How Advocate and Cerner developed a population health team

What started as a foray into accountable care resulted in a continued partnership and a population health management program for Advocate Health Care and Cerner.

In 2011, Advocate Health Care was in discussions to launch a new accountable care agreement with Blue Cross Blue Shield of Illinois. The new mindset of the health system based in Downers Grove, Ill., started by approaching a value-based payment system instead of a traditional fee-for-service model. As the health system developed its readmission risk model and dove deeper into discussions with payers, leaders decided to include Cerner, the main vendor for Advocate's inpatient EMR system, to automate the new model into the workflow.

Advocate initiated discussions with Cerner regarding readmission risk, but soon the conversations turned toward population health, says Tina Esposito, vice president of Advocate's Center for Health Information Services.

"We needed to develop a data platform that would support readmission and the other population health needs as well as [a] more analytical health platform that would support and answer some bigger questions on improving outcomes and reducing cost across the continuum," Ms. Esposito says.

The platform
Advocate decided to implement Cerner's HealtheIntent, a population health management platform. HealtheIntent gathers data from all clinical systems across the healthcare continuum, including ambulatory, acute care, claims systems and patient portals, to provide a healthcare map of sorts of people and populations.

"This formulates a true longitudinal record that is de-duplicated and reconciled at major clinical concepts level to display to clinicians a comprehensive picture of every patient in the population," says Bharat Sutariya, MD, vice president and CMO for population health at Cerner. "If you want to improve the health of a community, you've got to leverage that broad context across the community."

Physicians need this type of actionable information and transparency surrounding data of their patients to determine opportunities to manage health utilization and improve health status, Dr. Sutariya says.

Ms. Esposito says having the clinical information at clinicians' fingertips is critical to population health, as historically algorithms are on the payer side and based on claims data. "The ability to leverage the clinical data, marry it with claims at times or standalone provides a little more specificity to a clinician on information, intelligence and the next step for them to support patients' health," she says.

The platform is EMR-agnostic and gathers data from across a range of IT systems. Advocate alone has more than six EHRs across the organization, so they needed a platform that is interoperable and sits above these record systems to offer greater content and intelligence, according to Dr. Sutariya.

Ms. Esposito said having a platform that accommodates all Advocate's data systems was definitely a "win" for the organization. "When you think about leveraging clinical data [and] marrying that to claims data we're getting back from payers, that's daunting enough to support an enterprise master index. But when you have maybe five different clinical EHR vendors and have to work through those hurdles, partnering with something like Cerner helps from the tech perspective," she says.

What's more, Dr. Sutariya says the platform is near real-time, providing as close to current information as possible, compared to traditional population health systems that are retrospective and offer information months or quarters behind.

The team
Adopting and implementing the platform was no flick of a switch. Advocate and Cerner developed a jointly staffed multidisciplinary team of high skilled individuals to oversee this collaborative effort. Dr. Sutariya says this team's core focus is to leverage the platform for the sake of innovation.

Ms. Esposito divides the areas of expertise and resources from the staff members into three buckets. The first, she said, is the technical skill set. Three of the team members supported the technical skills and resources to prepare for the go-live date, such as obtaining and mapping information. The second bucket was focused on analytics. Ms. Esposito says the team hired its first data scientist to work within this realm. Third are the clinical process designers. Ms. Esposito says these individuals are clinical by background and ensure that whatever the team does supports the clinician and is applicable to the real world.

"We can have all these smart people in the room come up with all these great ideas, but this is not an academic exercise," Ms. Esposito says. "We want to make sure what we're creating is helpful."

Beyond the technical and clinical side and the jointly staffed team is what Dr. Sutariya calls the psychosocial or behavioral health type of analysis, a team fielded by Cerner. "If you want to engage those patients, you have to understand their intrinsic motivation, their social economic barriers, their psychosocial issues," Dr. Sutariya says.

The goal of this team is to understand what drives the clinician practice, what is changing in the model of healthcare and how to develop talent in specific areas to truly deliver to and enable the client.

Outcomes and continued innovation
The HealtheIntent platform has been up and running for more than three years, and initial results trend positive.

For starters, Ms. Esposito says the health system has never leveraged clinical data so usefully before. "It has always been available, but I just don't think we had the ability to use it or to learn from it as much as we have [now]," she says.

The journey for Advocate and Cerner is far from over. Dr. Sutariya says the platform, while fulfilling many current needs, also opens the opportunity for further research and innovation.

"That data across Advocate's 12 hospitals — plus more than 4,500 physicians mixed across clinical and financial sources — all have been available to a team of expert researchers that leverage that data and solve real-life problems faced by Advocate and other health systems broadly across the world," he says. "The beauty of this collaboration is we get to walk the clinical hallways, talk to executive leadership and determine what the real problems faced by these leaders and push the innovation roadmap forward often setting our sites three to five years ahead in terms of reducing cost and improving outcomes."

More articles on population health:

Old school, getting back-to-basics: Population health defined
CVS Health partners with IBM's Watson to develop care management solutions for chronic illness
University of Missouri Health Care names medical director of population health: 4 things to know

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