HIT Breakdown 12 - Healthy Planet: Opportunities and challenges

Transcript

Lauren: Hi, I'm Lauren Griessmeyer, one of the practice directors at Nordic. I'm here with Andrew Nordmeier, one of our consultants out in California. Why don't you go ahead and introduce yourself, and tell us a little bit about your background.

Andrew: Hello. I worked at Epic for about two and a half years. I've worked with Orders, ClinDoc, Beacon, MyChart, Bridges, kind of run the gambit with the clinical apps. Currently, for the last year, I've been heavily involved with Healthy Planet and managing patient health and patient populations.

Lauren: Healthy Planet is kind of a hot topic in the industry right now. Can you talk a little bit about what problems that tool within Epic is meant to solve?

Andrew: Yeah, Healthy Planet is really overlaid on all the functionality that you already have. It's really a tool that is out there to better manage patient populations, especially high-risk patient populations. It's really better manages their health, and it just gives you a lot of different ways to do that.

Lauren: Can you give us some examples of some patient populations that may be used for Healthy Planet?

Andrew: One that comes up over and over again is the diabetic population.

Lauren: Sure.

Andrew: Diabetes in the U.S. continues to grow. Along with that, comes the associated health needs. It's very common to say, "Hey, for our diabetic patients, we want to make sure things happen." Like, make sure that they have a recent A1C. Make sure that their A1Cs are under control. Make sure that they've had a foot exam. Those type of tests that are really specific to the diabetic population and are really important to their long-term health and long-term care of themselves.

Lauren: Using the diabetic population as an example or a jumping off point, can you talk about some of the technical barriers that you have to overcome when setting up the registries within Healthy Planet?

Andrew: There's technical barriers and there's just organizational barriers.

Lauren: Okay.

Andrew: They kind of blur together a lot. The first thing is, "How do you actually define a diabetic patient?" Is that a patient that has diabetes on the problem list ever? Is that a patient that has an encounter diagnosis of diabetes. Do they have diabetes on a claim? You think, "Oh, they're diabetic."

Lauren: Yeah.

Andrew: It actually gets a lot more complicated than that. Even as a subdivision of that, like, "Do you count gestational diabetes as a diabetic patient?" The answer is very often no, from a clinical perspective. From the technical perspective, that means you then have to take out all of those diagnoses that indicate gestational diabetes, as opposed to regular diabetes.

Lauren: Actually being able to slice and dice the data, in a way that's actually clinically relevant, is a big portion of the design or a big challenge of the design.

Andrew: Yeah.

Lauren: Okay. Once you have kind of figured out, "Okay, how are we going to define a particular patient population?" What other challenges do you end up having to overcome?

Andrew: Once you've defined the patient population and how you want to define the patient population, the next big step is, "What do you want to track?" Epic comes with a ton of information and a ton of options already for a diabetic registry that you can track. Then it's, "What labs do you want to track? What medications do you want to track? What office visits do you want to track?" For instance, with the diabetic patient, you'd probably want to see the last time they saw a nephrologist. That's important information. There's also labs and what not, that are important, but just the fact that they had a visit, is important information. The real big question is "What do you want to track?" Then, getting into the nitty-gritty of, "How do you set that up in the system to track it?" 

Lauren: Then, once you have decided what you want to track, are there set ways that you can drive the system to help with follow up?

Andrew: Yeah. With the initial stages of registries, the first stage is defining your patient population. Second stage is determining what you want to track. Then, once you have that, Healthy Planet allows you to do a lot of patient population management from reports built off of all these things. You can have a report of all your diabetic patients, who have an A1C that's less than eight, or less than nine, or whatever your organization decides is the cut-off point, and you can send all those patients a message saying, "Hey, your A1C is high." You can also actually order A1C for all of these patients at the same time. You can just say, "Hey, I ordered you another A1C. Come in whenever you want."

Lauren: Yeah.

Andrew: Just schedule it, so it let's you be a lot more proactive with reaching out to patients and ordering for these patients. Even being aware of these patients. That, "Hey, I have 200 diabetic patients that have an A1C that's really high. So, let's focus on those and what can do to bring that number down?"

Lauren: It sounds like it can be a pretty powerful tool for providers. Are there any sort of barriers for provider adoption?

Andrew: There are, just like everything else. There's always some initial resistance to it. Part of it is, it is a great tool for providers, but also, a lot of this work can be, and maybe should be, done by someone else. As an example, maybe the MA should be the one sending the patients these messages. Just saying, "Hey, your A1C is high." A lot of providers are incredibly busy, as we all know.

Lauren: Yeah.

Andrew: For something as simple as sending a message, it's something their MA can do. You do get into questions of, "Who does it? When do they do it?" You don't want to send the patient a thousand messages, all saying, "Hey, your A1C is high."

Lauren: Right.

Andrew: You really have to define, "Is the provider going to send it? Is the MA going to send it? Is the clinic manager going to send it?" If all three send a message saying, "Your A1C is high." The patient is, "Hey, I heard this, thanks."

Lauren: Probably going to start ignoring it. Yeah.

Andrew: You're getting into a lot of those organizational decisions of who does what when.

Lauren: Talking about the diabetes example for your population health, at your current client, that's a pretty big patient population. Once you have gotten your hands around that patient population, is there any way to more focus on different subgroups within the population?

Andrew: Yes. Healthy Planet allows you to define risk scores based upon whatever factors that you consider important. They'll assign each patient a score, and when you're running you're Healthy Planet reports, it'll list out all the patients, and it'll list out the risk scores. "Oh hey, this patient's a 15, and this patient's an eight, and this patient's a two." In this case, let's say higher is worse off.

Lauren: Okay.

Andrew: "Hey, the patients who are 15 and above, these are the patients we really need to focus on, and these are the patients who really need help."

Lauren: Are these set up as kind of "at-a-glance" sort of reports for providers? Or, we talked about different groups of people using the reports. Who are these typically targeted at?

Andrew: It's providers, MAs, case managers, often clinic managers. You can set up different reports for these different groups, because they never quite want the same information.

Lauren: Sure.

Andrew: It's just really, that you can set up the reports for these different groups however you want.

Lauren: They're pretty flexible tools.

Andrew: Yeah.

Lauren: Okay.