umass memorial medical group · 2016-09-28 · umass memorial medical group has 2,200 employees,...
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Organizational Profile UMass Memorial Health Care (UMMHC), a non-profit 501(c)(3), is one of the largest and most respected healthcare systems in New England. As clinical partner to the UMass Medical School, UMMHC has access to the latest technology, research, and clinical trials.
The massive UMMHC system encompasses:
• Fourmemberhospitalsonsevencampuses,includingthenationally recognized UMass Memorial Medical Center
• Sixaffiliatedhospitals
• TheChildren’sMedicalCenter,theonlychildren’shospitalinCentralMassachusetts
• Fiveurgentcarecenters
• 1,700physiciansonitsactivemedicalstaff,includingmorethan 500 primary care providers (PCPs)
• 3,000registerednurses
• 12,000totalemployees
• 1,125bedsinitshospitals
• Threerehabilitationfacilities
• 25nursinghomes
UMMHC’snetworkofemployedphysicians—bothPCPsandspecialists—arepartofamanagedcarenetwork(MCN)thatincludesphysiciansintheUMassMemorialMedicalGroupandcommunity-basedphysicians(employedandindependent)in22communitiesinCentralandWesternMassachusetts.
UMassMemorialMedicalGrouphas2,200employees,including1,100specialistsandPCPswhoserveasbothpracticingphysiciansandmembersoftheUMassMedicalSchoolfaculty.Ofthe500PCPsintheUMMHCnetwork,180areemployedasfull-timePCPsatUMassMemorialMedicalGroup(hereinafterUMass).Themedicalgroupalsoemploys25 advanced practice providers (APPs).
UMass serves one million patients in Central New England and handlesthreemillionvisitseachyear.Groupmembersworkin80community-andfacility-basedinterventionsites,includingthethreeWorcestercampusesofUMassMemorialMedicalCenter.
UMasswasformedin1998andtodayisthelargesthealthcaredeliverysysteminCentralandWesternMassachusetts,withover$450millioninrevenueannually.
Executive SummaryLikemanyprovidersintoday’shealthcarelandscape,UMasswantedtomaximizethenumberofadultsreceivingannualimmunizationsforcommonpreventablemaladies.Adultimmunizationsareproventopreventlife-threateningdiseaseand costly hospitalizations.
UMassjoinedtheAMGAAdultImmunization(AI)BestPracticeLearningCollaborative(AICollaborative)asawaytolearnandsharebestpracticestodriveimmunizationrates.Increasingtherateofadultimmunizationscouldimprovequalitywhileloweringcosts.Becauseofcontractswithseveralpayers,UMassneededawaytotrackqualitymeasurestoseeanyupsideundervalue-basedreimbursement.TheworkoftheAICollaborativewasalignedwiththeworkthatUMasswasalreadydoing.ThepopulationhealthdivisionasawholeatUMMHCwasworkingonsomethingsimilar—includingHEDISmetrics—andhadjustinitiatedACO/GPROmetricsforimmunization,sotheAICollaborativewasagoodfit.
AsoneofsevencareprovidergroupsfromaroundthecountryparticipatingintheAICollaborative,theUMassAICollaborativetargetedpneumococcalandinfluenzaimmunizations,withanemphasisonhigh-riskpopulations,asdefinedbytheCentersfor Disease Control and Prevention (CDC).
LeadershipfortheUMassAICollaborativestudycamefromanexistingPopulationHealth/ClinicalIntegration(PH/CI)groupatUMMHCresponsibleforallsystem-levelpopulationhealthinitiatives,includingthoserelatedtocommercialriskcontracts,aMedicareACO,andMedicaidpaymentreformprograms.
ThePH/CIgroup,ledbySeniorMedicalDirectorDr.ThomasScornavacca,consistedofnon-physiciancolleagueswhoprovideddata,analytics,andperformancereportingsupport;practiceandqualityimprovementfacilitation;patientoutreach;clinicaldocumentationsupport;caremanagement;andintegrated information technology enhancement.
