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‚óŹ Strategic Directives Population health management

in a clinically integrated network Automation yields a wealth of benefi ts for IT, administrators, clinicians and patients. By Melanie Ezzell-Nelson


overnment and private insurers are moving away from encounter-based reimbursement and rapidly developing new payment models that reward coordination of care and population health management. Orlando Health,

a seven-hospital, 1,780-bed Florida health system that is one of that state’s most comprehensive not-for-profi t healthcare networks, saw the change coming and knew it had to act. In standing with its size, the health system set an ambitious goal: be the highest-quality, lowest-cost provider in central Florida. “We like to be leaders, not followers,” explains Rick Schooler,

Orlando Health vice president and chief information offi cer. As a fi rst step, in partnership with UF Health, the University

of Florida’s healthcare system, Orlando Health’s leadership is working to form a clinically integrated network (CIN) that in- cludes its 400 employed doctors, independent primary care and specialty physicians, and eventually practitioners employed by the University of Florida healthcare system. Clinical integration promises to coordinate patient interventions, manage quality across the continuum of care, drive population health management and enable value-based contracting. To get there, Schooler, a former CHIME/HIMSS CIO of the

Year, realized the health system would need to signifi cantly scale its care management and patient engagement eff orts. Above all, it would need population health tools to help identify patients at risk of acute episodes, fi nd the gaps in their care, engage them

and evaluate performance – all without spending large amounts of money on care coordination and care management. “We knew that a key part of clinical integration and of surviving

the future of healthcare is to manage the health of a population,” explains Schooler. “To do that, you need tools that are tailored to the individual level that allow you to intervene, interact, prompt, reach out, remind and analyze. You have to be able to take that indi- vidual information and aggregate it to the population level to detect trends, stratify patients based on clinical risk or other factors to re- ally understand how you are doing on quality and cost utilization.” Adds Jennifer Endicott, Orlando Health’s vice president of clini- cal integration: “We had already recognized that an EMR would not get us where we needed to go. An EMR is a data repository that’s designed to allow healthcare providers to manage those patients who are in front of them, not those who are not in front of them. T at task is just too cumbersome and diffi cult – and frankly impossible for most EMRs.”

An exhaustive search When evaluating solutions, Orlando Health felt it was vital to

invest in a single platform for both clinical integration and popula- tion health management. Moreover, it needed a solution that would not put added stress on an already overloaded IT staff . Like all health systems, Orlando Health has many competing demands and not enough resources. T e solution provider would need to do the heavy lifting, including data integration and workfl ow assessments, data mapping to protocols, system confi guration, training and implementation. A member of Schooler’s senior project management team led the vendor selection committee. After a systematic search of 12 diff erent vendors that included multiple site visits, the health system ultimately chose Phytel. At Physician Associates, the health sys-

A favorite tool of providers and case managers at Physician Associates is Phytel Insight, which lets users view any cohort across 100 primary care providers and see on a scatter plot where patient vitals fall and who the outliers are.


tem’s employed group of 100 primary care physicians, Orlando Health has successfully interfaced Phytel with the group’s Allscripts EHR and implemented four modules: Phytel Outreach patient engagement tools, Phytel Remind appointment reminders, Phytel Insight reporting and dashboards, and Phytel Coordinate care management tools. A fi fth module (Phytel Transition, to enhance coor- dination of discharged patients) is planned for implementation by the end of the year. Phytel also is interfaced with Orlando Health’s Allscripts Sunrise inpatient EHR to capture information on patients discharged from the system’s hospitals.

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