Chapter 7

Patient Engagement:
Engaging Patients in
the Care Process by
Leveraging
Meaningful Use Goals
 Learning Objectives

• Understand how a patient engagement road map can add

value for hospitals, clinicians, and patients.
• Explore the use and application of various tools and
methodologies that support patient engagement as part
of meaningful use and health reform.
• Identify opportunities to leverage the patient engagement
framework to support population health and health
information technology.
Patient Engagement Framework

A five-phase continuum used by hospitals and other care providers

to gradually expand the methods and tools for informing,
engaging, empowering, and partnering with patients and their
communities in order to improve both the quality of the care they
receive and their overall quality of health.

The framework was developed through a collaborative partnership

facilitated by the National eHealth Collaborative (NeHC).

National eHealth Collaborative. The patient engagement framework.

http://www.nationalehealth.org/patient-engagement-framework
 Patient Engagement
Framework: 5 Stages
1. Inform Me: This stage makes it easier for providers to
help patients find and understand care information.
2. Engage Me: This stage supports provider interaction
with patients to improve care.
3. Empower Me: This stage enables patients to become
an integral part of the care team.
4. Partner with Me: This stage facilitates provider-patient
partnership through shared care planning.
5. Support My e-Community: This stage expands the
network of patient support to include community.
 Meaningful Use
The provision of financial incentives for providers who
“meaningfully use” certified EHR technology to improve results
over time.

Grounding patient engagement in such important policy initiatives

will help guide the development of future population health and
patient engagement strategies and strengthen the provider-
patient relationship across the continuum of care.

Office of the National Coordinator for Health Information Technology. Meaningful use definition
and objectives. HealthIT.gov website.
http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives
 Level 1: Inform Me

Goal for the Provider: Goal for the Patient:

“Make it easy for me “Make it easy for me
to point my patients to to find accurate, up-
information I want to-date information
them to access and relevant to my
understand.” health, my care and
my medical needs.”
 Inform Me
• Most healthcare systems address the “Inform Me” need
through their patient and marketing portals.

• Providing health information through the hospital’s

website adds a degree of authenticity that leads patients
to trust the information and feel more comfortable
sharing what they’ve learned with their trusted clinicians.
 Inform Me
• Even before HIT, progress was made with respect to educating patients at
the “Inform Me” level.

• Tools like self-care handbooks have been critical in helping patients to

determine when and where they should seek care, if at all, and to decide
whether home treatment and self-care are sufficient to manage symptoms.
Examples: Kaiser Permanente and the Veteran Administration’s use of self-
care books.

• In some cases, a patient’s use of clear, understandable health information

has helped the patient seek life-saving treatments.

• Printed health education materials, in addition to HIT-enabled tools, can

contribute to greater patient engagement and loyalty.
 Level 2: Engage Me

Goal for the Provider: Goal for the Patient:

“Help me interact “Make it easy for me
with my patients and to understand my
recommend steps provider’s
they can take to instructions so I can
improve their health.” do self-care well.”
 Information Therapy

• “Information Therapy” is the prescription of the right

information to the right person at the right time to
help the person make a better health decision or
improve a health behavior.

• Just as treatments or medicines can be prescribed

and reimbursed, so can health education.

Kemper DW, Mettler M. Information Therapy: Prescribed Information as a Reimbursable Medical Service.
Boise, ID: Healthwise; 2002.
 Results of Engagement
• In one study, patients suffering from depression were given
interactive engagement tools. These patients showed a 33%
increase in antidepressant medication adherence and lower
overall depression scores, resulting in a 61% increase in
satisfaction with treatment.
• In another study, patients with diabetes who used an online
patient portal to refill medications increased their
medication adherence and improved their cholesterol levels.
• Patient reminders can help patients keep their upcoming
appointments (reducing “no show” rates for providers) and
assist them in remembering preventive cancer screenings or
flu shots, thus improving scores on quality measures for
providers.
J Gen Intern Med. 2011; 26(7): 698–704.
J Health Qual. 2013; 35(5): 7–19.
Am J Public Health. 2014; 104(supp 1): e7–12.
 Level 3: Empower Me

Goal for the Provider: Goal for the Patient:

“The information I “Make it easy for me
learn from my patients to be a part of my
helps me provide healthcare team.”
better care.”
Secure Messaging Allows the Full Care
Team to Get Involved

As noted in a meaningful use case study, “Secure

messaging actually cuts down on the phone calls
and the back and forth.”

—Tracy Morris, Primary Health Medical Group

Office of the National Coordinator for Health Information Technology. Patient portal benefits
patient care and provider workflow. HealthIT.gov website.
 Health Education Campaigns

• A patient engagement campaign is a series of educational

experiences presented to a select group of people who
are facing a common health problem or moment in care.

• Health education campaigns (health education assets

delivered over time) can increase patient activation by
30%.

Solomon M, Wagner SL, Goes J. Effects of a web-based intervention for adults with chronic conditions
on patient activation: online randomized controlled trial. J Med Internet Res. 2012; 14(1): e32.
doi:10.2196/jimr.1924.
 Results of Empowerment
• At Geisinger Health System, patients involved in a study
accessed their medication lists and provided feedback online to
providers through the patient portal. As a result:
– Providers reported that they were able to keep medication
lists updated more efficiently.
– Patients were “eager to provide feedback on medication data
and felt that it enabled them to track their medications in a
more effective manner.”
– Pharmacists made patient-suggested medication changes in
80% of the cases, and providers found that the online
communication with patients resulted in time savings.
– Further, patients indicated that pre-visit online messaging
improved the quality of communication with providers
Deering MJ. Issue brief: patient-generated health data and health IT. Report presented at The Office of the National Coordinator
during
for Health Informationoffice
Technologyvisits.
meeting; December 20, 2013.
Level 4: Partner with Me

Goals for Provider and Patient:

“Help us clarify and record
what we know and do
together to manage patient
health.”
 Personal Care Plans
A personal care plan brings together all of the care plans,
wellness goals, and supporting resources available to help a
person achieve the outcomes that matter to him or her.
• A personal care plan integrates the patient with the care
team members chosen by the patient.
• This team participates in a variety of roles and
responsibilities, with the patient highly integrated at the
center of care.
• Ideally, the patient’s values, goals, and health status
inform the process and the participants in a fluid and
seamless way.
 Impact of Shared Accountability

UCSF and Stanford Medical Center Study showed that with

collaborative care planning and decision aid use:
• More patients reached an informed decision during the first
visit.
• Patients reported higher confidence in knowing what
questions to ask doctor.
• Surgeons believed questions asked by patient were
appropriate.
• Surgeons reported greater efficiency with clinical encounters.
• Surgeons reported greater satisfaction with clinical
encounters.
Journal of Bone and Joint Surgery, Inc. 2013;95:1633-9
 Level 5: Support My e-
Community
Goal for the Provider Goal for the
and Patient: Community:
“Expand and include “Make it easy for me
the co-producers of to support the
health of the patient.”
patient.”
 Results of Community Support

• Researchers at New York City’s Mount Sinai Hospital have

found that “patients’ relationships with care providers
and their ratings of the quality of their care all depend …
on the way care is delivered.”
• Care delivery encompasses an array of factors, such as:
• Patients’ use of health information technology
• Quality of patient-provider rapport
• Degree of connectedness patients feel to their care
facility
• Patients’ confidence in their decision-making ability
• How informed patients feel about their health
Advisory Board Company. How a hospital used social workers to cut readmission. Daily Briefing. September 30, 2013.
http://www.advisory.com/daily-briefing/2013/09/30/how-a-hospital-used-social-workers-to-cut-readmissions. Accessed
February 2, 2014.
 Access to e-Communication
Levels the Playing Field

Use of health technology is another factor that reduces the

gap in care experiences between higher- and lower-income
Californians—in particular, sending and receiving e-mails
and text messages to and from providers.

Efforts to open these communication channels should help

address the discrepancy between low- and high-income
patients in their satisfaction with their care.

Blue Shield of California Foundation. Health care in California: leveling the playing field. http://www.blueshieldcafoundation
.org/sites/default/files/publications/downloadable/BCSF_leveling_the_playing_field.pdf. Published November 2013.
 Overarching Results of
Patient Engagement
• Patients receiving care from providers with whom they
shared in decision making showed a 12.5% reduction in
hospital admissions, as well as lower costs.
• The delivery of clear, easy-to-understand patient
education has been shown to reduce readmissions for
heart failure.
• Ultimately, more engaged patients incur lower costs,
while less-engaged patients can generate up to 21% more
health costs.

