Keystone Summit 2016
Population Health IT Definition

The results of this summit are publicly shared in an effort to improve the success with which population health IT solutions are deployed and adopted.

Provider Population Health IT Framework

Objective

Define core competencies of a provider population health IT solution and recognize the vendors that have developed and widely implemented these solutions. This framework was developed to differentiate current technologies, with an expectation that it will need to evolve in parallel with the evolution of the population health IT market.

VERTICAL 1

Aggregation

Compilation of disparate clinical/ administrative data sources to support population health

Basic Functionalities

• Ability to incorporate data using common industry standards
• Timely aggregation/incorporation of
  • ADT feeds
  • Pharmacy, prescription data
  • Claims/payer data
  • Inpatient clinical (EMR) data
  • Outpatient clinical (EMR) data
• Aggregation of data from multiple, disparate sources
• Incorporation of platform-generated data (such as assignments to registries)
• Ability to normalize and clean incoming data
• Reliable MPI (including duplicate record merging/deletion)
• Compilation of a longitudinal record (multi-sourced longitudinal summary of all clinical activity, including clinical, claims, and care management interventions)

Advanced Functionalities

• Integration with other organization MPIs
• Advanced data quality monitoring tools (automated recognition and flagging)
• Data quality monitoring tools
• Aggregation of
  • Patient-sourced data
  • Social determinants of health/community health data
  • Nontraditional data sets (i.e. public data sets, genomics, bio-market structures, etc.)
  • Imaging data

VERTICAL 2

Analyze

Segmentation of aggregated data to communicate meaningful information

Basic Functionalities

• Functionality to assign patients to registries (patient/risk stratification)
• Configurable functionality to attribute patients to care providers
• Quality measures and analytics (including MIPS, MACRA, etc.) scaled down to individual facility/caregiver level
• Integration with visualization tools
• Physician scorecard and dashboards
• Common predictive analytics (i.e. readmission risk)
• Goal targets/simple benchmarking (internal, static) including customized outcomes measurement tracking
• Regulatory reporting compilation and submission (if applicable)

Advanced Functionalities

• Advanced benchmarking (including external and dynamic benchmarks)
• Meaningful advanced predictive analytics (i.e. big data analytics, individualized disease progression)
• Analysis of data on social determinants of health

VERTICAL 3

Care Coordination/Health Improvement

Scalable care management support for standardized interventions

Basic Functionalities

• Configurable care plans
• Program management (including care coordination and care management)
• Making the care plan accessible across the continuum of care
• Tools for care managers (within-team communication, reference materials, consolidated patient view)
• Tools to manage care managers (monitoring of CM team including time spent, members reached, programs initiated and completed, etc.)
• Chronic disease management
• Online health risk assessments

Advanced Functionalities

• Single view of longitudinal data

VERTICAL 4

Administrative / Financial

Internal and external strategic program analysis

Basic Functionalities

• Total-cost-of-care analytics
• Organization financial performance tracking under risk-based contracts
• Integration into organizational reporting dashboards (export/import capabilities into visualization tools)
• Executive quality performance tracking, including standard quality metrics (such as HEDIS/Stars)
• Role-based dashboard reporting (clinician, executive, administrative, etc.)
• Tools for tracking of ROI on care management activities and programs
• Employer/insurer dashboard
• Network utilization tracking (including “leakage,” “steerage,” and multiplenetwork tracking)

Advanced Functionalities

• Actuarial contract risk analysis
• Network optimization analysis/modeling
• Timely medical economics analysis support (opportunity and performance tracking within episodic and procedural bundling)
• Service line modeling, including activitybased costing
• Identification and management of high-cost care options (medication, procedures, diagnostics, etc.), including ability to authorize
• Gainsharing tracking/windfall tracking

VERTICAL 5

Patient Engagement

Patient-centric communication and alignment with health goals and improvement

Basic Functionalities

• Coordination and integration with organizational patient communication/ engagement channel
• Secure messaging between patients/care providers/care managers
• Patient outreach tool set (phone, email, social media, etc.)
• Patient education delivery functionality
• Patient satisfaction monitoring of programs and providers
• Precision profiling and communications

