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basic. Before the right tools can be used, incentives to use those tools must be provided. Aligning incentives across the care continuum is where it all starts. Payers, health systems and providers need to be more collaborative

in their eff orts and focus on contracts that incentivize all members of the system to improve cost and quality outcomes. T ere needs to be alignment through a collaborative payer who ties a signifi cant portion of compensation to value-based initiatives, including cost, quality metrics, access, patient satisfaction and participation. T en when those metrics are met, all involved need to be rewarded for their work. After that structure is in place, it becomes a matter of having the right tools and information to make data actionable for better-informed and value-based decisions.

Bonnie Cassidy, Senior Director of HIM Innovation, Nuance

T e copious amounts of data will be daunt-

ing at fi rst. Without a doubt, it will take a focused eff ort on behavior change within the healthcare industry to begin to regularly monitor and parse through all the information, analyze it and convert it into actionable strategies. In order to be successful, there must be full buy-in from patients, providers and payers. Data is useless if no one commits to properly leveraging it. Analyzing accurate clinical data from patients will help providers gain insights into their patient populations’ larger health needs, identify challenges and opportunities for improvement, and work toward creating a healthier community.


Tony Jones, M.D., CMO, Philips Healthcare’s Patient Care and Clinical Informatics’ Business Unit

T ere’s no doubt this is a mammoth task, and while we might not be

there yet, we are certainly getting closer. T ere are still challenges ahead: organizations are learning lessons from the early adopters and trying to determine the best ways to cooperate and share data. Undoubtedly, the amount of investment required to make Big Data technologies work is more than what a single segment of the market can aff ord. T at means all stakeholders, including pharma, will have to work toward a com- mon vision. But with accountable care organizations (ACOs) paving the path for payers and providers to work more closely together, we are heading toward success and, more importantly, better patient care.

Karen Handmaker, MPP, Vice President, Population Health Strategies, Phytel

T e weakness of analytics solutions in general is that they fl ood ad- ministrators and clinicians with an overwhelming amount of raw data and reports but off er no process for making use of the data. Dashboards alone are not enough to make the information meaningful and to drive lasting results. Accomplishing this requires not only advanced analytics that can integrate data from multiple enterprise systems both inside and outside the organization, but also automated tools that make the resulting data quickly actionable and meaningful for clinicians and care managers.

Here are a few examples of such a solution in use at Northeast

Georgia Physicians Group (NGPG) in metro-Atlanta: Phytel aggregates and normalizes data supplied by the group’s EHR so that the care coordinators can focus on providing exceptional patient care rather than waste time gathering the data they need from patient charts. Care coordinators embedded in practice sites are able to look at

the provider schedule and, right under each patient’s name, see op- portunities for their care to be improved. T ey can see the patient is past due for an A1c test or hasn’t had a mammogram or hasn’t had a colonoscopy. T e big advantage for the care coordinator is that when he or she clicks on a patient’s name, Phytel takes them to a patient summary profi le that shows them everything they need to know about that patient: their last blood pressure reading, their last A1c, etc. While that information is also available in the EHR, the nurses might have to click through six to eight screens to collect it. In addition, Phytel aggregates data outside their EHR such as patient-reported information and predictive risk scores. Moreover, Phytel fl ags all patients who are high risk and in need of immediate attention, whether or not they have visited their provider recently. Without that type of prioritization, nurses are able to see the patients in front of them, but they may not easily be able to see Mr. Jones with an A1c of 14 who hasn’t been in for nine months. Using technology that continually mines that data provides care teams with important information to improve the health of patients. In addition, Phytel can be used to launch a variety of interventions

for diff erent segments of the population. If NGPG wants to off er a diabetic education program, for example, the Phytel solution enables the care managers to email all of the patients who could benefi t from such a program with the click of a button. And they can do the same for elderly patients who are due to come in for fl u shots. Phytel also prioritizes patients for care teams. It uses green-yellow-

red identifi ers so those patients who are poorly controlled and have the most care opportunities appear on top with a red icon next to them. T ose who are better controlled and have fewer opportunities are at the bottom and are green. So if a care coordinator has four hours on a particular day to dedicate to care coordination patients, Phytel enables them to see which patients need their time the most so they can make a real diff erence in their lives. NGPG’s physicians also use Phytel to manage their daily patient

load. Physicians and their nurses use the solution every evening to look for care gaps in patients scheduled for visits the following day. Knowing in advance which patients are missing tests or need additional support helps the team pre-schedule tests and assign the appropriate care team member to the patient. A patient with extensive psycho-social needs related to their diagnosis, for instance, may be better off seeing a care manager instead of, or in addition to, their physician.

HMT: Acknowledging that every patient is physiologi- cally different and distinct, what are some of the key pieces of information that might contribute to “predict outcomes, measure trends and establish correlations that drive quality care at lower costs?”

Todd Rothenhaus, Chief Medical Information Offi cer, athenahealth

Personalized medicine and personal health ownership is absolutely essential to more effi cient, lower cost, quality care. In the future, I think we’re going to fi nd that genetic testing is going to be an essential tool in determining medication eff ectiveness and therapy selection. T is is an area that is ripe for automation and supported decision-making. Otherwise, at a macro level, we need to stratify our patient popula- tion – those who are completely well, stable with chronic disease and so sick they can’t be helped – and hone in on the treatable diseases and


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