Population Health Tools: Empowering Primary Care Clinics

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Population Health ToolsEmpowering Primary Care
Clinics
CAPT Dan Frederick, MC USN Naval Hospital
Bremerton Disease Management Conference 16 March
2008 Attribution CDR Von Thun, MC, USN
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Words to Remember

• The most valuable commodity
• I know of is information.
• Gordon Gecko
• aka Michael Douglas
• Wall Street

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Outline

• History of Disease (/Condition) Management
• The New Interest in Population Health
• Pop Health Tools
• Population Health Navigator Dashboard
• Details Content (Graphs-HEDIS)
• Population Health Navigator
• Hx/Data Sources/HEDIS
• Patient Action Lists
• Screen Shots Account Applications

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History of NavyDisease Management

• First Formalized in BUMED Policy, Dec 2004
• BUMED NOTE 6310
• Diabetes, Asthma, Breast Health
• Effective management.improves patients health
  and reduces health care costs.
• Requirement of Clinical Champions and Program
  Coordinators at each MTF
• Second BUMED Policy Document, Aug 2006
• Added Dental Health
• Synchronized with BUMED Business Plan
• Additional Measures- Cervical Colorectal
  Screening

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Population Health Tools

• Display Tool
• Population Health Navigator Dashboard
• Action Tool
• Population Health Navigator (PHN)

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Dashboard Content

• Compares to other clinics/MTFs
• Contrast own clinic/MTF over time
• Displays denominators, values, and benchmarks
• Navy averages
• HEDIS 50th percentile
• HEDIS 90th percentile

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Dashboard Details

• No accounts/ passwords required
• CAC enabled
• Updated monthly once PHN refreshed
• Also available via NEHC webpage, and NMO as
  resource kit
• https//dataquality.med.navy.mil/reconcile/popheal
  th

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Child DMISs name and Parent DMIS average here
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• Population Health Navigator

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PHN History

• USAF developed the Population Health Portal
• Adapted for Tri-Service use Fall 2003
• BUMED incorporated into FY04 Business Plan

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Summarizes data from . . .
PHN Dashboard
DEERS
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CHCS Labs/Rads/Path
PHN
M2 (SADR,SIDR)
PDTS
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About PHN

• PHN Components
• Demographics
• Clinical Preventive Services
• Condition Management
• Disease Management
• Provides HEDIS measures to compare clinical
  quality of delivered healthcare.

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HEDIS metrics

• Healthcare Effectiveness (formerly Health Plan
  Employer) Data and Information Set
• Standardized performance measures for comparing
  health care plans
• HEDIS metric ? standard of care
• Very precise definition based on
• Continuous enrollment
• Age and gender
• Inclusion and exclusion criteria

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PHN Strengths

• Corporate level (HEDIS) metrics
• Patient Action Lists drill to patient/provider/cli
  nic levels
• Data on patient care
• Inpatient outpatient care
• Entire MHS
• Network MTF care
• Can be displayed in Excel for easy use of data
• No cost to command

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PHN Weaknesses

• Updated monthly, 4-6 week lag time
• Network care with greater time lag
• Only predefined modules, not able to query

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Security Awareness

• Need command approval for access to the PHN
• Must read and accept the Security Requirements
  prior to entering the site
• Maintain HIPAA compliance with downloaded
  Personal Health Information (PHI)
• Store on
• Secured network drive
• Removable drive that is in a locked cabinet
• Delete obsolete data periodically
• Use minimum amount of information required to
  accomplish task

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219/322 68
117/322 36
These are the values that appears in the PHN
Dashboard and the Tri-Service Business Plan
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• PHN Pearls

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Raw Table
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Master Spreadsheet
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Basic Excel Skills

• Basic/Intermediate Excel Skills can serve you
  well in analyzing Pop Health Navigator data.
• Filter e.g.
  isolate clinic, doc
• Sort e.g.
  sorting/ranking
• Pivot Tables e.g. Subtotals
• Count If COUNTIF(range,"lt7") e.g. A1C lt7
• Highlighting, copying, pasting (Keyboard)

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Practical Application

• How will you use this tool in your clinic?
• Who will analyze the data?
• How often will the data be analyzed?
• With whom will you share the data? And what
  pieces of the data?
• Who should have an account?

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Obtaining an Account

• Need command endorsement
• Complete 1 page form
• Need to request account electronically via PHN
  website
• Primary Navy Administrator
• LCDR Vanessa Richards (BUMED)
• E-mail phn.admin_at_med.navy.mil
• Phone [phone]
• Fax [phone]

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Enter name as LT John Doe - NOT ALL CAPS -
nor all lower case
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Quick Example Disease and Condition Management
Support for Primary Care Clinics at NHB
Time Permitting.
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NavHospBrem

• Pop Health Support
• Two Web tool Products created from Population
  Health Navigator
• 1) Provider and Clinic HEDIS Metrics/Patient
  Action Lists
• 2) Preventive Health Review with Clinic Visit
• Two way Communication between
• Pop Health and
• Primary Care Clinics (PCMs and Support Staff)

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Pop Health Web tool 1 Purpose Process

• Goal To provide actionable information
• For Proactive Intervention by
• Providers and their Support Staff
• Thru Data Conversion Sequence
• of Pop Health Navigator product
• KEY TO SUCCESS TEAM APPROACH

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Data Conversion SequencePop Health Webtool 1

• Imported into Excel
• Create Provider specific Patient Action Lists
  
• Generate Metrics
• Provider to Provider
• Clinic to Clinic
• Includes NHB overall and HEDIS metrics
• Eye friendly Graphs
• Save into Shared folder
• Access on NHB intranet

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NHBs Pop Health Web tool 1

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NHBs Pop Health Webtool 1
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NHBs Pop Health Web Tool 1 Executive Summary
Graphs
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NHBs Pop Health Web Tool 1 COMMUNICATION AGAIN!

• Success REQUIRES Dialogue Between
• Pop Health
• Providers
• Support Staff
• More important than Website Metrics--
  Patient Action Lists
• Hard copies help place Metrics in Context
• (Providers NOT required to GOTO
  www.yetanothersite.navy )
• Feed back on Discrepancies help with Data
  Accuracy
• Quarterly Face to Face Review
• Directors/OICs Clinical(DH/SMOs)/Support Staff
  leaders

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Pop Health Web Tool 2 Purpose Process

• Goal To provide actionable
• Preventive Health Review
• For Point of Care Intervention by
• Providers and their Support Staff
  
• Thru Linking of 6 Excel (PHN) Tables in
• one Access Database (Refreshed
  monthly)
• KEY TO SUCCESS COMMUNICATION

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NHBs Pop Health Web Tool 2

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Pop Health Web Tool 2 Top Half
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Pop Health Web Tool 2 Bottom Half (Example 1)
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Pop Health Web Tool 2 Bottom Half (Example 2)
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Pop Health Web Tool 2Summary

• Simple to use, Staff Training is short
• Type in FMP SSN
• Print color copy of single page Review
• CA Screening- Breast, Pap, CR
• Chronic Disease-Asthma, DM, Depression, Lipids,
  Htn
• Flu Vaccine recommendations
• ER Visit numbers
• Information is color coded based on Action needs,
  i.e. Red needs to have appointment made
• Intended for Patient to take home after visit,
  NOT DOCUMENTATION FOR RECORD