Carman KL, Dardess P, Maurer M, et al. Patient and family engagement: a framework for understanding the elements and
developing interventions and policies. Health Af. 2013; 32(2): 223‑231. doi:10.1377/hlthaff.2012.1133.
Heart failure education reduces readmissions [news release]. Robert Wood Johnson Foundation Newsroom; February 26, 2013.
Hibbard JH, Green J, Overton V. Patients with lower activation associated with higher costs; delivery systems should know their
patients’ “scores”. Health Af. 2013; 32(2): 216-222. doi:10.1377/hlthaff.2012.1064.
 Patient Engagement

Inform Me
Engage Me
Empower Me
Partner with Me
Support My e-Community
The tools discussed here that support each of the five stages can
positively effect change and influence the achievement of better care,
better health, and lower cost.
 Patient
Engagement
HCA 428 – Week 8
Learning Objectives
• Understand how a patient engagement road map can add
value for hospitals, clinicians, and patients.
• Explore the use and application of various tools and
methodologies that support patient engagement as part
of meaningful use and health reform.
• Identify opportunities to leverage the patient engagement
framework to support population health and health
information technology.
Introduction
• Patients who are engaged tend to be healthier and have
better outcomes.
• They are ready to engage with their health care providers
• Current policy and health IT environment can help
support engagement.

27
Legislation & Regulations
• The American Recovery and Reinvestment Act of 2009 –
Recovery Act
• Enactment of the Health Information Technology for Economic
and Clinical Health Act (HITECH Act)
• EHR Incentives & Certification
• The Affordable Care Act of 2010
Meaningful Use
The outcome goals of meaningful use include:
• Patients understand their disease and treatments
• Patients participate in shared decision making
• Patient preferences honored across care teams

Source:
https://www.healthit.gov/providers-professionals/ehr-incent
ives-certification
The 2016 HIMSS Connected
Health Survey
• 52% of hospitals currently use three or more connected
health technologies
• 69% of respondents using a mobile optimized patient portal
• 47% expect to expand their use of connected health
technologies in the next few years
The connected health technologies include: mobile optimized
patient portal, apps for patient education/ engagement,
remote patient monitoring, telehealth (audio visual fee for
service, concierge service: digital consult, pay per e-visit), SMS
texting, patient generated health data
Source: http://www.himss.org/2016-connected-health-survey
PE Framework
• Developed through a collaborative partnership facilitated
by the National eHealth Collaborative (NeHC).
• It’s a five-phase continuum to inform, engage, empower,
and partner with patients and their communities in order
to improve both the quality of care they receive and
overall quality of health.

• Patient engagement toolkit:

http://www.himss.org/library/patient-engagement-toolkit
Source: Patient Engagement Framework
Stage 1: Inform Me
• This stage makes it easier for providers to help patients
find and understand care information.

Goal for Provider Goal for Patient

“Make it easy for me to point my patients “Make it easy for me to find accurate, up-
to information I want them to access and to-date information relevant to my health,
understand.” my care and my medical needs.”
How to Inform Me
• Patient and marketing portals
• E.g. PatientConnection
• Website
• Self-care handbooks
• E.g. Kaiser Permanente Healthwise Handbook
• Printed health education materials
Stage 2: Engage Me
• This stage supports provider interaction with patients to
improve care.

Goal for Provider Goal for Patient

“Help me interact with my patients and “Make it easy for me to understand my
recommend steps they can take to improve provider’s instructions so I can do self-care
their health.” well.”
How to Engage Me
• “Information Therapy” is the prescription of the right
information to the right person at the right time to help
the person make a better health decision or improve a
health behavior.
• Symptom checkers, e-trackers, other web based apps for
convenience
• Patient reminders
Mold, F., Raleigh, M., Alharbi, N. S., & de Lusignan, S.
(2018). The Impact of Patient Online Access to Computerized
Medical Records and Services on Type 2 Diabetes:
Systematic Review. Journal of Medical Internet
Research, 20(7), e235. http://doi.org/10.2196/jmir.7858
Stage 3: Empower Me
• This stage enables patients to become an integral part of
the care team.

Goal for Provider Goal for Patient

“The information I learn from my patients “Make it easy for me to be a part of my
helps me provide better care.” healthcare team.”

38
How to Empower Me
• Pre-visit interactions
• E.g. Zoomcare, Inc
• Secure messaging – safe two-way communication (add
time dimension, add value to the office visit, allows the
full care team to become involved)
• Patient engagement campaigns
• E.g. http://www.makemyhealth.me/

39
Stage 4: Partner with Me
• This stage facilitates provider-patient partnership through
shared care planning.

Goals for Provider and Patient

“Help us clarify and record what we know and do together to manage
patient health.”

41
How to Partner with Me
• Shared accountability
• Personal care plan
• Personal preferences and values are honored

42
Stage 5: Support My e-
Community
• This stage expands the network of patient support to
include community.

Goal for Provider and Patient Goal for Community

“Expand and include the co-producers of “Make it easy for me to support the
health of the patient.” patient.”

43
How to Support My e-
Community
• e-health community
• E.g. Trilogy Integrated Resources
• RWJF Health and Health Care in 2032 – creating culture of
wellness
Results of PE
• Reduction in hospital admission
• Reduce readmission
• Lower Costs
Conclusion
• The tools can influence the achievement of better care,
better health, and lower costs

48
Chapter 9
Health System
Navigation: The Role
of Health Advocacy
and Assistance
Programs
Characteristics of the U.S.
Healthcare System
• Disorganized—both benefits and medical delivery
• Expensive—we spend more per capita than any other
developed country
• Technologically sophisticated and often designed for
provider convenience, not consumer’s
• Complexity frustrates consumers
 Taking a “Populations” Approach Can
Help Target Interventions
Every person can be placed in one or more groups
according to health-related factors:
• Conditions—asthma, heart disease, etc.
• Level of health spending
• Medications
• Employer
• Type of health insurance coverage
• Provider(s)
 From Health Advocacy
Perspective, There Are Only Two
Populations of People

• Those who have a health problem

• Those at risk of getting a health problem

Regardless of which group a person is in, help

navigating the healthcare system is useful.
 Of Those with a Health Problem,
Health Advocates Recognize
Two Types of Health Consumer
• Those who can find their way through the healthcare
maze
• Those who cannot

Those who cannot find their way through the healthcare

system are unlikely to reach the best possible outcomes
and will drive up costs unnecessarily.
 Private Health Advocacy
Programs

• Recent development—last 15 years

• Fee-based—paid either by employer or consumer
directly
• Employer benefit model has gained significant traction
• Work in concert with patient’s physicians
 Goals of Health
Advocacy Programs
• Consumer engagement in health decisions?
• Provide consumer education?
• Change consumer behavior?
• Improved employee productivity?
• Or, just help people cope and find solutions?
 Factors Driving Health Advocacy
• Healthcare cost increases
• Complexity of health benefits programs
• Consumers being asked to assume greater responsibility for
managing their own health
• Medical care system disorganization and inefficiencies
• Problems getting access to care
• Increasing medical technology and super-specialization
• Information overload
• Increasing focus on quality of care and patient safety
• Difficulty of managing a parent’s health issues
• Privacy concerns of employees with health issues
• No where else to turn for help
 Employer’s Perspective
• Employer’s perspective:
– More American adults get benefits through their
employers than other sources
– 91% of employers with >50 employees offer health
benefits
– Kaiser Family Foundation: 2013 health premium for a
family of four = $16,351
– 2003–2013 family health insurance premiums grew
by 80%
 Employer’s Perspective

• Main focus is on cost of health benefits

• Want “value” for their investment
• Recognize that good health is good for business
• Attempts to constrain costs have resulted in multi-
layered, difficult to use, benefit programs
 Small Employer’s Perspective
(<100 employees)
• Usually “insured”—pays premium to health plan that
bears financial risk
• Offers relatively standard insurance programs
• Few staff at employer to help resolve employee issues
• Benefit brokers play a big role in selling and after-sale
support
 Middle Market Employer’s
Perspective (100–1,500 employees)

