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Improving Population Health Through Info. Mgmt. & Analytics

Improving Population Health Through Info. Mgmt. & Analytics. A look under the hood. David Mohr, MD VP Clinical Informatics and Transformation Sentara Healthcare. Population Management Vision. A vision for sustainable growth. Used by permission of Cerner Corporation.

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Improving Population Health Through Info. Mgmt. & Analytics

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  1. Improving Population Health Through Info. Mgmt. & Analytics A look under the hood David Mohr, MD VP Clinical Informatics and Transformation Sentara Healthcare

  2. Population ManagementVision A vision for sustainable growth Used by permission of Cerner Corporation

  3. Designing new Models of Care requires reporting & analytics across the care spectrum 3

  4. Population Health Improvement (mgmt) Enterprise Information model: The ideal starting point

  5. PMS ClinicalProcess Hospital HospitalADT Reg Revenue Processes Systems EMR DW Data EMR System DomainCirca 1990’s the IOM Computer-Based Patient Record

  6. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain

  7. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Dept. Example of CDS involving source system and EMR data

  8. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain . Example of CDS + Analytics involving single EMR within a multisite organization

  9. Point of Care Patient Dashboard By patient for visits in this EMR 9

  10. SMG Quality Dashboards 2010 Work Plan Multi indicator dashboard

  11. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Example of CDS + Analytics for care manager using multi- source aggregated data Amalga

  12. by care mgr- multiple source systems

  13. by risk group multiple source systems

  14. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Epic Example of CDS + Analytics for care manager using multi- source aggregated data Amalga

  15. Care Coordination Visit Navigator

  16. Care Coordination: Patient Lists and System Lists

  17. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Epic Example of CDS + Analytics for care manager using multi- source aggregated data Click for Care??

  18. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Example of Analytics using integrated multi-site, multi-source EDW

  19. Business Objects Reporting (Web Intelligence)

  20. Web Intelligence Report Creation

  21. Enterprise Central Line Associated BSI Report

  22. Patient Satisfaction Patient Safety Core Measures Balanced Scorecard Readmissions Finances

  23. Data Warehouse

  24. Use of EDW for comparison with external metrics such as National Cardiovascular Data Registry (NCDR) or CMS top 10%

  25. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain SE MN Beacon Regenstrief Example of Analytics using integrated multi-site, multi-source HIE database

  26. Beacon Community Health Report

  27. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain Humedica Or MedVentive Example of Analytics using Claims database

  28. Population Risk Management: Clinically-Based, Predictive Modeling Patients most at risk of CHF-Related Hospitalization Clinically Based Risk Prediction Patients At Highest-Risk of CHF-Related Hospitalization 0-80 [Least Likely] 80-90 [Less Likely] 90-95 [More Likely] 95+ [Most Likely] Generate Patient Lists by Risk Level 29

  29. Processes PatientFacingProcess EMRProcess Care Mgt.Process Home CareProcess SNFProcess HIEData ClaimsData Systems EMRS Care Mgt.Aps Home CareSystem Post-AcuteCare System ? DW Population Health System Domain ”ADL” Cerner “Beyond Now” Other Sentara Post-Acute databases to incorporate in the future

  30. Questions?

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