2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comCreative Commons Copyright Dr. Greg Spencer & Luke Skelley Data Driven Care: The Key to Accountable Care Delivery from a Physician Group Perspective

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Todays Agenda Why a regional physician group is heavily investing in analytics and data warehousing Crystal Run Healthcares strategy to turn data into improved care as well as financial viability in the future How Crystal Run manages across its patient population who are covered by 24 payer entities Some of the preliminary challenges and successes engaging clinicians in the use of data The importance of an adaptive data architecture to turn clinician questions into actionable results

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright POLL QUESTION #1 What best describes the group you belong to? Health Plan Physician Group Provider Organization Vendor Other

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Healthcare Physician owned MSG in NY State, founded 1996 300+ providers, 16 locations Joint Venture ASC, Urgent Care, Diagnostic Imaging, Sleep Center, High Complexity Lab, Pathology Early adopter EHR (NextGen) 1999 Accredited by Joint Commission 2006 Level 3 NCQA PCMH Recognition 2009, 2012

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Healthcare Single entity ACO April 2012: MSSP participant December 2012: NCQA ACO Accreditation 25,000 commercial lives at risk MSSP 10,400 attributed beneficiaries 82% primary care services within ACO

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Healthcare The mission of Crystal Run Healthcare is to improve the quality and availability of, and satisfaction with, health care services in the communities we serve. To accomplish this goal, the practice emphasizes both traditional medical excellence as well as responsiveness to consumer needs through service excellence and patient empowerment.

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright The Goal: The Triple Aim Improve the health of the population Enhance the patient experience of care Reduce, or at least control, the per capita cost of care

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Strategy and Objectives Embrace goals of Triple Aim Physicians play a crucial role in driving change in healthcare Focus on providing coordinated care Population health management is critical Competition from hospitals and health plans is occurring Coverage area is expanding, and needs to expand further Physicians and their teams need to work together for the best of their patients A strategic pillar is to be the practice of choice for physicians, patients, and employees

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Governance Model Establish data warehouse priorities Set policies for data access, information security and privacy Develop process for setting data definitions and standards Coordinate with Partners eCare leadership JOINT CLINICAL AND FINANCIAL GOVERNANCE MODEL Hal Teitelbaum, MD, JD, MBA Managing Partner & CEO MichelleA. Koury, MD Chief Operating Officer Greg Spencer, MD Chief Medical & Chief Medical Info Officer Mary DeFreitas Chief HR Officer Erlene Washington Senior VP of Finance &Accounting EDW EXECUTIVE SPONSORS Greg Spencer, MD CMO & CMIO Jonathan Nasser, MD Medical Director Miguel Hernandez Technology Director Lou Cervone BI Director EDW Steering Committee EDW GOVERNANCE

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Care Management Strategies Embedding Care Managers at different offices, medical homes and hospitals Identify high-risk patients from registries and PCP/ team referral Implement evidence based protocols Use EHR and mobile / home devices

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Quality Structure 27 divisions each headed by its own physician specialist Manage quality efforts and information Work with Best Practice Council (quality committee) to define registries Report to practice-level committee for quality and patient safety

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential 12 Why Crystal Run is heavily investing in analytics and data warehousing

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright POLL QUESTION #2 If you are a health plan, physician group, or provider organization, do you currently exchange clinical and claims data with these other constituents?

