NextGen Population Health

NextGen® Population Health
“The Game Changer”
May 14, 2014
Industry dynamics driving
population health management
Presented by Elise Freedman, MBA
Senior Market Manager, Business Development
Population Health is hot!
Everyone says they have a population health solution….Really?
If it was that easy….
And population health is defined differently depending on who is using the term
NextGen Population Health
Helps providers to deliver the most appropriate preventative care and intervention
based on the patient’s condition, risk and severity of illness …. across the entire
patient panel.
An automated and targeted patient outreach and engagement solution
(“Set it and Forget it!”)
Fully integrated with NextGen EHR, PM, Patient Portal and Dashboard
Helps healthcare providers improve:
Patients health
Quality of care
Practice productivity/efficiency
Financial outcomes
Population Health is very “Popular”
Core objectives of population health
Deliver better care in lower cost settings
Reduce avoidable ER visits and hospitalizations
Reduce hospital readmissions
Significantly improve patient health outcomes
Financial Benefits
Maximize financial return for value-based care
Reimbursement preventative care
Payment for “non‐visit” contact
Negotiate better risk sharing terms with payers
Dynamics driving need for population health
• US healthcare system ― fragmented care, unsustainable costs
• Increasing chronic disease and comorbid conditions,
• obesity, heart disease and diabetes
• Baby boomers (born between 1946 and 1964) extremely high utilizers
especially end of life care
• Approximately 10,000 Americans turn 65 every day
• 40.3 million people age 65 or older in 2010; by 2050 projected 88.5 million;
8 in 10 seniors suffer from at least one chronic condition
About 25 percent of seniors are obese
20 percent have diabetes
70 percent have heart disease
Projected physician shortage
Patient non-compliance with treatment
Transition to coordinated, collaborative, integrated, value-based
New diagnostic/treatment available to improve chronic conditions
How providers get paid is changing
Payer trends
• Started with CMS quality incentive programs, now
commercial payers on board with performance-based
payment models (because Medicare is going broke, had to
do something)
„ atient Centered Medical Home (PCMH) and practices
implementing Accountable Care (ACO) programs
Paying per member/per month (pm/pm) care
management fees and gain sharing revenue for
lowering healthcare costs
Payers are buying physician groups and launching
physician group practices, IPAs
But the clincher is: Responsibility for patients’
health is shifting to providers
The onus for managing, improving and reporting
the health of patients is shifting to providers,
particularly primary care physicians
Reporting on these outcomes will impact how
and how much they get paid
Regardless of whether or not your patients are:
Chronically ill
Sick  short term
My Patients’ Health
“Your patient  your
The impact of patient noncompliance
• Non-compliance accounts for:
- 11% of all hospital admissions
- 40% of nursing home
- 20% prescriptions never filled
- 30% prescriptions never refilled
• Contact with doctors and
hospitals is sporadic/infrequent
• Problems are not addressed
until patient is in crisis
• 2020, 25% of the American
population will have multiple
chronic conditions
Source: Wu, S., & Green, A. Projection of Chronic Illness Prevalence and Cost Inflation. In RAND Corporation.
The prevalence of chronic diseases has
created a national health care crisis
Six "unhealthy truths" about chronic disease in the United States:
• 1 Chronic diseases are the No. 1 cause of death and disability in the U.S.
• 2 Treating patients with chronic diseases accounts for 75 percent of the nation's
health care spending (75% of $2.8 trillion!)
• 3 Two-thirds of the increase in health care spending is due to increased prevalence
of treated chronic disease
• 4 The doubling of obesity between 1987 and today accounts for 20 to 30 percent of
the rise in health care spending
• 5 The vast majority of cases of chronic disease could be better prevented or
• 6 Many Americans are unaware of the extent chronic diseases could be better
prevented or managed
Many chronic diseases can be prevented with
lifestyle and behavioral changes
Modifiable behaviors that cause illness, suffering, and early death
related to chronic diseases
lack of physical activity
poor nutrition
tobacco use
excessive alcohol consumption
Blame is not a factor  possible reasons for
patient non-compliance
• Language barriers (including
regional semantics)
Example: (Diabetes vs Sugar)
• Socio-economic conditions
• Unwillingness to follow
• Lack of understanding
treatment instructions
• Insufficient provider follow-up
What else is going on with my patients?
