These challenges for PCMHs fall in to two categories:
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:
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.
"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
PCMH Sign Business Associate HIPAA agreements with Vitreos®
PCMH sends EHR files and claims files (if available) for the patient population to our secured FTP.
Vitreos team will normalize the data and run it through Vitreos® Population Predictive Risk and Care Management Analytics Tool.
PCMH access the actionable reports to execute on within 4 weeks of EMR & claims data submission
VitreosHealth’s platform can help PCMH organizations achieve 46 points towards the NCQA certification as shown below.
|Point||Standard & Element||
|20||1 Enhance Access & Continuity|
|4||Access during office hours|
|2||Medical home responsibilities|
|4||The practice team|
|16||2 Identify & Manage Patient Populations|
|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|
|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 patient- family experience|
|2||Report data externally|
|0||Use certified EHR technology|