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Data Analytics Strategy Implementing formal quality improvement methodology Implementing EDW with multiple data sources Implementing analytical applications Daily financial reporting Order tracking: In-house vs. Sent out Claims Data Integration RVUs Standardization

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Analytics Current State Quality improvements heavily dependent upon data Using simple analytical tools Excel, Access, Tableau Time and effort spent on manual data entry and extraction is excessive and poorly scalable Decisions about what data to use based on amount of disruption vs. value Data entry/analysis not done at Top of Licensure Reporting quality metrics resource intensive kept it simple

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Physician Dashboard

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Physician Dashboard

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential Turning data into improved care & ensuring financial viability in the future

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Dr. J. 15 Cases $60,000 Avg. Cost Per Case Mean Cost per Case = $20,000 $40,000 x 15 cases = $600,000 opportunity Total Opportunity = $600,000 Total Opportunity = $1,475,000 $35,000 x 25 cases = $875,000 opportunity Total Opportunity = $2,360,000 Total Opportunity = $3,960,000 Cost Per Case, Vascular Procedures Physician Variation Analysis

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run Results Reduced hospital admissions 4+% in one year Improved mammogram rates from 60-65% to greater than 75% Achieved less than 9% rate of A1Cs > 9 Blood pressure control in hypertensive patients improved to greater than 75%.

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Improved Quality Breast Cancer Screening Mammography 66.0% 67.0% 68.0% 69.0% 70.0% 71.0% 72.0% 73.0% 74.0% 75.0% 76.0% 1st Quarter 2011 2nd Quarter 2011 3rd Quarter 2011 4th Quarter 2011 1st Quarter 2012 2nd Quarter 2012 3rd Quarter 2012 4th Quarter 2012 1st Quarter 2013 2nd Quarter 2013 3rd Quarter 2013 CRHC Results NCQA Goal

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Outcomes: Avoidable Admissions#AvoidableAdmissions 17% 0 10 20 30 40 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Avoidable Admissions Monthly Quality Trend

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Outcomes: Readmissions 16.50% 17.00% 17.50% 18.00% 18.50% 19.00% 19.50% 20.00% Q2-2012 Q3-2012 Q4-2012 Q1-2013 Q2-2013 Q3-2013 CRHC Linear (CRHC) 30 Day Readmission Rate for Medicare

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Total cost difference 2012 pre-pathway 791 patients $595,920 2013 post-pathway 817 patients $368,160 TOTAL COST SAVINGS $227, 760 PEG-filgrastim use in Breast cancer patients (equalized as cost per patient treated)

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Reducing Pharmaceutical Costs $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 Physician A Physician B Physician C Physician D Average PEG Filgrastrim cost per patient before and after breast cancer pathway

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright A Culture Of Efficiency: Improving Access 41,823 fewer visits 30,206 more patients Created 12 physicians

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Variation Reduction Spread Reduction in Charges DIAGNOSIS DEPARTMENT % CHANGE PP TOTAL $$ CHANGE CHF Cardiology -6% -$53,457 Diabetes PCP/Endocrine -17% -$844,755 Thyroid Nodule Endocrinology -26% -$304,224 Otitis Externa ENT -2% -$2,373 GERD GI -20% -$178,381 Cholelithiasis General Surgery -7% -$11,408 COPD Hospitalists -20% -$9,215 HTN Primary Care -16% -$943,002 Hyperlipidemia FP/IM -19% -$1,150,376 HA/Migraine Neurology -10% -$208,054 Breast Cancer Oncology -7% -$393,622 Lateral Epicondylitis Orthopedics -8% -$27,647 Asthma Pediatrics -10% -$24,570 Asthma Pulmonology +3% +$26,238 Renal Mass Urology -4% -$62,812 TOTAL -$4,187,658

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Variation Reduction Spread Improving Access DIAGNOSIS DEPARTMENT CHANGE IN VISITS CHANGE IN PATIENTS CHF Cardiology -722 +213 Diabetes PCP/Endocrine -3,051 +41 Thyroid Nodule Endocrinology -1,971 +132 Otitis Externa ENT +70 +65 GERD GI -143 +266 Cholelithiasis General Surgery -12 +59 HTN Primary Care -3,013 +339 Hyperlipidemia FP/IM -2,966 -561 HA/Migraine Neurology -550 +225 Breast Cancer Oncology -278 +16 Lateral Epicondylitis Orthopedics -84 -4 Asthma Pediatrics -92 -134 Asthma Pulmonology -66 +1,132 Renal Mass Urology -11 -6 TOTAL -12,889 +1,783