Advanced Functionalities

• Full CRM tool set that includes integrated patient portal, patient outreach, education, satisfaction monitoring, and precision marketing
• Management of unique circumstances (behavioral health, adolescence data)
• Tracking of outreach efforts, including event tracking and management of closedloop communication
• Patient health dashboard, including patient goals
• Ability to show/estimate patient out-ofpocket costs, or capability to connect to a third party to show/estimate
• Patient permissions for data sharing, gathering, etc.
• Virtual care tools

VERTICAL 6

Clinician Engagement

Actionable workflow integration for clinicians

Basic Functionalities

• Supports single sign-on integration
• Integration/ability for a care provider working in the population health tool to efficiently take action in the EMR
• Integration/presentation of care gaps to providers within the provider (EMR) workflow.
• Ability to integrate with multiple EMR platforms
• Ability to track clinician usage and activity

Advanced Functionalities

• Timely integration of population health tool data and alerts to be displayed within the EMR workflow and stored within the EMR
• API-based (FHIR or other API) integration with EMR solutions
• Presentation of care gaps to providers within the provider workflow with the ability to act within the provider workflow

Underestimating Complexity:

Vendor organizations tend to underestimate complexity in two key areas: (1) data aggregation and (2) clinical workflows. Vendors could do better in helping provider organizations locate and identify the scope of available data sources. Great vendors also accept the invitation to go on-site “in the trenches” and learn the complexity of clinical workflows.

Right People in the Room:

Great vendors help ensure that the right people are in the room from the provider side, ensuring overall project success. Great vendors are not silo-selling.

Vision is Overrated:

Many if not most vendors today have a great vision of where population health is going; however, providers are looking for real wins in the present. More than providing vision, great vendors are able to provide excellent examples of success.

More Than a Tool:

Great vendors don’t sell just a siloed tool. New population health tools need to fit into an overall ecosystem. While it scares many CIOs, the population health world today is a best-of-breed world, and everything needs to work together for organizational success.

Honesty and Sales:

The biggest disconnect many providers see with vendors is not with the on-the-ground implementers or the leadership. Instead, the greatest disconnect is often with the sales teams. The population health market has been plagued by overselling. Honesty and a lack of buzzwords are strong sales pitches in today’s environment.

We Need the Best Practices:

Some of the greatest value that vendors can provide is education and best practices. Vendors need to bring the best practices for their solutions as well as examples of success from other provider organizations.

CIO-to-CEO Relationships Are Key:

Many vendors agree that a key predictor of success in provider organizations is the relationship that CIOs, CMIOs, and CEOs share. Vendors agree that when a sale is mostly to a CEO or mostly to a CIO, it often ends in failure. The CEO leads up culture while the CIO leads up technology. A combination of culture and technology comes from CIOs, CMIOs, and CEOs working together.

Strategy before Technology:

Great provider organizations have aligned their strategies before focusing on technology. This is a relationship that is seen in many other industries but is often overlooked.

Becoming Risk Takers:

Provider organizations that appear to be ready for risk have a deep respect for the way their business models are changing and are willing to take the risks that they need to in order to be successful in tomorrow’s world. At the same time, these organizations are also great at executing on the basics that will be important regardless of changing business models.

Learning from Other Countries:

Most vendors who have had international experience see the possibility that many countries outside of the United States could leapfrog forward with the care they provide because of a willingness to engage populations and social programs. Much can be gained by learning from these countries and their approaches to health.

Commitment to the Future of Value-Based Care:

Today, conversations with provider organizations have changed significantly. No organizations are saying that they do not believe in changing business models. The great provider organizations realize that there will be a tipping point and are running toward that change, knowing that no organization can be great at delivering on two business models long term. Provider organizations who see population health as an adjunct, side business are those who are not ready for the future.

Healthcare IT Professionals

Brigitte Nettesheim
CEO, Accountable Care Solutions
Aetna

Marvin Harper, MD
CMIO
Boston Children’s Hospital

Deborah O'Dell
VP, Business Intelligence
Catholic Health Initiatives

George Reynolds, MD
Former CMIO & CIO
Children’s Hospital Omaha

Russ Branzell
CEO/President
CHIME

Katherine Schneider, MD
President, CEO
Delaware Valley Accountable
Care Organization

Richard R. Vath. MD
SVP/CCTO
Franciscan Missionaries of our Lady
Health System, Inc.

