Population health performance final v2 12 8 14 by KLAS

PERFORMANCE REPORT

December 2014

Population Health Performance EMERGING MARKET, EMERGING VALUE

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NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.

Population Health Performance: Emerging Market, Emerging Value TABLE OF CONTENTS PAGE

SECTION

DISCOVER FINDINGS

DRILL DEEPER

COMPARE VENDORS Vendors with 6+ validated sites

     

Advisory Board eClinicalWorks Epic Explorys Forward Health Group i2i Systems

     

Kryptiq

    

Medecision

  

Healthagen

McKesson Optum Phytel Verisk Health Wellcentive

Vendors with 3–5 validated sites

    

Alere Allscripts athenahealth Conifer Health Solutions Evolent

NextGen Healthcare Premier Valence xG Health

Other Vendors with fewer than 3 validated sites

  

Caradigm Cerner Health Catalyst

119

EXAMINE DETAILS

130

KLAS PERFORMANCE DATA

132

SPECIAL QUESTIONS COMMENTARY

Lumeris Siemens

Population Health Performance 2014 I 1

Population Health Performance Emerging Market, Emerging Value

MARK ALLPHIN

REPORT AUTHOR

Today, energy around population health management (PHM) solutions continues to grow, with some vendors starting to deliver value. While most vendors currently have a small number of live clients, PHM offerings abound and the number of solutions is still increasing. Which vendors are effectively driving outcomes? Where is the needle when it comes to providing better patient care and reducing costs? KLAS interviewed 203 providers at 173 organizations to find out. ABOVE AVERAGE AVERAGE BELOW AVERAGE

Vendors with 6+ validated client organizations. Insufficient Data No Validated Sites

SPEED TO VALUE

*Does not meet minimum

KLAS Konfidence level. (6-14 organizations) Small sample size (3-5 respondents)

% of Implementation Implementations on Completed Time <6 Months

CONNECTIVITY Average # of Clinics

Data Sources Connected

  

VEN DOR PERFORMANCE

BREADTH OF OFFERING

OUTCOMES % Reporting Tangible Benefits

++ + + + +

DELIVERY OF PERFORMANCE Delivery of New Lives Up to Expectations Technology

Performance Score

Data Aggregation

Risk Stratification

Care Management

Patient Engagement

8.3

7.0

8.0

7.6

8.0

8.5

89.8

7.4

8.0

7.5

7.0

7.6

7.6

87.2*

8.3

7.8

86.9*

6.4

7.4

6.8

7.5

7.6

79.8*

6.6

6.2

7.2

6.0

7.2

82.3*

7.5

8.0

7.3

7.9

7.4

82.6*

6.3

6.3

6.2

6.6

6.3

77.4*

7.9

7.5

7.3

7.5

79.7

+ +

6.9

7.9

6.4

7.0

79.7*

6.6 6.9 5.8

Early Leader

PHYTEL



++ +

FORWARD HEALTH GROUP



I2I SYSTEMS







++ +

High Performing

Performing

ADVISORY BOARD EPIC



+ +

KRYPTIQ



OPTUM



EXPLORYS

VERISK HEALTH



+ +

ECLINICALWORKS



MCKESSON



++ +

WELLCENTIVE

6.8

5.6

6.7 6.6

7.0

6.8

6.7

77.6*

8.1

7.0

7.7

6.8

6.4

67.3*

7.3

6.0

4.3

5.7

5.8

62.5*

Low Performing

WORTH KNOWING PHYTEL EMERGING AS THE EARLY LEADER AS PERFORMANCE GAPS WIDEN IN THE PHM ROSTER. Phytel currently stands 10 points above the PHM market average as a result of quick implementations, deep user deployment, and high provider satisfaction in all performance areas. All Phytel respondents reported tangible benefits and a high number of linked clinics. 70% REPORTED TANGIBLE OUTCOMES, WHILE EXPLORYS, PHYTEL, AND WELLCENTIVE RESPONDENTS ACHIEVE EVEN MORE. Phytel is the most mentioned for helping customers effectively manage their general and high-risk patients through better prevention and care planning. Explorys and Wellcentive are most mentioned for improving outcomes and quality measures, and Wellcentive respondents also mentioned achieving better care planning. HIGH CONSIDERATION YET RELATIVELY LOW ADOPTION TODAY OF EMR PHM OFFERINGS. ONLY EPIC AND ECLINICALWORKS HAVE ENOUGH EARLY CUSTOMER PARTICIPANTS TO GENERATE A PERFORMANCE SCORE. In a KLAS perception study earlier this year, PHM solutions offered by EMR vendors had the highest consideration among providers planning a population health strategy. EMR vendors are just starting to compete, and not many providers are utilizing their solutions at this point. athenahealth, NextGen Healthcare, Cerner, and Siemens still have a very limited number of live sites compared to their EMR client bases.

DECEMBER I 2014

TA N G I BL E B E N E F I TS R EALI Z ED

VEN D OR E A R LY VI E W Vendors with 3–5 validated client organizations.ǂ

A LL S

% OF IMPLEMENTATIONS COMPLETED UNDER 6 MONTHS

SPEED TO VALUE

I PT

If you have seen benefits, which benefits have you seen or which metrics have you used to measure success? (n=74)

AVERAGE # OF CLINICS

CONNECTIVITY

EN EA

RISK STRATIFICATION

LTH

% of clients validated using each module

CARE MANAGEMENT

BETTER CARE TO HIGH-RISK POPULATIONS

39%

DATA AGGREGATION

BREADTH OF OFFERING

IMPROVED OUTCOMES & QUALITY MEASURES

H AT

DATA SOURCES CONNECTED

23%

PATIENT ENGAGEMENT

ER HEALTH SO

AVERAGE BELOW AVERAGE

BETTER PREVENTION & CARE PLANNING

CO NIF

TANGIBLE BENEFITS %

ABOVE AVERAGE

20%

TOP PERFORMERS

L VA

I ON

ENC

22%

COST SAVINGS

LU T

Insufficient Data

Wellcentive

○

Optum

O L

Optum Phytel

○

McKesson ○ Kryptiq

Verisk Health

○

McKesson

T M ED

E CI SIO N

XT G

ǂ Alere, Premier, and xG Health have 3-5 validated organizations, but insufficient data to show the metrics above.

Only

17%

of respondents reported utilizing all four areas of PHM offerings: data aggregation, risk stratification, care management, and patient engagement.

DATA S OU RC E S CO N N E CT E D From which sources is your vendor aggregating data? (n=123)

69%

AMBULATORY EMR

50%

INPATIENT EMR

41%

PROVIDER CLAIMS DATA

Most Linked°

Least Linked°

(6+ Validated Organizations)

eClinicalWorks, Explorys, i2i Systems

Verisk Health, McKesson

Advisory Board, Explorys, Optum

eClinicalWorks, Kryptiq, Verisk Health

Explorys, McKesson

Epic, Forward Health Group, i2i Systems, Kryptiq

LAB DATA

38%

i2i Systems, McKesson

Phytel, Verisk Health, Kryptiq, Forward Health Group

PAYER CLAIMS DATA

37%

Explorys, Verisk Health

Forward Health Group, i2i Systems, Kryptiq

Epic, Explorys

Most Vendors Not Linked

eClinicalWorks, Epic

Most Vendors Not Linked

Explorys

Most Vendors Not Linked

eClinicalWorks, Epic

Most Vendors Not Linked

15%

REGISTRIES

11%

HIE

HOME HEALTH

PATIENT MOBILE DEVICES 0%

10%

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20%

30%

40%

50%

60%

70%

80%

°Based on % of clients on each data source.

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Drill Deeper

4 I Population Health Performance 2014

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

Drill Deeper

 DRILL DEEPER About This Report With all the complexities in the emerging population health market, it can be difficult to publish a view on the large scope and diversity of vendor offerings available today. In an effort to simplify the market definition and capture aspects of that diversity, KLAS categorizes vendor capabilities into four pillars: data aggregation, risk stratification, care management, and patient engagement. Not all solutions are created equal, and not all profess to be able to function within all four pillars or even plan to provide that functionality. Provider needs and expectations are continually evolving, and as such, many of the sample sizes represented in this report are smaller. However, they are still representative of the market as a whole. With so many vendors offering population health management solutions, this report is an early view of those vendors who had a large enough sample size for KLAS to validate early performance. KLAS labels customer feedback on software products as preliminary or early data if fewer than 15 unique organizations were interviewed. Typical KLAS reports put less emphasis on these vendors as their performance scores are subject to greater variability. But considering the high level of provider interest and low overall market penetration of population health solutions, in this report KLAS includes early data vendors alongside those with 15 or more interviewed organizations. Throughout the report, these early data vendors are tagged with an asterisk when shown with a KLAS performance score. KLAS received vendor-proclaimed complete client lists from most but not all of the commercial vendors included in this study. Some vendors weren’t included because they have relatively few live clients. KLAS did not attempt to interview every single client claimed but instead attempted to interview a portion of each client base to get a picture of each vendor’s population health activity. The criteria used to determine how each vendor is displayed in this report is as follows:  To be shown with an overall KLAS performance score with no asterisk (*): Vendor product(s) must be live and validated by KLAS at a minimum of 15 unique organizations.  To show an overall KLAS performance score with an asterisk (*): Vendor product(s) must be live and validated by KLAS at 6–14 unique organizations.  Vendors with a minimum validation of 3 unique live organizations are discussed in the Discover Findings and Drill Deeper sections of this report.

Population Health Performance 2014 I 5

Introduction In 2013, when KLAS did our first report on population health management (PHM), there was no clear leader and vendor capabilities were just starting to emerge. Today, vendor capabilities have coalesced around four main “pillars” of population health: data aggregation, risk stratification, care management, and patient engagement. The PHM field has been inundated with vendors from all types of backgrounds who claim to do population health through various offerings. Which vendors have emerged as early leaders, and what functionality do these vendors offer? Which vendors are effectively driving outcomes, and where is the needle when it comes to providing better patient care and reducing costs? KLAS interviewed 203 providers at 173 organizations using 29 different products to find out. In order to best help providers, this report will focus on those vendors who are gaining the most traction. In the following sections, vendors discussed in detail are those who had six or more customers interviewed. Refer to the Other Vendors section for early performance summaries of those who did not meet this threshold.

Breadth of Portfolio Four Pillars Defined Provider strategies are still emerging in the population health sphere. Some providers are still developing their strategies, while some have a clear program to roll out and just need to find the right vendor to meet their needs. Vendors are offering a wide range of solutions to help meet these needs. PHM can be organized into four areas that are most prominent in providers’ population health strategies today. KLAS has defined those four pillars as follows: 



Data aggregation is combining patient data from disparate sources such as EMRs, billing, payers, pharmacy systems, labs, HIE, and registries and sorting it into a repository for easy access. Additional functionality includes clinical and claims data handling, multi-EMR data, terminology mapping, and unstructured data handling. On a basic level, risk stratification includes segmenting populations and prioritizing interventions. Providers can filter and sort patients into lists or registries to identify care gaps. Additional functionality includes predictive financial risk models, performance reporting, provider dashboards, and external benchmarking. Care management means directing a caregiver’s efforts through use of patient registries, care-gap reports/alerts, and visit planners/patient summaries. Additional functionality includes coordination workflow, clinical decision support, care plans, care transitions, and EMR integration.

6 I Population Health Performance 2014

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ď&#x201A;§

Drill Deeper

ď&#x201A;ˇ

Patient engagement includes engaging patients in their care through mobile applications, a patient portal, or patient education. Additional functionality includes automated reminders, response tracking, patient assessments, and wellness programs.

Figure 1

Breadth of Utilization While some vendors offer a full suite of products spanning all four pillars, others plan to stay in their niche or are still developing additional features and functionality. Whatever the case, respondents identified which vendors they are using most/least for each of the four pillars and rated how satisfied they are with the functionality they receive (see figure above). Deep Portfolio Utilization: Many vendors offer a range of functionality, allowing providers to utilize them for most, if not all, of their population health needs. However, Phytel and Kryptiq have the highest reported adoption in all pillars except for risk stratification. Within risk stratification, Phytel users reported an average level of adoption and Kryptiq users reported below average adoption. Low Portfolio Utilization: With a myriad of offerings to choose from, providers adopt their vendorsâ&#x20AC;&#x2122; functionality at different rates. Explorys and Optum users reported the lowest overall adoption across the four pillars. Explorys users reported 100% utilization for data aggregation, but few utilize risk stratification and care management, and KLAS Population Health Performance 2014 I 7

could not validate any use of patient-engagement capabilities. Optum users also reported high utilization in data aggregation, as well as risk stratification, but few users claimed use of care-management capabilities, and there was no validated use of patient engagement.

Overall Performance In addition to provider adoption and breadth of vendor portfolios, provider satisfaction must also be considered, and it varies vastly across vendors (see figure above). So which vendors are receiving the highest/lowest marks from providers utilizing the four pillars? High Provider Satisfaction: Early indicators show that Phytel and Optum receive the highest average satisfaction ratings from providers. Phytel excels in all areas (aside from their average performance in risk stratification) by capturing accurate data and by providing quick, effective implementations and an intuitive user interface. As a result of strong reporting and analytics, providers report that Optumâ&#x20AC;&#x2122;s strengths lie in data aggregation and risk stratification. Low Provider Satisfaction: Due to various levels of dissatisfaction and unmet expectations, early data shows that McKesson and Kryptiq have the lowest average ratings from providers. McKesson performed below average in all pillars except risk stratification. Also, McKesson customers experience longer than anticipated implementations. Lower ratings on delivery of new technology and living up to expectations also contributed to an early overall KLAS score for McKesson of 62.5. Despite the broad utilization of their portfolio, Kryptiq performed below average in early data in all four pillars. However, this can be attributed to a couple of dissatisfied customers who utilize all four modules but report not being able to achieve what they want to do. The rest of the client base is happy overall. Quick implementations and reasonable pricing contributed to Kryptiqâ&#x20AC;&#x2122;s KLAS score of 77.4, which is close to the market average.

Data Aggregation At an early glance, many vendors have been able to fulfill providersâ&#x20AC;&#x2122; population health needs. Additionally, many providers are satisfied with the capabilities their vendor offers. A deeper look into each pillar shows how providers are utilizing their vendors for PHM and what their successes and struggles have been. Data aggregation includes aggregating, reconciling, and normalizing patient data from a variety of sources, including inpatient and ambulatory EMRs, provider and payer claims data, lab data, and more. Data aggregation is the most common use of PHM solutions as it is an essential first step. The goal is to create a comprehensive view of each patient to enable providers to make the best decisions in their care. 100% of Phytel, Explorys,

8 I Population Health Performance 2014

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Kryptiq, McKesson, and i2i Systems (early data) respondents reported using their vendor’s data aggregation capabilities. Figure 2

Top Performers: With a wide span of providers using data aggregation in their population health strategies, some leaders have emerged. Phytel, Optum, and i2i Systems (early data) received the highest marks from providers. Phytel is a standout leader, and their users are highly satisfied with their ability to pull data from EMRs. Phytel users are gathering the bulk of their data from ambulatory EMRs, while the least amount of data is being pulled from labs and payer claims data. Optum receives high performance ratings and a high adoption rate for data aggregation. Many providers shared their satisfaction with Optum’s understanding of the structures of various data sources and their ability to normalize data for their providers. Users reported gathering the bulk of their data from ambulatory and acute care EMRs and the least amount of data from labs and payer claims data. With limited feedback, i2i Systems respondents reported high satisfaction with i2i Systems’ Custom Data Integrator. Low Performers: Many providers reported low utilization and low satisfaction with the amount of data they are able to pull in with their PHM solutions. Epic, McKesson, Kryptiq, Advisory Board, and Wellcentive customers are least satisfied with data aggregation.