AtUMass,thisPH/CIgroupistaskedwiththedevelopmentofqualityimprovementclinicalpathways.Dr.Scornavaccaandhisgroupalsooverseeapodstructurewhichencompasses
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employed and independent physicians in the UMass Memorial managedcarenetworkandphysiciansintheUMassMemorialACO.
TheleadershipteamoftheUMassAICollaborativestudy(AITeam)includedthefollowingstaffpulledfromDr.Scornavacca’sPH/CIgroup:
• Thomas Scornavacca, D.O., Senior Medical Director, UMassMemorialPopulationHealth,OfficeofClinicalIntegration
• Francis Wanjau,Manager,PracticeImprovement,whooverseesallpracticeimprovementfacilitatorworkasaresourcetothepractices
• Pat Ramos,Supervisor,Outreach&Coding,whooverseesateamofoutreachcoordinatorsin-housetocallpatientsonbehalfofpracticesfortargetmeasuregaps
• Tracey Wilkie,Director,PopulationHealthReporting&Analytics, who oversees all performance reporting and analyticstodrivestrategyandquantifysuccess
Asafirststep,theUMassAITeamreviewedcurrentpracticesatUMassregardingadultimmunizationandidentifiedopportunitiesforimprovementinprocessflow.Theydevelopedanactionplantoimprovedeliveryofimmunizationsacrossallpopulations,withspecialattentiontohigh-riskpatients.
AttheendoftheAICollaborativeinterventionperiod,UMasshadimprovedbothpneumococcalandinfluenzaimmunizationrates in all categories.
Program Goals and Measures of Success Collaborative GoalsBeforeestablishinggoals,baselinedataforeachgroupwasreviewedbyOptumAnalyticsandimmunizationrateswerecalculated.Afterreviewingnationalgoalsandavailablenationaldata,andwithinputfromtheCollaborativeadvisors,goalsweresetfortheAICollaborative.
TheminimumgoalwasbasedontheCDCNationalHealthInterviewSurvey(NHIS)estimatesofnationalimmunizationratesfor2012-2014timeperiods(themostrecentavailableatthetime).PneumococcalimmunizationratesintheNHISwere59.9%foradultsaged≥65years.Foradultsaged19-64who
weredeterminedtobeathighriskfordevelopinginvasivepneumococcaldisease,NHISrateswere20.0%.1Forinfluenza,NHISimmunizationratesforadultsaged≥19yearswerereportedtobe43.2%.2
HealthyPeople2020goalsfromthefederalOfficeofDiseasePrevention and Health Promotion (HP2020)3 were selected as challenge goals or goals on the high end. HP2020 goals are:Adultsaged≥65yearsPneumococcal90%,High-RiskPneumococcal60%,andInfluenza70%.
A“stretch”goalwasestablishedbetweeneachgroup’sbaselineandHP2020.Thestretchgoalwassetat50%ofthegapbetweenbaselineandHP2020.Whereonestretchgoalisreportedforallgroups,itisbasedonthemedian.
UMass GoalsInternalgoalswerecenteredonthefollowingpriorities:
• ImprovingratesofadultimmunizationsacrossUMasspatientpopulationbytheendofCY2015
• Learninghowtoadaptandtargetreportingtoimprovespecificmeasures
• DeterminingwhichopportunitiestheUMasssystemhasinplacetoinfluenceperformanceatpracticesites,specifically with regard to:
o Patientoutreach
o Patienteducation
o Providereducation
UMassreviewedcurrentprocessesandanalyzedexternalresourcestoidentifyopportunitiesforimprovementtoitsinternalsystemsalreadyinplace.UMassestablishedadditionalgoalsforitsAICollaborativestudy:
• EducatingtheprovidersandstaffontheCDCandACIPrecommendationsforadultpneumococcalandinfluenzaimmunizations,withparticularemphasisonhigh-riskpopulations
• Inselectpractices,providingadditionalresourcesforpatientoutreachandeducationusingPH/CIoutreachcoordinators
• BuildingintrainingonhowstaffcouldinputandcollectdataonimmunizationsreceivedoutsideUMass.
