Following the Process of

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• Following the Process of
• Care Management

                                                                                                                        
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Speaker Bio

• Gary M. Austin, VP-NHII Solutions, Practice Lead,
  MA/NY/PA based
• Formerly BCBSMA, Director IT Strategy and Health
  Mgmt Systems
• eRx Collaborative principal (4m payer investment
  in eRx)
• Project Director, MA-SHARE MedsInfo project (Rx
  Payers to ED)
• Mass eHealth Collaborative thought leader (50
  million payer investment in EMR)
• eRx for Homeless project director
• Speaker, HIT, NMHCC, DMC, TEPR, WEDI and other
  conferences on Payer Involvement in RHIOs
• Leading MEDecisions RHIO pursuits in over 30
  markets
• Previous lives at
• Payers Excellus, CIGNA, Preferred Care,
  Providence Healthcare
• Delivery Systems SHARP, St. Luke-Shawnee
  Mission, The Health Alliance
• Nothing to do with Healthcare Rolls-Royce
  aerospace, Automotive Network Exchange, British
  Petroleum, Marine Midland (Hong-Kong Shanghai)
  Bank

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About MEDecision

• MEDecision is the software leader in
  Collaborative Care Management. Founded in 1988,
  the companys Integrated Medical Management
  solutions create a seamless payer-based medical
  management system to analyze, apply, administer
  and automate management of healthcare programs
  and provide a common patient view at the point of
  care.
• MEDecisions clients include 21 of the countrys
  Blue Cross BlueShield plans and over 40 other
  payer clients -- improving patient outcomes,
  reducing medical errors, and increasing
  operational efficiencies for approximately one in
  every six (43 million) Americans.
• Client list includes
• BCBS Plans
• Anthem CareFirst HCSC
• Massachusetts Michigan Excellus
• Medicaid Plans
• Keystone-Mercy (PA) Avidyn KeyPro
• IDNs
• Fallon (MA) Scott White NY Presbyterian

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Assumptions Behind DE PCS Project

• Payers and providers can work together to improve
  patient outcomes by supplementing provider
  electronic medical records with payer member
  information
• Payers can jumpstart RHIO efforts by
  pre-populating electronic health records systems
  with payer-based health record (PBHR) information

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Christiana Care-BCBSD Project

• Payer-provider collaboration to share
  multi-source patient data at point of care
• One-year pilot to test impact and establish
  evaluation criteria
• Common goals
• Improved patient care through better information
• Lower costs through reduced duplication and
  improved outcomes

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Collaboration for ImprovedPatient Care
Patient data from all providers
Phase 1
BCBSD
MEDecision
Patient Eligibility
Integrated Medical Management
Patient Clinical Summary
CCHS EmergencyRoom
Data on patients treated within the Christiana
system
CCHS
Patient Summary Report
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Collaboration for ImprovedPatient Care
RHIO
Patient data from all providers
BCBSD
Other Regional Payers
Follow-on Phases
MEDecision
2 Way
Integrated Medical Management
Patient Eligibility and Patient Summary Report
Consolidated Patient Clinical Summary
CCHS EmergencyRoom
Other Clinical Settings
CCHS
Integrated patient recordaccessed at point of
care
Patient Summary Report combined with Patient
Clinical Summary
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The Provider Viewpoint
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Christiana Care Health System

• Largest provider in Delaware
• Also serving portions of PA, MD, NJ
• 2 hospitals, plus multiple services
• Half of all admissions in DE
• 92,000 ED visits annually
• 17th busiest nationwide
• Level I regional trauma center with 2600
  admissions annually

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Background

• Collaborated with ED in 2003-04 to improve
  information flow
• Huge repository of clinical information (e.g.,
  lab and radiological data to 1992)
• Created Patient Summary Report
• Patient demographics
• Last 5 hospital visits and diagnosis
• ER visits
• Last 5 lab and radiology visits
• Last 10 physician visits

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Background (contd)

• Patient Summary Report automatically printed when
  patient registers at ED
• ED personnel note reduction in duplicate tests
• After 6 months, limitations were obvious
• Need for more information sources
• Pharmacological view
• Other providers and procedures

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Basis for Improvements

• MEDecisions PCS similar to CCHS PSR
• BCBSD adds patient data from physicians,
  pharmacies, imaging centers, etc.

Christiana Caredeep
BCBSDbroad

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Expectations

• Improved decision-making
• Reduction in preventable errors
• Higher quality of care plus greater safety
• Cost savings through reduced duplication
• Why not us? from other providers
• A preview of what DHIN can accomplish

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The Payer Viewpoint
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Why Get Involved?

