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Applied Population Health: Delivering Value-Based Care with Actionable Registries [Minkštas viršelis]

  • Formatas: Paperback / softback, 286 pages, aukštis x plotis: 254x178 mm, weight: 1400 g, 22 Tables, black and white; 20 Illustrations, black and white
  • Serija: HIMSS Book Series
  • Išleidimo metai: 17-Dec-2019
  • Leidėjas: CRC Press
  • ISBN-10: 0367196670
  • ISBN-13: 9780367196677
Kitos knygos pagal šią temą:
  • Formatas: Paperback / softback, 286 pages, aukštis x plotis: 254x178 mm, weight: 1400 g, 22 Tables, black and white; 20 Illustrations, black and white
  • Serija: HIMSS Book Series
  • Išleidimo metai: 17-Dec-2019
  • Leidėjas: CRC Press
  • ISBN-10: 0367196670
  • ISBN-13: 9780367196677
Kitos knygos pagal šią temą:
"Electronic Health Record (EHR) systems today provide increasing levels of clinical decision support and are the fulcrum for change for value-based healthcare delivery. Billions of dollars of government and insurer payments are dependent on evidence-based workflow design and quality report. In this context, quality measurement is no longer a retrospective exercise, but an essential prospective process embedded in clinical operations. Population health tools in the EHR enhance the efficiency and effectiveness of interventions thus improving the quality of care at lower cost. Population health methods are effective in ensuring that the right patient receives the right care at the right time. This book provides a clear framework for design, implementation, and monitoring of innovative population health tools to accelerate measurable improvements in care delivery. Key benefits for readers include conceptual framework, team approach, and technical insights that result in improved patient care, improved performance on quality measures and increased revenue from quality performance incentives and risk-based contracts. This is also a practice guide to the healthcare professionals many roles who are eager to build or improve population health programs with the goal of delivering high quality value-based care"--

Electronic Health Record (EHR) systems today provide increasing levels of clinical decision support and are the fulcrum for change for value-based healthcare delivery. Billions of dollars of government and insurer payments are dependent on evidence-based workflow design and quality report. In this context, quality measurement is no longer a retrospective exercise, but an essential prospective process embedded in clinical operations. Population health tools in the EHR enhance the efficiency and effectiveness of interventions thus improving the quality of care at lower cost. Population health methods are effective in ensuring that the right patient receives the right care at the right time.

This book provides a clear framework for design, implementation, and monitoring of innovative population health tools to accelerate measurable improvements in care delivery. Key benefits for readers include conceptual framework, team approach, and technical insights that result in improved patient care, improved performance on quality measures and increased revenue from quality performance incentives and risk-based contracts. This is also a practice guide to the healthcare professionals many roles who are eager to build or improve population health programs with the goal of delivering high quality value-based care.