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OneofthegoalsabovewasthatprovidersandstaffwouldreceiveeducationregardingtheadultimmunizationrecommendationsfromtheCDCandACIP,includingthedefinitionofhigh-riskpatients.AlthoughtherewasconsiderablevariabilityamongUMassproviderswithregardtothedefinitionofhigh-riskpatients,variabilitywasallowedinupto20%ofthepatientsthuscategorized,aslongasthemajority(or80%)receivedthevaccineasindicated.
Data Documentation and StandardizationAttheinitiationoftheAICollaborative,OptumOneanalyzedthepotentialimmunizationEMRdocumentationsourcesforthegroupsinthiscollaborativeanddeterminedthatimmunizationswerecapturedin:
• RxTables
• RxPatientReports
• ImmunizationTables
• HealthMaintenanceTables
• CPT/Gcodes
• ICD-9codes
Significantvariationindocumentationpatternscanbeseenacrossgroups,resultingfromvariationsinEMRproviderandconfiguration,immunizationdocumentationprotocols,andadherencetodocumentationprotocols.ForthegroupsintheAICollaborative,pneumococcalandinfluenzavaccinationsweremostcommonlydocumentedinImmunizationTables,HealthMaintenanceTables,andCPT/Gcodes.TheleastcommonlyusedsourcesfordocumentationamongthegroupswereRxTablesandRxPatientReports.
FortheAICollaborativegroupsthatdemonstrateddocumentationbetweenmultiplesources,suchasUMass,theOptumteamprovidedthisdatasothatgroupscoulddetermineastandardizeddocumentationbestpracticeinternally.
UMasslikewiseusedOptumOnetomeasurepotentialareasofimmunizationdocumentationsources.OptumOnegenerateddatatoshowwhichdocumentationsourcesweremostcommonlyusedandthoseleastutilized.Informationwas delivered to UMass to help determine and implement standardizeddocumentationpractices.
TheUMassAICollaborativeteamleveragedtheOptumOnedatatochoosepoint-of-caremetricsthathadthebroadestpopulationsandcouldremainagnosticofpayer/project:
• Developedandimplementedapopulationhealthflowsheet for all metrics
• WorkedwithUMassITtoensureitemswerediscretedatapoints
• EnsuredmappingwithLOINC/MEDCINcodesproperlypickedupbytheclinicaldecisionsupporttool
• CreatededucationalmaterialsaspartofapopulationhealthtoolboxusedbyUMassasvalue-addtoprimarycare practices
Population IdentificationTheUMassAICollaborativestudyinvolved135primarycarelocationsand350full-andpart-timePCPsinCentralandWesternMassachusetts.(Since the Collaborative, the number of PCPs in the MCN has grown to include more than 500 employed and independent PCPs.)
Alleligiblepatientsreceivedthesamepoint-of-careremindersforneededimmunizations.TheinterventionswerenotlimitedtotargetedAICollaborativegroups.Reportedresults,however,arespecifictothetargetgroupsforpurposesoftheAICollaborative.
Thispopulationencompassedalltheprimarycareserviceswithintheentirenetwork,includingprivatePCPswithindependent practices, PCPs in health centers, and PCPs employedbyUMMHC,aswellascommunitypractices.
InterventionThefirstUMassinterventionthatimpactedtheworkoftheAICollaborativebeganin2012,theyearUMassasanentitydecideditwastimetoworkonhealthcarereform,improvequality,andthinkaboutissuesfromapopulationhealthperspective.
Beforethat,UMasswasspecialtyfocused,concentratingonhigh-tech specialized care.
WhatUMassneededwasacrediblemeanstohelpitsprimarycarebaseunderstandthepremisebehindhowpopulationhealthworksandyetmaintainsapatient-centricflavor.
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Considering the size of their healthcare system and the inertia involved,thereweredifficultiesinherentinchangingdirection.ItwasliketurningtheTitanic.
