HIMSS Small Business and Diversity Roundtable Presentation HIMSS13 Annual Conference ERNEST CARTER, MD, PHD Deputy Heal

1. Health IT – Optimizing Care, Information Exchange and Small Business in Prince George’s County – An Emerging Model of Excellence in IT Use and Workforce Development HIMSS Small Business and Diversity Roundtable Presentation HIMSS13 Annual Conference ERNEST CARTER, MD, PHD Deputy Health Officer Prince George’s County Public Health Department March 5, 2013

2. Conflict of Interest Disclosure Ernest Carter MD PhD Participates on various boards including CRISP*

3. Presentation Objectives • Demonstrate innovative and effective use of information technology to meet the critical healthcare needs of a major county and a diverse patient population • Continue the focus on the management and elimination of health disparities as a critical component of improving the overall health of our Nation • Present demonstrable examples of the application of information technology in a health information exchange HIE delivering improved outcomes and compliance with current and emerging healthcare standards • Present collaboration models being used by the Prince George’s County Health Department for supporting small business and workforce development

4. Prince George’s County Health Characteristics Unique County Characteristics • Culturally-diverse • Majority population minority • Mixed urban, suburban, rural • Educational attainment • Relative affluence, with pockets of poverty • Revenue generation restricted by TRIM 4

5. Prince George’s County Characteristics Unique County Characteristics • Uninsured/underinsured ~ 80,000 • Shortage of PCPs/FQHCs • 5 hospitals with a variety of premier services • Extensive park and recreation facilities • University of Maryland School of Public Health/Bowie State School of Nursing 5

8. Hot Spot Definition HOT SPOT* = PCP-to-population ratio of 1:3,500 or worse + Lower education and/or lower median income level than County + Higher 30-day hospital readmissions and/or hospital discharge for preventable conditions than County *Public Health Impact Study of Prince George’s County – University of Maryland School of Public Health

10. Population Health Improving Population Health Policy. Practice. Research. David A. Kindig MD, PhD editor http://www.improvingpopulationhealth.org/blog/what-is-population-health.html

11. Rushern L. Baker, III County Executive Healthcare in Prince George’s County Significant Health Indicators

12. The Contexts of Coordinated Care • Living Environment • Social Environments • Psychological Environments • Technological Environments • Health Services Environments

13. Health Information Managed in the Home Appointments Contact Info Insurance Treatments Provider Info Literature

14. Where Do People get Health Information? Family Physician

15. Team-Based HealthcareDelivery Population Health Access to Care Patient is the centerof theMedical Home Advanced IT Systems Patient-Centered Care Decision Support Tools Refocused Medical Training Patient & Physician Feedback Enhancing Health and the Patient Experience Medical Home Model Model adapted from theNNMC Medical Home

16. Smarter Healthcare… 36.3% Drop in hospital days 32.2% Drop in ER use 9.6% Total cost 10.5% Inpatient specialty care costs are down 18.9% Ancillary costs down 15.0% Outpatient specialty down Outcomes of Implementing Patient Centered Medical Home Interventions: A Review of the Evidence from Prospective Evaluation Studies in the US, K. Grumbach & P. Grundy, November 16th 2010

17. The Patient-Centered Medical HomeDrivers Enhance access Build on consumer-driven health and patient satisfaction Activate patient engagement and whole-person care Rationalize and coordinate health care processes and utilization Improve outcomes.

18. Accountable Care Organizations ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve. Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  

19. PCMH in Action Vermont “Blueprint” model A Coordinated Health System Hospitals Community Care Team Nurse Coordinator Social Workers Dieticians Community Health Workers Care Coordinators Public Health Prevention HEALTH WELLNESS PCMH Health IT Framework Specialists Global Information Framework PCMH Evaluation Framework Public Health Prevention Operations http://hcr.vermont.gov/blueprint_for_health

20. Sustaining Community Care Coordination Services Strategies • Tasks • Improve health data exchange • Support PCMH, Care Coordiantion, and ACOs • Strategy 1 • Adoption of Health IT in Community Care Coordination Services. Community Engagement Health Promotion • Task • Become Enabling Care Coordination service for community health system • Strategy 2 • Contracting with Managed Care Organizations • Strategy 3 • Partnering in Community-Based Participatory Research • Task • Create innovations in Community Care Coordination Shared infrastructure Data and analysis Public Health Information Network

21. Technology Enables the Progression to Clinical Integration and Accountable Care “Accountable Care Enablement” “Clinical Integration Enablement” Risk , UM & Care Management Financial & Utilization Analytics Financial & Utilization Analytics Care Management Care Management “Meaningful Use Enablement” Patient Health Record Patient Health Record Clinical Quality Metrics Clinical Quality Metrics Clinical Quality Metrics Registry & Population Mgmt Registry & Population Mgmt Registry & Population Mgmt EMR / PMS EMR / PMS EMR / PMS • Digitization & Interoperability • Identify gaps in care • Team based care and workflow • Enable Patients • Manage populations • Manage performance • Price / manage risk • Create a sustainable economic model

