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Essential population health management tools: HIE, CRM, data analytics
With population health management tools, one size does not fit all and that's why it's important to include a mixture of technologies including HIEs, CRM and data analytics.
When considering health IT at St. Barnabas Health System, the fifth largest healthcare system in the state of New York, "one size does not fit all," according to Jitendra Barmecha, senior vice president and CIO.
St. Barnabas, which manages over 385,000 patients and over 220 healthcare organizations with 5,000 providers, manages not only a patient population but it also has an insurance program called Health First, Barmecha explained.
St. Barnabas is also participating in a New York state program called Delivery System Reform Incentive Payment (DSRIP) Program. The goal of this program is to reinvest in the Medicaid program with the primary goal of reducing avoidable hospital admissions by 25% over a five-year period.
Multiple population health management tools needed
Jitendra Barmecha
Barmecha explained that population health requires more than one technology and while many people initially connect population health with claims, he emphasized that provider management is also an important aspect and needs to be included. Ultimately, this requires various population health management tools.
Barmecha explained the various technologies at play:
Clinical platform: St. Barnabas is using Allscripts' clinical platform called Sunrise Clinical Manager. "All our ambulatory care networks have this same database as we have for inpatient and emergency room," Barmecha said. "It's a single database, same EMR for ambulatory care including our very large behavioral health, substance abuse [information] and our inpatient."
CRM: To engage the various organizations and providers that are part of St. Barnabas, "we needed a customer relationship management tool to house all their credential information, [and] performance metrics," he said. St. Barnabas is using Salesforce's CRM platform.
HIE and data analytics: St. Barnabas is leveraging its regional HIE, Bronx RHIO. "Several of our member organizations and providers are already inputting clinical data and they have received claims data from Medicaid as well as part of the pilot program," Barmecha said. "A majority of our analytics is being performed from Bronx RHIO as well."
Tech important to population health, MACRA
Barmecha said these technologies are important to population health for two reasons: managing day-to-day operations whether providers or patients, and seeing the outcomes.
Because St. Barnabas is participating in the DSRIP Program, it has very specific goals.
We have a little bit different approach on the technology because of so many different groups of providers and organizations … one size does not fit all.
Jitendra Barmechasenior vice president and CIO at St. Barnabas Health System
"The objectives are to reduce preventable admissions, preventable readmissions and ED utilization by 25% during this five-year period and in order to achieve those goals or objectives these technologies or the workflow or the processes and the people, I believe … are [all] equally important," Barmecha said.
He added that all these technologies are not only important to achieving a successful population health management strategy, but also to fulfilling the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requirements which focus more on the provider side of healthcare. That's why having population health management tools to manage provider credentialing and maintain the database is important, Barmecha said.
"Although this is the first year for MACRA in terms of reporting … all these tools will definitely augment or help or assist our MACRA or MIPS strategy as we move forward," he said.
St. Barnabas experiencing benefits from this tech
Barmecha said St. Barnabas has experienced a few benefits since implementing these various population health tools.
One benefit was connecting providers within the St. Barnabas health system who had never talked to one another before.
"Through this, I would say, transformative process now we are connecting dots [and providers] so that it is very patient-centric transformational healthcare delivery," he said.
In addition, Barmecha said St. Barnabas has already seen a decline in volume of inpatient admissions.
"Not only in our health system but regionally," he said. "Because of the appropriate care coordination and care management we have moved [the] needle to decrease those inpatient admissions or preventable admissions."
Very interesting article and a good example of a design-driven thinking approach put in place to meet customer/large population health needs. My question to anybody who may have insider insights is, how are the software integrators and architects keeping the myriad of systems within an integrated "information-model" or "user-needs-based" model to avoid breeding complexity. Are you using a SAFe or DevOps approach with customer/user live monitoring and feedback to inform system design? Lastly, if you are doing this, I hope one of you is out there to answer this thread, I would like to speak to you about this because I am organising the first ever industry-driven conference on software excellence and user-centric agile/DevOps in Germany and want good speakers from large hospital systems. I have NHS already but nobody from the US. I will be interested to hear your perspectives!
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Has anyone had to produce an PHM report for NCQA? I'm looking for templates and was wondering if there are any resources online