Agents of Change

IT is enabling healthcare’s transformation to value-based care

____simple_html_dom__voku__html_wrapper____>Advocate Health Care is looking to big data and predictive analytics to improve patient care and better control costs. However, executives there acknowledge that succeeding under value-based care is more than a technology challenge.

The Downers Grove, Ill.-based system operates 10 hospitals in metropolitan Chicago and has a strong history of collaboration with physicians, built over the last 10 years. While information technology is supporting greater expansion into value-based care initiatives, Advocate realizes it’s only an enabler.

“Technology is not a solution by itself,” says Rishi Sikka, MD, senior vice president of clinical transformation for Advocate. “We need to ensure that our tools are integrated into clinicians’ workflow, and we need to have an understanding of whether interventions are effective. Globally in the industry, when tools or interventions are put in place, the effects are poorly understood or anecdotal. To succeed under value-based care, you have to be able to quantify the impact you’re having on outcomes and costs.”

Advocate, which has five years’ experience with value-based contracts, has had to rethink its data strategy, adds Tina Esposito, vice president of Advocate’s Center for Health Information Services. It had operated a hospital-focused clinical data warehouses, but has found that other providers, such as physician offices and home care providers, need information, too.

“We had to restructure our data to bring together information from disparate sources, and we had to look at the care continuum,” she says. “The strategy has to be bigger than your EMR strategy.”

Growing risks

When it comes to shifting to a value-based care model, Advocate has a lot at stake. It operates 10 hospitals in metropolitan Chicago and two hospitals in central Illinois, a home health business, and a multi-specialty medical group.

Information is power, and now that patients are generating their own medical data—and will be doing much more so in the years ahead—a major power shift is getting off the ground.It also operates Advocate Physician Partners (APP), a collaboration between Advocate’s hospitals, physicians employed by Advocate and independent but closely aligned physicians. APP—which includes more than 4,900 physicians—oversees patient-care coordination among its members and managed-care contracts with governmental and commercial payers.

APP enables a strong partnership and alignment with physicians, Sikka says. It’s decade-long history of integration with physicians “allowed us to develop a model of culture and alignment, and has allowed us to move into population health, and actually move a long way in a short period of time. What isn’t often appreciated are these softer areas of culture, governance, leadership and alignment – they take time to develop and solidify.”

Advocate has been operating for years as a value-based care provider. In 2011, Advocate inked its first value-based contract with Blue Cross Blue Shield of Illinois, and in 2012 joined Medicare’s Shared Savings Program—in which doctors and hospitals earn incentive payments for working together to meet cost and quality targets.

New information needs

As the organization began its transition to value-based patient care with that first contract in 2011, Advocate’s executives soon realized that they needed to provide physicians, nurses and other caregivers with comprehensive and timely information on which to base patient-care decisions.

They wanted clinical information on all of its patients’ encounters with the healthcare system—including test results, medications and procedures—integrated into a single, longitudinal record for each patient.

They wanted algorithms to predict medical events, such as patients at high risk for an unplanned hospital stay. And they wanted access to real-time patient data for analysis as opposed to relying on claims data, which can be dated.

“It was really about how we leverage data and information to understand the population that we have attributed to us—their needs” and how to “target the right patient to the right intervention,” Esposito says.

But Advocate’s rich store of real-time electronic patient data resided in a disparate group of proprietary EHR products, such as for inpatient and outpatient services, and ancillary clinical systems, such as for pathology and radiology. Those silos made it difficult for Advocate to aggregate information about patients’ interactions across sites of care, such as physicians’ offices, emergency departments, and hospitals.

The health system has partnered with Cerner, a vendor of electronic health-records systems and other healthcare products, to develop analytical tools hosted on Cerner’s cloud-based population-health management software platform, called HealtheIntent. Advocate already was a customer of Cerner’s cloud-based EHR product, Millennium.

With HealtheIntent deployed, Advocate Health Care and Advocate Physician Partners then worked with Cerner to develop software products that the health system needed.

The tools that resulted from the partnership are a configurable suite of HealtheIntent products that facilitate tracking of patients based on automatically updated clinical data, such as blood glucose levels, and predicting outcomes, such as an unplanned hospital stay.

