Eastside Health Network, a physician-led clinically integrated network headquartered in both Bellevue and Kirkland, Washington, deals with data across nearly 1,200 physicians operating on numerous electronic health record systems across a wide geographic area.

It needed a cost-effective way to aggregate and normalize this data. It also needed to combine this data into one actionable, longitudinal patient record, enabling caregivers to make more informed care decisions and discover trends.

THE PROBLEM

Aside from just aggregating the data, the provider organization also needed to make the data actionable and accessible across the entire network, ensuring that clinicians could readily use data to manage health and take on financial risk.

With clear population health and value-based care goals, it was critical for Eastside Health Network that data be available and meaningful to encourage quality, activation and collaboration among clinicians and their patients.

PROPOSAL

Eastside Health Network turned to vendor Philips Wellcentive to aggregate data to design a population health management framework in order to succeed under four value-based care contracts.

With Philips Wellcentive, Eastside Health Network developed customized dashboards for each contract, allowing clinicians to receive at-a-glance views of members' risk profiles and track care needs for each member.

After digesting the data, caregivers can begin implementing changes and looking for ways to engage patients in a proactive, population health-oriented model, said David LaMarche, chief administrative officer at Eastside Health Network.

"Our decision to use the third-party solution instead of seeking to convert all participating practices to a single EHR proved to be the most feasible approach to data integration, enabling and supporting providers to continue using familiar systems," he explained.

MARKETPLACE

There are many population health management systems on the market today. Vendors of this burgeoning technology include Allscripts, CareEvolution, Cerner, Epic, Geneia, GSI Health, Innovaccer, MAP Health Management, Optum, Privis Health, Varian Medical Systems, Vivify Health and ZeOmega.

MEETING THE CHALLENGE

Currently, Philips' platform is being used to engage and support providers across the network, where it is helping to get the right data, create meaningful algorithms to identify the right patients, and use these insights to better manage care, said Sara Rutherford, quality program manager at Eastside Health Network.

"Implementation started with interfacing and integrating clinical and claims data, beginning with the largest primary care practices to the smaller single care practices where possible, which is the phase we're entering now," said Rutherford.

"Across all of these EHRs and practice management systems, there were many interfaces containing data which needed to be normalized, which is challenging given all of the other data elements that are coming in including EHRs, health information exchanges, payers, labs and custom data sources," she added.

With the new platform, Eastside Health Network developed customized reports and alerts for each value-based contract, equipping the care management team to receive at-a-glance views of members' risk profiles and help them track care needs and metrics for each member, LaMarche explained.

"Eastside Health Network also created quality measures and set goals for participating physicians, who initially set goals to increase screenings for diabetes, breast cancer and colorectal cancer," he said.

"To better manage care, we are leveraging this data to identify the at-risk patients and our care management and care coordination teams are performing outreach to engage and activate those patients," he added.

RESULTS

Among other things, Eastside Health Network has integrated 10 payer feeds, more than 40 practice billing systems, and around 20 EHR feeds across two large health systems, and has aggregated data across 1,380 physicians and 185 practice locations.

"The transition we made requires a lot of collaboration, planning and buy-in across every level of the organization – from the C-suite, IT staff, clinical care teams, payers, and both employed and independent providers," LaMarche said. "Every level needed to be willing to take risk, shift resources and encourage leadership as a part of this long-term goal."

As a physician-led network, it was understood that the future is in value-based care, and integration was key, Rutherford said.

"In order to secure more value-based contracts and truly improve patient care, we knew we needed a comprehensive view of our data that enabled us to take action – all in a way that physicians and nurses would be familiar with and willing to use," she said. "And while a transition like this takes tremendous amounts of collaboration on the provider side, it also requires a true partnership with vendors."

In order for such an integration to be successful, it requires the technology to be customized to a provider's unique infrastructures and processes, Rutherford explained.

As a result of this partnership during implementation, the Wellcentive platform has created the ability to create transparent access to longitudinal, normalized and accurate patient records and reports all in one place, which has been critical for creating insights into key performance metrics, she said.

"While this is still a work in progress, Wellcentive's ability to ingest virtually any type of data feed gives us the unique flexibility to integrate to a higher level than most alternative products in the marketplace," she said. "It acts as a data translator of sorts – no matter what language your information speaks, the system interprets it so it can be understood and actionable."

Incentive-based models will not last forever, and payers and employers will increasingly demand more value from their contracts, LaMarche stated.

"Anticipating that the deliverables of shared savings models will eventually be basic elements required in value-based care, Eastside Health Network is preparing for the future by focusing on benefit design and advanced care management models in concert with employers and payers," he said. "Eastside Health Network's data management foundation will continue to be critical as networks narrow, and it takes on greater risk."

On another note, as of 2018, Eastside Health Network is managing 35,000 lives under value-based care contracts, which include incentive-based models, shared savings, up/downside risk and full capitation for ERISA-based self-funded employee plans.

"Using the Philips Wellcentive platform has improved our ability to manage data, enabling us to secure a growing number of value-based care contracts and take on a variety of risk," LaMarche said. "We've been able to aggregate and analyze data, create meaningful algorithms to identity the patients who need support and intervention and use these insights to better manage care."

For each value-based contract, Eastside Health Network developed customized reports and alerts, targeting specific elements of each arrangement that will help it target those elements it is responsible for in reporting and outcomes.

"Having the flexibility to design within Wellcentive to the needs of the type and nature of the contractual arrangement is a key strength of Wellcentive," he said. "We think about the population differently within each of these contracts, and that influences how we leverage Wellcentive as our hub of data for each, as well as our care management and patient outreach strategies."

For example, he explained, under incentive-based contracts, which are mostly Medicare Advantage arrangements, Eastside Health Network has focused on closing care gaps and improving its STAR rating. It uses Philips Wellcentive to generate patient compliance reports in order to gain insights into which quality measures to target.

"These reports function like a registry, bringing together all of the patient cases and clearly delineating whether a care gap exists," he said. "The reports also show when a patient had their last office visit, and if they've received outreach from a team member in the last three months. Putting this information into the hands of the providers and their support staff teams has helped us achieve remarkable results."

In addition to closing care gaps, for shared savings contracts Eastside Health Network uses Wellcentive largely to focus on managing transitions of care to prevent readmissions and avoidable emergency department visits, and to ensure primary care providers are up to date on their patients' conditions.

"To help manage this strategy, we use Wellcentive's high-utilizer reports," Rutherford said. "The reports identify patients who've had three or more emergency department visits in a six-month period, or two or more unplanned inpatient admissions within the last 45 days, or a combination of the two. The reports allow our care management team to ensure patients coordinate with their primary care physician and access care appropriately."

ADVICE FOR OTHERS

"I believe it is critical that organizations clearly define what problem they are trying to solve when selecting a technology-based tool, and then evaluate if the tool under consideration has documented success in doing so," said LaMarche.

"Organizations should consult with other providers of similar composition that have worked with the vendor to tackle similar challenges in a non-beta environment. Ultimately, there isn't one solution that is a panacea; successful organizations are learning how to integrate different tools from a variety of vendors to get the solutions they need."