22. Patient Health Information Technology Drivers • Ubiquitous Internet connectivity among health citizens • Universal adoption of computers, tablets, mobile phones, •  use of smart phones especially in underserved communities • greater access to health information online • greater social networking online overall; health has followed other consumer verticals • Greater consumer-directed care

23. Patient Health Information Technology:Example ApplicationHealth 2.0 - Definitions • "The use of social software and IT-based tools to promote collaboration between patients, their caregivers, medical professionals, and other stakeholders in health.”1 • "New concept of health care wherein all the constituents (patients, physicians, providers, and payers) focus on health care value (outcomes/price) and use competition at the medical condition level over the full cycle of care as the catalyst for improving the safety, efficiency, and quality of health care.”2 Source: 1Wisdom of Patients, Jane Sarasohn-Kahn, California HealthCare Foundation, 2009. 2Scott Shreeve, The Enabling Technologies and Reform Initiatives for Next Generation Health Care, 2007.

24. The Promise of Moving Toward PCMH, HIT and Patient Empowered Health Care • Achieving optimal health outcomes is a team sport; patient as engaged player • Enabling technologies are in place: broadband, mobile (mHealth), Internet • Local markets forging ahead…pioneers… • Innovating payment: Kaiser, Geisinger, etc. • Innovating care delivery: Center for Connected Health Cleveland Clinic • The emergence of participatory health care…

25. Role for Adoption of Health IT in Community care coordination services Sustainability • Improve efficiencies in Community Care Coordination • Lower cost and improve quality • Promote interoperability for health data exchange • Improve reporting of health outcomes • Align with ONC strategy • Help physician practices and community based health systems move to Meaningful Use • Promote patient centered medical home model

26. Steps to Adoption of Health IT in Sustaining Community care coordination services • Enterprise architecture that is compatible with CMS and CDC for seamless data exchange • Adopt a standards-based record system (“EHR/PHR”) that will • capture and exchange data from multiple community sources, i.e. EHRs, scanned documents, social services systems, etc., • capture and exchange population services data • enable outcomes reporting to CMS, CDC, and the State • Integrate telehealth / telepresence into system applications • Integrate with local and state HIEs • Integrate with ACO information technical infrastructure

27. Steps to Adoption of Health IT in Sustaining Community care coordination services • Establish online education and training • Establish online knowledge sharing and social networking • Establish a management and billing system integrated into the records system (“EHR”).

28. Public Health • The 1988 IOM report The Future of Public Health provides two critical definitions. The first is the mission of public health, defined as “fulfilling society’s interest in assuring conditions in which people can be healthy” (IOM, 1988, p. 140). • The second is the substance of public health, defined as “organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology” (IOM, 1988, p.41). • In 2002, the IOM released The Future of the Public’s Health in the21st Century, which reinforces the idea that public health’s broad mission of ensuring healthy communities requires interactions among a number of health-influencing actors, such as communities, businesses, the media, governmental public health, and the health care delivery system (IOM, 2002).

29. Public Health Aims The nine aims help guide public health practices across the entire system to ensure quality for increasing positive population health outcomes. • Population-centered: Protecting and promoting healthy conditions and the health for the entire population • Equitable: Working to achieve health equity • Proactive: Formulating policies and sustainable practices in a timely manner, while mobilizing rapidly to address new and emerging threats and vulnerabilities • Health promoting: Ensuring policies and strategies that advance safe practices by providers and the population and increase the probability of positive health behaviors and outcomes

30. Public Health Aims • Risk reducing: Diminishing adverse environmental and social events by implementing policies and strategies to reduce the probability of preventable injuries and illness or negative outcomes • Vigilant: Intensifying practices and enacting policies to support enhancements to surveillance activities • Transparency: Ensuring openness in the delivery of services and practices with particular emphasis on valid, reliable, accessible, timely and meaningful data that is readily available to stakeholders, including the public • Effective: Justifying investments by using evidence, science and best practices to achieve optimal results is areas of greatest need • Efficient: Understanding costs and benefits of public health interventions and to facilitate the optimal use of resources to achieve desired outcomes

31. Quality in Public Health “Quality in public health is the degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy.  The HHS vision for public health quality, as defined by the Assistant Secretary for Health, is to build better systems to give all people what they need to reach their full potential for health” http://www.hhs.gov/ash/initiatives/quality/quality/index.html

32. Primary Drivers of Quality: Six Priority Areas • Population Health Metrics and Information Technology • Evidenced-based Practices, Research and Evaluation • Systems Thinking • Sustainability and Stewardship • Policy • Public health Workforce and Education Nolan, T. (2007). Executing for system-level results: Part 2. Retrieved July 30, 2010, from http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/ ImprovementStories/ExecutingforSystemLevelResultsPart2.htm

33. Public Health Quality Drivers

34. Public Health & Primary Care Integration In the 21st Century, improvement in Quality will require Public Health initiatives to be integrated into Primary Care that will strengthen Public Health Quality Drivers.