Population Health Performance 2014 I 9

Epic respondents reported not being able to connect to outside vendors and rated Epic low, mainly because of their immature and limited aggregation abilities. This is not surprising seeing as Epic is still developing their Cogito product at a number of sites. McKesson respondents reported pulling in data from labs and provider claims at higher rates than customers of the other vendors, but they also described a cumbersome process. One provider said, “The overall product gives us a significant ability to do data aggregation, but it also takes a significant amount of our own resources to do that. McKesson has some key end reports that are nice but not exactly what we need, so we have a lot of reports that we generate with our own analytics people going through the back door. From a registry standpoint, the data aggregation for the front-door reports is not as much a part of it. Data aggregation works on more of a patient-by-patient basis than a population basis.” Kryptiq respondents reported bringing in data from the lowest number of data sources, and low provider satisfaction is a result of this limited number of data sources. Advisory Board respondents laud their ability to bring in data from a few sources but have issues with timeliness and data normalization across disparate systems. Lastly, Wellcentive users reported issues with interfaces and getting data back into the EMR correctly. Many providers have achieved success in using their PHM vendor to aggregate data, but others have been left with unmet expectations. Currently, all providers recognize that this seemingly fundamental step is by no means a walk in the park with any vendor. Yet, some providers are ahead of the general market, and it is encouraging to know that this type of connection exists. One provider explained, We aggregate from our EMRs, our cancer center app, our different lab interfaces, and our different document interfaces. Even within the EMRs, we get problems, diagnoses, allergies, immunizations, procedures, and medications. To date, we probably have around 60 active interfaces running into dbMotion Population Health. . . . We aggregate our hospital’s health plan claims data into a dbMotion Population Health database. We do keep a second, separate database from our provider for legal reasons. The third database is the HIE. Those nodes are all federated and secure. So if I am at a patient’s bedside, I am going to see information from all three of those nodes, provided the patient hasn’t opted out of the HIE.” Still, there is a long way to go for many providers to be satisfied with the amount of data they can pull in and the accuracy with which they can aggregate, reconcile, and normalize that data for their larger population health strategy.

10 I Population Health Performance 2014

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Risk Stratification Risk stratification includes filtering and sorting patients into lists or registries based on health conditions, quality thresholds, and utilization in order to best calculate risk. These functions allow providers to measure performance and predict financial risk of patients. This is becoming an important function as more providers are assuming risk with their own health plans or through value-based agreements with CMS and commercial payers. Through risk-stratification modules, providers hope to receive sophisticated statistical models that deliver fast, reliable analysis of claims data from their vendors. Figure 3

Top Performers: Risk stratification is the second most used pillar in population health management. The vendors with the highest levels of adoption of risk stratification are Optum and Verisk Health (with 100% adoption), eClinicalWorks (with 88%), and Advisory Board (with 83%). Additionally, Verisk Health and eClinicalWorks received high performance ratings from providers, and early data from Explorys and Forward Health Group respondents indicates high performance. Many Verisk Health users acknowledge that risk stratification is Veriskâ&#x20AC;&#x2122;s strength, and providers use the predictive modeling to understand risk and patient care gaps. One provider explained, What we see in the tool for risk stratification is that it will take groups of patients or individual patients . . . and it will tell us predictive risk scores based on some intuitive things that have been built into the program as well Population Health Performance 2014 I 11

as a large database. It tells us about the patient’s condition and tells us the patient’s chances of having an ED visit in the next 30 days, a readmission, or an admission. It also analyzes the patient’s clinical data to tell us on a scale whether that patient has gaps in care. The higher the score, the more gaps the patient has, and that is where we focus. eClinicalWorks providers use CCMR to assign questions and appropriate tolerance levels to patients in the system. From there, the system can calculate risk. Providers are highly satisfied with the functionality and laud the available flexibility and customization. While only 50% of Explorys respondents reported to be using Explorys for risk stratification, early data indicates high satisfaction: “What tipped the scale toward the system was that it was as close to plug and play as we can get. . . . Explorys had a nice solution that was easy enough to implement with few staff members maintaining it, so it seemed like a good way to go. We are using some of their disease registries and ACC risk scoring.” One provider using Forward Health Group explained why he is satisfied: “PopulationManager® does things I have never seen anything else do. I can actually select patients with a blood pressure above 140 and A1c above 9, and I can find all the patients who fit into that high-risk group. I can then select diabetes and hypertension, and the system will show me the 22 patients who meet all of the criteria and their insurers. I have never seen a product that works so quickly to allow me to aggregate high-risk patients.” Providers utilizing Optum reported high performance through strong usability and flexibility of the solution’s predictive modeling. However, providers rated Optum a little lower than the four top performers; some providers voiced the need to receive more guided action plans from Optum for high-risk patients. Stratifying patients into different sections and levels of care is key if providers are to deliver better care to those who are most at risk. Many vendors have succeeded at guiding providers, yet some have fallen short of moving the needle. i2i Systems and Wellcentive both offer risk stratification, and they both have many providers using this functionality. Neither got a rating for risk stratification in this report because neither had enough customers in this sample provide ratings for the riskstratification question. Low Performers: Epic and Kryptiq received lower performance ratings for risk management. Epic users mentioned that Healthy Planet does not have the functionality needed to do risk stratification and one noted that they are using a homegrown solution in conjunction with Epic in order to fill that need. One Kryptiq respondent particularly noted the lack of clarification he received among risk categories: “[Kryptiq CareManager] didn’t clearly notify the clinicians of the risk categories. 12 I Population Health Performance 2014

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So they had to go in and build the logic for identifying patients in risk categories. That wasn’t automatic. The module itself is designed specifically for COPD. We expected the system to have some knowledge about the risk factors related to COPD, but it was really up to the clinicians to define those.” Other Kryptiq users reported that the system meets their needs but suggested that Kryptiq add more filters.

Care Management Energy around care management is picking up as providers are learning how to better stratify data and identify care gaps. Care-management capabilities include guiding clinicians and care managers to meet a patient’s individual care needs through prioritization, guidance, and communication. Many vendors help in this effort to provide care plans that result in the best patient care. This is a fairly new area of effort for vendors, and just over half of respondents in this study reported to be using their PHM vendor for care management. Figure 4

Top Performers: Phytel stands out as the leader, with high adoption and high provider satisfaction of care-management capabilities. Many respondents are pleased with how Phytel guides the actions of care managers and coordinators to improve patient care and outcomes. One provider related, “The Phytel Transition product is basically for every hospital discharge or a patient that hits our ER. It is an automated follow-up that asks a series of five or six questions to inform us how to escalate a particular patient’s needs. We can find out whether the patient needs to go to a care coordinator, whether the patient’s Population Health Performance 2014 I 13

pain is worse than the day he or she was discharged, whether the patient is having trouble getting medication, and those types of things.” Forward Health Group performs well for customers because it enables them to understand where their patients need the most care and allows them to see the results of their action plans. One provider explained, “The clinicians are using PopulationManager® to see where the patients are at with their drug and alcohol use and risk and protection from use. Those are all broken out and reviewed with the client. The tools we are using and how PopulationManager® shows those results over time are really helpful in assessing where a client is in specific ways.” Providers using Explorys also reported that they receive guidance to identify gaps in patient care. Low Performers: Many providers mentioned that in order to be able to provide the best care management, they need to know things like what a patient’s economic situation is or what a patient’s family life is like. Providers want a way for their care coordinators to better manage their patient populations, and they feel that all vendors are lacking completeness in this area. Vendors do offer adequate care-management functionality, but can they do more? Early indicators show that McKesson and Kryptiq receive the lowest provider ratings in this area. Some Kryptiq respondents mentioned having functionality or data issues in coordinating care with hospitals, while others are pleased with Kryptiq’s previsit planning capabilities. Some McKesson respondents mentioned using multiple products to accomplish care management. They reported using McKesson as a supplementary tool because it cannot meet all of their care-management needs on its own. At 9%, Optum has the least care-management adoption, a fact that is consistent with provider comments about Optum needing more care-management functionality. Overall, providers called for care-management technology that helps care managers understand patient needs and points them toward where they need to focus their efforts. One provider noted, I think the key is having a system that helps the care managers understand what they need to do with each individual patient to help the patients stay compliant with their care plans. The care managers need a place to document their work. They need to know how to scale up their efficiency as the organization goes from 30,000 lives to 300,000 lives in two years. The most precious thing any worker has is time. They need to know where to focus their time to get the best bang for the buck. Maybe they should focus on the transitions, like when somebody gets out of the hospital and gets tied up with the PCP. Maybe they should look at medication lists to make sure patients are not on drugs they shouldn’t be on for their ages. Maybe they should create a strong disease-management outreach program for

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diabetes. Those are the tough questions people have to ask when ramping up care management teams.

Patient Engagement The fourth pillar, patient engagement, includes driving patient participation in care plans through various types of patient-outreach initiatives. A providerâ&#x20AC;&#x2122;s population health initiatives will not work without the participation and awareness of their patients. As patient engagement is an early area for most vendors and providers, it carries a high energy with it. About one-third of respondents in this study reported adoption of their vendorâ&#x20AC;&#x2122;s solutions for patient engagement, the lowest adoption rate of the four pillars. In part due to varying expectations from providers about what vendors can provide, patient engagement also receives the lowest satisfaction ratings of the four pillars. As this pillar is still in the early stages, the lower score is also due to immature functionality and a lack of usability. Those who have successfully utilized vendors for patient engagement are doing things like patient self-monitoring, self-education, and automated outreach programs. Figure 5

Top Performers: Again, Phytel stands out as a leader, with the highest adoption of patient-engagement functionality in addition to receiving the second highest performance rating. Phytel users like that the Phytel system identifies patients who need preventive care and targets them with automated texts or calls to remind them of Population Health Performance 2014 I 15

appointments and to increase awareness. Additionally, Phytel offers educational materials to providers. One provider utilizing Phytel explained, “Phytel helped us put together a patient education kit to put in our practices. It helps explain to the patients what the product is, why they are receiving calls, and why we are providing population health management as a value-added service to the patients. Patient engagement has been phenomenal because we have been able to contact noncompliant patients who haven’t visited the practice in over a year; further, Phytel has given us the material necessary to educate those patients once they come to the practice. They have been a strong partner.” Early feedback on eClinicalWorks is that their system allows providers to engage with patients through self-education functionality. In addition, there is a patient monitoring app in development that will link directly to CCMR. Providers look forward to it because it will give patients a more interactive and accessible way to interact. Though eClinicalWorks received average or above average ratings in all four pillars and the majority of their clients are satisfied with the product, two out of the nine providers interviewed struggle tremendously with data accuracy and system reliability, and this led to an overall low PHM KLAS score of 67.3. Average Performers: Epic, Forward Health Group, and Wellcentive fall in the mid-level performance category. At least 75% of Epic respondents reported to be using Healthy Planet for patient engagement, and while they like the automated patient outreach methods, they feel the product needs additional functionality for reaching out to patients and for documenting care plans in order to better engage patients. Though providers rated Epic’s data-aggregation and risk-stratification abilities lower, most of them are utilizing what Epic has to offer in care management and patient engagement. The energy around the continued improvement in Healthy Planet’s usability together with provider preference for an EMR-integrated PHM tool contribute to an early KLAS score of 82.3. Wellcentive offers a patient report card feature that is used to interact with patients, and providers feel it is a nice feature but think it could be more patient focused than clinician focused. About half of Forward Health Group’s respondents are utilizing the patient engagement functionality the vendor offers. Educating patients with relevant data is one of Forward Health Group’s strengths, as one provider explained: “Because we have ability to track over time and display data, patients quickly realize that the information they fill out goes into a database and that they can see it from time to time. That knowledge forces selfreflection and is a self-correcting mechanism for the client and clinician to look at hard data historically.” Some clients wish it were a little easier to weave this piece into the physicians’ workflow. Low Performers: Though Kryptiq has one of the highest usage percentages, early data indicates low satisfaction with functionality. Multiple providers mentioned that they would like to see more detailed information presented to them in CareManager. They 16 I Population Health Performance 2014

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would like to be able to more easily understand the patient summary in order to best engage and care for their patients. Early data shows that McKesson’s education piece is time consuming for providers. One provider mentioned that it takes a “significant amount of work” to compile a patient summary and that while they can show it to the patient, there is no way for the patient to proactively engage.

Tangible Benefits/Outcomes Achieved with PHM Solutions When providers were asked if their PHM vendors have been able to provide tangible outcomes, 70% of them said yes. Vendors with the highest percentage of respondents reporting tangible benefits are Phytel, Wellcentive, and Explorys. Providers noted that Phytel guides them toward better managing high-risk populations and provides help with prevention and care planning. Wellcentive was most mentioned for improving outcomes and quality measures while achieving better care planning. Explorys customers most frequently noted improved outcomes and quality measures. Figure 6

Four main tangible benefits were reported by providers in this report, and the vendors stood out in each one as follows: Improved outcomes and quality measures: As providers consciously gather data, stratify risk, better manage patient care, and then engage patients in their care, goals are met Population Health Performance 2014 I 17

and improved upon. Wellcentive and Optum have the highest percentage of respondents reporting improved outcomes and quality measures. Through Wellcentive, providers can be aware of their whole patient population regardless of payer data and can improve incentive scores. They are also able to improve outcomes through tracking patients and contacting those who need to come in. Some quality measures improved by Optum include reduced hospitalizations, hospital readmissions, and ED visits due to care managers being able to use Optumâ&#x20AC;&#x2122;s data to reach out to patients. One provider summarized how his organization uses PHM products to track quality metrics and improve outcomes, We have really great data sets that physicians can see in real time and that are very actionable, and we can correlate those with our goals, whether we are driving toward screening, a certain blood pressure level, or the identification of heart risk. We have about 32 metrics that we track for primary care. We have basically all of our 150 primary care doctors tracking those 32 metrics. We compare their practices and the outcomes they achieve against the goals that have been set up by the quality- and performance-improvement committee. The goals are really more outcome goals, not necessarily process goals, so the patients are getting great care. It is amazing what great care patients can get if people believe the tracked metrics can truly make a difference. Figure 7

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Better care to high-risk populations: Better managing high-risk patients is the ultimate success of all the identification/stratification capabilities. Providers report Optum to be a standout vendor because of their strong benchmarking and risk-stratification capabilities, which have proved to drive good outcomes. Providers can create intensive, specific programs to define high-risk patients and then reach out to them. They can also track cost savings and ROI from delivering better patient care through these programs. Better prevention and care planning: Even beyond high-risk patients, many providers are looking to provide better preventive care to their whole patient population by identifying care gaps to be filled. Phytel has the most providers who reported having achieved this objective. One Phytel respondent mentioned how his organization is able to improve outcomes, saying, “We have certainly been able to identify patients that have gaps in their care. For example, we have been able to find diabetics and create lists of patients by site, by physician, and by disease. We are not able to easily do those things with our EMR. We have educated the physicians and the nurse leaders at each of our practices about what Phytel Atmosphere can do. We have started doing previsit planning, and Phytel Atmosphere is the tool that tees up those planning huddles for us.” Kryptiq and McKesson also had a high percentage of providers mention that their products have given them the resources to better identify gaps in patient care. Once those gaps are identified, providers are enabled to be more proactive in preventive care and to better monitor patient improvement. One provider explained, “The Kryptiq CareManager dashboard is pretty user friendly. It is all color coded, and I think it is pretty easy for most people to understand. It allows the providers to see our full panel of patients. Kryptiq's clinic team is going to help them with their PCMH accreditation and continuing efforts to improve patient care.” i2i Systems’ huddle reports were mentioned by multiple providers who get together with their teams in the morning to draft a plan of how to best care for each patient they will see that day. Overall, these products are giving providers an avenue for better care. Cost Savings: 20% of providers who reported seeing tangible benefits mentioned that they are able to achieve a certain level of cost savings thanks to their PHM vendor. Providers using eClinicalWorks, McKesson, Optum, Phytel, Verisk Health, and Wellcentive all mentioned the cost savings they experience through their population health initiatives. One provider using McKesson explained, “We have a huge amount of anecdotal evidence that our population health efforts are working. Patients are avoiding readmissions and emergency visits, and both patient and physician satisfaction has increased. We have cost-savings evidence from Humana that we have not only bent the cost curve, but taken it in a negative direction. We saved 10% in our first reporting period.”

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In an emerging market, early indicators show a varying level of tangible outcomes. The most exciting part is that some providers are reporting real outcomes and better patient care as a result of their population health initiatives. The journey has really just begun. There is still a long way to go, especially for providers still investigating strategies around population health, ACO, and BI/analytics. One provider explained his organization’s position: “We are discussing which is our most valuable vendor right now. We have got a few big players that all want to deliver that same tool for us and tell us they can do the different tasks. We are trying to figure out the best spot for business intelligence, ACO management, and population health. Several of the vendors overlap into all three buckets and say they can give us an ACO dashboard so we don’t have to go anywhere else, but none of them do it quite right.”