• Mix of insured (smaller) to “self-insured” programs

• Self-insured companies hire an administrator—could be a
health plan or a third party administrator (TPA)
• Start to see some customization of benefits—e.g., carve-
out pharmacy benefits to a pharmacy benefit manager
(PBM)
• Consultants as well as brokers sell and support clients
 Large Employer’s Perspective
(>1,500 employees)
• Nearly all are “self-insured”
• Plan administrator likely to be a health plan
• Customized benefits—“best of breed” approach
• Examples of carve-out programs:
– Pharmacy benefit manager (PBM)
– Mental health manager
– Disease management
– Case management
– Employee assistance program (EAP)
– Nurse triage service
– Dental plan
– Wellness program
Consumer’s Perspective—Consumer-
Driven Health Care
• Preferred provider organization plans (PPO) dominate the
benefits landscape
• In- and out-of-network benefits introduce complexity—
reasonable and customary (R&C) reimbursement and balance
billing
• High-deductible, “consumer-driven” health plans (CDHP)
 High-Deductible Health Plans
• Consumer has more “skin in the game”
• Does having to spend more of your own money make you
a “better” health consumer?
• Data shows people in these plans spend less than non-
CDHP
• Consumers need help understanding provider cost and
quality measures
• Population health outcomes under CDHP as yet unknown
 Physician’s Perspective
• Some physicians will try to help patients deal with administrative
issues—to a point
• Don’t have the time or the skills—prefer to focus on clinical
issues
• Don’t get paid for helping patients deal with their health
benefits
• Support health advocacy programs that reinforce their
treatment plan and support their doctor-patient relationship
 Health Plan and
Administrator’s Perspective
• Some health plans have enhanced member service
functions or their own advocacy programs.
• Consumers in general do not trust their health plan.
• 2/3 of consumers worry that health plan cares more
about making money than doing the right thing for
members.
• Almost 50% of consumers report having had a problem
with their health plan in the last year.
• Health plans may include advocacy support as a
“differentiator” in the marketplace.
 Health Advocacy as an
Independent Service
• Engage the individual at their time of need
• Typically opt-in programs, not data driven
• Create trusted relationship with user
• Protect privacy—HIPAA
• Personal relationship between user and advocate
• Provide help with any health-related issue facing
consumer
 What Help Do Consumers Need?
• Utilization of advocacy services—6% to 10% in large
companies, 10% to 15% in small companies
• Use often mirrors what is going on in employer’s benefits
program—change of carrier, plan design, etc.
• Over half of all initial calls related to an administrative
issue—bills, benefits, appeals, denials, grievances
• Cross relationship between types of issues—clinical issues
often lead to administrative concerns and vice versa
• The people who call needed some type of care for some
medical issue and have a question or problem
 What Help Do Consumers Need?
• Access to care issues:
– Finding physicians for common needs
– Identifying specialists
– Second opinions
– “Best” doctors, hospitals
– Network participation status
– Personal desires and preferences
– Scheduling appointments
– Getting medical records transferred
 What Help Do Consumers Need?
• Single point of contact through the advocacy program
• Making connections to other benefit programs:
– Right time, right place approach to get patient to the right program
to meet their needs
– Referrals to disease management, case management, PBM, EAP,
nurse triage service
– May involve disability carrier, Family and Medical Leave Act (FMLA)
approval
• Provides coordination across a fragmented system
Can We Change Consumer Behavior?

• Consumer-driven health plans assume that the consumer

can be “activated” to engage in their own health
management.
• Those who perform well in consumer-driven plans may
be “different” from the average individual—inherently
more “activated.”
• Advocacy programs can help activate consumers and help
others who merely are trying to cope with their situation.
 Conclusions
• The U.S. healthcare system will continue to struggle until
we find some means to reduce costs.
• Employers will continue to respond to the increased cost
of health benefits by increasing the amount individuals
must pay for their health care.
• Individuals will have to assume a larger role in managing
their own health and making healthcare decisions.
• Health advocacy programs aim to help consumers make
more informed and better health decisions, which can
lower costs and improve outcomes.
Health System Navigation
HCA 428 – Week 13
Learning Objectives
• Examine the forces driving increased demand for health
advocacy
• Review challenges of health benefit programs
• Assess the value of advocacy and assistance programs
Introduction
• Disorganized—both benefits
and medical delivery
• Expensive—we spend more
per capita than any other
developed country
• Technologically sophisticated
and often designed for
provider convenience, not
consumer’s
• Complexity frustrates
consumers
Introduction
• Taking a “Populations” Approach Can Help Target Interventions.
• Every person can be placed in one or more groups according to health-
related factors:
• Conditions—asthma, heart disease, etc.
• Level of health spending
• Medications
• Employer
• Type of health insurance coverage
• Provider(s)
Introduction
• From Health Advocacy perspective, there are only TWO populations of people:
• Those who have a health problem
• Those at risk of getting a health problem
• Regardless of which group a person is in, help navigating the healthcare system is
useful.
Introduction
• Of those with a health problem, health advocates recognize TWO types of health
consumer:
• Those who can find their way through the healthcare maze
• Those who cannot
• Those who cannot find their way through the healthcare system are unlikely to reach
the best possible outcomes and will drive up costs unnecessarily
Private Health Advocacy
Programs
• Developed since 1990s
• Fee-based—paid either by employer or consumer directly
• “Employer benefit” model has gained significant traction
• Work in concert with patient’s physicians
Goals of Health Advocacy
Programs
• Consumer engagement in health decisions?
• Provide consumer education?
• Change consumer behavior?
• Improved employee productivity?
• Or, just help people cope and find solutions?
Factors driving Health
Advocacy
• Healthcare cost increases
• Complexity of health benefits
• Consumers have greater responsibility managing own
health
• Medical care system disorganization and inefficiencies
• Problems getting access to care
• Increasing medical technology and super-specialization

• Information overload
Employer’s Perspective
• More American adults get benefits through their employers than
other sources
• 91% of employers with >50 employees offer health benefits
• Kaiser Family Foundation: 2013 health premium for a family of
four = $16,351
• 2003–2013 family health insurance premiums grew by 80%
Employer’s Perspective
• Main focus is on cost of health benefits
• Want “value” for their investment
• Recognize that good health is good for business
• Attempts to constrain costs have resulted in multi-layered, difficult to
use, benefit programs
Small Employer’s Perspective
(<100 employees)
• Usually “insured”—pays premium to health plan that bears financial
risk
• Offers relatively standard insurance programs
• Few staff at employer to help resolve employee issues
• Benefit brokers play a big role in selling and after-sale support
Middle Market Employer’s Perspective
(100–1,500 employees)
• Mix of insured (smaller) to “self-insured” programs
• Self-insured companies hire an administrator—could be a health plan
or a third party administrator (TPA)
• Start to see some customization of benefits—e.g., carve-out
pharmacy benefits to a pharmacy benefit manager (PBM)
• Consultants as well as brokers sell and support clients
Large Employer’s Perspective
(>1,500 employees)
• Nearly all are “self-insured”
• Plan administrator likely to be a health plan
• Customized benefits—“best of breed” approach
Large Employer’s Perspective
(>1,500 employees)
• Examples of carve-out programs:
– Pharmacy benefit manager (PBM)
– Mental health manager
– Disease management
– Case management
– Employee assistance program (EAP)
– Nurse triage service
– Dental plan
– Wellness program
Consumer’s Perspective
• Preferred provider organization plans (PPO) dominate the
benefits landscape
• In- and out-of-network benefits introduce complexity—
reasonable and customary (R&C) reimbursement and
balance billing
• High-deductible, “consumer-driven” health plans (CDHP)
High-Deductible Health Plans
• Consumer has more “skin in the game”
• Does having to spend more of your own money make you a “better”
health consumer?
• Data shows people in these plans spend less than non-CDHP
• Consumers need help understanding provider cost and quality
measures
• Population health outcomes under CDHP as yet unknown
Physician’s Perspective
• Some physicians will try to help patients deal with
administrative issues—to a point
• Don’t have the time or the skills—prefer to focus on
clinical issues
• Don’t get paid for helping patients deal with their health
benefits
• Support health advocacy programs that reinforce their
treatment plan and support their doctor-patient
relationship
Health Plan’s Perspective
• Some health plans have enhanced member service functions or their
own advocacy programs.
• Consumers in general do not trust their health plan.
• 2/3 of consumers worry that health plan cares more about making
money than doing the right thing for members.
• Almost 50% of consumers report having had a problem with their
health plan in the last year.
• Health plans may include advocacy support as a “differentiator” in
the marketplace.
Health Advocacy as an
Independent Service
• Engage the individual at their time of need
• Typically opt-in programs, not data driven
• Create trusted relationship with user
• Protect privacy—HIPAA
• Personal relationship between user and advocate
• Provide help with any health-related issue facing consumer
What Help Do Consumers
Need?
• Utilization of advocacy services—6% to 10% in large companies, 10%
to 15% in small companies
• Use often mirrors what is going on in employer’s benefits program—
change of carrier, plan design, etc.
• Over half of all initial calls related to an administrative issue—bills,
benefits, appeals, denials, grievances
• Cross relationship between types of issues—clinical issues often lead
to administrative concerns and vice versa
• The people who call needed some type of care for some medical
issue and have a question or problem
What Help Do Consumers
Need?
• Access to care issues:
– Finding physicians for common needs
– Identifying specialists
– Second opinions
– “Best” doctors, hospitals
– Network participation status
– Personal desires and preferences
– Scheduling appointments
– Getting medical records transferred
What Help Do Consumers
Need?
• Single point of contact through the advocacy program
• Making connections to other benefit programs:
– Right time, right place approach to get patient to the right
program to meet their needs
– Referrals to disease management, case management, PBM,
EAP, nurse triage service
– May involve disability carrier, Family and Medical Leave Act
(FMLA) approval
• Provides coordination across a fragmented system
Can We Change Consumer
Behavior?
• Consumer-driven health plans assume that the consumer can be
“activated” to engage in their own health management.
• Those who perform well in consumer-driven plans may be “different”
from the average individual—inherently more “activated.”
• Advocacy programs can help activate consumers and help others
who merely are trying to cope with their situation.
Conclusions
• The U.S. healthcare system will continue to struggle until we find
some means to reduce costs.
• Employers will continue to respond to the increased cost of health
benefits by increasing the amount individuals must pay for their
health care.
• Individuals will have to assume a larger role in managing their own
health and making healthcare decisions.
• Health advocacy programs aim to help consumers make more
informed and better health decisions, which can lower costs and
improve outcomes.
Chapter
10
Transitions of Care
The Goals of Our Health
System

