Florida Medicaid manages the healthcare of more than 5 million children, pregnant and postpartum women, disabled adults and seniors. The cost to run this public program is nearly $40 billion dollars and has increased 3% each year.

THE PROBLEM

To increase value, the program seeks to both reduce costs and improve quality of healthcare. One of the greatest drivers in the cost of healthcare is potentially preventable visits to the emergency department, which is estimated at 27 million visits annually at a national cost of $32 billion.

Some real-world examples of potentially preventable visits are patient encounters for a skin rash or wound check after surgery. Most of these visits are best assessed in less costly, non-emergent settings, such as a medical office or telehealth visit with a patient's trusted primary care doctor. Thus, reducing potentially preventable visits is one of the top priorities for Florida Medicaid.

"The challenge that all Medicaid programs face is that, currently, the historical claims data that are typically used to design policy interventions such as reducing potentially preventable visits lags by months to years," said Dr. Christopher R. Cogle, chief medical officer at Florida Medicaid. "This lag time impairs the ability to accurately assess potentially preventable visits or the impact of policy changes."

The lag time limits policy interventions to slow-cycle improvements, he added.

PROPOSAL

Care coordination health IT vendor Audacious Inquiry has been working with the Agency for Health Care Administration since 2012. The agency has been using the encounter notification services (ENS) system since 2014 through Florida HIE Services. AHCA has worked with Audacious Inquiry to support health information exchange throughout the state.

"More than 215 hospitals in Florida share data through patient ENS enabled by Audacious," Cogle noted. "ENS is the flagship service of Florida HIE Services, and it enables providers to improve care coordination and quality of care, thereby reducing potentially preventable visits and lowering costs.

"The greatest challenge for healthcare providers in taking advantage of encounter notification system data is realizing the population-scale value in addition to the individual-scale value."

Dr. Christopher R. Cogle, Florida Medicaid

"ENS provides real-time notice of when patients encounter acute care facilities to subscribing health systems, health plans, accountable care organizations, community health centers and physician practices, regardless of the electronic health record system being used at each facility," he continued. "Providers use the ENS notices as active prompts to contact their patients for successful transitions from facility to home, assessment for social determinants of health, and follow-up with the provider in the outpatient setting."

To assist Florida Medicaid in addressing potentially preventable visits at the population health level, Audacious Inquiry offered a new data workflow that enabled the Medicaid program to visualize utilization trends across the state.

Data dashboards could then be crafted by Florida Medicaid to identify outlier facilities where potentially preventable visits are taking place, the reasons for potentially preventable visit encounters, and the exact timing of the encounters to monitor trends.

MEETING THE CHALLENGE

As part of the ENS service with Audacious, Florida HIE Services receives admission-discharge-transfer notifications from more than 300 hospitals and other healthcare facilities in Florida, matching the information to patient lists provided by subscribers.

Cogle and his data team created a method to prepare the data files for appending into a long table of encounters. The long table is then queried for longitudinal analyses.

"In one case, an algorithm was used to identify Medicaid recipient encounters to EDs that did not result in a hospital admission within 24 hours," Cogle explained. "These visits were then plotted against the exact hour of the day and facility location across the state.

"The facilities were ranked according to the percentage of encounters occurring outside of usual business hours and encounters per 10,000 Medicaid recipients in the region," he continued. "This ranking and visualization showed outlier facilities for ED encounters that don't result in admission, which may represent avoidable visits."

The team also ranked top reasons for encounters at each facility to provide clinical insights on non-acute conditions. Collectively, the data empowers Florida Medicaid, healthcare facilities, managed care organizations, clinical providers and patients to make adjustments to policy, systems and environments that better avoid expensive acute care services, he added.

RESULTS

The real-time data enabled the engagement of specific outlier facilities, managed care organizations (MCOs) and primary care providers in the vicinity of the outlier facilities. The data showed specific geographies in need of improved health literacy among the public as well as improved office hours of primary care providers and outpatient medical offices or urgent care centers to offset ED utilization.

"Ongoing real-time data, including daily potentially preventable visit encounter numbers and seven-day average visualized by region and exact hours of the day, enable immediate monitoring of impact of interventions, rather than waiting months to years to see the effects," Cogle reported.

"Overall, this process supported data fluidity, as the hospitals and MCOs are simultaneously data sources and end users that benefit from health information exchange," he continued. "Today, ENS delivers more than 800,000 notifications a month to subscribers across the state."

Activating the combination of historical and real-time data enables state Medicaid programs, state health departments, health systems, MCOs and providers to address a range of clinical and quality measures that improve the value of healthcare, he added.

"While this use-case focuses on potentially preventable visits as the healthcare outcome of interest, this partnership demonstrates the feasibility of combining real-time encounter notification technology with a mission and authority to improve healthcare and MCO operations," Cogle said. "Emerging interests for this technology will be in the areas of substance use disorders and home and community-based settings.

"More broadly, this partnership demonstrates the future trend of health policy to incorporate real-time data for rapid-cycle interventions, thereby enabling more strategic improvements in population health interventions," he added.

ADVICE FOR OTHERS

"The greatest challenge for healthcare providers in taking advantage of encounter notification system data is realizing the population-scale value in addition to the individual-scale value," Cogle advised. "By aggregating the real-time ENS data across systems and geographies, healthcare organizations – especially non-profit organizations with expectations for improving community health – can better understand the contemporary needs of their region.

"The unique value-add of ENS data is its immediacy," he concluded. "As we enter a new generation of health IT where higher dimensional data and multiple data sources are combined for synergistic insights, ENS data will be the critical stream that makes visualizations relevant to now."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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