Improving Care Coordination and Readmissions Using Real Time Predictive Analytics from an HIE

1. Improving Care Coordination and Readmissions Using Real Time Predictive Analytics from an HIE New Jersey / Delaware Valley HIMSS Conference Atlantic City, NJ October 29, 2015

2. Speakers Dev Culver, Executive Director, HealthInfoNet Eric Widen, CEO, HBI Solutions

3. Agenda • Background • HealthInfoNet • HBI Solutions • Case study: St. Joseph’s Healthcare • Summary and Q&A

4. Background: HealthInfoNet Quick Facts • Founded 2004 • Independent, nonprofit organization • Operates the Maine HIE • Provides a single, state-wide electronic patient health record • Real time data from provider electronic health records • Data is standardized and aggregated • Provides reporting and alerts • Disease reporting to CDC • Real time clinical rules and alerts • Predictive risk scores

5. Background: HealthInfoNet Key Data • HL7 messages • ADT • Laboratory orders and results • Outpatient prescriptions • Clinical notes and documents • Coding Connections • 35 of 37 hospitals (all to connect in 2014) • 38 FQHC sites • 400+ ambulatory sites Key Statistics • >1.4 million patients • >600,000 annual encounters • >3500 users

6. Background: HBI Solutions • Healthcare analytics company founded in 2011 • Based in Silicon Valley • Leader in real time patient risk applications • Applications are used by providers, payers, ACOs and HIEs HBI team collective experience • Unique talent and experience: • Stanford researchers, data scientists • Frontline physicians • Performance improvement practitioners • Healthcare IT executives Mission: Improve patient and member health using data science to predict health risks and reduce practice variation

7. Background: HIE Analytic OfferingModules • Identify populations and individuals most at risk for future high costs, inpatient admissions, and emergency room visits. • Identify inpatient encounters most at risk for 30-day readmissions or 30 day ED revisits. • Understand resource variation by disease and cost category (length of stay, laboratory, radiology, etc...) to reduce unnec­essary practice variation. • Compare actual to target performance for key performance indicators (KPI) using case mix and severity adjusted targets, including statewide norms. • Track and trend volumes and market share by service area, disease, payer and patient demo­graphics. • Population Health • 30-Day Readmission / Return Risk • Variation Management • Hospital Performance • Volume and Market Share

8. Background: HIE Analytic OfferingPredictive Risk Models Patient History Patient Risk of Event or Outcome Risk Model Development • Available Risk Models • Population Risk Models • (predicts future 12 months) • Predicted future cost • Risk of inpatient admission • Risk of emergency dept (ED) visit • Risk of diabetes • Risk of stroke • Risk of AMI • Risk of hypertension • Risk of mortality • Event Based Risk Models • (predicts future 30 days) • Risk of 30 day readmission • Risk of 30 day ED re-visit Multivariate Statistical Modeling – Decision Tree Analysis Machine Learning • 1000s of Patient Features • Age • Gender • Geography • Income • Education • Race • Diagnoses • Procedures • Chronic conditions • Visit and admission history • Outpatient medications • Vital signs • Lab orders and results • Radiology orders • Social characteristics • Behavioral characteristics

9. Background: HIE Analytic OfferingPredictive Risk Use Cases

10. Background: HIE Analytic OfferingAdoption The following types of healthcare organizations are using the HIE analytic applications for predictive risk management, population health management, budget forecasting, market share intelligence, and throughput management. • Health Systems • Fee for Service Community Hospitals • ACOs • Medical Group with Insurance Product • State Medicaid Program • Federally Qualified Health Centers

11. Case study: St. Joseph Healthcare

12. Background: Saint Joseph Healthcare • Healthcare system in Bangor ME • 112 bed acute care community hospital • Primary care and specialty physician practices • 20,000 covered lives • Partner with FQHC • Participates in several ACOs • Medicare shared savings • Medicaid • Commercial: CIGNA, Anthem, Harvard Pilgrim • Using real time predictive risk scores daily to manage patients

13. Workflow:Ambulatory Patient Risk Management St. Joe’s Ambulatory Patient Population Management 20,000 Patients Assigned to St. Joe’s PCPs Ambulatory based care managers assess real time population risk scores, including patient risks for costs, admission, ED visit, disease, and mortality. The practice sets thresholds for each risk category to flag “high” risk patients. Care managers proactively reach out to high risk patients to provide education and manage care gaps. Medium Risk Low Risk High Risk

14. Workflow:Ambulatory Patient Risk Management Population Health Dashboard / Patient List – Understand patients at risk for ED visits, IP admissions, disease and cost

15. Workflow:Ambulatory to Acute Patient Risk Management St. Joe’s Acute Inpatient and Emergency Patient Risk Management 6,000 Annual Inpatient Discharges 20,000 Annual Emergency Visits St. Joe’s Ambulatory Patient Population 20,000 Patients Assigned to St. Joe’s PCPs Medium Risk Low Risk High Risk % Visit St. Joe’s Hospital Community At Large Population Medium Risk Low Risk High Risk % Visit St. Joe’s Hospital Upon admission, hospital based care managers assess real time risk scores for 30 day return to the hospital, and develop appropriate discharge plans Medium Risk Low Risk High Risk

16. Workflow:Ambulatory to Acute Patient Risk Management Inpatient Encounter List – Understand patients at risk for 30 day readmissions

17. Workflow:Acute to Ambulatory Patient Risk Management St. Joe’s Acute Inpatient and Emergency Event Management 6,000 Annual Inpatient Discharges 20,000 Annual Emergency Visits St. Joe’s Ambulatory Patient Population 20,000 ACO Patients Assigned to St. Joe’s PCPs Patients discharge back to home Medium Risk Medium Risk Low Risk Low Risk High Risk High Risk Community At Large Population Post discharge, patients assigned to St. Joe’s PCPs are handed off to the ambulatory care manager for follow up. Patient’s risk drives the post-discharge care plan. Medium Risk Low Risk High Risk

18. Results: St. Joe’s Readmission Rate Trend Reduced readmission rate overall and below target Target (State Adjusted Norm) Performance Actual Performance

19. Saint Joseph Summary Findings • Real time risk scores using clinical data from EHR • Time savings and productivity improvement • Algorithms have identified at-risk patients that would have been missed • Algorithms provide better prediction at the higher risk levels • HIE provides longitudinal patient record across Maine • Risk scores are helpful - a robust care team and processes, however, are required to impact patient outcomes • We use analytics across the care continuum