• Better health

• Better care

• Lower cost
Care Management Has Shifted

Acute Care Chronic Care over Time

Episodes
• Diabetes

• Infections • Heart disease
• Trauma and • Cancer
injury • Mental disorders
• Functional
disabilities
 U.S. Chronic Disease Statistics
• ~ 125 million in United States have > 1 chronic condition

• 50% have multiple chronic conditions

• Expected 157 million by 2020

• Prevalence of chronic disease increases with age

Mollica RL, Gillespie J. Care coordination for people with chronic conditions, January 2003.
http://www.partnershipforsolutions.org/solutions/index.html. Accessed April 2, 2014.
Machlin SR. Trends in health care expenditures for the elderly age 65 and over: 2006 versus 1996, August 2009.
http://www.meps.ahrq.gov/mepsweb/data_files/publications/st256/stat256.pdf Medical Expenditure Panel Survey
Statistical Brief #256. Accessed December 17, 2009.
 U.S. Chronic Disease Statistics
• 82% of Medicare beneficiaries > 1 chronic condition

• 25% of Medicare beneficiaries > 4 chronic conditions

• 70% of all deaths are attributable to chronic illnesses

• Medicare beneficiaries with > 4 chronic conditions are 99% more

likely to be hospitalized and receive services from 14 different
physicians (on average)

Hoffman C, Rice D, Sung HY. Persons with chronic conditions, their prevalence and costs. JAMA. 1996;276(18):1473–9.
Wagner EH. Meeting the needs of chronically ill people. BMJ. 2001;323(7319):945–6.
Wolff JL, Starfield B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the
elderly. Arch Intern Med. 2002;162(20):2269–76.
 Pareto Principle Applies
to Health Care

• 20% of the U.S. population consumes 80% of healthcare

resources.

• 5% of the U.S. population consumes 50% of healthcare

resources.

http://kff.org/slideshow/health-spending-trends-and-impact/, see Slide 5. Accessed March 18,

2014.
 Context as a Vital Sign
• Health happens—one person at a time, one day at a
time, one decision at a time
• Within the context of where and how people live:
− Where they work, learn, play, shop
− Influenced by their level of education, income,
employment
− Determined by their access to healthy food, safe
environments, available transportation,
healthcare services
• Health does not happen primarily within healthcare
sector:
− It happens within the context of each person’s life
o Their cultural, social, and economic frameworks are modified
by their values and priorities.
New Models of Care
• Structure
• Health/medical homes
• Community-based care
• From hospital to home
• Function
• Team-based
• Ancillary staff
• Community health workers
• Financial
• Accountable care organizations
• Bundled payment models
• Value-based purchasing
• Risk-based accountability
 Transitions of Care Across the Continuum
• Enhanced assessment of post-hospital needs
• Effective teaching to facilitate learning by the patient
and family caregivers
• Post-hospital care follow-up, including medical and
social services
• Boundary-less transfer of critical information as the
patient transitions to the next clinician or healthcare
organization or home

Institute for Healthcare Improvement, State Action on Avoidable Rehospitalizations (STARR) Initiative,
www.ihi.org/engage/initiatives/completed/STARR/Pages/default.aspx. Accessed April 3, 2014.
Transitions of Care
Performance of the US Health
Care System
• How much the U.S. spends to treat different diseases like
circulatory conditions and cancer?
• How much the U.S. spends on hospital care?
• What are the major drivers in per capita health services
spending?
• What are we getting in return for these higher-cost
treatments?
Source: http://www.healthsystemtracker.org/
Source:
http://www.healthsystemtracker.org
/
Total Spending = $3.2 trillion
Hospital = 32.3%
Physicians & Clinics = 19.8%
Prescription Drugs = 10.1%

Source: Peterson Kaiser Health System Tracker

Health of the Healthcare
System 
The Goals of Our Health
System
Triple Aims:
• Better health
• Better care
• Lower cost
Pareto Principle Applies
to Health Care
• 20% of the U.S. population consumes 80% of healthcare
resources.
• 5% of the U.S. population consumes 50% of healthcare
resources.
Chronic Diseases
• Are the leading causes of death and disability in the US..
• About 86% of annual health spending are for people with
chronic and mental health conditions.
• About half of all adults had one or more chronic health
conditions; 25 % had two or more chronic health
conditions.
• Largely preventable…
Chronic Diseases in America
• Chronic Disease and Wellness in America
• Chronic Conditions in California
• Chronic Conditions & Elderly
• Chronic Conditions Data Warehouse
SOURCE: Chronic Condition Data Warehouse (CCW). Medicare Beneficiary Summary Files.
Care Management Has Shifted

Acute Care Episodes Chronic Care over Time

• Infections • Diabetes
• Trauma and injury • Heart disease
• Cancer

• Mental disorders
• Functional
disabilities
Context as a Vital Sign
• Health happens - one person at a time, one day at a time,
one decision at a time
• Within the context of where and how people live:
− Where they work, learn, play, shop
− Influenced by their level of education, income, employment
− Determined by their access to healthy food, safe environments, available
transportation, healthcare services
• Health does not happen primarily within healthcare sector:
− It happens within the context of each person’s life
− Their cultural, social, and economic frameworks are modified by their values
and priorities.
New Models of Care
• Structure: medical homes, community-based care
• Function: team based, ancillary staffs
• Financial: bundled payment, value-based purchasing, risk based
accountability
New Models of Care :
PCMH
• Patient Centered Medical Home (PCMH)
• Care facilitated between patients and providers
• Use registries, IT, HIE for care coordination
• May not be very cost effective

• For more info:

• https://pcmh.ahrq.gov/
New Models of Care :
ACOs
• Accountable Care Organizations (ACOs)
• Groups of doctors, hospitals and other providers working
together
• Medicare patients
• Meet quality guidelines and contains costs and share the savings
• One sided or two-sided plans
• Still does not meet the all the requirements for chronically ill
older patients
• Care can still be fragmented
• Need coordination by providers continuously
ACOs
• Note the differences between HMO and ACO
• How can ACOs provide better care?
• How does ACO save money for patients?
• How can ACOs make money for themselves?