Other Vendors (Those with 3–5 Validated Sites) In addition to the main vendors, there are other vendors in the population health space with smaller sample sizes (3–5 validated organizations each). Providers have used these vendors in various population health areas, and high-level overviews of these vendors are provided below. Alere Health Population Health Management Suite Note: Insufficient data to show metrics

% Say Current PHM Vendor Drives Most Value 33% % of Clients Reporting Tangible Outcomes 67%

% Say Current PHM Vendor Drives Most Value 33% % of Clients Reporting Tangible Outcomes 100%

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% Say Current PHM Vendor Drives Most Value 33% % of Clients Reporting Tangible Outcomes 33%

Conifer Health Solutions has gained traction in the population health space with a specific emphasis on predictive analytics. Conifer’s historical strength was in revenue cycle, giving them experience with claims data. Providers reported early success in data aggregation, risk stratification, and care management. Providers reported that Conifer is responsive to their requests. Evolent Health Identifi % of Implementations Completed <6 Months 0% Number of Data Sources Connected 5 (out of 9)

% Say Current PHM Vendor Drives Most Value 33% % of Clients Reporting Tangible Outcomes 100%

Evolent was started in 2011 under the direction of UPMC and Advisory Board. They offer strategic services and technology as a combination. Evolent had some early customers report positive feedback on their risk-stratification capabilities. Care management and patient engagement are still in early stages with little feedback from customers. Medecision Aerial for Population Health Management % of Implementations Completed <6 Months 100% Number of Data Sources Connected 8 (out of 9)

% Say Current PHM Vendor Drives Most Value 67% % of Clients Reporting Tangible Outcomes 67%

NextGen Healthcare NextGen Population Health % of Implementations Completed <6 Months 67% Number of Data Sources Connected 5 (out of 9)

% Say Current PHM Vendor Drives Most Value 67% % of Clients Reporting Tangible Outcomes 100%

Premier’s population health strategy is a combination of partner solutions mixed with their own technology and consulting services. Premier partners with two vendors scored in this report, Verisk Health for capabilities in risk stratification and with Phytel for capabilities in care management and patient engagement. For data aggregation, KLAS has validated Premier’s enterprise data warehouse and business intelligence solution, PremierConnect Enterprise. In addition, providers see Premier’s consulting services as valuable as they move forward toward population health. Premier’s leadership was validated in the recent KLAS ACO services report. Valence VISION % of Implementations Completed <6 Months 33% Number of Data Sources Connected 8 (out of 9)

% Say Current PHM Vendor Drives Most Value 33% % of Clients Reporting Tangible Outcomes 67%

xG Health came from Geisinger Health, and they provide services coupled with technology. Providers report that xG Health analyzes data and determines where they should focus their efforts. Initial feedback from customers indicates that they are getting 22 I Population Health Performance 2014

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value from the solution and that xG Health is a good company to work with. Some providers noted challenges with the analytics software and would like more control over which reports can be pulled. Note: To view vendors with less than three KLAS-interviewed clients (namely, Caradigm, Cerner, Health Catalyst, Healthagen, Lumeris, and Siemens), please refer to “Other Mentions” in the Compare Vendors section.

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Mark Allphin REPORT AUTHOR mark.allphin@klasresearch.com

Lois Krotz REPORT COAUTHOR lois.krotz@klasresearch.com

Lauren McConkie CHIEF EDITOR lauren.mcconkie@klasresearch.com TO VIEW OTHER TEAM MEMBERS CLICK HERE. FOR QUESTIONS OR COMMENTS ON THIS REPORT, CONTACT: KLAS 630 E. Technology Ave. Orem, UT 84097

Ph: 800-920-4109 Fax: 801-377-6345 Web: www.KLASresearch.com

TO PURCHASE THE FULL VERSION OF THIS REPORT, LOG ON TO OUR STORE. READER RESPONSIBILITY: This report is a compilation of research gathered from websites, healthcare industry reports, interviews with healthcare provider executives and managers, and interviews with vendor and consultant organizations. Data gathered from these sources includes strong opinions (which should not be interpreted as actual facts) reflecting the emotion of exceptional success and, at times, failure. The information is intended solely as a catalyst for a more meaningful and effective investigation on your organization’s part and is not intended, nor should it be used, to replace your organization’s due diligence. KLAS data and reports represent the combined opinions of actual people from provider organizations comparing how their vendors, products, and/or services performed when measured against participants’ objectives and expectations. KLAS findings are a unique compilation of candid opinions and are real measurements representing those individuals interviewed. The findings presented are not meant to be conclusive data for an entire client base. Significant variables including organization/hospital type (rural, teaching, specialty, etc.), organization size, depth/breadth of software use, software version, role in the organization, provider objectives, and system infrastructure/network impact participants’ opinions and preclude an exact apples-to-apples vendor/product comparison or a finely tuned statistical analysis. NOTE: Performance scores may change significantly with new participant provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients We encourage our clients, friends, and partners using KLAS research data to take into account these variables as they include KLAS data with their own due diligence. For frequently asked questions about KLAS methodology, please refer to the KLAS FAQs.

COPYRIGHT INFRINGEMENT WARNING: This report and its contents are copyright-protected works and are intended solely for your organization. Any other organization, consultant, investment company, or vendor enabling or obtaining unauthorized access to this report will be liable for all damages associated with copyright infringement, which may include the full price of the report and/or attorney’s fees. For information regarding your specific obligations, please refer to the KLAS Data Use Policy.

ABOUT KLAS: For more information about KLAS, please visit our website.

OUR MISSION: KLAS’ mission is to improve the delivery of healthcare technology by independently measuring and reporting on vendor performance.

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Compare Vendors

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 Vendors With 6+ Validated Sites (Alphabetical Order) 

ADVISORY BOARD CRIMSON POPULATION HEALTH: 79.8* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Advisory Board has been in the population health sphere since 2008, when they acquired Crimson. They offer a suite of population health products collectively referred to as Crimson Population Health. They have a wide install base in IDNs and hospitals and are known for being responsive to their customers. The Crimson Population Health suite of products includes predictive risk analysis, provider performance reporting, and care management. The different Crimson products work well individually; however, there was some mention of connectivity issues between Population Risk Management and Care Management. One provider said, “Crimson Population Risk Management doesn’t feed automatically into Crimson Care Management. We may identify patients who need follow-up coaching because their risk scores are very high, but we have to manually enter those into Crimson Care Management to begin that management. The systems don’t talk to each other. It would be really nice if they did.” Advisory Board receives lower marks around data aggregation, with issues related to timeliness and data normalization across disparate systems. “Right now we are just using our own patient data from our EMR and practice management system. Advisory Board still only wants data quarterly. We will send the data to them in 30 days, and 45 days later they will call us and say that they are still having some problems scrubbing data and need 15 more days. Usually our quarterly data is up in 60 days, and by then it is already 5 months old.” With many avenues to pull patient data from, early indicators show that Crimson Population Health performs high in its ability to connect to multiple data sources. Customers also reported that the highest percentage of data being pulled into Advisory Board comes from the inpatient EMR.

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ECLINICALWORKS CCMR: 67.3*

*Does not meet minimum KLAS Konfidence level (6–14 organizations)

eClinicalWorks Care Coordination Medical Record (CCMR) consists of different modules for HIE, a patient portal, risk analytics, and care management. eClinicalWorks received their highest ratings in the risk-stratification and patient-engagement areas. Despite the fact that eClinicalWorks customers have a fewer than average number of clinics connected, CCMR is one of the report leaders in bringing in data from multiple sources. Providers gave average or above average ratings on eClinicalWorks’ functionality in all four pillars, and the majority of their clients are satisfied with the product. However, two out of the nine providers interviewed struggle tremendously with data accuracy and system reliability, and their lower scores resulted in an overall low KLAS score of 67.3. Providers reported high satisfaction with CCMR around its ability to engage patients and do risk stratification. One nurse said, “eClinicalWorks CCMR is good for risk stratification. It is easy to find the reports and find any information we need about a certain population. . . . eClinicalWorks has made patient engagement very easy. eClinicalWorks CCMR is easy for patients to access and navigate and easy for physicians to explain and talk about. Results are very accessible and patients can understand how to use the system.” In addition, CCMR respondents reported reduced readmission rates as one of the tangible benefits they have seen since implementing the product. Multiple providers reported that CCMR offers basic functionality and is not an out-of-thebox solution. Some providers specifically mentioned the lack of preloaded content for reporting as something eClinicalWorks could improve. One CMO explained, “There are a lot of repetitive, predictable activities and steps in care coordination and case management. If eCW offered a prebuilt feature that let people outline a requirement so that those repetitive tasks were automatically done, that would be very helpful. The problem of setting eClinicalWorks CCMR up ourselves for case management and utilization management was just not worth dealing with. We didn’t want to assess every step by ourselves. That should already be built in when people buy this product.”

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EPIC HEALTHY PLANET: 82.3* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Epic Healthy Planet is not a new product but has been developed from a combination of Epic products and functionality that when used together compose a broad population health solution. Though providers rated Epic’s data-aggregation and risk-stratification abilities lower, most of them are utilizing what Epic has to offer in care management and patient engagement. The energy around the continuing improvement in Healthy Planet’s usability together with provider preference for an EMR-integrated PHM tool contributed to an early KLAS score of 82.3. Only 25% of Epic customers reported seeing tangible benefits; this is likely tied to the fact that many of these providers are still early adopters. Much of the early use of Healthy Planet has to do with registry functionality. Providers laud the easy-to-build population registries and appreciate the actionable lists. One customer noted, “Healthy Planet is really just a collection of rebranded Epic tools working together. The collection includes registries, which we can run reports against. We can also make those reports actionable. So if I get a list of a thousand people that are overdue for a given test, I can generate orders for them from a report.” 100% of respondents said that Epic’s Healthy Planet is part of their long-term plans. The value in Healthy Planet being integrated with the EMR is shown by this provider, who said, We are basically using the same tools included in EpicCare ambulatory. The difference is that Healthy Planet has a rules engine, and the rules engine is able to take a look at data that we have identified and mapped to certain concepts or terms. Those concepts can be written into rules for inclusion or exclusion criteria to determine who gets into a registry or into a cohort. Those concepts can also be used to identify interventions, tests, or treatments that need to be done for a cohort of patients based on rules by frequency of interval or by goal. I think the overlay is that the clinical rules engine is able to gather all the information flowing into the EMR for a patient, then abstract that information and get an actionable summarylevel view. Epic is one of only a handful of vendors in this study to have users validate data coming in from all but one measured source (home health), but they have a low percentage of providers pulling data from provider or payer claims data. Providers did express some concerns about Healthy Planet handling claims data and about its limitations in pulling in data from sources outside of Epic. One IT director deciding whether to roll out Healthy Planet explained, “Unfortunately, we have a lot of claims outside of Epic. We are managing a population that goes to other hospitals for services we might not have or for emergency purposes. We use Epic for internal components, for registries, and for population health within our system. But unfortunately, [Epic Healthy Planet] doesn’t do any claims analysis, and it doesn’t develop any patient profiles, so that is a big limitation.”

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EXPLORYS PLATFORM & EPM SUITE: 82.6* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Explorys came out of Cleveland Clinic in 2009. They offer a broad suite of population health products. Providers see Explorys as an innovative company and gave them one of the highest ratings in this report for delivery of new technology (7.9 out of 9.0). Providers report high satisfaction with risk stratification and their ability to pull data from multiple sources. Explorys clients described some disappointment due to the lack of ontime implementations. The Explorys platform has the ability to consume both claims and clinical data. Explorys, tied only with Epic and eClinicalWorks, is able to pull from a high number of data sources and was one of the few vendors with providers pulling in home health data. A high percentage of respondents noted that they have already received tangible benefits since implementing Explorys, including improved quality measures for ED visits, readmissions, and hospital visits. 100% of providers using Explorys said they are utilizing it for data aggregation. Early data indicates good performance in care management as it helps providers identify gaps in care. Of the four pillars, risk stratification received the highest ratings from providers, although it is only being used by 50% of the providers in this study. To explain where he feels Explorys is headed, one provider mentioned, “Explorys really understands where the market is going. They are innovating quickly, they are executing the back-end, big data technology the right way, and to top things off, they are a pleasure to work with. They are selling a population health management platform.” When providers were asked what one vendor is bringing the most value to their organization in terms of population health, Explorys was mentioned only a few times by current users. 76% of customers reported that Explorys is part of their long-term plans, and some providers see aspects of Explorys as temporary until their EMRs are able to develop the same functionality. One provider explained, “There are benefits to Explorys, but not as many as we had originally hoped for because we are using it reactively instead of proactively. We are looking at single entities instead of the entire population. When we started, we realized that the market was not mature, so we are using Explorys as a bridge solution while the market matures and our EMR gets up to speed so it can provide us with some of this functionality.”

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FORWARD HEALTH GROUP POPULATIONMANAGER®: 87.2* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Forward Health Group offers a solution centered on risk stratification, performance reporting, and care management. Traditionally found in smaller clinics, Forward Health Group is seen as a nimble company that does quick implementations leading to provider outcomes. Their early KLAS score of 87.2 represents one of the highest scores in the study. 100% of respondents reported that their implementation took less than six months, and many providers reported that Forward Health Group is meeting their expectations. The reporting tool that allows organizations to see how they are performing against quality metrics helps providers see the impact their efforts are having. This fact was emphasized by one of the vendor’s early customers: “The tangible benefits reported from our staff involved in the pilot are that PopulationManager® helps with patient engagement, treatment planning, quality improvement in treatment planning, and self-correcting perceptions of the clinician and client. When we collect the information, sometimes the therapists might be thinking the clients are doing better than they are or the clients think they are doing worse than they actually are. If the clinicians can pull up historical scores and show clients where they were three months ago and where they are now, the clients can self-correct.” PopulationManager® is being utilized most in smaller organizations and is on the lower tier in terms of providers being able to pull in data from multiple sources. No customers reported bringing in any data from labs or payer claims data. A lack of partnership between the customer and Forward Health Group was mentioned by one provider who said, “Forward Health Group hasn’t really given our providers any training on how to use PopulationManager®. We kind of have to just do that ourselves. They made the product available to us, but training our providers is certainly one of the challenges we have. I don’t know that we have seen our health and quality measures improve significantly, but I think the providers who use PopulationManager® like it.”

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I2I SYSTEMS I2ITRACKS: 86.9*

*Does not meet minimum KLAS Konfidence level (6–14 organizations)

i2i Systems i2iTracks specializes in registry reporting and analyzing care gaps. The product helps direct the care team toward what measures it should focus on for each patient. Providers feel that i2i Systems is very responsive to their requests and tries to develop what they need. i2iTracks is seen primarily as a specialty care gap-reporting tool rather than an all-encompassing population health solution. As i2iTracks is used mainly as a registry to identify care gaps, one of its main functions is to produce a daily report “huddle” that informs the care teams about who is coming into the office that day. For each patient, care teams are able to look at what measures they need to focus on to deliver the best care. 100% of i2i Systems’ respondents reported that they have seen tangible benefits from using the system, and all are highly satisfied with the functionality it provides. One CIO explained, “This product stays ahead of the curve and still provides better registry reporting than I have seen anywhere else. It is really what got us to meaningful use. Nobody else does the repository or registry like this system. It has its own interface that pulls our data a couple of times a day, so it stays updated. It was one of the first to offer huddle information. It takes a snapshot of who we are going to see and what we have for the day. The whole thing is automated. And it actually tracks when we sent letters.” Providers noted that i2i Systems is responsive to their needs, that the product is easy to use, and that it works with different EMRs. i2iTracks brings in data from a low number of sources, with the majority of data coming from ambulatory EMRs. i2iTracks is much more of a niche system than an all-encompassing population health solution. Providers didn’t describe using i2iTracks much for risk stratification, and they would like some more development around patient engagement. As a specialty product not designed to provide all functions of population health, i2iTracks is seen by some providers as a temporary solution until their EMR can fulfill the same needs. One provider described, “At first I veered away from going with i2iTracks because I figured my EMR’s tools and reports would be sufficient. . . . However, because of the way our organization is set up and the way we have grown, we got i2iTracks simply because we needed something in the interim while Cerner developed their product. We know i2iTracks will have a short lifespan here, but it fills our needs.”

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KRYPTIQ CAREMANAGER: 77.4* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Kryptiq CareManager is owned by Surescripts and has been in the population health space for more than a decade. CareManager offers a broad range of population health functionality, and Kryptiq was one of a handful of vendors in this study with providers fully utilizing all four functions of population health. Despite this usage, Kryptiq performed below average in early data in all four pillars. However, this can be attributed to a couple of dissatisfied customers who utilize all four modules but reported not being able to achieve what they want to do. The rest of the client base is happy overall. Quick implementations and reasonable pricing contributed to Kryptiq’s KLAS score of 77.4, which is close to the market average. CareManager is described as an out-of-the-box solution for risk stratification, care management, and patient engagement. One provider praised Kryptiq for integrating forms into the EMR: “Kryptiq provides encounter forms we can use within the EMR that tie back to CareManager. One of the encounter forms has a control panel that gives the providers an overall view of patients’ needs based on their diagnoses. Providers can filter the data based on their criteria or what they are doing for an office visit. They can filter it, create one letter, and send out a customized letter to each patient.” CareManager users reported pulling information from a limited number of sources. 83% of users are pulling from ambulatory EMRs, with no customers reporting pulling provider or payer claims data. One physician explained, “The data that we get is pretty good, but it is not as robust as I would like to see from a registry product. Even though some of the individuals that work for Kryptiq are very attentive, the product is not really changeable. We get what we get out of the box, and that is the way it is. In terms of expanding the registry functionality, Kryptiq has not kept up with the times the way that other vendors have.”

