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Medical homes, neighborhoods and beyond T e health system is moving forward on several fronts. Orlando


Health is one of 15 health systems nationwide to participate in a CMS-funded Patient Centered Medical Neighborhood demonstra- tion project. T e initiative, which utilizes technology for population health management, is designed to connect acute-care hospitals with technology-empowered primary care, specialty and subspecialty practices to drive better quality, superior patient experience and population health at a more aff ordable cost. Key to Orlando Health’s selection for the program was that a majority of its ambulatory care offi ces have been offi cially recog- nized by the National Committee for Quality Assurance (NCQA) as patient-centered medical homes (PCMH). T e medical home model is widely embraced as a prerequisite for population health management.


An early win for Orlando Health has been its use of Phytel Out-


reach, says Chris Jordan, Orlando Health’s chief applications offi cer for ambulatory systems. By creating ongoing automated messaging campaigns, Orlando Health has persuaded many patients who need preventive or chronic care to make appointments with their doctors. But while Jordan says Phytel Remind and Phytel Outreach were essential to driving the group’s success with PCMH, it is Phytel’s reporting and care management tools that really empower users. Phytel Insight, the reporting module, excites Jordan “because it al- lows providers and case managers to look at our entire population and see how we’re doing,” he says. “T eir favorite tool is the scatter plot that lets you look at all our diabetics or heart-failure patients or any other cohort across our 100 primary care providers and see where their vitals fall. On just one screen, they can see thousands of patients and see who the outliers are.” Physician Associates’ care coordinators utilize the tool to focus


their resources on the patients who need them most, Jordan says. Instead of having to search electronic charts and run reports, he says, the care coordinators can use Phytel Insight to spot “the 50 or 100 patients who are way outside of the control factor and concentrate on them fi rst.” T e practice also is using Phytel Insight to help determine physician quality bonuses, which track their compliance with quality measures, Jordan says. “For instance, our doctors need to have 60 percent of their


hypertension patients in control (with blood pressure 140 over 90 or less). Insight is really cool, because we can go in and say ‘Show me every doctor and their status on their entire population of hypertension patients.’ And we can immediately qualify them for their quarterly bonus. Without that tool, it would be really, really diffi cult for us to do that.”


ACO assistance Orlando Health’s most ambitious population health eff ort yet is its accountable care organization (ACO), a Medicare Shared Sav- ings Program participant. Under the program, Medicare rewards ACO participants for meeting certain thresholds of quality on 33 diff erent population health measures. Orlando Health will be able to utilize the platform to track and improve each of these performance measures. Phytel Insight delivers metrics and dashboard reporting that enable the health system to evaluate and measure its eff ective- ness across key quality initiatives. And Phytel Coordinate provides care teams with an advanced toolkit to risk-stratify patients and create personalized, automated interventions to better manage those populations and optimize each patient encounter. T e Orlando Health team in charge of the ACO reporting


program has designed it to reduce physician work, minimize new clinical documentation steps and have the same clinical documenta- tion process address both the federal meaningful-use program and ACO documentation, when feasible.


www.healthmgttech.com HEALTH MANAGEMENT TECHNOLOGY January 2014 19


For innovative patient encounters, WEDI recommends …


The Workgroup for Electronic Data Interchange (WEDI) Foundation released the 2013 WEDI Report on Dec. 5, 2013. The report is the culmination of a nine-month public-private effort with more than 200 subject matter expert volunteers. It aims to provide a new roadmap for health IT over the next decade. According to the report, “innovative encounters” are touch points such as email, texting and telehealth used “to engage patients and providers without reference to location or time and allow non-emergent conditions to be evaluated and in many cases treated without the need for a physical visit.” WEDI’s recommendations for innovative encounter models include:


• Identify use cases, conventions and operating standards for promoting consumer health and exchange of telehealth information in a mobile environment.


• Facilitate adoption and implementation of “best-in-class” approaches that promote growth and diffusion of innovative encounters across the marketplace and that demonstrate value for patients, providers and payers.


• Identify existing or proposed federal or state-based laws or regulations that create barriers to the implementation of innovative encounters (including licensure)


The full report is available at: http://www.wedi.org/topics/2013-wedi-report. Source: WEDI


Right tools, right partner Moving forward, the second phase of Orlando Health’s Phytel


deployment will make the platform available via health information exchange (HIE). “We will tie our population health solution into our HIE so that


our affi liated physicians in the fi eld can get access to the Phytel reports on care gaps and other functionality,” says Jordan. “We’re also going to be implementing a patient summary screen within our affi liated physicians’ EHRs to provide an at-a-glance summary view of the patient’s care gaps.”


HMT For more on Phytel: www.rsleads.com/401ht-202


Melanie Ezzell-Nelson is a freelance writer who specializes in healthcare IT topics. She is based in Marietta, GA.

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