Overtimetheybuiltateamfocusedonpopulationhealth,withdeliverablestoPCPstohelpthemunderstandthenewwayoflookingatpopulationhealthandqualitymetrics,aswellasawaytovisualizeperformancereportingthatwasactionable.Thequestionswere:WhatcouldUMassprovidetothedoctorsthattheywoulduse,notdismantle,andtakeactiontoimprovepatientcare?Whatwouldbeacredible,quality-driveninitiativethatwouldhelpthemcareforpatients?Physicianengagementisthemostimportantpieceinanypopulationhealthinitiative.
UMassbuiltreportingplatformsandaphysicianengagementnetworkandinfrastructure,sotheywouldnothavetostartfromscratchforeveryideaorproject.IthadtobedesignedwiththeideathatPCPswouldbetheendusers.Thepopulationhealthguruscouldstrategize,datacrunch,anduseanalyticandlogic,buttotheenduser—thePCP—ithadtobepatient-centricandpresentdataasclean,actionable,up-to-date,andasclosetorealtimeaspossible.
UMassparticipationintheAICollaborativewasanaturalprogressionofthisworkthatwasunderway.
SeveralinterventionsweredesignedtoimproveratesofadultimmunizationsacrossUMass’patientpopulationbytheendofCY2015.TheteamsoughttodetermineopportunitieswiththeinfrastructureUMasshadbeenbuildingtoinfluenceperformance at practice sites, specifically with regard to patientoutreach,patienteducation,andprovidereducation.
Highlightsincluded:
• AsanACO(effectiveJanuary2015),UMasswasusingtheNQFmeasurestandardassociatedwiththatprogramforentireadultpopulation.
• DataonimmunizationswascollectedduringprimarycareofficevisitsandenteredintotheEHR,claims,stateregistries, etc.
• Adultimmunizationinterventionswereincorporatedintotheexistingpopulationhealthmanagementandqualityimprovementinfrastructure,including:
o PatientCareRegistriesidentifyingevidence-basedgaps in care for the entire primary care panel (patient- and practice-centered)
o Outreachcoordinatorstoschedulepatientsforserviceswhenpracticeresourcesareinsufficient
o PracticeImprovementFacilitators(PIFs)whoworkwithphysiciansandpracticestaffonworkflowredesignandeducation
o Transparentperformancereportingandcustomizedpopulationhealthanalytics,integratingclaimsandclinical data
o Physicianleadershipstructureincludingmedicaldirector and primary care “pods,” each with a physician leader
TheinterventionsfortheAICollaborativeinvolvedaddingtoorimprovingcommunicationswithintheexistingPopulationHealth/ClinicalIntegrationinfrastructurethatUMasshadbeendevelopingforthreeyearspriortotheAICollaborative.
CommunicationwiththepopulationofPCPsinvolvedpoint-of-careremindersbuiltforthephysiciansandembeddedintheelectronichealthrecord(EHR).Thephysiciansandstaffhadpreviouslyreceivedtrainingonhowtousethedashboard,todeterminewhichgapsshouldbemetduringpatientvisits.However,informationonimmunizationshadnotpreviouslybeenincludedonthedashboard.
Specificallyforfluandpneumoniavaccines,aspartoftheAICollaborativeinterventions,thegapswereprovidedonthedashboardforallagesandpopulations,notjustforadultsandhigh-riskpatients.Reporting,however,forpurposesoftheAICollaborativewasfocusedonthetargetedgroupsandageranges.
ThePH/CIteamtrainedstafftoentervaccinesintotheEHRsystem—includinginformationreceivedfromotherphysicianoffices,hospitals,orpharmacies—toconverttheinformationintodiscretedataintheflowsheet.
ThePH/CIteamalsousedgapreportsonamonthlybasis–todooutreachtolistsofpatientswhohadnotbeenseenatall—andthosegapreportsincludedallpreventivecaretheyshouldreceive,ataminimum,includingimmunizations.
Also,UMassdeployedwhattheyconsidertheir“bootsontheground”inthepractices:PracticeImprovementFacilitators(PIFs).PIFswereutilizedtoteachprovidershowtodeliverthemessagesandtoprovidetrainingandtools,includingthedownloadingandregularuseoftools(e.g.,CQS,aclinicaldecision tool).