• Patient safety expectations amongst patients and
  accounts that we are trying to improve the safety
  of the care provided
• Cost containment
• NCQA accreditation
• Improved relations with major providers of care
• Incubator for other ways to share data

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Why? (contd)

• Christiana Care an attractive partner
• Academic rigor
• High-volume Level I trauma center
• High overlap with BCBSD
• ER best site for proof of concept
• Controlled setting and access
• Most likely to deliver ROI from reduced
  duplication

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Payer Concerns

• HIPAA and patient privacy
• Concerns of BCBSD
• Data may not be current
• Claims history file may not contain all details
• Project costs and ROI
• Capital and operating expenses
• Personnel and training
• Measurement criteria

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Some Prospective Metrics
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Utilization Statistics

• 25,257 total ED visits during CY 2004
• 10,922 ED visits resulted in lab testing being
  performed
• Total cost of lab tests 5.8 million
• 12,192 ED visits resulted in a radiological
  examination
• Total cost of radiology tests 6.1 million

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Utilization Prior to ED Visit

• 425 doctor visits had a lab test within 30 days
  of the ED visit
• 296 doctor visits had a lab test within 14 days
  of the ED visit
• 598 doctor visits had a radiological examination
  within 30 days of the ED visit
• 457 doctor visits had a radiological examination
  within 14 days of the ED visit

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Utilization After ED Visit

• 811 doctor visits had a lab test within 30 days
  after the ED visit
• 574 doctor visits had a lab test within 14 days
  after the ED visit
• 2,582 doctor visits had a radiological
  examination within 30 days after the ED visit
• 2,043 doctor visits had a radiological
  examination within 14 days after the ED visit

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Measuring Success

• ED staff satisfaction
• Was the data valuable?
• Member satisfaction
• ROI calculations

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Vendor Perspective
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The Electronic Health Record
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Leveraging Payer Data

• The PBHR is one component of a comprehensive
  Electronic Health Record (EHR)
• The PBHR is a clinically useful summary based
  upon data the payer holds demographic, claims,
  care management, Rx, Labs, risk analysis, etc.
• Data is aggregated, sanitized, and presented to
  the clinician
• Clinical rules highlighting gaps in care, care
  opportunities and the like can be overlaid,
  yielding the Patient Clinical Summary (PCS)
• Clinical data can also be included as you mature
  the system
• MEDecision KNOWS payer data as well as any
  company in the industry it is forming data
  alliances with data owners and clinical systems
  companies in a drive to deliver comprehensive
  EHRs

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A Payer RHIO Win!

• Utilize the Payer-based Health Record (PBHR) as a
  launch strategy
• Turn on payers in a market one at a time
• Initial delivery to high cost delivery sites such
  as hospital EDs
• Subsequent delivery to ambulatory providers
• Speed to Value 90-120 days following receipt
  of clean data from plans
• Clear public, payer, and clinical value
• Low risk (payer data), low cost (by the drip),
  low complexity (ASP and web)
• A wonderful public story Betty came into the ED
  unconscious

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Sample Preliminary ResultsFrom Retrospective
Study
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Study Methodology

• Inclusion Criteria
• Registered in the CCHS ED on or after 2/1/2005
• Triage severity level 1 or 2
• (scale 1 to 5, 1 most severe)
• Verified as BCBSD members
• Sampling Strategy
• The patients were sorted in order of registration
  date and 59 consecutive patients meeting the
  above criteria were selected.

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The Study

• 59 consecutive BCBSD patients
• High triage severity
• Compare completeness of medication record (ED
  admission medication records compared to Payor
  PBM claims)

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Review Outcome
PCS Contributed Value
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Other Interesting Observations

• Patients with chest pain in the ED who had
  already received a full cardiac workup and EGD
  within the last 6 weeks
• Patients with asthma who had no claims for home
  nebulizer therapy
• The most severely ill patients had the greatest
  number of missing medications
• Trauma patients unknown to be taking
  anti-platelet or anticoagulant medications
• Patients with symptomatic coronary artery disease
  taking Viagra
• More To Come

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Edward Ewen, Jr, MDDirector of Clinical
Infomatics, CCHS
The Moral of the Story

• In an emergency setting alone it appears this
  information could significantly impact medical
  decision-making and clinical outcomes

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For Further Information

• Gary M. Austin, D.A.
• VP, MEDecision
• 610.389.3562 or Gary.Austin_at_MEDecision.com