List of Tables xiii
List of Figures xv
Acknowledgements xix
About the Authors xxiii
1 Introduction
1(8)
Part 1: Fundamentals
3(2)
Part 2: Effective Delivery of Applied Population Health
5(2)
Part 3: Applied Population Health of Today and Tomorrow
7(1)
Let's Get Started
8(1)
Part 1 Fundamentals 9(84)
2 Policy: Drivers for Value-Based Payment Models
11(12)
Pay-For-Performance (P4P)
13(2)
Risk Sharing Programs
14(1)
Risk Adjustment
15(1)
Savings
15(1)
Healthcare Measurement Frameworks
15(3)
Published Results
18(3)
Cardiac Health
18(2)
Tobacco Cessation
20(1)
Diabetes
21(1)
Human Immunodeficiency Virus (HIV)
21(1)
Benefits of Early Intervention
21(2)
3 People
23(24)
Organizational Characteristics
24(10)
Engaged Leadership
24(3)
Data-Driven Value Improvement Workgroups
27(3)
Empanelment and Attribution
30(2)
Team-Based Care and Care Management
32(1)
Promoting Information Flow Using a Communication Plan
33(1)
Case Study: Provider Engagement at OCHIN
34(2)
Conclusion
36(1)
Understanding Patients and Patient Groups
36(6)
Social Determinants of Health
37(1)
Race, Ethnicity, and Language Standard
37(5)
Case Study: Lessons Learned on Patient Perception of Ethnic Background
42(5)
Sexual Orientation and Gender Identity
42(1)
Finding and Addressing Health Disparities
43(1)
Patient Engagement
44(3)
4 Process
47(18)
Clinical Interventions
48(7)
Cascade of Care
48(3)
Harmonize Measures
51(2)
Create a Population Health Protocol
53(2)
Case Study: Doing the Right Thing...with Medication Monitoring
55(5)
Direct and Indirect Interventions
56(1)
Value Improvement Cycles
57(3)
Technology Flaws Underlying Healthcare Waste
60(5)
Why Have One Way When We Can Have 10?
61(1)
If I Can't Find It, the Data Aren't There
62(1)
If It Works for the Computer, It's Fine for Human Use
62(3)
5 Technology of Health Registries
65(22)
Early Operational Registries
66(1)
Actionable EHR Registries
67(1)
The Spectrum of Registries
68(12)
Active Patient Registry
69(1)
Payor Registries
70(1)
Managed Care Registries
70(1)
Affiliate Registries
70(1)
Acute Care Registries
71(1)
Post-Acute Care Registries
71(1)
Primary Care Registry
72(1)
Wellness and Prevention Registries
72(1)
Patients at Risk
73(1)
Chronic Condition: Diabetes, Hypertension, Coronary Artery Disease, etc.
73(2)
Registry Suites
75(1)
Medication Management Registries
76(2)
Patient-Based Registries
78(1)
Event-Based Registries
78(1)
Decedent Registry
79(1)
Case Study: Use of Social Security Decedent Data in an EHR Registry
80(1)
Registry Architecture
80(2)
Registries: From Taxonomy to Ontology
82(5)
6 Measuring the Quadruple Aims
87(6)
Health Outcomes
87(2)
National Quality Forum
88(1)
International Consortium for Health Outcomes Measurement (ICHOM)
89(1)
Per Capita Cost
89(2)
Patient Experience
91(1)
Provider Experience
92(1)
Part 2 Effective Delivery Of Applied Population Health 93(70)
7 Applied Population Health Technical Foundation
95(4)
8 Quality Measure Management Systems
99(16)
What Is Healthcare Quality Measure Management?
100(11)
Do-It-Yourself (DIY) Quality Measure Management
101(49)
A Quality Program Cash Flow Report
102(1)
B Quality Program Submission Planning Report
103(3)
C Quality Baseline and Goals Report
106(2)
D Quality Measures Details Report
108(3)
Case Study: Tactical Planning for Quality Programs
111(4)
9 EHR Population Health Projects
115(10)
Judicious Use of Redundancy
116(1)
Case Study: Automated Clinical Documentation Project
117(1)
Best Practices for Population Health Projects
118(1)
Population Health Project Request Form
119(3)
Case Study: Registry Project Request
122(3)
10 The Who: Cohort Management with EHR Registries
125(4)
Active Patient Registry
126(1)
Wellness and Prevention Registry
126(1)
Chronic Condition Registry
127(1)
Medication Registry
127(1)
Case Study: Complex Cohorts ACO-30 Aspirin Therapy for Ischemic Vascular Disease