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FortheAICollaborative,thePH/CIoutreachcoordinators,inselectpractices,scheduledappointmentsviaphone.Theoutreachcoordinatorsatthepracticelevelareoftenusedasaresourceforpatientoutreach,andtheywereusedselectivelyintheAICollaborativestudytodrivetargetedimmunizations.
AspartoftheAICollaborative,therewereinitiativesdevelopedbyhealthcenterswherethestaffvoluntarilyorganized“wellnessclinics”(e.g.,aSaturdaywherepeoplecouldwalkinunannouncedandgetimmunizations,aswellasbloodpressurechecks,mammograms,etc.).
UMMHC hospitals already had initiatives in place and were offeringfluandpneumoniavaccinestoallpatientsadmitted.
Outcomes and Results • Leveragedcurrentphysicianengagementinfrastructureforeducationandreporting
• Alignedallpopulationhealthworktobeagnosticofpayersand programs
• Implementedclinicaldecisionsupportatpointofcare
• ResultsfromOptumOnemeasurements:
o Pneumococcalimmunizationratesforpatients65yearsandolderincreasedfrom60.6%atpre-interventionperiodto80.2%
o Pneumococcalimmunizationratesforhigh-riskpatients19-65yearsincreasedfrom26%atpre-interventionperiodto31.6%
o Influenzaimmunizationratesforentiretestgroupincreasedfrom40.5%fromJuly2014toApril2015to43.4%fromJuly2015toApril2016,exceedingtheCollaborativeaverageinterventionperiodvaccinationrateforthe2015-2016fluseason(37.3%)
OptumOnemeasurementsallowedUMasstoexpandpracticesfromtheAICollaborativefocusedonadultimmunizationstootherinitiatives.
Lessons Learned and Ongoing ActivitiesMostoftheAICollaborativeinterventionsusedbyUMassinthisstudyinvolved“piggy-backing”ontotheexistinginfrastructureatUMass.Thatexistinginfrastructureforphysicianengagementhasenabledthemedicalgrouptobeagilestrategically,developleadershiprolesthroughoutthenetwork,andprovidecommongroundforawidespreadnetworkofemployed,academic,andindependentproviderstoworktowardasystemoftrulywell-coordinatedcare.
Leveraginganinfrastructurethatwasbuiltinanagnosticwaytoachieveallpopulationhealthgoals—andusingthatinfrastructuresuccessfullytoachievetheAICollaborativegoals—onlyconfirmedtheimportanceofbuildingtheinfrastructureinthefirstplace.
ThekeytosuccessisastrongcorestructureofPCPsengagedincarepathwaysbi-directionally.Pivotalchangescanbeaccomplishedoncethatcoreisinplace,butfirstanorganizationmustbuilditsinfrastructure.ThePCPsneedasupportteam.Smallgroupsneedthesupportofalargerorganization.
Thisismoreaboutbuildingacultureandadatasystemforthepurposeofdeliveringhigh-qualityservices
Thelinksbetweenpatientexperience,patient-reportedoutcomes,andpatientengagementareavitalpiecetothepopulationhealthpuzzle.Inordertoprovideactionableaccuratedatatoprovidersandhealthcaresystems,thealignmentofqualitymetricsisessentialtoreducethecomplexityofworkatthepointofcare.Furthermore,theadoptionofunifiedmetricsatthepayerlevelacrossthenationshouldbetheprimaryfocusofthenewhealthcareenvironment,inclusiveofpatientexperience,patientengagement,andpatientreportedoutcomes.
ThePH/CIgroupatUMassandthedata-driven,physician-led,patient-centeredinfrastructureithasbuilthelpedguidethisworktomaintainthepatientatthecenterofcarewithoutlosingthe physician voice.
Physiciansatthepointofcaremustbeprovidedwithdatathatispatient-centeredandactionable.Datahastobeaccurateandreal-time.Resultsofinterventionsmustbetransparent.