Marty Paslick
CIO
HCA (Hospital Corporation of America)

Matt Walsh
SVP & COO
Health Alliance Plan

Mary Alice Annecharico
SVP & CIO
Henry Ford Health System

Marc Probst
VP & CIO
Intermountain Healthcare, Inc.

Mark Christensen
Strategic Sourcing Manager
Intermountain Healthcare, Inc.

Joe Mott
VP of Population Health
Intermountain Healthcare, Inc.

David Nash, MD
Dean
Jefferson College of Population Health

Alan Ying, MD
KLAS Advisor
KLAS

John Kenagy, PhD
SVP & CIO
Legacy Health

Micky Tripathi
President, CEO
Massechusetts eHealth Collaborative

Anita Ying, MD
Executive Medical Director
MD Anderson

Ewa Matuszewski
CEO
Medical Network One

Shawn Griffin, MD
Chief Quality and Informatics Officer
MHMD -The Memorial Hermann
Physician Network

Mansour Al-Swaidan
ICT General Supervisor of, Assistant for
Clinical Applications
Ministry of Health, KSA

Tom Denwood
Director of Provider Support and Integration
NHS Digital

Timothy Zoph
Former SVP, Administration
Northwestern Memorial HealthCare

Rick Schooler
VP & CIO
Orlando Health

Brian Wetzel
Director of Diagnostic Imaging
Our Lady of Lourdes Memorial Hospital

Keith Fernandez, MD
Senior Physician Executive
Privia Health

Brian Patty, MD
VP and CMIO
Rush University Medical Center

Rachel Dunscombe
CIO
Salford Royal NHS Foundation Trust

Jim Whitfill, MD
CMO
Scottsdale Health Partners

Richard Royle
Executive Director
UnitingCare Health

Peter S. Rahko
Director Adult Echo Lab
University of Wisconsin Hospital

Rasu Shrestha, MD
Chief Innovation Officer and EVP
UPMC Enterprises

Becky Magee
SVP, CIO
Washington Regional Medical System

Vendors

Robert Musslewhite
Chairman, CEO
The Advisory Board Company

Dennis Weaver, MD
EVP, CMO
The Advisory Board Company

Caitlin Reiche
Director, Enterprise Business Strategy
athenahealth

Ed Park
COO
athenahealth

Neal Singh
President, CEO
Caradigm

Vicki Harter
VP, Care Transformation
Caradigm

John Glaser
SVP; Population Health & Global Strategy
Cerner

Ryan Hamilton
SVP Population Health
Cerner

Thomas Lynn, MD
CMO
Conifer

Megan North
President, Value Based Care
Conifer

Mitch Morris
Vice Chairman
Deloitte

Brian Flanigan
Principal, U.S. Value Based Care Leader
Deloitte

Luis Machuca
CEO
Enli

Jacquelyn Hunt
Chief Population Health Officer
Enli

Carl Dvorak
President
Epic

Alan Hutchison
Vice President -Connect, Population Health
Epic

Seth Blackley
President
Evolent

Michael Barbouche
Founder/CEO
Forward Health

Dan Burton
CEO
Health Catalyst

Dale Sanders
VP, Product Development
Health Catalyst

Steve McHale
CEO, Explorys
IBM

Anil Jain
SVP, CMO at Explorys
IBM

Michael Long
Chairman and CEO
Lumeris

Art Glasgow
President, COO
Lumeris

Jeff Felton
President
McKesson Connected Care & Analytics

Tina Foster
VP, Advisory Services
McKesson Connected Care & Analytics

Deb Gage
CEO
Medecision

William Gillespie, MD
EVP Population Health Management, CMO
Medecision

Michael Weintraub
President, CEO
Optum Analytics

Sarah London
Chief Product Officer
Optum Analytics

Susan DeVore
President, CEO
Premier, Inc

Leigh Anderson
SVP & CIO
Premier, Inc.

Daniel Garrett
Partner
PwC

Kevin Carr, MD
Partner
PwC

Tom Zajac
CEO
Wellcentive

Mason Beard
Co-Founder and Chief Product Officer
Wellcentve