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MCKESSON POPULATION AND RISK MANAGER: 62.5* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

McKesson Population and Risk Manager came from McKesson’s acquisition of MedVentive in 2012. McKesson Population Manager is used to help understand at-risk patients and offers evidence-based guidelines for caring for these patients. McKesson aggregates both clinical and claims data, and among the rated vendors in this study, they had the highest percentage of customers pulling provider claims data. Implementations are described as taking longer than anticipated. Providers rated McKesson lower on delivery of new technology and lives up to expectations—both of which contributed to an overall KLAS score of 62.5. McKesson officially launched Care Manager in October 2014, and that product is not represented in this study. Providers said they use McKesson to understand how their physicians score on any number of quality metrics and programs. The quality reporting and drill-down features are good and are used to fill gaps in care. Many provider’s reported that they are able to provide better prevention and care through the use of this product. One explained, With McKesson, we have seen our physicians' compliance with regulations increase for the populations our physicians are overseeing. The physicians have told us that they start to pull up the McKesson records before they see the patient, so they have the care gaps in front of them. The EMR might be able to produce that information, but they haven't used it that way. They say the McKesson tool helps them focus when patients come in for visits. I don’t know that we have gotten people to do any outreach calls to bring patients in, but I think when patients present, our physicians are much more focused on the right things. 50% of McKesson respondents reported implementations that took over 12 months to complete, and this contributed to a low implementation on time rating of 4.3 out of 9.0. Providers reported that the solution is not built into the EMR workflow where care managers would like it to be, leading some customers to plan on looking at different options down the road. One provider explained, McKesson Population Manager will never be tightly integrated with the EMR. None of the population health vendors will ever have that for their products, and at the end of the day, that is what I need. I believe that within two or three years Epic could have a fully functional population health platform that is fully integrated with Epic systems, and that could put a lot of people out of business. I couldn’t replace McKesson with only Epic today because the functionality is still just so rudimentary, but the integration is there. There is going to be a huge shakeout of winners and losers in the next three to five years, and McKesson Population Manager needs to be dramatically enhanced.

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OPTUM ONE POPULATION HEALTH: 79.7

Optum One Population Health is a comprehensive suite of applications supporting population health. It includes both Impact Pro and Humedica, among other pieces of technology. Optum’s experience in the payer space is seen as a plus for providers looking to take on risk-based contracts. Optum has tools for handling both claims and clinical data, and that helps contribute to a solid score of 7.9 out of 9.0 for data aggregation. Providers mainly utilize Optum for data aggregation and risk stratification, with very little use in care management and patient engagement. Optum offers predictive analytics and has proven to be good for analyzing claims data. Providers reported seeing early savings benefits from providing better care to their highrisk populations. One provider explained, On the Impact Pro side, we are approaching a very intensive caremanagement initiative for people who are very high cost and high risk and have multiple chronic conditions. The fact that we can do the analytics to define those cohorts of patients using Impact Pro is really helpful. It will more than easily offset the cost of the program. These are complex patients, and in our pilot program, we were saving around $4,000 per member per month. It was a very successful pilot, and we expanded it and made some hard dollar savings commitments to ourselves as an employer so we could change the cost curve for that targeted population. We have been successful so far. A high percentage of current users also said that out of all the vendor products used in their population health strategy, Optum stands out as the most valuable piece. Optum One Population Health Management users have reported pulling in a high volume of data from inpatient and ambulatory EMRs and a lower volume of lab and payer claims data. 100% of respondents reported using Optum for risk stratification. Very few providers reported using Optum for care management or patient engagement. While providers see Optum One Population Health Management as a solution with a lot of potential, they are waiting for additional development and would like to see how all the different applications will work in concert together. For providers, the jury is still out on whether the merge of claims-based and clinical analytics will be successful. One provider explained, “There aren’t a lot of vendors that have been successful in taking claims-based analytics and clinical-based analytics and pushing them together into a single analytics platform. If Optum is successful, they will be in a very good spot and will be very helpful to us, but I don’t have a clear line of sight for how all that will be brought together. . . . Conceptually, Optum has really good products and potentially has a powerful set of tools.”

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PHYTEL POPULATION HEALTH MANAGEMENT SUITE: 89.8

Phytel Population Health Management offers a suite that spans across the four pillars of population health. Phytel customers rated them above average in all functions except risk stratification, where ratings were just average. Customers gave positive feedback for all modalities, but Phytel is the strongest in patient outreach and care management. Providers reported fast implementations and pointed to quick outcomes as a result of using the solution. Phytelâ&#x20AC;&#x2122;s KLAS score of 89.8 is the highest in the segment. Phytel is a clear leader in the space as a result of quick implementations, deep user deployment, and high provider satisfaction. Phytel delivers solid implementations and fast speed to value, with all customers completing their implementations in under six months. Customers also reported an intuitive interface that is easy to train new users on, and most customers are pleased with the level of support and attention they receive from Phytel. 100% of clients have seen tangible benefits, some of which are described by the following provider: Phytel has a phenomenal outreach component. We use that with advanced protocols that scour the data and identify the patients. For example, a simple scenario might be identifying males over 50 years old who have not had a colonoscopy on record, a result, or an order. One of our protocols is to identify those patients and make sure they do not have a future appointment already booked. Then Atmosphere makes a phone call or texts out to the patients asking them to call to make an appointment. We get statistics on that, and we can see how well the system is doing and how much revenue has been generated because the system has done its outreach. There is a clear ROI, with the Phytel investment showing us that just that component alone pays for the whole thing and then some. When asked which system is most valuable to their population health strategy, 89% of respondents said that Phytel brought them the most value. Phytel users also reported an ability to connect many hospitals and clinics within their population health networks, putting their connections higher than most other vendorsâ&#x20AC;&#x2122;. Through those connections, Phytel users have been able to bring in data from many data sources, with the highest volume coming from ambulatory EMRs.

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VERISK HEALTH POPULATION HEALTH ANALYTICS: 79.7* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Verisk Health Population Health Analytics is an early leader in risk stratification, with a rating of 7.9 out of 9.0. Providers reported that Verisk is attentive to their needs and delivers quick implementations. However, the solution is described as being expensive, and providers would like to see more care-management functionality. 71% of providers see Verisk as a long-term solution. Used for risk stratification, Verisk Population Health Analytics works great with payer claims data and is known for its ability to predict financial risk around a group of patients. Providers rate Verisk above all other vendors in risk-stratification capabilities, and they appreciate that the product is easy to learn. Among the main vendors, Verisk has the highest percentage of users (88%) pulling from payer claims data. However, very few providers have leveraged Verisk in their care-management and patient-engagement activities. All respondents reported that they were able to implement Verisk Population Health Analytics in under six months, and providers find value soon after implementing. One provider explained, “Verisk Health Medical Intelligence is a 360-degree view of the claims data and the patient care history. That is very, very insightful to most of our physicians. Since implementation, we have been developing monthly reports for our physicians. That has been a huge educational endeavor because most physicians don’t think in terms of ER utilization on a risk-adjusted basis per thousand or inpatient basis per thousand. That is very useful information, and we believe it will be impactful as we go forward.” Many providers see Verisk Population Health Analytics as a high-cost solution and would like more functionality. These two issues have some providers looking at other options. One provider explained, “Verisk Health's cost is really high. They have a really high per member per month fee, and by the time we get to be a large ACO, that is just really expensive. That cost is a downside. Verisk Health also just has claims data right now, and they do claims and clinical data directly out of the EHR. If another vendor also did the financial component, I would dump Verisk Health's product because of the expense and because Verisk Health only does claims.”

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WELLCENTIVE ADVANCE OUTCOMES MANAGER: 77.6* *Does not meet minimum KLAS Konfidence level (6–14 organizations)

Wellcentive Advanced Outcomes Manager focuses on helping providers improve quality measures, and Wellcentive stands out as one of the early leaders in helping customers see tangible benefits. Wellcentive has products that span across all four pillars, but they have a low number of respondents using them for risk stratification. Additionally, some providers mentioned challenges with implementations. Wellcentive is viewed by their customers as being a partner. Respondents feel that Wellcentive works to help them be successful. One provider explained, “I can say that so far Wellcentive has certainly been better than average as a partner. We have been talking to Wellcentive about our plans, what our strategy is, and what they need to do to help us meet our goals. We haven’t asked for a whole lot yet, but nothing has been denied. The answer is never no, that something can’t happen, or that they can’t do something. Instead they want us to let them figure things out and find a way to do what we need.” 89% of Wellcentive users mentioned accomplishing tangible benefits by utilizing Wellcentive, mainly because they are able to see improved outcomes and quality measures. “Advance Outcomes Manager has made a difference in our quality scores because we can see the changes that need to be made. Physicians can compare their scores to other physicians. That has caused some changes. There are incentives attached to all of those quality measures, so we get reimbursed for those too.” Implementations have proven to be challenging for some, and experiences vary depending on what resources the provider can allocate to the project. Generally, Wellcentive implementations require a lot of resources, and providers ask for better communication: I think there is certainly value in the tools that are there, but the devil is in the details. A lot of resources are needed for customers to have a successful implementation. I would say that if people are willing to devote a large amount of resources to the implementation, I would recommend Wellcentive Advance Outcomes Manager. If people just want an easy implementation and don't want to worry about things or work with Wellcentive, then I wouldn't recommend it at all. The implementation just won't get done unless a lot of resources are devoted to it. Even though we are having trouble with the implementation and learning the ins and outs of the system, the actual functions are very user friendly for end users.

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 Vendors with 3–5 Validated Sites (Alphabetical Order) 

ALERE HEALTH POPULATION MANAGEMENT SUITE

Alere acquired Wellogic in 2011 and is developing their population health solution around Wellogic’s data aggregation and exchange platform. Early customers like that Alere offers an EMR-agnostic solution but would like to see more development. One customer commented, “Having point of care access to patient information has really improved our caregiving experience. The product is able to keep the staff informed about histories and relevant data, giving us confidence and improving our overall operation.” At this point, Alere does not have many customers outside of their core HIE customers, and their population health pieces are taking longer to develop than customers anticipated. One provider’s experience follows: “There are two main phases of our population health strategy. We were hoping to be well into the second phase by now, but because adoption rates are low among the people involved in the first phase, we haven’t been able to move on to our second phase yet. Along with the fact that the system is not easy to use, there was missing functionality for a long time that caused the low adoption rates.”

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ALLSCRIPTS DBMOTION POPULATION HEALTH

Acquired by Allscripts in 2013, dbMotion is an HIE solution with strong data-aggregation capabilities. Many providers see it as a next-generation data-aggregation tool that will help support population health. Providers report high satisfaction with dbMotion for data aggregation, but few are using it for risk stratification and care management. dbMotion is part of Allscripts’ larger population health strategy, which consists of other Allscripts products like EPSi, Care Director, and FollowMyHealth. Provider perceptions of dbMotion are generally positive as it is viewed as an exceptional data-normalization and -aggregation tool. It is vendor agnostic, unlike other EMR-vendor offerings in population health and can connect to any number of different EMRs to share and aggregate data. dbMotion users rated the system as above average for the total number of data sources it can connect with. However, the majority of that data is being pulled from inpatient EMRs and lab data. No respondents are pulling payer claims data. One clinical director explained, “We aggregate data from multiple EMRs, our different lab interfaces, and our different document interfaces. Even within the EMRs, we get problems, diagnosis, allergies, immunizations, and procedures. To date we probably have had around 60 active interfaces running into dbMotion Population Health.” Providers would like to see more development from dbMotion around analytics and claims data, as this CNIO described: “Allscripts should focus on predictive analytics. We are looking to partner with them on future development on the claims piece, but they have very little experience in that. There is a lot of experience from the clinical data, but not necessarily from the claims data side.”

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ATHENAHEALTH ATHENACOORDINATOR ENTERPRISE

athenahealth’s population health solution combines some of their existing and legacy services with a number of new capabilities and features. Not all of athenaCoordinator Enterprise’s functionality is represented in this report. Providers describe athenaCoordinator Enterprise as a good tool for risk stratification and analytics and mention that athenahealth is a partner with them. Still, providers would like to see quicker development around population health. athenahealth is viewed as a good partner by their customer base. athenahealth customers noted that athenaCoordinator Enterprise has an easy-to-use interface and that they mainly use it for claims aggregation and analysis. athenaCoordinator Enterprise is able to connect to many data sources, as this manager of informatics noted: “athenaCoordinator Enterprise is a really powerful tool. It takes data from most of the very disparate data sources that we have in individual silos, and it displays that data all in one location. That helps us look at an entire population or even at the individual patient level.” Providers do report, however, that athenahealth has been slower to develop and that the care-management and care-coordination pieces are still fairly immature, so the system is not a one-stop shop for population health. One director of operations noted, “Things were better before athenahealth purchased this tool. They have bogged this tool down. I don’t know whether the problem is just their corporate structure, the change in management, or the fact that there are now more people in the chain, but the development has definitely slowed down. They are hitting the product requirements, but new development is slow. We expressed concern about that when the tool was bought, and they said it wouldn’t happen. We get more pushback from them now, and they don’t have the resources to get to a very structured delivery system where projects are appropriately prioritized.”

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CONIFER HEALTH SOLUTIONS POPULATION HEALTH INTELLIGENCE PLATFORM

Conifer Health Solutions continues to gain traction in the population health space with a specific emphasis on predictive analytics. Conifer’s historical strength was in revenue cycle, giving them experience with claims data. Providers reported early success in data aggregation, risk stratification, and care management. Providers reported that Conifer is responsive to their requests. One customer mentioned, “The support for Conifer Population Health Intelligence Platform is extremely responsive. The support people communicate well with me and help me with anything I need. They are very good at supporting this product. In addition, they are helping us accomplish our goals.” Providers noted that one of Conifer’s biggest strengths is in looping in the entire care team around certain high-risk patients. One provider described how Conifer helps her organization tackle the communication needed to care for their patients: “The system does a really good job of reaching out to everyone when there is an alert for a patient and of documenting that alert. We use it with our wellness coaches, nurses, and doctors. The benefit of the Conifer tool is being able to do risk stratification and target the individuals on whom we can make the biggest impact. It has allowed us to target certain programs and really impact the utilization of those programs and the health outcomes of the patients who have modifiable risk factors.”

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EVOLENT HEALTH IDENTIFI

Evolent was started in 2011 under the direction of UPMC and Advisory Board. They offer strategic services and technology as a combination. Evolent has some early customers that reported positive feedback on their risk-stratification capabilities. Care management and patient engagement are still in early stages, with little feedback from customers. A key differentiator shows that Evolent offers a wide range of services coupled with technology. This assists providers in launching and supporting their population health initiatives. Though the product is early, it is meeting customer expectations for risk stratification of their patient populations. One provider explained, “Evolent Health Identifi is meeting expectations. Evolent is growing. They have a good service to offer, but I also think they are learning on the fly as well. I don’t think Identifi is quite a totally mature product for them. It isn’t without its bumps, but we have worked through them and it is going fine.” Evolent is a growing company with seemingly limited resources, and customers have noted that there doesn’t seem to be a uniform approach to implementations. One customer noted, “The quality and effectiveness of the Identifi implementation were not the greatest. That is not unusual for a totally new topic and venture. We hit some bumps in the road, which were not unusual, but the implementation was one area that was one notch below everything else.”

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MEDECISION AERIAL FOR POPULATION HEALTH MANAGEMENT

Medecision is an experienced vendor, familiar with population health through their work with health plans. Early provider feedback is positive, with 100% of respondents reporting that Medecision is part of their long-term plans. Medecision is able to pull data from multiple sources, and they work mainly with large organizations. All three respondents reported that their implementations took less than six months. Customers reported limited use around data aggregation and risk stratification. Providers reported that Medecision specializes in care management. They are one of only a handful of vendors in this study to have users validate data coming in from all but one measured source (patient mobile devices). The volume of data coming in from lab and home health sources is above average compared to other vendors. Early customers noted that part of the success with Medecision comes from their personnel and their experience working with care management. One provider views Medecision as a good asset, saying, â&#x20AC;&#x153;Medecision allows us to jump-start the business process of population health. So the act of using the software makes us better at the act of care management. The value of the software comes less from what features the software has and more from the fact that the Medecision people installing the system know how to do care management.â&#x20AC;?