Also, through the partnership, Cerner now provides Advocate with access to an enterprise data warehouse called HealtheEDW and HealtheAnalytics analytics software that allows the health system to produce custom reports using Tableau visualization.

Gathering data

The health system feeds data from more than 60 different clinical and transactional sources into the HealtheIntent platform, including numerous proprietary EHRs deployed in hospitals, doctor’s offices and Advocate’s home care operation. It uses Cerner’s EHR product at 10 of 12 hospitals, but uses other vendors’ products at two other hospitals, its home care operation and physician’s offices.

Advocate also pulls in data from insurance claims for both medical services and pharmacy benefits and other ancillary clinical systems, such as for pathology and radiology.

“Population health’s goal is to understand the care you’re delivering everywhere in your organization,” Esposito says. “You must pull all this information together. It was quite a bit of work and a significant challenge. You may have five different EMRs, but it’s not just taking the data from them – the real work is mapping the data to a standard. The mapping piece and the normalization is the hard part.”

Advocate completed the first iteration of its HealtheIntent data environment in 2013, but is “adding new sources of data all the time,” says Esposito. As of August 2015, Advocate had aggregated information on nearly 17 million patients.

The aggregated data runs in the HealtheIntent environment via an application, called HealtheRecord, that’s comprised of a longitudinal view of each patient, including 10 years of clinical data, such as tests results and surgeries; claims data, such as information on prescriptions and payments; and administrative data, such as home addresses and insurance carriers.

Big data alogorithms

From the beginning of their data partnership, Cerner and Advocate have been working to co-develop algorithms that predict patients’ level of risk for a given medical outcome, such as a hospital stay.

The most recent result of the Advocate-Cerner collaboration is an algorithm that leverages the HealtheIntent data set to help physicians choose the next level of care—such as a skilled nursing home, long-term acute-care facility or in-home health services—for patients being discharged from a hospital. The goal is to send patients to a level of care that reduces their risk of returning to the hospital within 30 days of discharge.

Advocate and Cerner conducted a randomized controlled research trial to test the algorithm from October 2014 to January 2015. The findings, which involved a total of 5,600 patients at one of the system’s largest hospitals, “look very positive. We have seen that when the model is followed, there is a lower readmission rate,” Esposito says.

Advocate plans to roll out the algorithm, which is already integrated into its inpatient EHR at most of its hospitals, in the next six to nine months. The Readmission Prevention Solution assesses hospital patients’ risk of readmission every two hours throughout their hospital stay based on about 30 variables, such as the primary medical issue, secondary diagnoses, and medications.

The hallmark is to keep it real. It has to have a positive impact on the front line of care.The information also is available via secure, web-based software hosted at Cerner, allowing physicians access to information from their offices, where they also use EHR solutions from vendors other than Cerner. Physicians or other caregivers drill down to find out each patient’s risk score (low, medium or high), what factors led to the score, and what clinical interventions would be appropriate to lower the risk.

Advocate saw results fairly quickly from the Readmission Prediction Solution. The application was live at all Chicago-area hospitals by the end of 2013. By March 2014, the 30-day, all-cause readmission rate among high-risk patients had dropped 20 percent, as these were the ones who received most of the intensive resources.

Engaging clinicians

Advocate then decided to help develop the companion tool—which matches patients to the appropriate next level of care after discharge from a hospital based on 100 variables—because “there was definitely a consensus in the organization that we needed to be more objective in how we placed our patients,” Esposito says.

The Advocate-Cerner predictive-analytics team plans to move into the ambulatory setting next. For example, the team would like to develop an algorithm to determine which patients should be assigned to outpatient care managers, who coordinate healthcare encounters proactively and encourage patients to adhere to their care plans.

For these types of solutions to be used consistently, they must fit into their workflows, solve problems that they help identify, and reduce work, not create it, Sikka says.

“The hallmark is to keep it real,” he says. “It has to have a positive impact on the front line of care. The way we do development work is we ask front-line caregivers what their pain points are. We have intense focus groups around those kinds of discussions. What we design really comes out of the sense of knowing what the unmet needs are and then designing the analytics.”

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