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential Managing patient populations across payer entities

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Runs payer mix 24 Payer Entities No dominant payer, so little to no leverage for discounts, etc. No dominant payer, so payers need to contract with Crystal Run to effectively do business in the area Complicates data analysis due to limited population/statistics by payer

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Payer Challenges Having data-focused payer conversations about shared savings Need claims data to support risk contracting Multiple payers limits ability to do valid statistical modeling Collaborating with multiple plans to develop shared savings model

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Living in Two Worlds Improvements in quality reduces costs to benefit of payer Reduction in patient visits offset by increase in patient volume Hospitals acquisition of physicians not based on value but to protect referrals Triple Aim is a threat to hospitals Hospitals have to align optimal patient care vs. optimal reimbursement

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential Clinician Engagement: Challenges & Successes

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Clinician Engagement Data used in physician recruitment and retention Data also used to support alignment and/or acquisition decisions Sharing physician performance data helps affect behavior even if no penalty or not tied to a quality effort Sharing physician data makes outliers come to consensus Not all physician practices focus on value Younger physicians sometimes avoid change more than older ones

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Its All About the Data The limitation is data. The doctors need performance data They have metrics to measure care ~ 80% of Business Intelligences time spent gathering versus analyzing data 90/10 of data capture time to analysis time.

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run EDW Requirements Fast to implement and fast to ROI Capable of easily expanding to add new data sources Library of analytical applications Vendor with healthcare experience and expertise Data model conducive to healthcare data Ability to become self sufficient Long term business partner

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential Adaptive Data Architecture: Turning clinician questions into actionable results

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Provider-Payer Collaboration Provider Payer Case mix analysis Utilization review Care management Regulatory measures Physician profiling Prior authorizations Contracting Prevent readmissions Evidence based guidelines Admission notification Discharge notification Risk stratification Case management Utilization review Wellness programs Consumer transparency Claims dataClinical data Care gap notification Physician profiling Case management Evidence based guidelines Wellness programs Consumer transparency Regulatory measures

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Provider Payer Data Sharing Provider Payer Case mix analysis Utilization review Care management Regulatory measures Physician profiling Prior authorizations Contracting Prevent readmissions Evidence based guidelines Admission notification Discharge notification Risk stratification Case management Utilization review Wellness programs Consumer transparency Care gap notification Physician profiling Case management Evidence based guidelines Wellness programs Consumer transparency Regulatory measures Claims data Clinical data

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run EDW Architecture

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Catalyst Apps and Claims Data Key Process Analysis Executive Dashboard Integration Tool Cohort Builder Comorbidity Analyzer Readmissions Explorer Population Explorer Claims Data

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Driven by business and clinical need Rapid development and deployment of data sources Built incrementally (i.e., less expensive) Ownership transferred to client with technical support as needed Align with access roles and data stewardship jurisdictions Applications support Healthcare Analytics Adoption Model Catalyst Data Warehouse Advantages

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Healthcare Analytic Adoption Model Level 8 Personalized Medicine & Prescriptive Analytics Tailoring patient care based on population outcomes and genetic data. Fee-for-quality rewards health maintenance. Level 7 Clinical Risk Intervention & Predictive Analytics Organizational processes for intervention are supported with predictive risk models. Fee-for-quality includes fixed per capita payment. Level 6 Population Health Management & Suggestive Analytics Tailoring patient care based upon population metrics. Fee-for-quality includes bundled per case payment. Level 5 Waste & Care Variability Reduction Reducing variability in care processes. Focusing on internal optimization and waste reduction. Level 4 Automated External Reporting Efficient, consistent production of reports and adaptability to changing requirements. Level 3 Automated Internal Reporting Efficient, consistent production of reports and widespread availability in the organization. Level 2 Standardized Vocabulary & Patient Registries Relating and organizing the core data content. Level 1 Enterprise Data Warehouse Collecting and integrating the core data content. Level 0 Fragmented Point Solutions Inefficient, inconsistent versions of the truth. Cumbersome internal and external reporting.