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NEXTGEN HEALTHCARE NEXTGEN POPULATION HEALTH

NextGen Population Health is described as a developing solution that combines registry filters with automated patient-outreach functionality. As with other PHM solutions from EMR vendors, providers see integration with NextGenâ&#x20AC;&#x2122;s EMR as a key value driver. Early ratings suggest that NextGen performs about even with the market average for all four pillars. Customers reported improved quality measures as one of the tangible benefits of using NextGen for population health. One of the early providers using NextGen cited cost benefits as one of the key drivers for going with their solution despite the additional development still needed: NextGen is still developing their population health area. I would say that NextGen's strategy for population health management doesn't exactly meet up with our strategy. We have expanded our use of NextGen Population Health, and it is currently part of our strategy, but I am not sure that it will be cost effective from a price perspective. However, the product is still more cost effective than other systems we have looked at. We are interested in seeing continued development of the product. I would like to see the product get smarter, especially with predictive analytics, and get better at facilitating population health management.

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PREMIER POPULATIONADVISOR

Premier’s population health strategy is a combination of partner solutions mixed with Premier’s own technology and consulting services. Premier partners with two vendors scored in this report—Verisk Health for capabilities in risk stratification and Phytel for capabilities in care management and patient engagement. For data aggregation, KLAS has validated Premier’s enterprise data warehouse and business intelligence solution, PremierConnect Enterprise. In addition, providers see Premier’s consulting services as valuable as they move forward toward population health. Premier’s leadership was validated in the recent KLAS ACO services report. One provider described Premier’s role: “Premier was on time with the PopulationFocus implementation, and they worked it through. It was appropriately resourced. We purchased a Verisk Health product through Premier, so the Verisk Health engine is running everything. The experience there was great. Premier was the lead negotiator, but when it came down to getting the deal signed, Verisk Health did what they needed to do for pricing. The contracting process was great. The implementation process was well structured and well directed. Information was uploaded and usable.”

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VALENCE VISION

Valence has been in the managed-services business since 1996, and they offer solutions spanning both services and technology. Customers describe Valence’s data-aggregation and risk-stratification capabilities as strengths. Valence was noted for being particularly good with analyzing payer claims data. Valence performs well with larger customers involving many practices and data sources. Some customers say that Valence needs to speed up their product development. Also, Valence is one of only a handful of vendors in this study to have users validate data coming in from all but one measured source (patient mobile devices). Valence customers feel that their voices are heard and that Valence responds to their needs. One of Valence’s strengths is data aggregation along with their ability to work with many different EMRs. One provider explained Valence’s approach to data aggregation this way: “Aggregating data is one of Valence's strong suits. But the one thing people need to understand is that Valence’s approach around data aggregation is not a bigdata approach. There are vendors that take the big-data approach and deal with both discrete and nondiscrete data elements. But Valance is very much about just discrete data, and they are still very good. They have a plethora of different data-integration capabilities around different types of data.” Providers have mentioned delays in product development as a negative. One provider explained her experience: “I guess we could say we use Valence VISION for population health. I can’t say our population health program is robust, but the tool is for population management. It has an active registry. Valence has a good concept, but their technology hasn’t lived up to the concept. The tool is conceptually better than Valence's first tool. They just aren't there yet, and that has resulted in a one-year delay of my program.”

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XG HEALTH POPULATION HEALTH ANALYTICS

xG Health came from Geisinger Health, and they provide services coupled with technology. Providers report that xG Health analyzes data and determines where providers should focus their efforts. Initial feedback from customers indicates that they are getting value from xG Health’s solution and that xG Health is a good company to work with. Some providers noted challenges with the analytics software and would like more control over which reports can be pulled: “I have not been very satisfied with xG Health's analytics software, and that is purely because we don't have an interactive tool. I don't have a tool I can use myself to go in and search. Moving forward, we need that. We can't keep relying on people to pull reports for us.” xG Health provides analytics services in which providers hand over the data and xG Health does much of the work. One provider explained, We send xG Health the raw claims we get from Medicare, and they put those in their software or databank. They analyze them, process them, and do whatever else they need to do. . . . Then we meet with their analytics staff and leadership to figure out the kind of information we need out of those files. We find the data output we need, and they make it happen. They sometimes share the logic behind pulling data from an operational standpoint of how that will help our population health based on their experiences elsewhere and what they have found successful. It is pretty interactive. xG Health stops us if we are sliding down the slope and turns us around. We don’t have access to their technology. . . . We have had a very positive experience.

Population Health Performance 2014 I 115

 Other Mentioned Vendors (Alphabetical Order) 

CARADIGM

Over the past couple of years, Caradigm has steadily released solutions spanning all of the population health functions. Known historically as having a strong data-aggregation and HIE solution, Caradigm has added solutions to their Intelligence Platform to address areas such as risk stratification, care management, and quality improvement to name a few. Caradigm has a few early customers utilizing aspects of their platform, and early feedback is positive. One customer noted success with aggregation: “Because of our work with Caradigm, the outside EMRs are able to push data to our core EMR system. . . . Providers can push their clinical documents into Caradigm, and then any of the EMRs that have the ability to consume can access that information and pull it in.” 

CERNER HEALTHEINTENT

Cerner HealtheIntent is described as an all-encompassing platform for population health. Cerner is leveraging some existing technology and developing others as part of HealtheIntent. Aspects of the solution are in development, but a handful of early customers are using the HealtheRegistries tool. One of the promising benefits of HealtheIntent is that it will be EMR agnostic. One early customer noted, “HealtheIntent is pulling in data from a lot of different sources that the system normalizes. The process is powerful in terms of identifying individuals, aggregating data, and tracking people. We are starting to feel comfortable with this and I am highly optimistic that this product will make a big difference.” As some of HealtheIntent is still in the development stage, there is a customer perception that Cerner is a little behind: “We are looking at Cerner, Advisory Board, and Phytel for population health tools. I am advocating for Cerner. If they are at least on the same level with Advisory Board, then they should get the nod because of the ability to integrate that workflow into my daily life. Their product is pretty immature, but I was pretty impressed with what I saw of their live code.” 

HEALTH CATALYST EDW

Health Catalyst is quickly gaining momentum around population health with their expertise in data aggregation and risk stratification. Providers reported using Health Catalyst mainly for enterprise data warehousing but are now moving toward using the platform for population health. Providers reported that Health Catalyst is easy to work with and a great partner. One provider said, “Health Catalyst EDW is a very well thoughtout product. As we first started looking for a data warehousing and analytics solution, we realized that we needed more than just a technology solution. We needed an analytics partner. We needed someone who had experience in this field and could guide and help us. This is what we are getting with Health Catalyst. They give us more than just a technical product; it is their partnership that is of value.” 116 I Population Health Performance 2014

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Drill Deeper

Some early customers are starting to use Health Catalyst for population health, specifically around risk stratification and care coordination. One customer commented, For care coordination for diabetes, Health Catalyst built a system that a care coordinator can use to identify the patients that are not meeting treatment targets and that allows the care coordinators to reach out and then manage those patients better in a way that we really didn't have before. That system identifies the patients down to the specific provider, it identifies how well the providers' patients are doing, and it identifies how well the individual clinic's patients are doing. The system develops a list of patients so that care coordinators can actually work a list. It gives physician feedback, clinic feedback, and a list that people can work off of. 

HEALTHAGEN POPULATION HEALTH MANAGEMENT SUITE

Healthagen Population Health Management Suite combines several mature solutions (using technology from Medicity, ActiveHealth, and HDMS Dart) into a single offering. While Healthagen has many customers on each of these solutions on a standalone basis, there are only a handful of early sites working with the entire suite. While these solutions work well individually, Healthagen is working to build native integration so that the solutions can be used in concert. Providers see Healthagen’s experience working with payers as a potential benefit as many of them move to managing risk. The initial feedback on Healthagen from some of their early customers is that they would like to see their solutions work better together, focusing on providers’ specific workflows. One customer noted the success they have had using HDMS for analytics: Specifically about Dart, I think it is a very dynamic tool. As I mentioned we can measure things at the very high aggregate level all the way down to the patient level, and that allows us to really identify cost-saving opportunities and efficiencies and areas of opportunity where we can focus at a physician group level, physician level, or patient level. We want to look across service components, like inpatient or outpatient professional, or within those categories to see whether there are cost drivers that are opportunities for us to better manage the population we are accountable for. The tool has the capabilities to do that. 

LUMERIS ACCOUNTABLE DELIVERY SYSTEM PLATFORM (ADSP)

Lumeris Accountable Delivery System Platform (ADSP) is a cloud-based offering that is EMR agnostic. Lumeris mixes technology with strategic services centered on helping providers figure out how to take on and manage risk. Early feedback suggests that Lumeris is a good partner that focuses on the disease-management aspect of population health.

Population Health Performance 2014 I 117

Providers reported that Lumeris works well with claims data, and they also mentioned that ADSP is customizable to providers’ needs: What Lumeris does is run our EMR data and build tools for the physician so that if I manage a population and I have either an at-risk population for how I am expending resources or if I have a particular disease like diabetes or back pain, then Lumeris builds tools that help me manage that. We decided to use the tool for our Medicare Shared Savings and at-risk plans and also for our own associate plan. They basically give the specific analytics that we need for those kinds of management challenges. It is really about disease management population health. It is not specific things like registries, although we could do that with them. 

SIEMENS CAREXCELL

Siemens has built CareXcell as their population health management offering. It is being used at only a handful of sites today, but early positive feedback suggests that it has a lot of promise. Siemens has developed new functionality for CareXcell while utilizing some of their already-existing solutions like MobileMD for data aggregation and data exchange. CareXcell is described by providers as a data-aggregation platform. Initial implementations seem to be strong, as one provider described: “The CareXcell implementation was a really good experience. The Siemens project manager laid out a solid plan, and we were able to go with the flow. The Siemens project manager was also a nurse and a great customer advocate. She was able to talk the talk with our management, nurses, and IT staff, and she was willing to fight Siemens for the things we needed to be successful. She did everything right overall, and the CareXcell project was on time and on budget.” Note: In addition to the 28 vendors represented in this study, KLAS recognizes that many other vendors, with various levels of adoption, are creating value for their clients. KLAS plans to continue to investigate and validate these vendors in future reports. Below is a list of some of the vendors that provide population health services and solutions but weren’t included in this study. 3M Acupera Advanced Plan for Health Amplify Health BridgeIT Solutions CareEvolution Covisint Deloitte Edgewater Technology eQHealth Solutions Essette Harris Corporation Health Care DataWorks

118 I Population Health Performance 2014

Health Endeavors HEALTHEC High Line Health Huron Consulting IBM ICLOPS Influence Health Infor Information Builders MEDITECH Meridios Morrisey Associates OMRON Healthcare

Oracle Orion Health Park Street Solutions Pharos Innovations Qlik Qvera Remedy Informatics Sandlot Solutions TEAM of Care Solutions Transcend Insights Truven Health Analytics Xerox ZeOmega

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Examine Details

Population Health Performance 2014 I 119

 SPECIFIC RESEARCH DATA Figure 107

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Figure 115

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Figure 123

â&#x20AC;&#x153;Otherâ&#x20AC;? includes Allscripts, CareEvolution, Conifer Health Solutions, Evolent, Greenway, High Line Health, homegrown, i2i Systems, Lumeris, Medecision, Microsoft Access, Milliman, NextGen, Orion Health, Premier, Relatient, Siemens, TigerText, Valence, and xG Health.

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KLAS Performance Data

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KLAS Performance Data

 KLAS PERFORMANCE DATA

5.3*

7.0

Wellcentive†

7.6*

Verisk Health†

8.0*

Phytel

Optum

8.0

McKesson†

Kryptiq†

Explorys†

5.0

i2i Systems†

Epic†

Forward Health Group†

eClinicalWorks†

Sales & Contracting Contracting Experience Product Works as Promoted Money’s Worth Avoids Nickel-and-Diming Implementation & Training Quality of Implementation Implementation On Time Quality of Training Functionality & Upgrades Overall Product Quality Delivery of New Technology Ease of Use Product Response Time Supports Integration Goals Product Has Needed Functionality Service & Support Quality of Phone/Web Support Proactive Service Executive Involvement Lives Up to Expectations Keeps Promises General Overall Communication Recommend to a Peer/Friend Overall Satisfaction Forecasted Overall Satisfaction Part of Long-Term Plans Would You Buy This Again Ranked Client’s Best Vendor

Advisory Board†

Figure 126: Side-by-Side Comparison – Population Health Vendor Performance

8.0

7.3*

7.0* 7.6*

5.2

8.0*

7.3

7.5

8.1

6.7*

4.8

7.1

8.4

6.7*

6.3

7.7*

7.5

8.6*

8.0

6.3*

5.7

7.1

8.2

7.3

7.3*

100%*

57%

80%*

90%

67%

100%

100%*

100%

89%

87%

100%

100%*

7.2*

6.5

7.3

7.7

7.6*

7.0*

3.4

7.7

8.2

7.0*

7.2*

6.0

6.6

7.7

7.8*

8.3*

4.3

8.1

8.4

5.8*

7.5*

6.8

8.1*

7.4*

7.7*

5.8

8.6

8.0

6.7*

6.8*

7.5

6.2

7.8

7.6

7.4

8.0

6.9

6.3

7.2

8.4

7.9

7.1

7.5

6.8

6.0*

7.9

7.6*

7.8

6.6

5.7

7.3

8.0

6.4

6.8

8.0

6.3

7.4*

8.2

8.4

7.9

6.1

6.9

8.4

7.3

7.8

7.3*

6.1

7.3*

8.2

8.0

7.6

7.8

7.0

8.5

8.4

8.8*

8.3

6.0

6.4

8.2*

7.3

7.9

7.8

6.8

5.9

7.1

8.1

7.4

6.7

90%*

33%

67%

71%

60%

17%

38%

60%

71%

7.3

6.9

7.6*

7.8

8.4

8.1

7.6

6.1

7.9

8.5

7.8

6.3

7.4*

5.9

7.8

7.7

8.1

7.0

6.2

8.0

8.4

7.0

6.4

8.4*

5.7

6.3*

8.7

7.8*

8.3

7.5*

7.3

8.1

6.6

6.5

7.6*

6.4

7.2

7.4

7.6

7.8

6.3

5.8

7.5

8.5

7.0

6.7

60%*

75%

100%

92%

100%

86%

69%

89%

94%

91%

89%

6.8

6.3

7.8*

7.8

8.3

7.9

6.5

6.6

7.9

8.4

7.6

6.5

8.1

6.8

8.4*

7.6

8.2

8.0*

5.4

7.2

8.5

6.9

7.3 6.6

7.8

5.9

7.0

7.5

7.9

8.1

7.6*

5.5

6.7

8.4

7.2

8.2*

6.6

8.0

7.5

8.5

8.1

7.8*

6.0

7.5

8.4

7.8

7.3

92%

78%

100%

74%

100%

90%

86%

67%

77%

87%

71%

86%

90%*

75%

100%

79%

100%

80%*

43%

80%

100%

85%

78%

43%

33%*

33%

60%*

44%

50%*

15%

50%

0%*

57%

† Does not meet minimum KLAS Konfidence level (6–14 organizations) *Small sample size (3–5 respondents) Note: The highest score for each indicator is highlighted in green; the lowest in red.