• https://youtu.be/ZsDfNov5CiM
Emerging Concepts
• Emerging Concepts in Care coordination
• Medical Neighborhood
• https://pcmh.ahrq.gov/sites/default/files/attachments/Coord
inating%20Care%20in%20the%20Medical%20Neighborhood.pdf
• Connect PCMH to other services such as long term care, acute
care, home health agencies, pharmacies, diagnostics
• Future of Health Care by Barry Bittman
• https://youtu.be/y51eT-1-BE8
Chapter
11
Healthcare Quality
and Safety across
the Care Continuum
 Learning Objectives
• Understand the evolution of the healthcare quality and
safety movement in the United States.
• List and describe the roles of key U.S. quality organizations.
• Explain how quality is measured.
• Describe governmental and private payer strategies for
quality and safety.
• Identify strategies to improve quality across healthcare
sectors.
• Understand the implications of the ACA for healthcare
quality and safety.

130
 Key Terms
• CMS quality initiatives
• Healthcare Effectiveness Data and Information Set (HEDIS)
• Hospital quality improvement
• National Quality Forum
• National Quality Strategy
• Patient safety organizations
• Retail clinic

131
 Evolution of Healthcare
Quality Improvement
• Institute of Medicine (IOM)—To Err Is Human (1999)
– Defined quality as:
• “The degree to which health services for
individuals and populations increase the
likelihood of desired health outcomes and are
consistent with current professional
knowledge”
– Systems, rather than people, are the issue
– What is not measured cannot be improved

132
 Quality Measurement
• Quality measures are developed by stakeholders based on
four criteria:
1. Is there sufficient evidence to indicate that the
measure can affect quality?
2. Is the measure scientifically acceptable to
produce valid and reliable results?
3. Is the measure usable in quality improvement
and decision making?
4. Is it feasible to collect data on the measure?

133
 Challenges to Measuring Quality
and Safety from a Population
Health Perspective

• Health care is delivered in a fragmented system, which

incentivizes volume, and not value, of services.
• With little interoperability among multiple existing health
information systems (HIT), it is difficult to assess the
health status of an individual patient or a population.
• Care for people with chronic conditions is not well
coordinated.

134
 Centers for Medicare and
Medicaid Services (CMS)
• Beginning in 2000, CMS implemented quality initiatives
incrementally, with increasing sophistication to ensure quality
health care for all Americans through accountability and
public disclosure.
• CMS standardized quality data collection and reporting
processes, initially focusing on the hospital setting.
• Current initiatives focus on publicly reported quality measures
for nursing homes, home health agencies, hospitals, dialysis
facilities, and ambulatory care providers.
• CMS launched Medicare.gov quality comparison websites,
where performance by hospitals, physicians, and alternate
care facilities is posted.
135
 National Committee for
Quality Assurance (NCQA)
• NCQA developed the Healthcare Effectiveness Data and
Information Set (HEDIS), which is the most widely
reported set of measures for evaluation of health plan and
provider performance.
• HEDIS measures address a broad range of quality and
safety concerns (e.g., appropriate management of chronic
conditions, access to prenatal services).
• NCQA, and other measure developers, submit quality
measures to the National Quality Forum (NQF) for
endorsement.

136
National Quality Forum (NQF)
• A nonprofit organization dedicated to improving the
quality of health care in the United States.
• NQF embodies a three-part mission:
1. To set goals for performance improvement
2. To endorse standards for measuring and
reporting on performance
3. To promote educational and outreach
programs

137
 Institute for Healthcare
Improvement (IHI)
• Brought together thought leaders to devise strategies for
improving healthcare quality
• Developed and launched Triple Aim, which focused on
enhancing patients’ experience of care, improving the
health of populations, and reducing costs
• Triple Aim became the building block for the National
Quality Strategy (NQS)

138
National Quality Strategy
(NQS)
• Established as part of the Affordable Care Act (ACA), the
NQS serves as a catalyst and a compass for a nationwide
focus on quality improvement efforts and approach to
measuring quality
• The NQS strategy is to concurrently pursue three aims:
• Better health
• Better care
• Lower costs

139
 Role of Health Information
Technology (HIT)
• The American Recovery and Reinvestment Act (ARRA) of
2009 established financial incentives for hospitals and
other providers to invest in and utilize HIT (e.g., electronic
health records) under the Meaningful Use (MU) Program.
• The goal of the MU Program is to build a national HIT
infrastructure that might be leveraged to improve
population health.

140
 Role of Health Information
Technology (HIT)
• HIT has potential for enhancing clinical care processes and
improving health outcomes by:
• Providing clinicians access to current treatment guidelines
and decision-support tools
• Alerting clinicians to patient allergies and potential drug-
drug interactions via electronic prescribing systems
• Helping clinicians identify and manage select patient
populations (e.g., patients with diabetes)
• Helping clinicians track their performance on quality
measures based on comparisons to national benchmarks

141
 Patient Protection and
Affordable Care Act (ACA)
Value-based purchasing:
• Programs vary in design, but share common goal
of decreasing costs and improving quality
• Program components include:
• Defined performance goals for select quality metrics
• Financial incentives for hospitals and individual
providers
• Reported results of pay-for-performance
initiatives are mixed

142
 Patient Protection and
Affordable Care Act (ACA)
CMS Hospital Readmission Reduction Program
• Hospitals are subject to rate reductions for high
rates of readmissions due to conditions deemed
“preventable” (e.g., heart failure, pneumonia)

143
 Patient Protection and
Affordable Care Act (ACA)
Patient-centered medical home (PCMH) model:
• Enhanced, multidisciplinary team care with a
primary care physician coordinating care among
different specialty providers and practice sites
• Improved access to care (e.g., extended hours,
improved patient-provider communication)
• Focus on preventing illness and engaging
patients in their own health

144
 Patient Protection and
Affordable Care Act (ACA)
Accountable care organizations (ACO):
• Affiliations of healthcare providers (hospitals, physicians,
and others) that collectively agree to be accountable for
the health, and associated costs, of a defined population
• ACOs are held accountable for multiple quality metrics
(e.g., preventive screenings, blood pressure control)
• The Medicare Shared Savings Program (MSSP) is an ACO
model that enables providers to share in the cost
savings realized from providing more appropriate, better
quality care

145
Patient Safety Organizations
(PSO)
• The Patient Safety and Quality Improvement Act of 2005
led to the creation of PSOs and a new framework for
collecting, aggregating, analyzing, and more effectively
addressing medical errors and adverse events.
• A PSO is defined as a group, institution, or association that
improves medical care by reducing medical errors.
• An organization can seek PSO status if its primary activity
is to improve patient safety and the quality of healthcare
delivery.
• Information reported to a PSO is protected from legal
liability and professional sanctions.

146
 Inpatient Hospital Quality
Improvement
• Groundwork laid by CMS’ Premier Hospital Quality
Incentive Demonstration project (2003), under which
participating hospitals earned incentive payments for
achieving performance goals on VBP metrics
• Financial penalties were implemented under the Deficit
Reduction Act (DRA) of 2005:
– Hospitals no longer received additional payments
for care rendered to patients with healthcare-
associated conditions

147
 Inpatient Hospital Quality
Improvement
• Under a comprehensive CMS VBP initiative (2012),
payments to hospitals are based on performance in six
domains:
1. Safety
2. Patient- and caregiver-based experience and
outcomes
3. Care coordination
4. Clinical care
5. Population/community health
6. Efficiency and cost reduction
148
 Ambulatory Care Quality
Improvement
• The NQF has endorsed ambulatory measures for assessing
the quality of care in a variety of clinical settings.
• Eligible providers can report on almost 300 unique quality
measures ranging from laboratory values to smoking
cessation counseling.
• CMS’ Physician Quality Reporting System (PQRS) is a
voluntary pay-for-reporting program for Medicare
providers.
• Providers who do not participate in quality improvement
programs are faced with financial penalties.

