All EHRs Are Created Equal

Set Provider Expectations

Minimal Provider Setup

Plan for Flexibility

Self-service Enrollment

Scalable Solution


Care Alerts Enrollment


Lessons Learned

Not all EHRs are Created Equal

Set Provider Expectations

Minimal Provider Setup

Plan for Flexibility

Self-service Enrollment

Scalable Solution


Care Alerts Workflow

Hospital

Provider

• HISP/Connectivity • Data Transformation • Provider Matching • Provider Enrollment • Reporting

• Connectivity • Data Normalization • Member Matching • Data Filtering • Data Transformation • Monitoring

• Patient Attribution • Check provider enrollment • Delivery method(s)


Care Alerts

Over 1,300 providers enrolled

Over 59,000 notifications sent


Future Care Alerts

Gaps in Care Quality/Risk/Medication Adherence

Electronic Medical Records Specialist and Urgent Care

Discharge Summary


Clinical Information Exchange


Patient Care Alerts... Integration into

Clinician Workflow

patient care alerts integration into clinician workflow€¦ · realize full potential • pursue...

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