Patient's personal life and circumstances could be
contributing to their poor health and non-compliance
What percent of your patient population looks like
Very Healthy
What percent of your patient population looks like
Mostly Healthy
What percent of your patient population looks like
Not so good
Where does this guy go when he goes into cardiac arrest?
When do you think he last saw a doctor for a check-up?
Then, there’s everyone else…
• When’s the last time you had a preventative screening on time?
• How many doctor’s appointments did you cancel this year
because you were too busy?
• Do you always take your medications as prescribed?
• Do you stop taking medication when you start feeling better?
• Do you eat properly?
• Exercise regularly?
• Get enough sleep?
Population Health as it relates to
NextGen Care Coordination
You can’t measure what you don’t track
• P4P programs (PCMH/ACO) earn incentive
payments for programs such PQRS, Bridge to
Excellence (BTE) and MU
• Practices must track and monitor the health status of
their entire patient population
• Providers are responsible for documenting and
reporting outreach efforts
Bottom line:
You can’t get paid on what you don’t report
NextGen Population Health generates reports
that track and analyze performance
Physicians and practice administrators can produce analytical reports
on CQM performance as well as detailed patient reports identifying
treatment opportunities within the patient population
Outreach communication reports that can be
scheduled for delivery
Graphical reports to measure performance
of outreach program
NextGen Health Quality Measures (HQM) collects
EHR data organized by patient encounter
Produces summary and detail outcomes results per
program rules
Performs automated calculation, tracking and reporting
Extracts new clinical data
Provides useable reports to provide insight and
performance metrics at a practice, provider and patient
Enables clients to receive incentive for performance
Automatically submits CQM reports for MU Compliance
Integrated NextGen solutions in a single platform
 bringing it all together
CCO Phase1 integrates and optimizes NextGen
products in our Ambulatory EHR and EPM
Patient Registry (new!)
Population Health
Patient Portal
NextGen Share
Tools for comprehensive provider-driven
population health management
CCO Phase 2 provides a complete, vendor-agnostic
solution leveraging Mirth products by providing:
• Comprehensive care management and
collaborative chronic disease management
• Central Data Repository and Data exchange
• Population health activation
• Advanced “cohort” analytics and risk modeling
Advanced data analytics identify treatment
opportunities and report those outcomes
Population Health
Ultimately, providers will need to predict
which patients are likely to get sick to
minimize future costs
Data driven workflows manage care
plans, track events, and schedule
appointments and reminders.
Patient engagement tools that enable
patient participating in their healthcare
NextGen care coordination goals
• Improve care quality and patient safety for decreased
hospitalizations and re-admittance
• Increase staff efficiency by reducing time required to
develop care plan
• Greater focus on patient goals and expected outcomes
• Establishes clear, organized and specific interventions to
improve patient care
• Improved patient compliance with their prescribed care
plans through automated communications and clinical
decision support
Care coordination workflow
Identify care team members and define roles
Enter, review and modify referral information
Identify barriers to care:
patient disabilities and limitations
other issues impacting patients ability to comply with
care plan
Review and modify current care plan and track progress
Log and review all patient-related communications, including:
phone calls
text messages
Patient communications documented by various categories
and filtered to show all or selected data
Manage the shared care plan
• Standardized care plan accessible to and modifiable by
designated providers, case managers and caregivers
• Customized to patient needs:
Health maintenance
Chronic care management
Complex cases
Advanced directives
• Includes patient directed goals
Patient preferences and directives
Planned provider and patient interventions
Barriers to care
Templates that advance PCMH & Collaborative
Enhanced care
coordination templates
provide efficient and
reliable care
coordination among
multiple providers to
provide safer and more
effective healthcare
Proactive Patient Engagement
Proactive instead of Reactive
Today you see patients when they are sick or due for an
They call you to make an appointment
As we shift from volume-based to value-based
care, providers need to focus on:
Proactive patient engagement for preventative care
Keeping patients from falling through the cracks
Quality reporting for an ever-increasing volume of measures
and mandates
Really important NextGen Population Health
Fully integrated with NextGen
Patient Portal
No interfaces required!
But wait…there’s more!