149
 Quality and Patient Safety in
Alternate Care Settings
• Retail clinics
– Walk-in medical facilities located inside pharmacies
and retail chain stores
– Care is delivered by nurse practitioners, often
without a physician on the premises
– A growing segment of the U.S. population (an
estimated 4.1 million in 2010) visits pharmacy-
based, nurse practitioner-staffed clinics for
preventive and non-emergent care
– The Convenient Care Association publishes quality
standards and conducts quality certification reviews
of member clinics 150
 Quality and Patient Safety in
Alternate Care Settings
• Urgent care centers:
– More than 9,000 facilities operating in 2014
– The American Academy of Urgent Care Medicine
offers an accreditation program and a process by
which organizations can measure their
performance against national benchmarks

151
 Quality and Patient Safety in
Alternate Care Settings
• Long-term care (LTC):
• Concept has evolved to encompass multiple settings and
forms based on the patient’s needs and wishes
• More than 15,000 Medicare and Medicaid certified nursing
homes in the United States
• Current nursing home quality measures are endorsed by
the NQF and publicly reported on the CMS Nursing Home
Compare website
• Under the ACA, LTC hospitals must submit data to CMS on an
increasing number of quality measures (e.g., catheter-associated
urinary tract infections, pressure ulcers, and influenza vaccination
rates of healthcare personnel)
152
 Quality and Patient Safety in
Alternate Care Settings
• Home health care:
– CMS requires more than 10,800 Medicare-certified
home healthcare agencies to collect and report
performance data on the Outcome and Assessment
Information Set (OASIS) tool
– A subset of these quality-based metrics is posted on
Medicare.gov Home Health Compare website
– Currently reported quality measures are related to:
• Managing pain and treating symptoms
• Treating wounds and preventing pressure ulcers
• Preventing harm
• Preventing unplanned hospitalizations
153
 Consumer Perspective
• A goal of the CMS Quality and Safety Strategy for 2013
and Beyond is to promote person and family engagement
as partners in their care.
• The ACA calls for a focus on the patient experience, self-
management, and shared decision making.
• The consensus is that informed, engaged consumers will
select high-quality providers and share in the decision-
making process.
• Consumer Assessment of Healthcare Providers and
Systems (CAHPS) surveys enable objective data collection
and public reporting related to perceptions of health care.

154
Quality & Safety
HCA 428 – Week 10
Triple Aim
Better Better
Patient Populatio
Care n Health

Lower Per
Capita Cost
 IOM “Landmark” Quality
Report
• Between 44,000 to 98,000
people, die in hospitals
each year as a result of
medical errors that could
have been prevented.
• More people die each year
from medical errors in U.S.
hospitals than from traffic
accidents, breast cancer, or
AIDS

157
“Never Event”
Never Events Statistics
The Joint Commission reviewed 805 repots of sentinel events during
2016/ 2017. Below is the 5 most frequently reported in 2017.
• Unintended retention of a foreign body (116 cases)
• Fall (114)
• Wrong-patient, wrong-site, wrong-procedure (95)
• Suicide (89)
• Delay in treatment (66)

Source: https://www.beckershospitalreview.com/quality/13-statistics-on-never-events.html
IOM Report
Focuses more broadly on how
the health system can be
reinvented to foster innovation
and improve the delivery of
care.
Toward this goal, the committee
presents a comprehensive
strategy and action plan for the
coming decade.
Six Aims for Improvements:
Safe, Effective, Patient-centered,
Timely, Efficient, and Equitable.
Six Aims for Improvement
• Safe: avoiding injuries to patients from the care that is intended to help
them.
• Effective: providing services based on scientific knowledge to all who could
benefit, and refraining from providing services to those not likely to benefit.
• Patient-centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient
values guide all clinical decisions
• Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care.
• Efficient: avoiding waste, including waste of equipment, supplies, ideas,
and energy. •
• Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
10 Rules for Redesign
• Care is based on continuous healing relationships.
• Care is customized according to patient needs and values.
• The patient is the source of control.
• Knowledge is shared and information flows freely.
• Decision making is evidence-based.
• Safety is a system property.
• Transparency is necessary
• Needs are anticipated.
• Cooperation among clinicians is a priority.
IOM “Landmark” Quality
Report
• Those errors are caused by “faulty” systems, processes,
and conditions that lead people to make mistakes or fail
to prevent them.
• What is not measured cannot be improved…
 Quality Measurement
1. Is there sufficient evidence to indicate that the measure can affect quality?
2. Is the measure scientifically acceptable to produce valid and reliable
results?
3. Is the measure usable in quality improvement and decision making?
4. Is it feasible to collect data on the measure?

164
 Challenges to Measuring
Quality
• Fragmented health care delivery system
• Lack of “interoperability” among multiple existing health
information systems (HIT)
• Lack of “care coordination” for people with chronic
conditions.

165
Quality “Big Player”
• Centers for Medicare and Medicaid Services (CMS) –
Quality Compare
• National Committee for Quality Assurance (NCQA) - HEDIS
• National Quality Forum (NQF)
• Institute for Healthcare Improvement (IHI) – Triple Aim,
the building block of National Quality Strategy (NQS:
Better Health, Better Care, Lower Cost)
• Patient Safety Organizations (PSO)
Quality & HIT
• The American Recovery and Reinvestment Act (ARRA) of
2009
• The Meaningful Use (MU) Program.
• HIT potentials for enhancing clinical care processes and
improving health outcomes
Quality & ACA
• Value-based purchasing (VBP)
• CMS Hospital Readmission Reduction Program
• Patient-centered medical home (PCMH) model
• Accountable care organizations (ACO)
Quality Improvement
• Inpatient Hospital – 6 domains of VBP
• Ambulatory Care – Physician Quality Reporting Systems
(PQRS)
• Retail Clinics – Convenient Care Association
• Urgent Care Centers - http://aaucm.org/
• Long-term Care
• Home Health Care – OASIS
Quality Improvement
• Partners in their care
• Focus on patient experience, self-management, and
shared decision making
• Informed, engaged consumers will select high-quality
providers and share in the decision-making process
• Objective measures of consumer perceptions: Consumer
Assessment of Healthcare Providers and Systems (CAHPS)
Quality & Safety
HCA 428 – Week 10
Triple Aims
Better Better
Patient Populatio
Care n Health

Lower Per
Capita Cost
National Quality Strategy
Priorities
• Safer care
• Effective care coordination
• Preventing and treating leading causes of mortality and
morbidity
• Person- and family-centered care
• Supporting better health in communities
• Making care more affordable
National Quality Strategy
Priorities
• Making care safer by reducing harm caused in the delivery of care.
• Promoting effective communication and coordination of care.
• Promoting the most effective prevention and treatment practices
for the leading causes of mortality, starting with cardiovascular
disease.
• Ensuring that each person AND family are engaged as partners in
their care.
• Working with communities to promote wide use of best practices to
enable healthy living.
• Making quality care more affordable for individuals, families,
employers, and governments by developing and spreading new
health care delivery models.
Safer Care
• Michigan Keystone Intensive Care Unit Project
• a research team at Johns Hopkins University partnered with the
Michigan Health and Hospital Association to implement CDC
recommendations to reduce central line blood stream infections
in 100 intensive care units throughout the State (The Keystone
Project)
• Safe Use Initiative:
http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/
• to reduce preventable harm by identifying specific, preventable
medication risks and developing, implementing and evaluating
cross-sector interventions with partners who are committed to
safe medication use.
Effective Care Coordination
• Advancing Primary Care Services and Medical Homes
• Multi-Payer Advanced Primary Care Practice Demonstration
• Developing Accountable Care Organizations
• Improving Care Coordination Through Health Information
Technology
• Meaningful Use
Preventing and treating leading
causes of mortality and morbidity
• CDC Community Transformation and Self Management
Grants
• Partnerships to Improve Community Health (PICH)
• Focusing on Priority Conditions
• http://millionhearts.hhs.gov/
• The Strategic Framework on Multiple Chronic Conditions
Person- and Family-Centered
Care
• Hospital Consumer Assessment of Healthcare Providers
and Systems (HCAHPS)
• To patient experience as a factor in quality reporting. The
Affordable Care Act uses HCAHPS as one of the measures to
calculate value-based incentive payments to hospitals beginning
in 2012
• AHRQ’s Patient-Centered Care Improvement Guide
• Establishing the Patient-Centered Outcomes Research
Institute (http://pcori.org/)
Supporting better health in
communities
• First Lady’s Let’s Move! Campaign
• “Circles of Care” initiative
• grants to Tribal communities to develop models of care, create
new partnerships, and help community members to obtain
comprehensive behavioral health services
Making care more affordable
• Establishing Health Insurance Exchanges
• Administrative Simplification
• Fostering Innovations to Promote Quality and Reduce Cost
Priorities in Action
• http://www.ahrq.gov/workingforquality/priorities.htm
Chapter 12
Information
Technology
 Learning Objectives
• Become familiar with the benefits of capturing clinical data
in structured form in an electronic health record (EHR).
• Understand the relationship between point-of-care systems
(e.g., EHRs), surveillance and tracking systems (e.g., patient
registries), and retrospective analytic systems (e.g., data
warehouses).
• Explain some of the challenges of integrating data collected
by a patient’s mobile apps into a provider organization’s EHR.
• Evaluate the strengths and weaknesses of clinical and
administrative data for health services research.
Learning Objectives
(continued)
• Become familiar with ways in which provider
organizations can use population-level analyses for
performance improvement.
• Understand the potential of cognitive systems in assisting
healthcare providers in “keeping up with the literature”
and applying new findings in caring for their patients.
• Recognize critical success factors for EHR implementation
and unintended consequences of inserting information
technology into healthcare workflows.
Paper Medical Records  EHR
• Moving from paper medical records to electronic health records
(EHR) allows for patient-level data to be aggregated to create a
picture of the population, their care, and the outcomes of care.
• EHRs are essential for managing population health, improving
quality, and reducing overall cost.
• Promoting effective use of IT is a key area of focus for U.S.
health policy and health reform.
 The Importance of Structured
Data
• Two key aspects:
• Discrete field (data element) for each concept
• Standard code set (controlled vocabulary) for expressing the data in
each field
• Structured data are “computable”:
• Computer can apply clinical decision support algorithms (e.g., drug
interactions, allergies)
• Less risk of misinterpretation by humans
• Semantic interoperability
 Administrative Data vs. Clinical Data

