Pay-for-Performance for PCMHs

These challenges for PCMHs fall in to two categories:

  • Healthcare Population Predictive Analytics
  • Cost-Quality Analytics

A fundamental challenge with PCMHs is that patient data comes from multiple financial, clinical, quality systems, and is unstructured, not normalized and not linked or classified. This makes predictive risk modeling and cost/quality at episode-of-care level very difficult and expensive. Unfortunately, without quality analytics at your fingertips, operating a PCMH efficiently and profitably is an impossible mission.

VitreosHealth Population State-of-Health (SOH) Predictive Analytics provides actionable insight and measurable information about actual health at population and patient levels, with visibility of controllable and non-controllable factors. The SOH model uses patient age, gender, ethnicity, family history, all clinical factors (like BMI, lipid panel, blood HM, HcA1C) and co-morbidities, to calculate an accurate SOH score for each encounter by disease and for the entire population. The SOH model does not use prior I/P or E/R admissions as an input (the inputs to the models are purely clinical). While payers have their own definitions and calculations for “risk”, VitreosHealth uses the terms “Risk” and “State of Health” interchangeably. The SOH model, combined with utilization, compliance and access-to-care models predicts risk of hospitalization

Our systems rely on patient medical records to measure state of health, and to evaluate the effectiveness of care programs and evidence-based medicine. Our customers use real-time clinical data from EHR records to identify high risk patients and create sub-registries, create individualized care management programs and reduce the high risk population over time. Because VitreosHealth decision support systems use clinical data, there is little or no analysis or interpretation required by the physician. As a result, care coordinators take ownership of care management, while primary physicians focus on delivering patient care. This is very good news for patients and providers, in light of predictions about the short supply of doctors over the next few years.

Cost Quality Analytics: PCMHs need the ability to analyze cost and quality variances and identify root causes. PCMHS also need to track monthly cost and quality performance of their physicians and care teams. This forms the backbone of pay-4-performance systems. VitreosHealth integrates ambulatory and acute cost, quality and risk data to:

  • Identify variances in cost, quality, and risk
  • Create predictive “what-if” scenarios to reduce variance and justify projects
  • Design and staff care management programs and projects
  • Understand physician and care coordinator performance
  • Track care management program effectiveness to understand project ROI

To understand VitreosHealth low-cost approach to data normalization, please read about the core competencies of VitreosHealth solutions.

To understand VitreosHealth EHR-based approach to population risk stratification and predictive analytics, please request a demo and  read White Paper | Population Health Management: Real-Time State-of-Health Analysis.

Get Access to Actionable Reports in 4 weeks


"VitreosHealth (PSCI) has been a very important asset towards our Patient Centric Medical Home, their experience in collecting EMR data and population risk stratification is very critical in how our care coordination program works."

Dr.Murray Fox,  - CEO, Patient Physician Network

A 4-Step solution towards your goal

  • Step-1

    PCMH Sign Business Associate HIPAA agreements with Vitreos®

  • Step-2

    PCMH sends EHR files and claims files (if available) for the patient population to our secured FTP.

  • Step-3

    Vitreos team will normalize the data and run it through Vitreos® Population Predictive Risk and Care Management Analytics Tool.

  • Step-4

    PCMH access the actionable reports to execute on within 4 weeks of EMR & claims data submission

Vitreos Impact on NCQA PCMH Certification

VitreosHealth’s platform can help PCMH organizations achieve 46 points towards the NCQA certification as shown below.

PointStandard & Element


20 1 Enhance Access & Continuity  
4 Access during office hours  
4 After-hours access  
2 Electronic access  
2 Continuity  
2 Medical home responsibilities  
2 CLAS  
4 The practice team  
16 2 Identify & Manage Patient Populations  
3 Patient information
4 Clinical data
4 Comparative health assessment
5 Use data for pop’n management
17 3 Plan & Manage Care  
4 Implement E-B guidelines  
3 Identify high risk patients
4 Care management
3 Medication management
3 Use electronic prescribing  
9 4 Provide Self Care Support & Community Resources  
6 Support self-care process
3 Provide referrals to community  
18 5 Track & Coordinate Care  
6 Test tracking & follow-up  
6 Referral tracking & follow-up  
6 Coordinate care transitions  
20 6 Measure & Improve Performance  
4 Measure performance
4 Measure patient- family experience  
4 Implement CQI
3 Demonstrate CQI
3 Report performance
2 Report data externally  
0 Use certified EHR technology  
10028 Elements46

VitreosHealth Value Proposition for PCMH

VitreosHealth Commitment

  • Vitreos offers a simple, affordable solution for Population Analytics
  • We offer an on-demand full-service intelligence solution as a pay-as-you-go service.
  • We provide full HIPAA security
  • With Vitreos, you don’t have to waste time learning new tools. Since we provide actual reports, you can spend your productive time delivering quality care to your patients
  • We provide/push actionable reports for your care coordinators and case managers
  • We offer innovation at affordable prices for Better Results and Better Outcomes