By Deborah Borfitz

November 4, 2019 | Beth Israel Deaconess Care Organization (BIDCO) in Boston—a clinically integrated network of physicians, clinicians and hospitals committed to improving care quality and patient health outcomes through population health initiatives—is using real-time electronic health record (EHR) data and insight-driven analytics to help keep healthy and rising-risk populations from dropping into the costly, high-risk top 5% group, according to Chief Information Officer Bill Gillis. The “impact score” of patients determines how limited resources, including care managers and health coaches, get segmented across the network.

The analytics asset is now being tapped by a medical director with the newly formed Beth Israel Lahey Health Performance Network (BILHPN), of which BIDCO is a part, for a pilot clinical study looking at successes and failures in postpartum care, says Gillis. It is the first clinical research program in the queue for the Arcadia platform.

Analytics and care management applications in Arcadia replace an assortment of data warehouses and systems previously used by BIDCO and has become a key enabler of success, says Gillis. Marrying the worlds of “builders” (IT) and “architects” (clinicians) has been another catalyst of improved patient outcomes and population health. Clinical and population health leaders have been involved and had an equal voice from day one with the technology.

Since going live with Arcadia in August of 2017, BIDCO has aggregated real-time clinical data from more than 40 different EHR platforms across more than 100 locations, says Gillis. BIDCO has since brought that number down to around 20 EHRs, six of which represent 86% of the network.

Electronic recordkeeping is a core requirement, says Gillis, noting that BIDCO’s EHR policy has shifted over the years to include six systems. Agreeing to deliver a payload of clinical data is a condition of membership for tier one (primary care) and tier two (typically specialties such as cardiology and orthopedics that manage high volumes of high-risk or at-risk patients) physicians. Using fewer systems for data exchange makes the process easier and more foolproof.

If BIDCO is pulling the data, which is the preferred approach, it matters less, Gillis explains. Arcadia has connectors that can pull required data elements from more than three dozen brands of EHRs, knowing the information may reside in multiple places. Data elements tend to be missing when providers opt to push out their data payload because conformity with the Continuity of Care Document standard for data exchange varies considerably vendor to vendor, hampering quality reporting efforts.

Documenting a diabetic visit is a straightforward proposition in EHRs that have uniform way of approaching documentation because “there’s one way to do things generally,” Gillis says. “But if you go to other EHRs, which can be massively customized… five physicians in the same practice may have five different workflows and templates that they want to use.” BIDCO has separate teams to manage the majority of those installs and build templates to match its data delivery needs.

The goal is to get data within a 24-hour period whenever possible, says Gillis, but “it sometime takes a little longer.” Whether the data is pushed or pulled, today the cost is borne by the practice group, he adds. “The pull methodology is ultimately more cost effective for everyone.”

Claims data typically comes through to provide any missing data elements, but claims lag can be 90 to 120 days, Gillis says. And problems may persist, including “large numbers” of claims that never make it out the door or were denied and eventually written off. Even if a procedure was performed and the clinical documentation exists, it is as if the procedure never occurred if the payer does not have a claim.

Getting it right matters, since risk-based contracts tie providers’ compensation to their performance, Gillis explains. BIDCO’s quality reports compare physicians at multiple levels—from groupings of primary care physicians (based on factors such as geography, employment and panel size) to single practices and, if requested, individual physicians. The reports come out every month and those in the top 25th percentile might be allowed to manage their own quality. Falling below that bar could also cause the loss of that delegated responsibility. 

Risk Navigator

Arcadia has a proprietary scoring system called the ARC Impact Score in its Risk Navigator module that ensures everyone in the risk pool gets assigned to the right level of care, says Gillis. BIDCO had the tool refined to exclude anyone in a cancer care program where high-cost care is a foregone conclusion. A higher score qualifies patients for additional care options, such as a care manager, weekly sessions with a health coach, and in-person in lieu of telephonic visits.

Everything known about patients, including their risk category and quality gaps, gets documented on their patient card, Gillis continues. Claims data helps flag super-utilizers, and scheduling data provides a peek forward. Care managers can see patients’ admission, discharge, and transfer status as well as all their labs, radiology results, and the social determinants of health (SDOH) information the patient is willing to share. In some cases, reducing emergency department visits is a matter of referring someone to a primary care physician for routine care.

Publicly available health and census data comes pre-loaded in Arcadia, identifying food deserts, neighborhood housing characteristics and education attainment down to the zip code—a potential starting point for a conversation with a team member, such as a community health worker, or the development of a new program, Gillis says. BIDCO used Arcadia to build out a template for all BIDCO-approved EHRs that has a defined script of 36 questions used in the SDOH component of the MassHealth Medicaid ACO launched early last year. “All certified EHRs have the capability to capture that sort of data,” he notes.

Standardizing templates for things like education, self-management, scheduling and the facility providing care helps with throughput and increases the number of patients touched by programs, says Gillis. “As clinicians take patients’ history, care plans are being built.” Binary data fields also enable analytics.

BIDCO recently rolled out a pre-visit planning program that uses morning huddles for care teams to identify and close care gaps before patients arrived at their next doctor’s appointment, he adds. That might mean getting their blood drawn for an A1C test or scheduling a colonoscopy.

Overall, BIDCO has seen improvement in terms of closing care gaps and keeping people out of the high-risk pool, Gillis says, which has admittedly involved a lot of attention-switching from one program to another. “We’re still trying to find that sweet spot and keep everything going in the same direction.”