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Focusandconcentrationonanygiventopicorinitiativewillwaxandwane.Thebattleistoconsistentlyremindthefront-linehealthcareproviderstorefocustheirenergiesontopicsaspriorities develop or change.
ProviderengagementfortheAICollaborativewasconsistent;itdidnotincreaseordiminishatanypointduringthestudy.Withphysiciansbeingbombardedwithsomanyregulations,demands,newinformation,etc.,regularcommunicationandreinforcement is essential.
Communicationavenuesmustbecomeregularandexpected.Forexample,takepatientcareregistriesforgapsincarethatthestaffuseforpre-visitplanning(includingimmunizations).ThePH/CIteamhasmadeitanintegralpartofthepoint-of-caredeliverysystem,somuchsothatiftheregistryisnotdeliveredregularlyonFridaysat12,staffwillnowtaketheinitiativetorequestit—whichdemonstratesthatstaffhasdeveloped a dependency on the registry.
TrueofallCollaborativesisthatbenchmarkingagainstpeersisthemaindriverofparticipationandoffersthemostmeaning.Organizationsarepromptedtoaskthemselves:“Comparedtosimilar systems, how are we doing in comparison? How can welearnfromthosewhoaredoingthingsdifferently,orevenoutperformingusincertainareas?Howaretheydoingit?Likewise,whatcantheylearnfromus?”
InthecourseoftheAICollaborative,itbecameapparenttotheUMassAITeamthatprovidersandadministratorscanusedifferentapproachesandbeequallysuccessful.So,inasense,thereareno“best”practices.Differentapproachesworkfordifferentcommunitiesanddifferentproviders.Thelessonisnottoconcentrateononeparticularway,butrathertoviewproviderinput,engagement,andacknowledgingworkflowaskey.
WhatmightUMasshavedonedifferently?PerhapstheAITeamcouldhaveconsidered:
• Initiatingeducationandoutreachpriortodevelopingperformancereportingandclinicaldecisionsupporttools
• Developingideasforeffectiveproviderengagementpriortoroll-outsimplybecausemovinglargeinitiativesontoprovidergroupsdoeshavemoreinertiathanexpected
• Trackingrelativeincreasesinimmunizationratesforpracticesthathadadditionalresources(likePIFsassisting
withpatientoutreach)orpracticesthatincorporatedspecialevents(likewellnessclinics),askingthequestion:“Dotargetpracticesgivenmoreresourcesoutpacetheperformanceoftheentirenetwork?”
Ongoing ActivitiesUMassiscurrentlyseekingtomorecloselyalignitshealthcaresystemwiththecommunity—toincludeleveragingcommunityresourcestohelpwithmarketingandawarenessaroundhealthcareissues.UMasscouldthussolidifyitsrelationshipsandconnectionsandbringoutsideresourcesinordertosupportinternalorcommunity-wideinitiativesthatwouldultimatelybenefitpatients.
InAugust2016,UMMHCsponsoredacommunityresourcesummitinvitingover60guestsrepresentingissuesthatimpactpatients—issuessuchasfood,money,andhousing.AnimportantlessonlearnedfrompeersintheAICollaborativewas that UMass had to leverage the care it was providing topatientsinthecommunityinamuchmoreextendedcontinuumofcare.UMasshadtogooutsidethewallsoftheclinical system and develop relationships with grassroots communityservicegroupsliketheAsianCoalition,thefoodbank,etc.
Also,inthePH/CIinfrastructure,therearenowmorethan73distinctmeasuresthatare“infocus,”includingoutcomemeasures(diabetes,cardiovasculardisease),prevention(cancerscreening),andpatientexperience(PROMs,engagement,etc.).Allperformancereporting/registriesaregroupedtogether―andareessentially“seamless.”Keepinmindthat,totheenduser,eachoftheseinitiativesisnotaninitiative.Insteaditshouldbeexperiencedasongoingandsimplyapartofthefocus,asawhole,onimprovingpopulationhealth.
Fortheproviders,inparticular,itshouldbeseenasonemoreway to improve patient care, one patient at a time.