Population Health Performance 2014 I 131

Special Questions Commentary

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Special Questions Commentary

 SPECIAL QUESTIONS COMMENTARY Comments for the following questions: What is the scope of your population health program? Rate your PHM solution’s strength in data aggregation. Rate your PHM solution’s strength in risk stratification. Rate your PHM solution’s strength in care coordination. Rate your PHM solution’s strength in patient engagement. Of all the technology currently used to drive your population health strategy (not limited to your PHM products), which one vendor is driving the most value for your organization and why? Additional Comments

Population Health Performance 2014 I 133

What is the scope of your population health program? Advisory Board Our population health management strategy is really about laying the framework for risk arrangements. Generally, this is going to be a walk-before-we-run exercise, where we want to start off with a couple of populations and work out our infrastructure, both for care management and technology, to manage those populations. Generally we will go with some sort of shared savings model with an ACO, hopefully to bring us more bucks in the beds, as they say in the industry. As we see fewer hospitalizations per thousand, the way to keep beds filled is to get more thousands. We have multiple commercial contracts in place and are focusing on reducing costs and improving quality in each of these agreements. In order to be successful, organizations need to have access to claims data. The fact is that if we donâ&#x20AC;&#x2122;t have payer claims on a population, we are limited in what we can do. There are two things that I am talking about. There is sort of the air campaign, which is the things we do for everybody. We also work with our doctors to have them tell all women who are eligible that they need to get mammograms, and that kind of thing. But if I can generate a gap list saying that these 27 women under Aetna donâ&#x20AC;&#x2122;t have a mammogram but our care managers are going to reach out to them, that is a different level of engagement and goes further toward helping clients. I think the ACO has become the framework on which we hang multiple strategies. The ACO is very important for physician alignment, especially in the independent physician market. Building up the quality and transitioning to care management is important so that we can gain better and more contracted lives for our health system. That will also help us expand our market share because it will help in our plans to build contracts that steer patients toward our facilities and our physicians. Then our physicians will see some bang for their buck and their participation, and the payers will see some cost savings, usually through the contracted rates they get with the facilities. There are more narrow networks with more concentrated lives being poured into them. So this is worth it for the participants. Our population health program is very limited. We are working to have a Medicare Advantage plan within 6 to 18 months in three of our markets. That is the first patient population we will have some risk for. As we run Medicare Advantage plans and funnel patients into our own narrow network of doctors and hospitals, the theory is that we will drive a little volume and control more dollars. If we can manage the patients, then we have an upside. What we are doing is no different than what other people are doing, but we are not doing anything that is national. We are getting our feet wet with a couple of Medicare Advantage plans. We are soup to nuts. We have populations that are 500 and populations that are 50,000. Our focus with most of those is on avoidable inpatient and ER admissions. For Medicare, 134 I Population Health Performance 2014

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we have a smaller number of providers, and for the commercial products, we have much bigger provider lists. We are trying to manage our own healthcare costs a little better. That is always a challenge because now that we look at athenahealth, they have their own population health solution built right in the product. We have been working on doing something like that. We use Advisory Board's population health system, and we are still trying to figure out which system is better. Advisory Board has a lot more comparative data. We have been working with a company called Veritas, which has been a much easier company to work with as far as developing the product and extracting data and being more nimble and flexible as a small company. There is nothing flexible, small, or quick about Advisory Board. There are about 1,850 lives in our system. The number is small because it covers just our own colleagues' lives and our own. That number is changing because we are also part of an ACO. We are working with the Hospital Corporation of America. We are working on a Carestream product to manage the patient data and population as we import information from our own systems into Carestream. We have about 20,000 patients. We have probably about 16 hospitals that our patients frequent. We have 14 home healthcare agencies that document within our record. We have an advanced illness management group that is a separate provider that documents in there, and then we have about 15 skilled nursing facilities that document in it as well. We have four hospitals, including an acute care rehab facility and a very small behavioral health hospital. We also have just under 200 physician practices and several major multispecialty suites throughout the area involved. We have several million patient lives that we are working towards getting bundled payment contracts on and other risk arrangements. Alere We are using our population health management program to focus on children in underprivileged school districts. These children do not have primary pediatricians and have higher rates of asthma, diabetes, and obesity. There are major healthcare information gaps, and these kids are getting sicker and sicker. Our thought is that partnering the hospitals with the area school districts will start to bridge these gaps from a population health perspective. The school nurses use this program to keep track of their students. Allscripts Our population health program is evolving. We are planning to partner with several other health systems in our region and put together our own health plan. This strategy has slowed down a few other initiatives, like our population health strategy. Population Health Performance 2014 I 135

We are utilizing Advisory Board and Allscripts for some early efforts with population health. Our population health program is very immature. Our goal with dbMotion at this point is strictly to get integrated internally. We want to be able to see our inpatient data when the patient is in the ambulatory setting and vice versa. Our short-term goal is to integrate with our outpatient areas, like homecare. We have McKesson in the homecare setting, so we want to integrate that information. We will begin to share our information exchange with nonemployed physicians in probably the next six to twelve months. We will use the dbMotion Collaborate suite to do that, and then we will also, on our ambulatory side, begin to use dbMotion Collaborate for population health management. We gather data from our local HIE. Having all that data helps us to better care for our populations. Prior to the HIE, our owned physicians didnâ&#x20AC;&#x2122;t have easy access to that data. But now as members of the HIE, they can just log on to our own systems and see that data. That leads right into better coordinated care because physicians can make better decisions. From a patient perspective, the population health program streamlines patients' care. It maybe doesnâ&#x20AC;&#x2122;t put in some of the delays that it might have otherwise if clinicians didnâ&#x20AC;&#x2122;t have the information. It could delay a start of a chemo treatment, and it lets clinicians track patients more fully. Part of the data available to clinicians at the bedside is our own health plan data. We integrated claims and provider data at the point of care. That helps to track patient activity. As long as the patient is one of our health plan members, clinicians can see that information at the bedside. The program might not have every little detail, but it lets clinicians know what procedures the patients had, what their diagnoses were, and if they actually had lab results. Our health line gets lab results too. The program starts to fill in those gaps. Once we start to fill in those gaps, it is obvious that we can then better care for our patients because we have that knowledge. athenahealth We have close to 10,000 doctors in 500 to 700 practices. The population is about 200,000, and athenahealth is probably over one half of that. We only use athenahealth for our risk patients within our health plan. CareEvolution About two years ago we started putting together a formal clinically integrated network. We used the services of a consulting group. We chose them because they were clearly one of the leaders in the country. They were the nuts and bolts of quality improvement and quality metrics that are meaningful for health outcomes, the line-up with various payers, and things like that. Concurrently, we worked on developing a registry program 136 I Population Health Performance 2014

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Special Questions Commentary

to track the quality metrics. We have a quality-metrics selection process that is committee based, and we have an IT solution to try to automate the tracking and reporting on those metrics. Now we are more in the phase of selling this network in the market. Our clinically integrated network, or CIN, is definitely different from an ACO. It is a functional and legal structure allowing independent and employed providers to come together under one organized roof. And it can contract. The basic principles encourage continual performance improvement in the quality sphere. The ultimate goals are to really reduce the total cost of care, improve the various quality metrics that are felt important, and drive better patient outcomes. Government ACOs are legislatively directed and very prescribed. The rules and everything else are very black and white. CINs really have no legal risk to them if all the rules are followed. There is a certain navigation of legal issues that is required to stay compliant with Federal Trade Commissionâ&#x20AC;&#x201C;type issues and things like that. But our efforts around population health are happening within the CIN. We do not participate in an ACO currently. We considered the Medicare Shared Savings Program, but we have tabled that discussion for a year. Most of the heavy lifting we are doing for population health falls squarely on primary care. All of our primary care providers are employed, so we have the integrated network as well as employed and independent specialists. We have mostly directed our analytics efforts toward the primary care sphere, and that is really where the greatest opportunities are. There is as much of a focus on our employed group as there is on the clinically integrated network. Cerner Our population health program covers all our hospitals and a couple thousand physicians in clinics and offices. We are managing 300,000â&#x20AC;&#x201C;400,000 patients that are governed in the accountable care population. We are aggregating information from the registries first. The next steps are to get into analytics and protocols. The first one we have worked on is the readmission module in areas like DVT and sepsis. Cerner is developing additional protocols and working on more registries. That is still a work in progress. We will see whether HealtheIntent can be the longitudinal record for an organization. Conifer Health Solutions In the beginning stages, we used Conifer Population Health Intelligence Platform for our work-site wellness in which we did risk stratification, did a health risk assessment, and looked at claims data. Conifer Health Solutions did our utilization review, case management, and disease management for non-lifestyle-related illnesses, and we Population Health Performance 2014 I 137

integrated our health risk assessment in with that. I have a wellness team at the hospital that managed our employees, and then we worked closely with our personal health nurse. We used Conifer Health Solutions' platform and a personal health nurse to help reduce claims. We used the system to figure out a better way to service our employees and to figure out what the barriers were. Now that we have the model worked out within our own employee wellness program and have integrated it into our medical plan design, we are going out to businesses to tell them what we have seen with our own employees, how that can help reduce claims for them, and how to use interventions to improve lifestyle behavior and disease management. We are still in the process of turning everything on for the community at large; we are keeping our employee wellness and medical plan separate. We are in a very good position with Conifer Health Solutions. They are interfacing the EMRs and HIEs, and we are going to put in the community piece. We are doing a pilot, and the purpose is to figure out how to link the pieces that donâ&#x20AC;&#x2122;t talk to each other. There are currently still some manual processes. Our population health program has a broad scope. We have a very large system, and we are trying to reach the program across the entire patient population. We use both Conifer and McKesson right now. Our program is in various stages across the country. We are moving out of disease management and into population health. We are looking for better management in episodic treatment. eClinicalWorks At the moment we are focusing on three Medicare Shared Savings Program ACOs and two commercial ACOs. We are a specialty clinic that cares for frail and elderly people in two states. We have teams that are customized for this care, including multiple physicians, nurse practitioners, social workers, and RNs, who work together to coordinate the care for these patients. We also have a nursing home as part of our practice. We are an internal medicine provider, so we see just about everything. We are getting the claims from the payers. But really we are not getting any claims data from the independent practices. In our ACO model, we have several independent practices that are competitors. We are not really sharing our own claims data with them. We are getting claims data from CMS. The data is actually way more robust this way because it includes everything the patients experience anywhere. They can be on vacation in Florida and go to the emergency room, and we will be able to see that.

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Special Questions Commentary

There is lab data coming in from the independent practices in our ACO. That is some of the HIE data that is accumulated. There are measures at the A1c level. We check whether patients are diabetic, whether the A1c level is above 9% or below 8%, and what the LDL cholesterol is doing. We are also getting blood pressure data; we know what the blood pressure is for our hypertensive patients and our diabetic patients. So we are measuring all of those things. In our ACO contract with Medicare, there are 12,000 patients. The system is smart enough to flag which ones are Medicare patients, and it is giving us compliance rates for those patients. We do not have to ask a two year-old whether he or she has had a fall in the last week. We have cardiology, internal medicine, OB/GYN, and pediatric practices. We also have multiple family practices, one of which runs a series of urgent care centers. All of those are reporting their data. We are actually talking to both of our hospitals. They are going to participate in the HIE. Possibly one will also participate in the ACO. It would be hard to restrict the HIE to only our ACO beneficiary patients. Right now we are getting data from everybody for the HIE, and then the system has to know which patients are also in the ACO. If next week I get a file from Medicare that says Joe Smith is in the ACO now, then we will already be prepared with Joe Smith’s data. He will just start to be included in the statistics that we report to the doctors. We are only a few months into using eClinicalWorks CCMR as a tool for population health. The first few months we were paying for it but couldn’t do anything with it because v.9 didn't support it. We didn’t appreciate that, and I don’t think the CCMR support people recognized the weaknesses. We are finally completing the mapping we need to be able to capture the structured data and let it flow into the various CCMR reports. In terms of patient care, we are just beginning with the first handful of patients that we have detail for, but we don't even have an adequate sample yet. We have 600 physicians. That is a community of hospital-employed and independentcommunity–based primary care physicians. Then there is one main hospital system with specialty practices. We have internal medicine and pediatricians, so we are a small practice. We have two part-timers. We have made quite a bit of progress in terms of our data analytics platform and aggregating data from our record and claims files from Blue Cross and CMS. We are working on integrating United Health data as well. Our next phase of development with eCW is in care planning work. We are collecting data by payer, so the number of patients we have data on will increase as we add new payers.

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Epic I would say that our population health program is in the early stages of development. It took less than six months from the point we contracted with Epic to the point where we felt like the tool was at least in use. Population health was one of the first things we started to stand up. We started looking at chronic disease management and had the typical pyramid approach of looking at utilization and the rising risk. We started out with that framework and grew it from there. We have a long history here with our patient-centered medical home and have gone through multiple iterations of it. But our focus has changed somewhat. Initially it was all about the measures and meeting targets. We have moved away from that and away from processes that really support chronic-disease management in population health. We are as far reaching as we can be. We have Healthy Planet rolled out and in use at our outreach and physician offices, clinics, and long-term care facilities. We are trying to move a lot into the population health space. We want to figure out what population we want to manage, dump the list for that population into some registry, stratify the risk for that registry, and give all that data to a person or a team so that they can do something for the high-risk patients or all of the patients, depending on our resources. We are doing that to a certain extent with our ACO. We have patient-centered medical homes. We have some data that shows what can be effective at reducing cost and improving quality for people that are far outside the norm. That is our strategy, because as soon as we hand the data off to people to do an intervention, things become very expensive, so we canâ&#x20AC;&#x2122;t apply a people solution to the whole population unless the population is really small. We have the medical group, all the hospitals and number of the employed-affiliated practices on Epic as well as a handful of private doctors who are on Epic's Community Connect products. We are also using Healthy Planet, which is really just a collection of Epic tools rebranded under the name of Healthy Planet. We have turned on our population health strategy for all of our clinics and all of our patients. Evolent Right now, we have about 18,200 lives on our health plan. Soon we will begin selling outside and signing up other people. We have created our own Premier Health Group and started offering it to our own employees as their insurance coverage. Basically, our program is for those employees that have chosen to sign up with our own health insurance rather than their spouseâ&#x20AC;&#x2122;s insurance. It is really contained to that group of our insured employees and their families 140 I Population Health Performance 2014

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right now. We are hoping over time that the program expands so we can go out and start brokering it to other businesses across the region, but that is where we have started with it. We engaged Evolent Health a little over a year ago to help us develop a blueprint for success in the population health environment. Because of that, we filed an application for the MSSP, and we became a legal ACO to serve as a platform for the MSSP application. Evolent Health was very helpful in our success with that MSSP application. We now have over 30,000 attributed lives under the MSSP application that we are actively managing in a population health environment for the ACO. Explorys A few years back, we wanted a tool that could solve everything. We went out on the market and went through a formal RFP process. Long story short, the requirements were very granular, detailed, and lengthy, and we couldn’t find a tool. We then decided to rethink our requirements and really drive toward population health and disease management. We wanted to identify gaps in care for the population as a whole and then drive that change into the workflow in our clinics. At the time, Explorys and Humedica had intriguing offerings to fit our requirements. We chose Explorys and were very optimistic about that in the beginning, but after two years, we have only implemented a small component of their functionality. We were hoping for one tool to really help solidify things, but we have found that we need to use four or five or six tools to bring some of that population health information together. Explorys EPM: Explore is similar to Epic’s slicer-dicer. Explorys EPM: Explore allows users to look at anonymous data for populations and cohorts of people. For example, a user can use the system to see all the smokers with diabetes who have visited our ED more than three times in the last six months. The system is scary fast. If we have an interesting research question, Explorys EPM: Explore certainly lets us find the data we are looking for. Explorys EPM: Measure uses data that isn’t anonymous, so actual patient data. It plugs through a whole series of industry-standard best-practice measures for things like cardiac issues, asthma, and diabetes as well as primary care and meaningful use. Finally, Explorys EPM: Registry allows us to basically create cohorts of the patients that persist. Those become part of a very dynamic registry that changes based on data collection and movement. We are using the registry engine in our primary care case management because some of the registries are really easy. We can look at all the kids, for example. We can also do risk scoring to see which patients are very high risk and potentially complicated and expensive patients. We are doing that now. That is probably the most successful part of our Explorys engagement, and we will be using it until we go to Healthy Planet. We don’t currently have any Epic functionality that allows us to do risk scoring, so we are using Explorys, but Healthy Planet has that functionality. One of our strategies with Explorys, and they know about this because we told them, was to sign a three-year agreement. It was remarkably cheap. We have spent basically Population Health Performance 2014 I 141

$200,000 a year. That is equivalent to two FTEs. I don’t think we were necessarily an early adopter, but I don’t know whether Explorys is still offering an equivalent contract. The cost was based on the amount of data we had and the number of physicians. We are probably not going to extend our contract with Explorys. I am not sure yet. The programs are fascinating, though. The population health program incorporates several hundred thousand patients and is made up of Medicare, Medicare Shared Savings, and Medicare Advantage. It encompasses the majority of our hospitals and practices. We are doing mainly data aggregation. We selected three pilot sites to be early adopters of the project while our organization fed in all the back-end clinical data, like the inpatient data, lab data, and so on, and did the normalization of that data. All three pilot sites had all employed physicians as part of the pilot, and those employed physicians had the NextGen medical record. That NextGen system was the main data pipe and main area of focus for the pilot, but we also had supplemental data from affiliates and nonowned physicians, who used a variety of EMRs, registry data, and so forth. We have five ACO contracts. They are both commercial and government, and they cover about 125,000 lives. We are still bringing up clinics. We don’t have everybody up, but our biggest ones are up. Just getting the biggest ones up took three quarters of a year. Forward Health Group Forward Health Group looks at things that we don’t necessarily look at. For example, they look at specific populations, such as intravenous drug users, and have different metrics from those we use internally. They really get down to the nitty-gritty. For example, with diabetic patients who are having A1c tests twice a year, they ask whether the most recent A1c shows that the patient's blood glucose levels are controlled. They start to exclude for certain types of CPT codes and to identify whether patients had certain types of provider visits in the past 12 months and whether they had two types of those visits in the past 18 months. We are a little more topical than Forward Health Group is. Each approach has its strengths. We are in the early phases of a PopulationManager® pilot program just for a portion of our population, which is around a fifth of the total patients. Not all of our patients are being entered into the database. There are two clinicians participating in the pilot, plus myself as an administrator. We have one location and offer eight different programs, including mental health and substance abuse. We are part of a state pilot project, so we only have a few of our clinicians getting information from patients. Then we put the data into PopulationManager®. The total has been pretty small. We are using PopulationManager® to collect data from patients on depression, anxiety, and alcohol use. We watch what happens with the scores over time.