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright POLL QUESTION #3 On a scale of 1-5, with 5 being very advanced, how far along is your organization in using data to guide your quality and cost initiatives?

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Organizational Structure Goals Provides steady state domain oversight GUIDANCE TEAM Refines Work Group output and leads implementation CLINICAL IMPLEMENTATION TEAM Provides clinical forum to develop clinical content and analytics feedback WORK GROUP Supports development of clinical content and analytics feedback CONTENT AND ANALYTICS TEAM Provides overall governance and prioritization of initiatives SENIOR EXECUTIVE LEADERSHIP TEAM ENSURE THAT Workgroups are created with institutional priority Appropriate leadership is engaged in prioritization Organizational barriers between team members are removed

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Organizational Teams Women & Childrens Clinical Program Guidance Team Pregnancy SAM Pregnancy MD Lead RN SME Knowledge Manager Data Architect Application Administrator RN, Clinical Ops Director Guidance Team MD lead (e.g., Pregnancy MD Lead) Subject Matter Expert Data Capture Data Provisioning & Visualization Data Analysis Normal Newborn SAM Normal Newborn MD Lead RN SME Gynecology SAM Gynecology MD Lead RN SME Permanent Teams Integrated Clinical and Technical members Supports Multiple Care Process Families

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright47 Workgroup Roles DATA CAPTURE Acquire key data elements Assure data quality Integrate data capture into operational workflow DATA ANALYSIS Interpret data Discover new information in the data (data mining) Evaluate data quality DATA PROVISIONING Move data from transactional systems into the EDW Build visualization for use by clinicians Knowledge Managers Data Architects (Analysis) Knowledge Managers Data Architects (infrastructure) Data Architects (Visualization) Application Administrators (e.g., EMR Administrators, Financial System Administrators) Subject Matter Expert Data Capture Workflow Analysis Data Provisioning Data Analysis

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Crystal Run EDW Teams EDW data acquisition Systems programmers Database administrator Clinical SMEs EDW data architecture and integration services BI director Data architects Business development Project manager Clinical SMEs

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Catalyst Resource Deployment Installation Improvement Independence Engagement Time Level of Engagement Technical Director Engagement Executive Primary owner Secondary owner SOW# 1 SOW# 2 SOW# 3 SOW# 4 SOW# 5+ Support

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright The Analytic Organizations Journey

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright http://www.healthcatalyst.com/

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright AHIP Institute 2014 June 11-13, 2014 in Seattle, WA AHIPs Data Analytics Forum will provide valuable insights on how stakeholders in the health care system utilize big data to enhance care quality, reduce costs, make better business decisions, and streamline operational processes. Please join Luke Skelly and Health Catalyst at Booth #911

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright 2014 Health Catalyst www.healthcatalyst.comProprietary and Confidential Questions?

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Seed Questions What are some of the barriers youve run across in acquiring claims from payers? What internal challenges do you see payers or providers facing in developing a data driven culture? How does Health Catalyst support a population health management approach using claims data from non-acute care settings (home health, skilled nursing facilities, etc.)

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Contact Information Dr. Greg Spencer, CMO Crystal Run Healthcare www.crystalrunhealthcare.com Luke Skelley, VP Health Catalyst luke.skelly@healthcatalyst.com www.healthcatalyst.com

2014 Health Catalyst www.healthcatalyst.com Creative Commons Copyright Survey Questions On a scale of 1-5, with 5 being the highest, how satisfied are you overall with the quality of this webinar? What do you wish the presenter had spent less time on? What do you the presenter had spent more time on? What topics would you like to see in future webinars from Health Catalyst? On a scale of 1-5, how interested are you in a demonstration of Health Catalyst Solutions? What additional comments do you have?