UMassnowhasmorethan500PCPsintheMCN—full-timeandpart-time,employedandindependent—andisgrowingrapidly.UMassis“movingthemasses,”indeed,buttheindividualproviderisstillpatient-centricandpatient-driven.ThePCPsarebeginningtounderstandthatinconcentratingoneachofthesegoals—patientbypatientbypatient—itiscumulativeandmattersintheoverallscopeaswellasintheindividualpatient’scase.
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References1.WilliamsWW,Lu,PJ,O’Halloran,A,Bridges,CB,Pilishvili,T,Hales,CM,&Markowitz,LE.(2014)CentersforDiseaseControl and Prevention (CDC). MMWR MorbMortal Wkly Rep.2014;63(5):95-102http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a4.htm.
2.Williams,WW,Lu,PJ,O’Halloran,A,Kim,DK,Grohskopf,LA,Pilishvili,T,Skoff,TH,Nelson,NP,Harpaz,R,Markowitz,LE,Rodriguez-Lainz,A,&Bridges,CB.(2016)SurveillanceofVaccinationCoverageAmongAdultPopulations—UnitedStates,2014;SurveillanceSummaries/February5,2016/65(1):1–36http://www.cdc.gov/mmwr/volumes/65/ss/ss6501a1.htm.
3.OfficeofDiseasePreventionandHealthPromotion(ODPHP).HealthyPeople2020.https://www.healthypeople.gov/.
Acronym Legend_________________________
ACIP: AdvisoryCommitteeonImmunizationPracticesACO: AccountableCareOrganizationAI Collaborative: AMGA’sAdultImmunizationBestPracticesCollaborative
AI Team: UMassAdultImmunizationBestPracticesCollaborativeTeam(drawnfromPH/CIteam)
APP: Advanced Practice ProviderCDC: Centers for Disease Control and PreventionCMS: CentersforMedicare&MedicaidServicesCQS: ContinuousQualitySysteminAllscriptsEHR:ElectronicHealthRecordGPRO: GroupPracticeReportingOption(GPRO)WebInterfaceforACOreportingtoCMS
HEDIS: HealthcareEffectivenessDataandInformationSetfrom NCQA
HP2020: Healthy People 2020LOINC: LogicalObservationsIdentifiers,Names,CodesMEDCIN: A system of standardized medical terminologyNCQA: NationalCommitteeforQualityAssuranceNHIS:NationalHealthInterviewSurveyPCPs: Primary Care ProvidersPH/CI Team: PopulationHealth/ClinicalIntegrationTeamat
UMassPIFs: PracticeImprovementFacilitatorsemployedaspartofUMassPH/CITeam
PROMs: Patient-reportedOutcomesMeasuresUMass: UMassMemorialMedicalGroupUMMHC: UMassMemorialHealthCare(umbrella
organization)
Ideally,systemscanbedesignedsothatproviderscanbegiven small goals related to their patients. That is the concept thatislacedthroughoutwhatUMassdoes.Theproviderisapracticing physician, and that is the priority for most of them. Aboveall,theydonotwanttolosethatconnectionwiththeirpatients—providingcaretothepeoplewhorelyuponthem.
Future StepsUMassisintheprocessofbuilding/implementingEpicasitsEHR.OneofthegoalswithEpic’simplementationistotakewhatwaslearnedintheAICollaborativeandbuildchangesintotheworkflowsofthenewsystemwithpoint-of-careremindersandbestpracticealerts.UMasshopestodiscoverandtakeadvantageofprebuiltdesigncomponentsfromotherEpicusers.Epicroll-outisanticipatedforOctober2017.
Project TeamThomas Scornavacca, DO
Senior Medical Director, UMass Memorial PopulationHealth,OfficeofClinical
Integration
Francis Wanjau Manager,PracticeImprovement
Pat Ramos Supervisor,Outreach&Coding
Tracey Wilkie Director,PopulationHealthReporting&
Analytics
OnePrinceStreetAlexandria,VA22314-3318
amga.org/foundation
ThisprojectwassponsoredbyPfizerInc. Pfizer was not involved in the development
ofcontentforthispublication.