128(1)
11 The What and the When: Building the Feedback Loop
129(4)
The What: Registry Metrics
130(1)
The When: Intervention Scheduling
130(1)
Precision Medicine
131(1)
Case Study: Complex Measures ACO-17 Tobacco Assessment and Cessation
131(2)
12 Applying Clinical Decision Support
133(8)
Workflow Modeling
133(4)
Ambulatory Care Screening Order Protocol
137(1)
Dynamic Orders
137(2)
Bulk Orders
139(1)
Key Technical Components That Require Support of the EHR Team
140(1)
Key Operational Steps in Building This Process
140(1)
13 Calculating Risk
141(8)
Risk Adjustment
141(1)
Risk Stratification
142(1)
Human Judgement
143(1)
Heuristics
143(1)
Risk Calculators
144(1)
Case Study: Implementation of HIV Risk Calculator in an EHR
145(2)
Machine Learning
147(1)
Evaluating Risk Scores
147(2)
14 Analytics Dashboards
149(14)
Measure Performance
150(3)
Provider Feedback
151(2)
Case Study: OHSU Ambulatory Quality Reporting White Paper
153(4)
Troubleshooting
156(1)
Prediction
157(1)
Technology Performance
157(4)
Monitor Technology Use
157(1)
Monitor the Technology Platform
158(1)
Monitor Technology Efficacy
159(2)
Quadruple Aim Outcomes
161(2)
Part 3 Applied Population Health Today And Tomorrow 163(32)
15 Moving Into the Future With a Learning Health System
165(10)
Learning to Deliver Better Healthcare
166(1)
Creating a Learning Health System
167(3)
Funding Research and Development
170(1)
Standardizing Financial Outcomes and Economic Impact
171(1)
Progress to Date
171(4)
16 We've Come So Far...Lessons Learned and Call to Action
175(12)
Case Study: Discovery of the EHR as a "Therapeutic"
175(3)
How Good Is Good Enough?
178(1)
Manage Complexity
179(1)
Design Systems for People
180(2)
Improve the Clinical Accuracy of Patient Groups
182(3)
Caught in the Middle
185(1)
Call to Action
186(1)
17 Visioning Population Health of Tomorrow
187(44)
Population Health in the Patient Digital Health Era
188(1)
Precision Medicine for Individual Health Balanced With Population-Level Standards
188(1)
Predictive Analytics With Dexterity Between Cost, Benefit, and Timing
189(1)
Aggregation and Risk Scoring of Data for State, National, and International Sharing Inclusive of Disparity Perspectives
189(2)
Improved Access to the Right Clinical Expertise
191(1)
Pushing the Envelope on the Subtleties of Prevention
191(2)
Epilogue
193(1)
Funding and Support
193(2)
References 195(8)
Answer Key 203(14)
Appendix A. Implementation of CDC Race and Ethnicity Codes (CDCREC) 217(8)
Appendix B. Population Health White Paper 225(6)
Appendix C. Job Descriptions for Population Health Team Members 231(14)
Job Description: Chief Medical Information Officer for Population Health
232(2)
Job Description: Healthy Planet Application Analyst
234(1)
Job Description: EMR Reporting Analyst
235(2)
Job Description: Population Health Lead Application Analyst
237(6)
Job Description: Enterprise Population Health Architect
243(2)
Appendix D. DIY System for Quality Measure Management 245(6)
Quality Program Table
245(2)
Quality Measure Table
247(3)
Import Additional Measure Details from CMS
250(1)
Appendix E. Ambulatory Care Health Screening Order Protocol 251(12)
Appendix F. Population Health Project Request 263(6)
Appendix G. Registry Best Practices 269(4)
Glossary of Registry Terms
269(1)
Diagnosis Value Sets
270(1)
Registry Testing Environment
270(1)
Required Reports
271(2)
Appendix H. Resources 273(4)
Centers for Medicare and Medicaid Services (CMS)
273(1)
Outcomes
273(1)
IHI Institute for Healthcare Improvement
274(1)
Public Data Set
274(1)
Electronic Clinical Quality Improvement (eCQI)
275(1)
Learning Health
275(1)
Information Usability, Visualization, and Presentation
276(1)
General Topics
276(1)
Index 277
Barbara Berkovich, PhD, MAFounder, CEO Applied Population Health