With other PH vendors…
Patient receives an alert to schedule appointment for a mammogram
When patient calls to schedule the appointment, reception pulls up the patient chart but
there is no info in the patient record regarding the alert and why the patient is calling
But…NextGen is fully integrated so all patient info is integrated within the workflow, The
receptionist will have all information about the alert sent for each patient contacted
NextGen integration  no interfaces required
NextGen Practice Management and NextGen
Ambulatory EHR streamline workflow
Display outcomes performance in NextGen
Creates alerts on patient chart with triggering event
Alert cleared when appointment is kept
Chart notes added in Practice Management with
reasons for outreach
Follow-up documentation goes directly into EHR
Evidence-based quality measures leveraged using
NextGen Health Quality Measures (HQM)
Data mining capability within PM and EHR
“Set it and Forget it”
– While you are away on vacation…
– 2,500 automated flu shot reminders have just been sent from your
NextGen® Ambulatory EHR to a targeted group of patients
– During the week, 50 patients schedule their flu shots
Pre-programed notifications
are automatically sent to
your patients
Target patients for follow-up and preventative care
• Hypertensive patients for blood pressure control
• Diabetic patients with A1C levels greater than seven
• Women age 55, who require pap smears and
mammograms in May
• Men, age 60 who require prostate exams in September
Patient engagement outreach channels
Phone & Interactive Voice Response (IVR)
Text Message
Patient Portal
Mobile & Remote Monitoring Integration
Program alerts using a stratified approach
• These alerts have been automatically programmed in your
NextGen EHR
• As these patients schedule appointments, all encounters are
documented and tracked in your EHR
• You can generate reports as you need them
You have just met an important Meaningful Use 2 requirement
• Reminders: “Use clinically relevant information to identify patients who should receive reminders for
preventive/follow-up care”
• Secure Messaging: “Use secure electronic messaging to communicate with patients on relevant health
information for 5% “
The patient profiler for simple stratification
• Diabetic patients with
A1C greater than 7
• Women age 50, require
pap smear and
mammograms in May
The patient profiler for more complex
Identify male patients age 40
who have:
Diabetes with history of high A1C
High blood pressure and
Hyperlipidemia with high total
cholesterol and LDL
No foot or eye exam for last 6
months and
No booking for next 2 months
ROI, NextGen client  Infinity Primary Care
Expected Revenue Projection
Reminders sent: 10,000 per month (calculated on full provider participation)
Roughly three patients contacted for each provider per day
% Patient of patients responded: Between 20 – 45%; average
of 33%
Approximate revenue per visit: $95
Generating one additional visit per day for each provider
Additional Annual Revenue: $3,420,000
Infinity Primary Care success story
“NextGen Population Health fills an important gap
between patient communication and patient health
management. In the past, we would dedicate hours of
staff time attempting to contact a small percentage of
patients. Now, we use a stratified approach to engage
our at-risk patients with a single click. NextGen
Population Health has improved the way we care for our
30% Average response rate
3 Patients contacted daily per provider
10,000 patient reminders monthly
Patrick Stevenson
Director of IT
ROI roughly ½ million $ additional annual
Activity and Variables
Number of providers
Number of patients reached at 200/month/provider
Response Rate
Potential Appointments
Number of additional appointments (from previous
year) Capacity for 3 additional patients per week
Average profit (stated as income) per visit
• Average profit for all new visits
Coming soon….
Data Integration &
• Integration with Payer
data (CCLF)
• Integration with thirdparty Risk Stratification
(Statictical and
Predictive modeling)
• Dashboards:
• Chronic Condition
• Payer Analysis
Care Coordination
Patient Engagement
• Enhance care
coordination workflows in
NextGen EHR with
population health data
(outreach & gaps in care)
• Actionable Patient
Registry with Referral
• Enhance patient
communication methods
• Gather survey and
remote monitoring data
from patients
Ready to take a deeper dive?
We will now demonstrate how easy
NextGen Population Health is to use
Kim Root will now show you various
features and functionality
Let’s see NextGen Population Health in Action
Live Demo presented by
Kim Root
NextGen Application Specialist
NextGen Population Health results 
Healthier clinical and financial outcomes
Outreach communications is the first step in
managing chronic conditions
Increase revenue from additional patient
encounters and treatment opportunities
Improves patients engagement which is
essential to meet health reform requirements
Augments EHR to meet ACO, PCMH, and
MU2 criteria
NextGen Population Health Resources
• Population Health web page
• Watch for future monthly population health webinars
• White paper
• Demo
• Video
• Brochure
• Contact your sales representative
• Request a live demo
[email protected]
[email protected]
Thank You !

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