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Health Catalyst We engaged Health Catalyst right around the beginning of this year to design and build an enterprise data warehouse for us. We had one homegrown system, but we needed something more modern and scalable with newer tools. Our experience has actually been really positive so far. The scope of the project is to implement an enterprise data warehouse while bringing different source systems on. Health Catalyst has applications that layer on top of the data warehouse that have different focuses, like the cohort builder, which identifies groups of patients. We are not an academic practice. We are a private multispecialty group, so for us the scope will be to identify groups of patients to reach out to or do something with. Health Catalyst comes from mostly an inpatient, academic world, so we are interesting for them because of our space, what we do, and the fact that we are an ACO and a physician-owned practice with mostly outpatient services. We are both gaining from each other’s experience. So far, our experience has been very positive. Within the pharmacy program, we have two hospitals and three clinics with medication therapy management pharmacists who are trying to build a base of 500 to 1,000 patients. i2i Systems We are basically doing a lot of work with patient-centered medical homes and all of the population management sort of functions that come along with that model for primary care. We are looking for a way to not only get good clinical information across an enterprise but also integrate claims data from various payers. We haven’t been able to do that yet. We have a proposal for i2i Systems to do that, and we just don’t have the money at the moment. So the only reason i2i Systems isn't supporting all of our needs is that with all the payment reform and shared savings programs out there, we are trying to integrate claims data from Medicaid and Medicare and other private payers to connect clinical visits and key clinical events with utilization outside of our system, like going to an ER or an inpatient admission. Kryptiq Our population health program is part of our patient-centered medical home strategy. Right now we only have Kryptiq CareManager in one clinic, and we are only doing diabetes at this time. The scope of our population health program is mostly just within the four walls of our facility. We do have researchers from the hospital who have access to the data, but that is just one hospital.

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We were basically doing a pilot program. I would say the pilot was not very successful because of the lack of training for the doctors. They technically know how to use Kryptiq CareManager, but it is unclear how they would actually manage the patient population. So they struggled there. The product is very limited. We have about 180 providers. About 10 of them use Kryptiq CareManager. It is rarely used. The original idea was to pull data from the hospital’s inpatient EMR, but there wasn’t really a way to make a connection to the hospital system, so the scope of the project was changed. We just used COPD data from the patients who were already in our database. If the physicians saw patients in the hospital with COPD, they would populate our database with that information so we could track the patients. We have 20 primary care practices, and those have about 90 providers. We also have endocrinology, asthma, pulmonary, and cardiology specialists. The specialists have been looking into the product, and their staff members are using it. The providers are not using it so much. Lumeris I don’t know how many associates we have. We have over 10,000, and if we roll in those with dependent coverage, that number could double. The non-Medicare, non-ACO work with our own associates is sort of in the ballpark of population health. We are in different stages. We keep adding scope, but we are actually going up on Lumeris ADSP this year. We have a few months' experience with the data in their systems, and we are starting to look at reports. I think one of the challenges is making sure we have good data flow from Epic to Lumeris. Right now we have a pay-for-performance arrangement which is a pilot program for our employees and their dependents. The next step is to expand to the other health systems in our area, so the program covers close to almost 40,000 lives with employees and their dependents. McKesson Our initial scope was trying to use McKesson Population Manager to help us with reporting on quality measures. We have an aligned physician model with hundreds of physicians that are not employed but aligned to share common goals with a health system. We initially started using McKesson’s product to take 837 billing files from multiple disparate sources, then do quality reporting on the physicians. The scope of the project evolved once that was in place, so we were then able to also bring in billing payer data from one of our primary payers and our employees to do analysis and population management based on that data. The next step is McKesson Risk Manager, so that is our next evolution. It will help with the claims data to let us identify the patients that are most at risk and will be the highest cost and biggest utilizers of our health system.

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Right now our organization has about 65,000 patients at risk. We just signed up for Medicare Shared Savings, so I think that we will add about 20,000 more. The main focus of our population health program was changing the culture and just getting physicians to look critically at their own data and recognize how their performance compared to that of other practices. The program was really less about the money and more about getting the physicians to understand the currency in which people now talk about population health. It doesn’t matter whether patients like our parking; it matters that we can say that a patient with diabetes is getting the right care. Our population health program involved publishing reports and getting ourselves to where we are today from where we were when we started the project and with some benchmark information the McKesson Population Manager has available. We didn’t have a financial target. I wasn’t held accountable to a particular bottom line, although I did have to have a return on investment for McKesson Population Manager. We were really just trying to get everyone ready for a more accountable world. We are at best doing bits and parts of the program and doing a lot of self-reporting. Our strategy has really not been to use any particular vendor but to use our standard reporting tools. We have our BI tools to be able to put data in our data warehouse and display it. We take claims data from Medicare and pull that together with clinical data from each of the EMRs in the group. That has really been our strategy so far. It is very labor intensive. It is difficult to get all that data reconciled quickly. We do not have a great master patient index. All of the things that a population health strategy should do for us are important. We are doing active population health management today, but we are just doing that with our hospital with a small group of 200. We have McKesson's population- and riskmanagement solution, which is their ACO software. We are self-insured, so we are trying to figure out how to reduce our healthcare costs. We used the ACO software from McKesson to import all our claims data and then filter specifically for obesity and diabetes. The filter was based on a very high threshold. We have been working with some of our unmanaged diabetics in order to reduce their expense and maintain improved health. We have a health clinic. All we are doing for that clinic right now is health-risk assessments. We are providing a sick clinic, and we don’t actually do the risk management of the population. That is pretty restrictive because we are going to be held accountable for seeing all the patients but are not necessarily going to be involved in managing their care plan or improving their illnesses. If we look at the current research that is out there, there are a lot of articles, documentation, and scientific papers that talk about wellness programs or population management. Very few people are combining wellness programs with population management yet, but it is important to tie the two together.

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We are focused more on population-based care management rather than disease-based. Our approach so far has been threefold. The first piece is implementing care coordination. That can be done by medical assistants, nurses, social workers, or any number of medical people. In general, our model is to have more MAs and fewer RNs and social workers. The goal in that program is twofold. One is to look at people in the emergency department or in the hospital setting that are being discharged because we know that in that transition of care, there are oftentimes hand-offs and gaps. Our care coordinators pay particular attention to any patient that goes through one of those transitions, and we use telephone and secure messaging and visit the patients just to make sure those transitions go well. Then we have another cadre of care coordinators that look to identify higher-risk patients, and by that we don't mean the patients in the ICU. Those patients are sick, and care coordination is not really going to help them. They are already plugged in and getting maximum resources. We tend to look at the people who are still in the outpatient setting but who are going to the ER six times in a year and getting admitted several times in attempts to figure out what the main barrier is to them being healthier. There could be a million things. As physicians, we generally donâ&#x20AC;&#x2122;t have a ton of time to dive into all those pieces, and we are very focused during office visits, whereas the care coordinators are functioning in between visits. If a patient comes to the office every month, the care coordinators will call and check up with the patient every other day to make sure things are going okay and try to course correct things before they blow out of proportion. That is a big arm of what we do. Our goal is to create a virtual world or data set where between the EMR and the HIE data, the care coordinators know everything that is going on. The second piece of our approach is the physician coordination piece that I lead with another physician, and third piece is our clinical committee, which is drawing up a number of clinical guidelines. We have a quality committee that tries to measure progress with those initiatives, and we do a lot of faceto-face work with the physicians like a medical director would in order to coordinate the network. That is our three-pronged approach. We have a large patient base and a large healthcare system, so we have a broad scope. We want our population health program to be operating at an optimal level soon. We have formed a clinically integrated network that is a lot bigger than just our physicians. McKesson has been the data aggregator and registry provider for that network. Our strategy is really around identifying various chronic issues and other health deficiencies where we want to coordinate care, not for just the employed physicians and the providers within our organization, but across a much broader network. That is our official play. The network is fairly new and is just getting its feet under it with the aggregation of the data. Our clinically integrated network has reached out and contracted with several large employers around managing employee populations. The strategy today is to get employers to sign commitment contracts to enhance the impact of their employees, partly by managing diseases. We are expanding those contracts with the employers and are looking at larger and larger populations of people to commit to. Our approach to 146 I Population Health Performance 2014

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population health involves the payer arm and contracting with this network of employers. Obviously the employers' goal is to reduce healthcare expenses, and we are doing that through a combination of activities, particularly for population health. We have multiple contracts including one with CMS. We are in the neighborhood of just shy of 25,000 covered lives across our ACO population, Medicare Advantage plans, and commercial employee plans. We have a few other smaller contracts that donâ&#x20AC;&#x2122;t have very many people in them due to the health insurance exchange phenomenon earlier this year. Our major focus has been identifying high-risk patients and looking at the performance and trends of a lot of our primary care practices to support our care-management program. We started our population health program last fall. Vendors tend to tell clients that the implementation time for population health products is a little bit shorter than for other tools. We are a couple of months into the pilot right now. Our data is limited, but we will expand to two million patients. We are still pretty early in that right now, but we are making headway, and our intent over time is to expand the program pretty broadly once we can consolidate our EMR data. We are just cranking up our HIE implementation pretty soon. Our intent is to go to an out-of-state HIE and connect that data to our population health manager to feed our metrics. Medecision Medecision Aerial for Population Health Management is being used only to drive our CMMI grant population, which is ischemic heart disease. Very soon, we will be expanding the program to include other disease states and also the population. We will be managing the health of enrollees pretty soon. We are not quite a year old yet. Part of what we have been doing at this point is using the clinical attributes of the product. We do use a lot of the reporting. It helps us identify from a HEDIS-measure perspective whom we should be focusing on getting to come in and receive services. We use the reporting capability of Aerial Care and some of the analytics it provides on a real-time basis. Our heavy lifting as a brand new organization clearly has been focused on the self-service capabilities surrounding authorization requests from both our primary and specialty care physicians. We have been starting off slow and moving through the implementation more aggressively as the weeks and months move, but the program has been very well received by our physician community and we are very pleased with what we have been able to accomplish with Medecision at this point. We use Medecision through a company that they had acquired called Cerecons as our provider portal, and we use that portal across our entire organization. It is our one and single portal. The actual core of the process is done within our claim system, which is Population Health Performance 2014 I 147

where we do most of our population management from the portal. We have a different case management system for inpatient and typical case management work. We are not a full adopter of all the Medecision products. NextGen We are doing a transition-of-care program to avoid 30-day readmissions. We have our inpatient case managers and clinic-based disease managers working with patients. We are doing quite a bit when it comes to population health. We have many facilities, both ambulatory and inpatient, and have tens of thousands of lives covered under some form of pay-for-performance model or modified-risk health plan. We have 50 primary and specialty offices. We opened NextGen's enterprise chart functionality, so we have one electronic chart that follows the patients throughout the continuum. We also have an inpatient hospital. We get claims data because of our ACO arrangements, but it is not integrated. That data is in independent data streams. Our stream is more reliable because it is in real time. Optum Our program is still very much a small-scale, central-analytics program. We are an ACO as of early this year. We have been sucked into ACO and MSSP measures, and that has been a big focus so far. We tried Optum because they said they could do some things, but unfortunately their measures didn’t really cover the full nuance and breadth on how we capture and store certain data elements in Epic. We ended up having to do our own reporting, which was a shame. We do use Optum Population Analytics, and it can expand its features well. The scope is still limited to a central group doing more querying and analysis and operationalizing, but unfortunately, most of our operations people are focusing on being an ACO and on our quality measures. At this point, we still have a broad query rather than exact measurements. We apply population health management protocols to all of our patients. We are getting claims data from multiple insurers and putting it in our own information system. We use Optum by the UnitedHealth Group. We use the same kind of software that the Blues use. Optum basically measures the same kind of things that Cigna or the Blues would. The beauty of us doing it, and not them doing it, is that we don’t just see the results for 5,000 people and try to make some kind of assessment of the quality of care and efficiency of care that providers deliver. The sample size is too small. We can’t really evaluate our physician population based on that small slice of data. We need to get multiple claims data from multiple insurers and actually put that in with Medicare data and so on. So now we can have a good view of the majority of each practice's work. Then we can start to answer good questions about quality and cost efficiency. That is why the insurers can’t do this work. That is why it has to be done on the provider’s side. 148 I Population Health Performance 2014

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We use Optum to add our own EMR data to all the claims data, and now we finally have good information about quality, but even more importantly, we have information about cost efficiency because we don’t have just a small slice of 10% of a practice's data. Because of the multiple claims data that we are putting together, we have a pretty good picture of the cost efficiency of physicians. Then we can sit down with them with critical, credible information and discuss it. This is why claims data has to come to the providers, and it is why the providers are really the only people who can truly manage care. Insurers have been trying to do it, and it has been a failure for many reasons. One is that they can’t really engage physician populations. Physicians need to be engaged by people they trust. Additionally, the insurers don’t have all the information. They just have a small slice of the information. They don’t have clinical information, and they don’t have data for enough of the whole population to be able to get the kind of information they need to fix things. We are looking at ambulatory and acute care data. We are looking at our own employee population and doing some work with a Medicare Advantage plan. Now that we are building our own internal infrastructure, we are going to aggressively market, and we anticipate that in 2015 we will be growing out and contracting directly under various kinds of risk arrangements; those could be incentive-based arrangements, case-rate risk sharing, or full risk sharing. We are the only hospital, but we have around 20 clinics and over 200,000 unique patients in the database that we are running through our population health initiative. There are a lot of great opportunities around to keep sick people from getting more sick, but we will need the government to say they will pay, because once they pay so will the other payers. Then it will be easier to move some of that technology. We currently have one ACO up and running in the IDN, and we are applying to add more. And we are running several population health initiatives in conjunction with our ACO program. We will eventually have 32 hospitals involved in these initiatives, but right now the majority of the work is taking place in our clinics. The movement right now is to keep patients out of the hospital so that we can totally manage patient care. We demand that our providers spend at least 20 minutes a month on population health, and we will probably increase that time. Some doctors are already spending an hour a month talking to care guides and their care team about at-risk patients. Sometimes we need that time to pull in patients for a visit or call them. Sometimes we need that time to figure out who is the right person to send a home health nurse out to. Our program is very much directed by the physicians in that sense. I am a very strong believer in embedding what is needed within the primary care clinic for the population, so we have actually embedded at least one community health worker in each of our clinics. Sometimes there are as many as three workers depending on how much the doctors there use the service. The care coordination is embedded rather than Population Health Performance 2014 I 149

remotely managed from a different city or from the payer. Care coordination is expensive, so we have to target it at the most expensive patients. We are engaged in risk arrangements that give us back 17Â˘ for every dollar of costs that we avoid. That is not very much. We could do better, but our program is a pretty cost-effective one in terms of getting care coordination to happen. We have to have a thoughtful program or practice in place. A good EHR will give us that. We never think we are doing the best we can. We always feel like we can do better. But we really have had some very good growth in our quality reporting in terms of significant results. We are definitely progressing. Optum has the ability to do HCC scoring, and Epic canâ&#x20AC;&#x2122;t deliver that just yet. That is a great tool to have. Both vendors do extremely well. Epic has come a long way in what they can do, and Optum has a little more functionality in certain areas. With Epic Healthy Planet, we are able to go in and get discrete data. For years we looked at claims, and now we can see how many of our diabetics are out of control with their A1c levels. We can see who is at a level greater than 8% and just get those people to come in. We pull data from our EMR into the Optum platform. We use it to analyze clinical metrics, primarily in the first few years. We are using Optum Population Analytics and other tools to do risk stratification, so our program is an amalgamation. We are finding that none of our tools are perfect, and we canâ&#x20AC;&#x2122;t get by with just one. We have used Optum Population Analytics mostly for clinical quality metrics like diabetes and hypertension. We have really enjoyed the Anceta Collaborative Optum put together. We thought the easiest way to test our population health program would be to use our own employees. We are self-insured and have over 20,000 employees and dependents. We did a lot of benefit redesign and created a very narrow network within our ACO. We use algorithms to determine our highest-risk patients so we can monitor them more often. Phytel Our scope has been focused on diabetes, but we just expanded to both hypertension and high cholesterol. We don't have results for those yet. We are a community health organization and has been around for about 26 years. We are federally qualified as a community healthcare center, so we have been doing community health population care for a long time. That is how we work. We operate a little differently than private practices. We look at our patients from all levels. We are trying to make sure they receive all the care they need. For population health, we look at different pockets, but we really look at 150 I Population Health Performance 2014

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the patients when they come in because they have so many needs. We focus heavily on immunizations for both pediatric and adult patients. We also work with mental health patients. Then we also have a whole subset of patients, so we do things like nutrition and social services work. We really try to manage all the care our patients need, not just do something small and focused. We are just starting with our population health program. We hired a CMO who will be much more involved in population health from a clinical standpoint. Population health from my business perspective is a volume-building opportunity. As we explore ACO development within our organization, it is important we have that population health management component. We can increase volumes using our existing patient population. Right now we are mostly trying to get new patients into our system, but we aren't really maximizing the revenue potential of our current population base. I want patients to be healthier, and I want to be able to manage them. With a CMO on board, our focus is going to be on care continuity, actually treating patients, and communicating throughout our system. We are going to focus on follow up with all of our patients, whether they have been discharged from the ED or an acute care setting. We have six primary practices and care managers that work to fill in gaps in care and try to get patients in for care. I don't have a number for patients involved in our program, but I know we are seeing many with chronic conditions. We manage our patient populations with Phytel using data from the payers and CMS. We can create performance dashboards for our providers. If we had better understood up front how the tools in Phytel worked, we could have asked more questions and implemented Phytel a little bit more robustly. Having a better understanding of the protocols would have helped us be a little more prepared to be live. The issues were really more on our side, though. We probably should have understood the processes a little better, but I think we were pretty well informed to begin with. After we put outreach in place, we decided to implement the automatic reminder calls. We had another company doing patient reminders, and it didnâ&#x20AC;&#x2122;t really make sense for us to use a vendor that didnâ&#x20AC;&#x2122;t integrate with Phytel, so the patient reminder module is the second piece we put in place. The third piece was the actual registry, which Phytel calls Insight. With that, we can create a registry once we identify a patient. The last piece was Phytel Transitions. So far, implementing the transitions piece is going very well. Phytel Transitions is basically outreach for patients who are discharged from the hospital or ED. Phytel usually interfaces that tool with the hospital system, but we actually had them interface with our HIE. That is a different model for Phytel, so the implementation has taken a little longer than it normally would. We have been going through the implementation process and trying to iron out bugs for about six months now. We are nearing the end of our implementation.

