The large: Orlando Health

By Tawnya Adkisson, director of care coordination

Based in Orlando, Fla., Orlando Health is one of the state's most comprehensive private, not-for-profit healthcare networks. Its 1,780-bed family of eight hospitals serves nearly 2 million Central Florida residents and roughly 4,500 international visitors annually.

The health system has been an enthusiastic supporter of the ACO model, participating in the Medicare Shared Savings Plan and Cigna's ACO program since 2013, joining Florida Blue's program in 2014 and AvMed's in 2015.

It was concern for the community as a whole that first led Orlando Health to PHM. Moving from a reactive mode to proactively encouraging patients to seek recommended care and close care gaps on the scale required, however, would not be easy since data about Orlando Health patients is held in several disparate electronic health record systems that are not compatible.

The health system needed a way to obtain a complete view of the patient. While the claims system could provide that view, the data might be six months old. And even if it could achieve a comprehensive view, the resources required to scan through millions of records manually to narrow the list to the most at-risk patients, identify care gaps, engage with them to set up appointments for the appropriate care and evaluate the program's performance were well beyond Orlando Health's budget.

To solve these issues, Orlando Health created a clinically integrated network by implementing a comprehensive PHM technology that could act as a pseudo-health information exchange. The technology already had the ability to interface with and accept data from the multiple EHRs and practice management systems used by the health system's 500 employed and nearly 3,000 affiliated physicians. This allowed the PHM technology to become the single reference source for patient data across all providers.

With that capability in place, the next step was to build patient registries for patients who met certain criteria, such as having one or more chronic conditions or those who fit the recommended parameters for preventive screenings such as mammograms or colorectal exams. Orlando Health then used the PHM platform to automatically contact targeted patients via phone, email and text. Messages were sent informing patients of care gaps and recommending they contact their primary care physician to schedule an appointment. As scheduled appointments approached, the PHM platform sent automated reminders.

In all, Orlando Health was able to identify a list of nearly 300,000 patients with some form of care gap, whether it was around a chronic condition such as diabetes or chronic obstructive pulmonary disease, or being overdue for preventive care that could help them avoid a costly emergency department visit or hospital stay later. After one year (April 2014 – March 2015), it was clear that the PHM program was working.

Results included:

• 7 percent increase in diabetic patients who had current HbA1c tests
• 10 percent increase in preventive mammograms
• 9 percent increase in preventive colonoscopies
• 15 percent increase in falls-risk screenings
• 10 percent increase in patients who were screened for depression and had a plan of care developed to address it
• 22 percent overall increase in the number of patients who took action to close a care gap after receiving an automated communication

The PHM effort paid off financially as well. Orlando Health was able to generate a combined $6.6 million in shared savings from its ACO contracts with MSSP and Cigna in 2013. The PHM platform was also instrumental in helping all but two of its PCPs meet Level 3 criteria as Patient-Centered Medical Homes by Q1 2015. As local PCPs learn about the PHM platform's ability to impact patient health and aggregate EHR data across platforms, more are requesting to become affiliated with the health system. These early successes continue to compound today.

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