• Administrative data (claims data):

– Typically insurance claims or bills
– Provide information on service provided, not outcome (i.e., lab
test or diagnostic procedure performed)
– Do not include care coordination, patient outreach, or
education
• Clinical data:
– EHRs allow for more clinical data to be shared (lab results,
physician findings)
– Enable patients and providers a more robust view of the
health of a patient/population
– Limited ability to transfer data between provider networks
 Incentives for EHR Adoption
• Cloud-based systems and federal incentives have
enabled smaller practices to implement EHRs and
practice management systems.
• In 2009, Congress authorized CMS to provide financial
incentives, up to $44,000 per physician for practices and
hospitals that achieve meaningful use of EHRs.
• Incentives began in 2012, with the first 3 stages of
requirements.
• By April 2014, 53% of physicians had received at least one
incentive payment.
 Using Population-Level
Analytics for Improvement
• Process redesign:
• Improve performance (reduce cost) for the typical patient
• Reduce variation
• Care coordination
• Exception management:
• Identify potential outliers for individualized attention
• Case management
• Pareto principle (“80–20 rule”)
 Mobile Health and Social Media
• Technology is rapidly changing the way care is delivered
and received.
• Patients are able to measure a variety of clinical
parameters on their own and communicate with
clinicians.
• Patient portals allow for patients and family members to
participate in patients care, as does telemedicine.
• Demand grows as baby boomers age.
 Systems for Provider
Organization
• IT systems within an organization include 3 major categories:
• Transaction systems
• Population management systems
• Data warehouses and analytics
• Transaction systems generally focus on the individual patient.
• Population management and data warehouses aggregate data
from patients within a provider organization’s population.
Creating Data Warehouses
• Data-driven analysis within and across provider
organizations
• Should include exploratory analysis of data, which
would allow for population-level analysis
• Ontology—hierarchy of concepts:
• Provides a name for concepts within a certain domain and
defines relationships among the concepts:
• Enables asking questions at any level of the hierarchy (e.g., was the
patient on a beta blocker? without having to specify the list of all
beta blockers)
Aggregation of Patient Data
• Longitudinal records—follow an individual patient over
time:
• Only over time can a full picture of a patient’s clinical
condition(s) be appreciated, as the patient receives care for
different conditions
• Integrate records from multiple providers
• Episodes of illness:
• An algorithm using longitudinal data to distinguish acute
episodes from ongoing care
 Enabling Data-Driven
Improvement
• Provider organizations, individual providers, and P4P
programs are evaluated on patient outcomes:
• Many factors other than quality of care can influence outcomes, such as
lifestyle, level of education, socioeconomic status
• Risk adjustment:
• Accounts for patient factors associated with a greater risk of certain
outcomes
• Critical for published provider “report cards” used as a basis for payment

• Clinical/administrative data used for PI and research:

• Internally (e.g., Veteran’s Health Administration and Kaiser Permanente)
• External data sharing (e.g., UHC, AMGA)
• Federally funded (PCORnet)
Health Information Exchanges
• An interoperable health information network
• Providers and patients can access and securely share patients’ vital
medical information electronically:
• Meant to improve speed, quality, safety, and cost of care
• Governed by the Office of the National Coordinator for Health
Information Technology (ONC):
• Operated by local, state, and regional organizations
• Blue Button initiative
• Challenges:
• Technology
• Culture
 Public Health Informatics
• Understand patterns of disease and needs for health services
(including prevention), for an entire population
• The “population view” in a provider or payor database is usually
a patient or beneficiary population, not the entire population
• Relies heavily on survey data (census, CDC)
• Surveillance is an important function:
• “Reportable” diseases
• HIEs allow for more effective surveillance
• Pharmacovigilance
 “Big Data” and Cognitive
•
Systems
Big data:
• Used for more than building warehouses and collecting known data sets
• Collect data from diverse sources without mapping
• Automated “knowledge discovery”
• Identify genetic variants that predispose to certain diseases
• Cognitive systems:
• Genomic profile
• IBM Watson
• Natural language processing
• Future of clinical decision support
 IT Implementation—Process Redesign and
Cognitive Support

• Clinical and operational leaders’ support is critical for a

successful EHR implantation.
• Redesign the care process to take advantage of IT:
• Recognize efficiencies and improvements
• Create a communication channel to avoid “alert fatigue”:
• Too many trivial alerts and reminders from an EHR
• Important alerts are ignored or missed
• Capturing structured data in an EHR allows alerts to be fine-
tuned for appropriateness
 IT Implementation—Process Redesign and
Cognitive Support

• “Culture eats strategy for breakfast”

• Create standard protocols and decision support
rules/tools
• View the EHR transition as part of a fundamental
transformation in practice
Conclusion
• Adoption of IT will enable better decision making in caring for
individuals and managing population health.
• EHRs and registries play an essential role in implementing what is
learned from data warehouses and improvement initiatives.
• Health care is on the threshold of another dramatic change
enabled by IT: over the next decade the availability of genetic
information will add a highly personalized approach to preventing,
diagnosing, and treating a variety of health conditions.
• Telemedicine will continue to transform “traditional” care delivery.
Information
Technology
HCA 428 – Week 12
Learning Objectives
• Understand the benefits of EHR
• Understand types of data
• Explain some challenges of mobile apps
Introduction
• “Good data are the cornerstone of PHM”
• HIT is moving beyond traditional, provider-focused
systems.
• Provider-payer data integration
• Patient (consumer) self management tool
• Customized (personalized) approach in preventing,
diagnosing, and treating variety health conditions.
Paper Medical Records  EHR
• Allow for patient-level data
to be aggregated to create a
picture of the population,
their care, and the
outcomes of care.
• Managing population
health, improving quality,
and reducing
overall cost.
• Key areas of focus for policy
and reform.
• Patient Level – improve clinical workflow, evidence based
decision making, and team based care
• Population Level – for care & learning
• For care – identifying patient at risk
• For learning – enhance practice
Unstructure
Structured
d
Data
Data