35. Principles of Public Health & Primary Care Integration Essential for successful integration of primary care and public health: • a shared goal of population health improvement; • community engagement in defining and addressing population health needs; • aligned leadership that • bridges disciplines, programs, and jurisdictions to reduce fragmentation and foster continuity, • clarifies roles and ensures accountability, • develops and supports appropriate incentives, and has the capacity to manage change; • sustainability, key to which is the establishment of a shared infrastructure and building for enduring value and impact; and • the sharing and collaborative use of data and analysis.

36. Our Future is in Partnerships The Future of the Public’s Health in the 21st Century, calls for significant movement in: “building a new generation of intersectoral partnerships that draw on the perspectives and resources of diverse communities and actively engage them in health action.” (Including public/private partnerships) Institute of Medicine. (2002) The Future of the Public’s Health in the 21st Century. Washington, DC, The National Academies Press.

37. Public Health Integration with Primary Care Promotes Small Business Opportunities • The value of using community health workers and connecting the care coordination services with HIT • Opportunities provided by data sharing and data analysis • Possibility of a third party to foster integration

38. Prince George’s County’s HD current Efforts to Integrate into Primary Care • Collaborations between community primary care providers, the health department and other agencies, extension of primary care services in non-traditional settings • Health Enterprise Zone (HEZ) and Million Hearts Pilot • Establish public health information network containing local exchange and care coordination system • Community health promotion activities involving diet, exercise and injury risk reduction as well as population-level interventions • CTG • Integrates wellness/prevention plans into EMR with patient portals • Collaborate with primary care providers in designing preventive services to adult and child populations • Childhood Obesity Reduction Initiative • Integrates on-line plans with EMRs, telehealth and kiosks

39. The Public Health Department’s Community Based Care Coordination Shared Infrastructure • Community Stakeholders • Local Businesses • Faith-based Organizations • Community Centers • Community Based Organizations PGCHD Evaluation Framework PGCHD Public Health Network PGCHD Community Care Coordination Team • Primary Care Providers (PCMH) • FQHC • Private Practices Public Health Department Coordinated Heath System PGCHD Public Health Operations • Hospital Systems & • Specialists • Regional Hospital • Local Hospitals • Specialty groups practices

40. BUSINESS STRATEGY FOR COORDINATED CARE ENABLING SERVICES • Primary Goal • Provide coordianted health care access services to direct clinical care and associated entities within a community • Strategy & Implementation • Integrate HIT platform and applications into service through public/private partnerships • Contract with companies focused on care coordiation i.e. MCOs, insurers, etc. • Secure Federal, State, and/or Foundation Funding • Develop Academic Partnerships • Market position • Nationally known as a coordinated care resource for State and Federal initiatives • Business to business leader in Coordinated Access to Care • Leader in Community-based research in delivery of Coordinated Care

41. PGCHD Strategy for Population Health Improvement • Task • Integrate into Primary Care: PCMH, Behavioral Health, and ACOs • Strategy 1 • Community engagement in defining and addressing population health needs HEZ Community Engagement Health Promotion CTG • Task • Establish collaborative interventions to address chronic diseases • Strategy 2 • Leadership Alignment • Contracting with MCOs, Hospitals, practices, etc MH • Strategy 3 • Services Aligment • Research Aligment Task Collaborate with primary care in designing preventive services CORI Shared infrastructure Data and analysis Public Health Network

42. PGCHD Public Health Network: Care Coordination Managed Services and Consumer Engagement Network CHW’s Care Navigation PGPS based Telehealth FQHC’s Public Health & Quality Reporting Consumer Engagement PHR Mobile Services PCP Medical Home Dental Screening Behavioral Health Health Home Chronic Disease Monitoring (M2M) Care Management • Communications & Collaboration eVisit EHR/eRx Medication adherence Billing X.12 Analytical Services (PCMH, ACO, HEZ) Disease Registries Interoperability Services ((HL7, v2.5, v3.0) SOAP, CCD, CDA, DIRECT, C32) • Connectivity, Security and Management (HIPAA HITECH/EHNAC) STATE sponsored HIE’s, CAH LHIE, ACO’s Query/lab/radiology results delivery/DIRECT/ENS DHHS Syndromic Surveillance Interstate exchange State/County DOH Registry Reporting, MU, Cancer, Chronic Disease, HIV/STD’s

43. PGCHD Million Hearts Project Medical Practice Patient @ home Hospital “at risk” Patient ID & Reports Scenario #1 Hospitalization Scenario #2 Office Visit Care Transition Care Coordination EMR PHR Reports Patient Liaison in Doctor’s Practice Discharge Summary Reports Action Plan Case management & exchange software Discharge Summary Reports Action Plan Data Entry & Reports Patient’s Community Health Worker associated with the practice Direct Messaging & Encounter Notification EMR ER Notification & Discharge Notification Discharge Summary Patient’s Doctor