Clinical and Technology Integration to Support Transformation

1. Clinical and Technology Integration to Support Transformation November 7, 2013 Stephen A. Morgan, M.D. Chief Medical Information Officer Senior Vice President Carilion Clinic

2. Greetings from Western Virginia

4. Carilion Clinic continues to be the premier healthcare delivery system in western Virginia • Accountable medical group with approximately • 600 physicians, • 150 advanced care practitioners • 300 affiliated physicians. • 850,000 primary care visits and 50,000 urgent care visits • Full or partial interests in eight hospitals • Full range of services and an active graduate medical education program • 56 percent inpatient market share in total service area • More than twice that of nearest competitor (HCA) • Health plan • Offering Medicare advantage and Medicaid plans • The Market • 85% FFS • Dominant payor with 70% market share

5. Carilion Clinic Mission: Improve the Health of the Communities We Serve Vision 2017: We are committed to a Common Purpose of Better Patient Care, Better Community Health and Lower Cost

6. Building Blocks of our Success Physician leadership Technology EHR - Data Analytics -

7. Building Blocks of our Success Patient Engagement Partnerships Payers Service Providers Provider Engagement

8. What’s Driving Change • Rising health care costs • Unstable economy • Changes in consumer demand • Advances in technology • Generational differences in physician work/life balance • Working “to license” • Working in teams • Workforce shortages

9. An all too familiar story…

10. Our National SpendAverage Healthcare Spending per Capita,1980–2009Adjusted for differences in cost of living Dollars THE COMMONWEALTH FUND Source: OECD Health Data 2011 (June 2011).

11. Life expectancy improved by 3 years • Years with disability increased • US fell from 14th to 26th compared to other nations. • Leading cause for premature deaths include • CVD • Lung Cancer • CVA • Leading cause of Disabilities • Back Pain • Musculoskeletal issues • Depression / Anxiety

12. Demographic Trends 1/3 US population – Baby Boomers 10,000 people a day reach 65 1 in 10 Baby Boomers is managing multiple chronic illnesses; by 2030: 1 in 4 have diabetes 1 in 2 have arthritis 1 in 2.5 will be obese Treatment of patients with co-morbities cost 7 x those without chronic illness 2/3 Medicare spending - 5 or more chronic conditions

13. Health Care Costs Concentrated in Sick Few—Sickest 10 Percent Account for 65 Percent of Expenses 1% 5% 22% $90,061 10% 50% $40,682 65% 50% $26,767 97% $7,978 Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2009 Annual mean expenditure Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.

14. Challenges with Today’s Care • Healthcare costs growing; burden to business • Overuse; volume “treadmill” • Inconsistent care; fragmentation • Lack of coordination • Payment model at odds with countering rising costs • Data held “close to the vest”

15. Improve access • Improve health outcomes • Reduce cost The Hope

16. The Strategy: Follow the Money • To optimize the healthcare dollar and improve health outcomes, both government and private payers are (gradually) shifting from volume-based reimbursement to value-based reimbursement

17. Emerging Payment Models • Bundle payments • Pioneer ACO • MSSP • ACO: Advanced payment model • FQHC • Medical Homes • Value based payment models-P4P • State engagement models – for integration of dual eligible individuals

18. Is Reform Possible? • Able to manage risk • Integration • Engaged physician leadership • Effective health information management • Time to change – pace

20. Our Areas of Focus • Population Health • PCMH • Care coordination for high-risk and high-frequency patients • Wellness, prevention, Choosing Wisely • Payment reform • Provider Engagement • Health IT • Integration

21. Phm Initiatives

22. System PHM Initiatives • Transformation Oversight Committee • Oversees work of committees in 3 areas: • Care Integration • Informatics • Finances/Contracting • Initial focus on COPD • Led by Chief Strategy Officer

23. System PHM Initiatives Problem Focus Areas Patient Risk Levels

24. System PHM Initiatives

25. Carilion Clinic: PCMH Today Total Program Sites: 27 • Family Medicine - 21 • Internal Medicine - 4 • Pediatrics - 2 Recognition Status • Level 3 Recognition – 27 Panel Size: 200,000 • 77% of Department Patients Providers: 136 • Physicians - 106 • ACPs - 30 Care Coordinators • Budgeted Positions: 22 FTEs

26. Payment Reform

27. Accountable Care Activities • Payor Arrangements • Managed Medicare and Medicaid • Owned – Medicaid HMO • MajestaCare • Contracted MAP • Humana, UHC • Aetna ACO (Whole Health) • Doctors Connected • ACO • MSSP • Commercial • Anthem PC2

28. Provider engagement

29. Physician Compensation • Moving from Volume to Value • Major Components: • Personal RVUs (~ 85%) • ACP oversight (RVUs) (~ 5%) • Performance metrics (~ 10%) • Panel size • Quality metrics • Expense management

30. Care Integration • Sub-Group of Transformation Oversight • Oversight of integrated projects • Representatives from all departments • Education for first year • Payment reform • Understanding our data / opportunities • Process improvement • Transitions of care • Employed providers

31. Working with Community Providers • Open Medical Model - Hospitals • Involvement of medical directors with LOS committee • Data sharing and transparency • Involvement in decision making • EMR • Joint leadership and affiliation

32. Healthcare IT and Accountable care

33. “Health IT is essential not only to accountable care organizations (ACO) but also healthcare in general” Kathleen Sebelius, MPA, Secretary of the U.S. Department of Health & Human Services

34. Population Health Management • Fundamental to every major healthcare reform initiative today • Patient-Centered Medical Home • Accountable Care Organization • EHRs alone are not sufficient to manage populations effectively • Provider groups and health systems that automate the spectrum of population health functions will be best positioned to succeed

35. Healthcare IT and ACOsThe Critical List • Population identification - attribution • Identification of care gaps – Decision Support • Risk Stratification • Cross Continuum Care management • Quality and Outcomes measurement • Patient engagement • Telemedicine • Mixing claims and clinical data • Predictive modeling • Clinical information exchange

36. Patient engagement

38. Bridging the gap between home, hospital , office and beyond…

39. Care Coordination

40. Chronic Disease Registries

41. High Risk Patients for Re-admission

42. Care Plans Across the Continuum • Developing a disease management section in the EMR navigator • High risk patients flagged • Using problem lists and linked episodes • Viewed by IP, AMB, and ED.

43. Transparent Data delivery to Providers

48. Primary Care Group Dashboard

49. Payor Data

50. ED Frequent Flyers