11 hospitals & health systems making health IT work for population health

Keeping a close watch on population health is more important for hospitals now than ever before, as they pursue value-based frameworks, take on more responsibility for patient outcomes outside the hospital and work to understand the factors that contribute to readmissions and failed care. The following 11 hospitals and health systems across the country have put health information technology to work for population health management in successful and innovative ways.

1. Children's Hospital of Alabama (Birmingham)
Improving referral care by decreasing image corruption

Goal: To create a stable image-viewing solution to improve referral-based care in the third-largest children's hospital in the country.

Solution: Having experienced problems with viewing images from referrals, Children's adopted the cloud-based Nuance PowerShare Network to view the 20 percent of images that were previously unusable, corrupted or unreadable, causing workflow disruptions to physicians and necessitating extra scans for patients. The system was first put in place in the emergency department.

Outcome: After implementing the system, Children's experienced a 60 percent decrease in corrupted referral images. Following success in the ED implementation, the solution was implemented institution-wide, and physicians often use the mobile capability, streamlining patient care. In addition, Children's has been successful in having referring organizations join them on the network.

2. Children's National Health System (Washington, D.C.)
Geospatial mapping of local kids' public health risks

Goal: To better understand the patterns of child health and wellness in the areas Children's National serves and identify factors associated with the population's risk of illness.

Solution: The system assembled a team of programmers, analysts and clinicians to identify data sources and populations of interest. Then, the team used geospatial mapping software to analyze socioeconomic and environmental variables behind three of pediatrics' biggest public health problems, including childhood obesity.

Outcome: Children's National is using its broader understanding of the factors leading to childhood illness and hospital readmissions to shape health interventions and educational opportunities for kids. The program has been so successful that the system plans to expand it to other conditions in 2015.

3. Hackensack (N.J.) University Medical Center
ACO saves millions after setting up care coordination system

Goal: To put a system in place to support this early ACO's cost and quality goals, including care coordination among sites and automated workflow processes.

Solution: In 2012, HackensackUMC put together a selection committee to choose a care coordination solution and ended up settling on EPIC and TEAM of Care Solutions to support their integration needs in creating value, achieving return on investment and achieving a single patient view.

Outcome: After recognizing and tackling the need for coordinated care across the continuum and within the institution, HackensackUMC's ACO saved $10.75 million, half of which is to be shared with the hospital and its ACO, making HackensackUMC one of the few early and successful ACOs in the country.

4. Integrated Health Network of Wisconsin (Brookfield, Wis.)
Proprietary tools to track and manage high-risk patients during care transitions

Goal: To establish the functional equivalent of “interoperability” in order to maximize effective management of patients moving within and among Integrated Health Network's member health systems.

Solution: Integrated Health Network created a centralized data warehouse, shared patient registries, a common care model and collaborative clinical leadership to encourage consistency, track performance and improve care coordination. IHN CMOs and other clinical leaders used common analytics, national standards, and their collective experience to create a common approach focusing on early intervention and health improvement for high-risk populations.

Outcome: Since implementation of the solutions, IHN has generated reduced readmissions rates and lowered use of emergency department services across its member organizations. In addition, care navigation services directed by data have increased patient medication safety and appropriate patient primary care visits.

5. MemorialCare Health System and MemorialCare Medical Group in Southern California (Fountain Valley, Calif.)
Adopting preventive analytics to keep patients healthy and avoid illness

Goal: To accurately analyze patients' health needs accurately enough to predict what their future health needs might be — and then prevent the need for unnecessary care, improving health outcomes and resource use.

Solution: MemorialCare dug deep into its EHR system to harness data analytics capabilities. In addition, the system began to build out its patient portal as a supplemental, patient-facing tool, helping engage patients in their care even as the system analyzed the type of care they might need next.

Outcome: The system now has the ability to quickly and more easily identify history of illness, chronic disease diagnoses, socioeconomic factors impacting health and potential interventions customized to improve health outcomes after care. In addition, this information has allowed the system to accurately create cohorts of patients, driving savings and allowing bulk interventions, all within the construct of the system's EHR. Through coordinated efforts, MemorialCare currently has about 200,000 patients on its patient-facing portal.

6. North Shore-LIJ Health System (Great Neck, N.Y.)
Harnessing data integration technologies to support care coordination for complex, high-risk patients.

Goal: To develop an application suite that combines "intelligent" clinical assessment and care planning, real-time notification and data analysis to maximize the quality and efficiency of care for high-risk populations.

Solution: Working closely with Care Solutions, North Shore LIJ’s care management organization, the system created The Care Tool, customized to support the unique workflows associated with management of high risk populations. The tool's features include clinical outreach, medication reconciliation, evidence based care planning, risk stratification, performance tracking and outcomes analysis. The Care Tool can be configured to conform to the specific requirements of multiple risk programs, all of which are accessible from a single user interface. Integration with the health system HIE was enabled by InterSystems HealthShare, an informatics platform, which provides real-time notification for acute events such as ED visits and readmission. The Care Tool is also used by the clinical call center, where data sharing and collaboration is essential for swift resolution of clinical issues.

Outcome: The Care Tool was piloted to manage cardiac, orthopedic and stroke cohorts for Medicare's Bundled Payment Care Initiative (BPCI). For the year to date, North Shore-LIJ has seen a 6 percent reduction in cardiac valve replacement patient readmissions, between a 10 percent and 28 percent increase in surgical patients discharged home instead of a nursing facility, a 56 percent increase in patient use of in-network home care, and overall improved infection control, readmissions and patient satisfaction rates.