Dr. Berkovich founded the consulting and professional education company, Applied Population Health in 2019. She is developing courses in Applied Health Data Analytics and Population Health for academic year 2019-2020. Her goal is to assist health providers with implementation of their population health goals, and to train the next generation of health informatics professionals in a standardized practice of Applied Population Health.

She accrued ten years of work experience at the University of California San Diego Health (UCSDH) where she designed and built tools in the Electronic Health Record to drive quality, safety, and outcomes to enhance patient care and meet state and national performance targets. As Lead Population Health Architect, she became an expert in sustainable timely operational registries in the EHR and managed an extensive portfolio of registries to track active patients, payer groups, affiliate members, medications, wellness, and chronic diseases. In 2018, her local work on the Get to Green quality campaign helped claim nearly $5 million of at-risk PRIME incentive payments that were in jeopardy.

Her Ph.D. research focused on the automated selection of disease cohorts for the delivery of evidence-based care. She has lectured nationally on population health methods, registries, and medical terminologies and has taught graduate level courses at the University of California San Diego. In addition to a Ph.D. in biomedical informatics from the University of Texas Health Science Center at Houston, she holds a Master of Education degree from San Diego State University and a Bachelor of Science in Industrial and Systems Engineering from the University of Southern California.

Amy M. Sitapati, MD, Clinical Professor, Department of Medicine, Division of Internal Medicine and Division of Biomedical Informatics, Chief Medical Information Officer of Population Health, Internist, La Jolla Internal Medicine, University of California San Diego

As Chief Medical Information Officer of the Population Health for UC San Diego Health, Dr. Sitapati provides strategic vision and oversight. Using enterprise solutions that improve quality, safety, and outcomes, she leads the design of population level systems that support workflows for organizational goals. Dr. Sitapati is the executive lead at UCSDH for two CMS programs called PRIME and QIP, worth more than $25 million annually in eligible performance incentive payments. In this role, she directs more than 20 projects containing more than 80 quality measures supported by more than 150 active team members. Across the health system, Dr. Sitapati synchronizes the strategic vision, mapping, prioritization and expertise related quality infrastructure supporting Pay for Performance (P4P), Physician Quality Reporting System (PQRS), Meaningful Use (MU), Merit-based Incentive Payment System (MIPS), Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), and Californias third largest Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) using more than 80 EHR based registries.

Dr. Sitapatis expertise includes Board Certification in Clinical Informatics and Internal Medicine, a bachelors in engineering at Case Western Reserve University, doctorate in medicine at Case Western Reserve University, coursework in clinical research at UC San Diego, business at UC Los Angeles Anderson School of Business, EHR training in Epic as a physician builder, and lean black belt training. Dr. Sitapati has been recognized for her work in promoting culturally competent care through recognition of the Sexual Orientation and Gender Identity workgroup which she chairs by the Chancellors 2018 UC San Diego Inclusive Excellence Award Recipients diversity award.

With more than a decade of experience in informatics associated quality improvement, Dr. Sitapati brings substantial experience in using data to drive improved clinical workflows that ultimately provide healthier patient populations. She began this journey nearly eighteen years ago caring for HIV/AIDS patients in inpatient, outpatient, and border care delivery sites. This evolved into a deep appreciation for the care continuum, complexity of multimorbidity, shortage of human health workforce, influence of social determinants and remarkable foundational importance that registries can serve to anchor and improve care. Dr. Sitapati has given much thought and daily iterative work in mastering patient centered care delivery, implementation of meaningful risk acuity scoring, development of dynamic decision support, quality driven care, and access to research. As a former member of the Agency for Healthcare Research and Quality (AHRQ) health information technology study section, and a current member of the National Comprehensive Cancer Network (NCCN) breast panel, Dr. Sitapati has experience in considering academic needs related to population health. Dr. Sitapati is the local investigator for the California Vital Records and give thought to the intersection between public and health system level data. She provides instruction in clinical informatics and Kelee meditation in the school of medicine to physicians, pharmacists, computer and computational scientists. From the perspective of research, she leads the local recruitment team for the NIH precision medicine movement, All of Us, and thinks about how the intersection between research and population health. Dr. Sitapati believes that medicine of the future will integrate research, continuous quality improvement, and population driven healthcare delivery into the daily practice of medicine in remarkable ways to serve as the penicillin of the future by directing the right care to the right patient with the right resources.