Dr. Jay W. Lee, medical director at Integrated Health Partners
Photo: Dr. Jay W. Lee
For Dr. Jay W. Lee, medical director at Integrated Health Partners of Southern California, the challenge as a family physician practicing at a community health center has always been showing his work and the work of his colleagues.
"Every day, patients are being cared for at dozens of clinical sites across our network," he said of the clinically integrated network and independent physician association. "Many of our health centers are on a different electronic health record. How do we ensure the hard work of delivering outstanding primary care is being captured in a unified way that represents care gaps being closed?
"And how do we identify patients that need extra support to achieve their health goals?" he continued. "Having an analytics technology platform allows us to do this at scale."
Centralized data asset
Integrated Health Partners selected the analytics platform from vendor Arcadia. The goal was to integrate disparate data systems from sites throughout the healthcare organization and build a centralized data asset for performance and utilization management.
"This data repository would enhance the organization's population health management capabilities to share and integrate best practice workflows across the network, support care management capabilities, and use reporting and analytic capabilities of the platform to identify actionable insights for value-based care initiatives," explained Sarah Cho, vice president of population health management at Integrated Health Partners.
Using the vendor's population health platform, the organization's health centers have enhanced visibility into the longitudinal record of patients so caregivers can act on known care gaps and identify special cohorts who need extra care and attention.
"We would otherwise be making educated guesses at who needs that outreach," Cho noted. "One of the foundational building blocks of high performing primary care is data-driven improvement. With the platform, we are able to drive changes in clinical performance informed by data."
Longitudinal master patient index
Integrated Health Partners worked with the vendor to build nearly 20 data connectors that were aggregated and normalized, producing a longitudinal master patient index across the care continuum. These feeds integrate: clinical data from nine health center electronic health records; health plan eligibility, claims and care gap files; ADT alerts from the HIE; immunization data; and lab data.
The healthcare organization continues to work with stakeholders to implement additional connectors and functionalities within the platform based on new and evolving organization initiatives including payer contracts, ongoing health center EHR migrations, social data integration strategies and grant opportunities, Cho added.
"Partnering with our population health IT team, we developed dashboards for our health centers that allowed them to see what care gaps remain open over time," Lee said. "This data is reviewed regularly with each health center and among the organization's health center clinical leaders. We like to say this transparency creates a spirit of 'co-opetition' wherein we are competing with the intent to enhance everyone's performance."
The top-performing IPA
Arcadia was the source of the organization-wide supplemental data extracts leading to the closure of more than 40,000 care gaps for one contracted payer in a year, Cho reported. This contributed to Integrated Health Partners being the top-performing IPA in the state for this health plan based on performance in the quality incentive program.
"As far as standard leader work for a clinically integrated network, our HEDIS performance continues to be top-notch, earning us the designation of top performer for three of our contracted health plans," Lee said. "Special projects have included reducing urgent care eligible ED visits by nearly 3%, readmissions within 30 days by 7%, and overall spend on high-cost injectables by pivoting infusions to a patient's ZIP code – including at home when appropriate – versus a tertiary hospital.
"The technology allowed us to identify patients for innovative interventions outside the four walls of our health centers and into the communities where our patients live," he added.
Advice for peers
For peers considering similar technology, Cho advised to work with stakeholders to define the scope of data needs and ensure there is an understanding of what the tool will and will not do.
"Set realistic expectations with stakeholders on the limitations of data types and analytic platforms and work with vendors who can accommodate for the unique data sources and analytics of the organization," she said.
Lee said healthcare organization executives should "know who you are now and who you want to become in the near future – think strategically."
"Knowing this going in will allow you to think clearly about what it is that you actually need versus what you are being sold," he continued. "Also, trust your 'Spidey senses' when it comes to building a relationship with a technology vendor.
"Listen to what your team is sharing with you and understand how a potential vendor fits with you now and imagine how they may grow with you," he concluded. "Nothing will be perfect out of the box, but you need to feel confident your vendor will be there with you and give a damn when you encounter headwinds after the honeymoon phase of implementation is behind you."
Follow Bill's health IT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.
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