7. Northwestern Medicine and Northwestern Medical Group (Chicago)
Integrating home blood pressure readings, 24-hour ambulatory blood pressure readings, and office blood pressure readings through the EHR

Goal: To optimize hypertension control by making actionable information about blood pressure more readily available to primary care physicians.

Solution: Northwestern Medicine developed the Expanded Hypertension Data Flowsheet, an EHR-based tool that presents a more accurate picture of a patient's true blood pressure by integrating patient blood pressures from home, ambulatory and office settings for physician viewing for any patient, any time, so physicians won't miss diagnosing or appropriately managing hypertensive patients. The tool was created from existing EHR functions, meaning the cost of the tool was negligible, and using the tool does not interrupt workflow, according to the system.

Outcome: By giving physicians actionable blood pressure data while they are seeing patients, Northwestern Medicine's physicians are better able to control hypertension, seeing a 7 percent gain in hypertension control rates in six months at their primary testing site in Evanston, Ill.. Preliminary pilots were successful enough that the innovation will be rolled out across all primary care offices system-wide. In addition, Northwestern Medicine has also integrated this data into the recently implemented PopulationManager at its Evanston prototyping site, which is a tool that lists each physician's chronic care patients and whether each patient is at disease-management targets, allowing real-time viewing of the effects of different treatment strategies. With time Northwestern Medicine also hopes to expand PopulationManager across the system.

8. Partners HealthCare (Boston)
Asking surgeons: Is that procedure really appropriate for your patient?

Goal: To clinically and financially optimize preoperative planning for high-cost surgical cases, both goals in line with Partners' position as a Pioneer ACO.

Solution: Partners implemented a procedure order entry decision-support system, Q-Guide, co-developed by QPID Health and Massachusetts General Hospital, to help physicians determine whether prescribed procedures are truly an optimal fit for that patient. The system draws upon the individual health data of each patient as well as published evidence-based guideline to calculate patient-specific risks and "appropriateness" scores and creates a customized consent form. Q-Guide can use information from both structured data and unstructured fields (such as visit notes).

Outcome: Improved shared decision-making among physicians and patients, who are able to better understand the risk they assume with surgical procedures, has led to higher levels of appropriate procedures at MGH than in the literature. The POE process is now used for eight surgical procedures, has been used over 3,400 times and will be expanded to 16 conditions and 45 procedures across the system that are high-cost, high-volume, or both.

9. Rochester (N.Y.) Regional Health System-Unity Health System, Rochester, N.Y.
Conquering diabetes through longitudinal patient records

Goal: To bridge four EHRs and create a single-record view of 3,000 diabetes patients to improve their care.

Solution: Led by its CIO, CMO and CMIO, the system applied for a grant from New York State and engaged a group of internal and external stakeholders to build a solution rooted in patient-centered medical home philosophies: the Community Diabetes Collaborative. The program is built on a public-private health information exchange, which uses Allscripts dbMotion technology to interoperate with four EHRs in use as well as with the information systems of outside providers. It also accesses data from labs, other hospitals and community-physician EMRs via effective connectivity with the Rochester RHIO. The Collaborative includes patient engagement tools, a data warehouse for collection of population data and glucose management tools.

Outcome: Transitions in care and out-of-hospital care improved for the system's diabetes patients after Collaborative went live. Through the HIE, patient information became more readily available within Unity and for outside providers, improving care coordination and referrals management. In addition, added decision support and performance management tools streamlined the treatment process of diabetic patients. Unity was also able to replicate the process for patients with other types of chronic disease, further extending the population health benefits of the program.

10. St. Vincent's Healthcare Partners (Bridgeport, Conn.)
Using tech to implement a "playbook" of minimum data-sharing requirements for care transitions

Goal: To monitor care transitions by instituting a mandatory data-sharing minimum among the physician-hospital organization's providers for most types of care transitions.

Solution: St. Vincent's implemented information platforms from McKesson to actively facilitate its "playbook," which mandates the minimum dataset that must be shared among members of the healthcare team during more than 140 different types of care transitions, automating the patient transfer safely and efficiently.

Outcome: As a result of platform implementation of the playbook, the organization has applied best practice interventions and decreased safety risks for patients, has experienced less patient loss to out-of-network groups, has better quality metric management, and has more appropriate utilization of ambulatory care. The use of the system also attuned individual practices within the PHO to modifications in patient care that could be accomplished in pursuit of the Institute for Healthcare Improvement's Triple Aim.

11. Tenet Health System, Lakewood (Calif.) IPA & Premier ACO
Investing in case management to improve quality in advance of ACO membership

Goal: To improve population health management in advance of applying to CMS' Shared Savings Program, following its relationship with the pay-for-performance program since 2005.

Solution: In 2010, the physician group did an infrastructure assessment of its ability to manage patients' population health in advance of joining the Medicare Shared Savings Program. In accordance with a consultant's guidance, the group selected ZirMed for its case management needs.

Outcome: After adopting ZirMed, the group built a customized clinical integration platform to keep track of the specific quality measures that are part of the MSSP program, many of which evaluate practice success in managing population health. As a result, the ACO's MSSP quality scores have increased 12 percent.

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