Health care Information Systems and Analytics

Sequent Health Physician Partners has placed population analytics at the core of its IT investment strategy. To maximize use of Sequent’s care management resources, it must prioritize where to place its focus within large groups of patients. Sequent must also have the ability to translate data into actionable insight for clinicians and care management staff. Therefore, Sequent has partnered with McKesson to aggregate data across the large number of practices and insurance carriers that operate throughout the network.

McKesson Population Manager is a population health management software solution that provides insight and actionable detail into the health of patient populations, helping provider networks achieve better health outcomes. Population Manager includes:

• Aggregated data from electronic health records (EHRs), practice management systems, pharmacies, labs and more
• Patient registries for common diseases to help manage populations by promoting evidence-based care and tracking individual patients while utilizing clinical events and lab results
• Compliance reports to identify patients who need screenings or other care to better coordinate and close gaps in patient care
• Physician alerts when a patient is due for care
• Automated workflows to allow physicians to focus on patients

The patient registries within Population Manager enable the Care Team to quickly identify patients needing care management. Currently, the registries include asthma, back pain, COPD, heart failure, childhood immunization, diabetes, preventive care/screening, and women’s preventive care/screening. Each registry is visible to any provider within the network that is responsible for a metric within the registry. For example, endocrinologists and primary care providers all see the diabetic registries for patients they have recently seen along with their status on the measures. Additionally, the relevant data from any provider within the network would be visible to the Primary Care Provider. For example, if the endocrinologist recently completed an HbA1c lab for a diabetic patient, the PCP could see the date of the visit, the date the lab was completed and the result of the lab. This helps to reduce repeat testing and provides assistance with referral tracking.

Currently, the primary data source comes from physician practice management systems and lab data from the three major lab providers in the area. This allows for near real-time data availability as opposed to waiting for payer data from adjudicated claims. Over time, this system will expand to include clinical data from the physician EMR, pharmacy, payer claims data and other data sources. As more data sources are added to the system, additional registries and care measures will be selected. There are currently over 50 registries available within the McKesson Population Management system with over 250 unique care guidelines that can be measured.

McKesson Risk Manager is a cloud-based solution that helps address a broad spectrum of cost and quality challenges, from population assessment and provider profiling to performance and provider management:

• Resource utilization management, including emergency department and hospital admissions
• Pharmacy cost management, drug substitution and formulary compliance
• Physician efficiency and performance reporting
• Patient profiling, risk stratification and predictive modeling that can inform providers of the need for a more intensive care management approach
• Population health management and outreach
• Point-of-care decision support
• HEDIS compliance management
• Pay-for-Performance (P4P) program management
• Network utilization and leakage

Being a part of Gwinnett Health System allows Sequent’s Data Analytics team to work together with the GHS Information Technology department. This includes guidance and direction from the CIO, the assistance in data extraction and analysis by the Enterprise Analytics team, data storage and database administration from the Database and Security division, and access to patient specific data via the Ambulatory Data division. The group works together to ensure the data is protected, the proper data is used for reporting, and to validate all reports via a formal data governance process that is approved by the Information Technology Committee.

The Data Analytics team is continually mining data in the various reporting systems to find new opportunities for the Care Management team. This includes mapping providers to patients to determine gaps in coverage areas, analyzing monthly claims data to identify differences since the last quarterly reports, and to produce reports that are meaningful and easy to use for the providers in the network.