Database

Everything Else Semantic

Interoperable
Not Relational &
No Pre-defined
Model Computable
Administrative vs. Clinical
Data
ADMINISTRATIVE DATA
Typically insurance claims or bills
Provide information on service provided, not
outcome (i.e., lab test or diagnostic procedure
performed)
Do not include care coordination, patient outreach,
or education
CLINICAL DATA
EHRs allows clinical data to be shared (lab
results, physician findings)
Enable patients and providers a more robust
view of the health of a patient/population
Limited ability to transfer data between
provider networks
Incentives for EHR Adoption
• Cloud-based systems/federal incentives have enabled smaller
practices to implement EHRs and practice management systems.
• In 2009, Congress authorized CMS to provide financial incentives, up
to $44,000 per physician for practices and hospitals that achieve
meaningful use of EHRs.
• Incentives began in 2012, with the first 3 stages of requirements.
• By April 2014, 53% of physicians had received at least one incentive
payment.
Mobile Health and Social
Media
Increase Patient Engagement:
• Patients are able to measure a variety of clinical parameters on their
own and communicate with clinicians.
• Patient portals allow for patients and family members to participate in
patients care, as does telemedicine.
• Online community support
Issues?
IT Systems for Provider
Organization
• Transaction systems: focus on individual patient
• Population management systems: aggregate data from
patients within a provider organization’s population
• Data warehouses and analytics
Creating Data Warehouses
• Data-driven analysis within and across provider organizations
• Should include exploratory analysis of data, which would allow for
population-level analysis
Aggregation of Patient Data
• Longitudinal records—follow an individual patient over time:
• Only over time can a full picture of a patient’s clinical condition(s) be
appreciated, as the patient receives care for different conditions
• Integrate records from multiple providers
• Episodes of illness:
• An algorithm using longitudinal data to distinguish acute episodes from
ongoing care
Enabling Data-Driven
Improvement
• Patient outcomes
• Provider organizations, individual providers, and P4P programs are
evaluated on outcomes
• Many factors other than quality of care can influence outcomes, such as
lifestyle, level of education, socioeconomic status
• Risk adjustment:
• Accounts for patient factors associated with a greater risk of certain
outcomes
• Critical for published provider “report cards” used as a basis for payment
• Clinical/administrative data used for planning/research:
• Internally (e.g., Veteran’s Health Administration and Kaiser Permanente)
• External data sharing (e.g., UHC, AMGA)
• Federally funded (PCORnet)
Using Population-Level
Analytics for Improvement
• Process redesign:
• Improve performance (reduce cost) for the typical patient
• Reduce variation
• Care coordination
• Exception management:
• Identify potential outliers for individualized attention
• Case management
• Pareto principle (“80–20 rule”)
Health Information Exchanges
• An interoperable health information network
• Providers and patients can access and securely share patients’ vital
medical information electronically:
• Meant to improve speed, quality, safety, and cost of care
• Governed by the Office of the National Coordinator for Health
Information Technology (ONC):
• Operated by local, state, and regional organizations
• Blue Button initiative: http://bluebuttonconnector.healthit.gov/
• Challenges:
• Technology
• Culture
Public Health Informatics
• Understand patterns of disease and needs for health services
(including prevention), for an entire population
• The “population view” in a provider or payor database is usually a
patient or beneficiary population, not the entire population
• Relies heavily on survey data (census, CDC)
• Surveillance is an important function:
• “Reportable” diseases
• HIEs allow for more effective surveillance
• Pharmacovigilance
“Big Data” and Cognitive
Systems
• Big data:
• Used for more than building warehouses and collecting known data sets
• Collect data from diverse sources without mapping
• Automated “knowledge discovery”
• Identify genetic variants that predispose to certain diseases
• Cognitive systems:
• Genomic profile
• IBM Watson
• Natural language processing
• Future of clinical decision support
IT Implementation—Process
Redesign and Cognitive Support
• Clinical and operational leaders’ support is critical for a successful
EHR implantation.
• Redesign the care process to take advantage of IT:
• Recognize efficiencies and improvements
• Create a communication channel to avoid “alert fatigue”:
• Too many trivial alerts and reminders from an EHR
• Important alerts are ignored or missed
• Capturing structured data in an EHR allows alerts to be fine-tuned for
appropriateness
IT Implementation—Process
Redesign and Cognitive Support
• “Culture eats strategy for breakfast”
• Create standard protocols and decision support rules/tools
• View the EHR transition as part of a fundamental transformation in
practice
Conclusion
• Adoption of IT will enable better decision making in caring for
individuals and managing population health.
• EHRs and registries play an essential role in implementing what is
learned from data warehouses and improvement initiatives.
• Health care is on the threshold of another dramatic change enabled
by IT: availability of genetic information will add a highly personalized
approach to preventing, diagnosing, and treating a variety of health
conditions.
• Telemedicine will continue to transform “traditional” care delivery.
Chapter
13
Decision Support
Executive Summary
• Measurement provides decision support and drives
innovation.
• Three main purposes of measurement in population
health:
• Improvement
• Accountability
• Research
• Decisions in the areas of improvement,
accountability, and research require different types
of decision support.
Learning Objectives
• Distinguish among the three purposes of population
health measurement and the various approaches for each
purpose.
• Describe the Model for Improvement and its associated
tools.
• Learn about the key metrics for the Triple Aim.
• Provide a framework for assessing value in population
health.
• Learn about the major types of population health and
health services research.
Measurement for Improvement:
The Model for Improvement
• Part One—Three Questions:
• What are we trying to accomplish?
• How do we know that a change is an improvement?
• What change can we make that will result in an improvement?
• Part Two
• Rapid and continuous cycles of Plan-Do-Study-Act
Measurement for Improvement:
Predictive Modeling
• Key Predictive Modeling Questions:
• What are you predicting?
• Why are you predicting it?
• How accurate is your prediction?
• What actions are taken based on the prediction?
• Quality of Predictive Models:
• Sensitivity
• Specificity
Measurement for
Accountability
• Measuring the Triple Aim:
• Population health
• Care experience
• Per capital cost
• Measuring value and efficiency:
• Value
• Efficiency
• Return on investment (ROI)
Measurement for
Accountability:
Measuring Value and Efficiency
• Value
–Worth, utility, or importance in
comparison with something else
• Efficiency
–Cost of care associated with a specified
level of quality of care
• Return on investment
–The size of a return relative to an
investment
Measurement for Research
• Efficacy research
• Whether or not an intervention can work under ideal conditions
• Effectiveness research
• Whether an intervention works in routine clinical care
• Comparative effectiveness
• Cost effectiveness
Conclusions
• Decision support tools and methods used in population
health depend on the kinds of decisions needing support:
• Improvement
• Accountability
• Research
• It is important to consider how they fit together into an
integrated analytic and evaluation system.
Decision Support
HCA 428 – Week 12
Learning Objectives
• Distinguish among the three purposes of population health
measurement and the various approaches for each purpose.
• Describe the Model for Improvement and its associated tools.
• Learn about the key metrics for the Triple Aim.
• Provide a framework for assessing value in population health.
• Learn about the major types of population health and health services
research.
Introduction
• Measurement provides decision support and drives innovation.
• Three main purposes of measurement in population health:
Improvement, Accountability, and Research
• Decisions in the areas of improvement, accountability, and research
require different types of decision support.
Measurement for Improvement:
The Model for Improvement
• Part One—Three Questions:
• What are we trying to accomplish?
• How do we know that a change is an improvement?
• What change can we make that will result in an improvement?
• Part Two
• Rapid and continuous cycles of Plan-Do-Study-Act
Measurement for Improvement:
Predictive Modeling
• Key Predictive Modeling Questions:
• What are you predicting?
• Why are you predicting it?
• How accurate is your prediction?
• What actions are taken based on the prediction?
• Quality of Predictive Models:
• Sensitivity
• Specificity
Measurement for
Accountability
• Measuring the Triple Aim:
• Population health
• Care experience
• Per capital cost
• Measuring value and efficiency:
• Value
• Efficiency
• Return on investment (ROI)
Measurement for Accountability:
Measuring Value and Efficiency

• Value
– Worth, utility, or importance in comparison with
something else
• Efficiency
– Cost of care associated with a specified level of quality of
care
• Return on investment
– The size of a return relative to an investment
Measurement for Research
• Efficacy research
• Whether or not an intervention can work under ideal conditions
• Effectiveness research
• Whether an intervention works in routine clinical care
• Comparative effectiveness
• Cost effectiveness
Conclusions
• Decision support tools and methods used in population
health depend on the kinds of decisions needing support:
• It is important to consider how they fit together into an
integrated analytic and evaluation system.