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We need to be a concentric network of providers within Aetna, Blue Cross, and so forth. We want to make sure that the business is going to one of the most efficient with the best quality doctors based on the data we have and the data the payers will share with us. Being a concentric network is the means to facilitate that collaboration. We donâ&#x20AC;&#x2122;t have any payers using a risk-based model. Of course, we are in the Medicare Shared Savings Program, and we are actually actively in negotiations with all of our commercial and Medicare Advantage plans and even our managed Medicaid. We are trying to move all of our agreements into a gain-share model. We produce encounter alerts, clinical alerts, and ADT alerts. If there is a cohort of patients and a group of physicians needs to know when any of those patients get admitted to a facility or an ED, we can do the mapping between the patients and physicians so that the physicians will be alerted when there is some sort of clinical event. That allows the physicians to jump-start the care-management process. Premier Our population health program is not highly developed. We use Premier for claims data from CMS, and Premier is helping us with the Medicare Shared Savings Program. That is it. What we are doing with population health is in its infancy. We have been trying to do some spotty things to change how we want to attack population health. We want to make some changes to how we do things here, but we don't have a cohesive plan of attack. A couple of groups in our hospital, like the ACO and informatics groups, each have their own tasks, but we need to work together to develop common goals and pool our resources. Siemens The scope of our population health program is our primary care base. Eventually we plan to include the inpatient side too. There are 30,000 primary care patients. About 5,000 of those patients are our patient-centered medical home population. Valence We are mainly on Epic EMR, but our community physicians aren't. We have 3,000 employed physicians and 1,000 independent physicians. We are just starting population management with the 3,000 employed physicians, and we have 18 family health centers, or 16 family health centers plus the main campus. With our 1,000 independent physicians, we probably have 300 locations. The independents probably have 50 different EMRs, so we have actually used billing data and some EMR and lab data to populate our registry. To date, we have just been closing care gaps related to chronic disease. We are just beginning some high-risk population management, but to date we have really done tons 152 I Population Health Performance 2014

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of chronic disease measures like cancer screenings, immunizations, and those kinds of things. We have approximately 125,000 lives within our market, and we are pretty mature in our population health management. Of course, there is still a ways to go because we have a ton of practices that are or will be providing data to Valence. I don’t have all the EMR data integrated yet, but we will get there. From a financial standpoint, it just takes baby steps to get there. We are three years into population health management, so we are still learning. But we do have a pretty complete data set at this point, so we can look at our entire IPA to identify gaps in care and close those gaps. Verisk Health I don’t think we are unique. We are a hybrid accountable care organization, and right now we have about 7,000 Medicare fee-for-service lives. We also participate in some commercial shared savings programs; one has about 5,000 or 6,000 lives and its own, proprietary tool. Then we also have an agreement with another large payer where we cover about 60,000 lives. We use a tool from the payer for that commercial program. Verisk Health Medical Intelligence looks good at a high level. It easily identifies our problem areas. The problem is that we want to compare all of our health systems, but Verisk Health Medical Intelligence either shows every system or one at a time. We can’t make a matrix to show all of our health systems simultaneously. That big shortcoming leads us to have to download a lot of information and then put that in a new data structure, which is very time consuming. Working with Verisk Health was initially a good learning experience for us. However, the groups got up to speed a lot more quickly than we thought they would. I work a lot with our CMO group, which is composed of the many CMOs across our health system, and that group got up to speed very quickly and was very focused on data. Our analyst was updating a Medicare Shared Savings Program dashboard in Verisk Health Medical Intelligence, and she had to download 32 files from Verisk Health in order to populate the dashboard. We just can’t deal with that type of inefficiency as we move forward. It hinders our process rather than helps. We don’t have access to any of the back-end data in Verisk Health Medical Intelligence, which was very important to us. We have several independent health systems who do things just slightly differently. Urgent care is a great example of that. Some of our health systems bill their urgent care under a professional service, some bill it under a facility component, and some do a facility component with a professional component. When we try to compare that across all our health systems using Verisk Health Medical Intelligence's standard categorization, we aren't really detecting real differences. We are just detecting billing differences. In some cases, we need to go in and reclassify that data ourselves, which we currently can’t do in Verisk Health Medical Intelligence. Population Health Performance 2014 I 153

We are just using CMSâ&#x20AC;&#x2122; data for our patients. We have about 13,000 patients, but we signed with a commercial payer, so that adds another 16,000, and then the hospital eventually wants us to take over their employee health plan so thatâ&#x20AC;&#x2122;s probably another 20,000. We are going to be up to over 40,000 patients, and we are obviously going to need some good data analytics to support what we have. We have 42 clinics in our primary care employed group, and we have more than that in the independent network. There are many different ways that we talk about populations. We could talk about patients that we are at risk for, patients that we serve in the course of a year, patients in a physician panel, and so forth. The scope is very different for all of those different definitions. We have about 330,000 patients in some form of risk contract. We have about 1.5 million patients that we touch on an annual basis, and we attribute between 750,000 and 800,000 of those 1.5 million to a primary care group and to accountability in one form or another. We have a three-way agreement between us, a public employer, and a payer as a thirdparty administrator. Then we have upside-only arrangements with five payers. In those arrangements, we get variable advanced payments for primary care and care management, and then we have opportunities for upside based on hitting quality and cost targets. We have dozens of patient-centered medical homes that have care coordinators who reach out to patients. We are still trying to figure out how to interact with each type of patient. Our goal is creating better health outcomes for our patients. We believe a byproduct of that will be less spending, but first and foremost for us is how we keep our patients healthier. Population health can be pretty scary financially for a hospital system. One of the reasons we are working with small populations is that we are not sure what the outcome would be if we really went the whole hog. We use Verisk Health, which does the predictive modeling, risk-stratification and care-gap analysis, and those types of things with claims data. We use Verisk Health for our ACO population and any population that we bring to the ACO front. Then we are actively finalizing negotiations with a couple of other vendors. Wellcentive At this point, we use a lot of the registry functionality to really try to identify patients with gaps of care. Right now, our primary focus is on preventative health, including things like screening measures, immunizations, and so on. We are also focused on diabetes and hypertension. The Johns Hopkins risk scoring methodology is something we are using in addition to Wellcentive. We have really latched onto that so we can give scorecard metrics to a number of providers based on their panel size and give them the median and average risk of our patient population.

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In the current phase of our contract we have our health plans and 3 of our 9 regions involved. So that would account for 11 hospitals and 2 health insurance plans, and within those 2 health insurance plans, 3 product lines, so in terms of numbers of patients and members, I would say right now we are projecting about 40,000 from the health plans alone, but it is tough to say how many we expect from the hospital programs. Among the 11 hospitals, usually there are a few hundred thousand discharges a year. The best estimate I could give is that north of 50,000 patients will be managed across this phase of the contract application. The contract is set up for us to have as many patients as 3 million. Our main population health initiative is to track diabetes among our patients. We are starting to add on asthma and hypertension. We are a mid-sized physician hospital organization serving over 200,000 members. We have over 500 providers from our community within our network as well as a large regional hospital system. We have an illness burden that is disproportionate to the rest of the state. We are the worst in health specifics for health behaviors, but we are ranked higher for our healthcare delivery system. We have lots of opportunity. We continue to use the Wellcentive tool for all of our incentive program participation with the commercial payers we contract with. We also run quality data for grant-funded demonstration projects and support ambulatory care management services and other community outreach services. We are using the registry tool to improve quality scores, manage our incentives and specific initiatives within the community, and move into more of the cost and utilization side with predictive modeling and risk stratification. We are responsible for the population health of the entire community. We are looking at everything, so we take all of the HEDIS measurements and the CMS Star Ratings for preventative health and chronic disease for all ages, and we are held accountable to those outcomes in our care contracts based on service lines. Outside of that we look at CDC data for obesity, BMI percentiles, and immunizations. We look at all conditions and the evidence-based guidelines that support the management of those conditions. In addition, for those patients who are fortunate enough to not have a medical condition, we look at all the preventative health measures, like cancer screenings, check-ups, and well-child visits. We are an ACO. We basically do it all. We are in a leadership state in the nation in terms of population management, so we are on the forefront of what is needed in this area. We use a number of EHR vendors, primarily NextGen, Epic, and eClinicalWorks. We are using Advance Outcomes Manager specifically to track three chronic diseases and three preventative measures that we track in it. Our main focus is diabetes, but we also look at coronary heart disease and coronary artery disease for the chronic diseases, and then for preventative measures we look at mammograms, servable cancer screenings, and well-child visits. Those are the things that we track on a monthly basis with Advance Population Health Performance 2014 I 155

Outcomes Manager, which obviously is interfaced directly with our EMR. That data goes over on a daily basis. We mainly use the population health program to watch over and keep track of our diabetics. We went into an agreement with Wellcentive just over a year ago. Basically we are using their product to build our population health program. We are creating our strategies, and it is enabling us to actually gather the information, get that information to the right providers, and ultimately impact patients. Wellcentive is connected to our EHR. They are also connected to our practice management system. And we are looking into connecting with external sources of information. xG Health xG Health became the insurance company or payers for our hospital's employees. Part of that was going beyond the traditional insurance function of promoting wellness to advancing medical home development to get closer to an ACO. We are not a complete ACO. At any rate, we are getting closer to being an ACO and that concept of developing patient-centered medical homes and organizations to care for those patients. xG Health is the data aggregator behind the scenes. xG Health basically provides us with data about the patient, admission rates, readmission rates within 30 days, and some utilization data. There is a risk-based assessment of our population in that data.

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Rate your PHM solution’s strength in data aggregation. Advisory Board Crimson Population Risk Management does really well at bringing the claims data in and working with it. It does a really good job of handling EMR data. But it doesn’t do a great job of offering a unified view of the patient by showing all of the data together. That is really hard to do. One of the things that people have to understand is that when people pull data from an EMR in a practice, they generally pull all of the data, not just data on the populations they have contracts for. Sifting through all of the data to find the data for just the contracted populations is a little tricky. So maybe a physician is, according to Aetna, doing 70% of eligible women’s mammograms, but then when I look at his office data, I calculate that he is doing 80% because I am looking at all of his populations. So it can be hard to really measure performance. Getting to a point where there is synthesis between ambulatory, inpatient, and payer data is still a very messy process. We do not have data standardization or data normalization across all the EMRs, and that is part of the challenge of interoperability. The data is not really apples and oranges; it is more like apples and concrete cinder blocks. Crimson Population Risk Management does what we need it to, but there is work we have to put into it. Right now we are just using our own patient data from our EMR and practice management system. Advisory Board still only wants data quarterly. We will send the data to them in 30 days, and 45 days later they will call us and say that they are still having some problems scrubbing data and need 15 more days. Usually our quarterly data is up in 60 days, and by then it is already 5 months old. There need to be more time stamps and canned reports and more flexibility in the custom reporting. Custom reporting needs to be a little easier to do. We just recently started working with a company to do data warehousing for our registry. Advisory Board pulls data from the various systems, but it is not aggregating the data, exactly. It is more like a central point, which is really important for ACO accreditation. You have to have a data warehouse registry for patient data. Alere Wellogic is not doing data aggregation, or at least they aren’t doing it for us. We have information for patients coming in from multiple sources, and if a patient has one problem but that problem is documented in several different places, then the system will stack each documentation all on top of each other to show the case multiple times rather than simplifying it into one.

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Allscripts I have had no issues aggregating and normalizing the data. dbMotion does a good job normalizing data. We aggregate from our EMRs, our cancer center app, our different lab interfaces, and our different document interfaces. Even within the EMRs, we get problems, diagnoses, allergies, immunizations, procedures, and medications. To date, we probably have around 60 active interfaces running into dbMotion Population Health. We sunset some interfaces because systems come and go, but over the years we have had about 100 sources, including the 60 that are live today. We aggregate our hospitalâ&#x20AC;&#x2122;s health plan claims data into a dbMotion Population Health database. We do keep a second, separate database from our provider for legal reasons. The third database is the HIE. Those nodes are all federated and secure. So if I am at a patientâ&#x20AC;&#x2122;s bedside, I am going to see information from all those three nodes, provided the patient hasnâ&#x20AC;&#x2122;t opted out of the HIE. If patients do opt out, that wish is honored and data is not shared. Allscripts has had so much experience with connecting to so many different EMRs over the years that they have really come to be an expert in that area. I believe that Allscripts still stands out because of their normalization or harmonization capabilities. Those capabilities are one of their strong points. athenahealth athenahealth is doing something no one has ever done with us before. They are bringing many disparate data sets together. athenahealth is very flexible and creative. They take the data and do a lot with it. Some of the other places that we looked into would make us do a lot of work on our own. athenaCoordinator Enterprise is a really powerful tool. It takes data from most of the very disparate data sources that we have in individual silos and that really bear no resemblance to each other, and it displays that data all in one location. That helps us look at an entire population or even at the individual patient level. athenaCoordinator Enterprise has been a huge boon for our network just because it relays information out to hundreds of users. CareEvolution We define algorithms and define reports to our needs. We are empowered with this system. We have done a tremendous amount of work with CareEvolution on data aggregation. We are bringing data in from pretty much everything. We are working on getting direct data sets from Anthem; this has taken some effort and been complicated because of 158 I Population Health Performance 2014

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business associate agreements, but we view it as extremely important. CareEvolution is very good for data aggregation. The end product has turned out to be wonderful. This has definitely been a process that has taken a fair amount of heavy lifting as we have cleaned up the data. We have had to learn the changing rules, that data may not be exactly what is expected, and even how data is filed in certain sources. But now we use the CareEvolution data to try to close the care gaps and hit preset targets. We use it in the incentive/compensation plan for all of our employed providers. It is just critical that the data is accurate and actionable. So that has taken a tremendous amount of work over the last two years. We have a very extensive clinic outreach program for specialties. A lot of the hospitals in that program are not part of our system, so they are not on Epic. Depending on the source of the labs, for example, the labs may not flow into Epic. Or maybe they get entered from a written lab-report sheet into a flow sheet in Epic, but that flow sheet may not be the ideal place to then pull data to the warehouse from and populate CareEvolution with. With CareEvolution, we have demographic screens, drill-down screens, and disease-entity screens. We have goals that are set by the quality- and performance-improvement committee, and we track physician performance against those. It is very easy to drill down into very patient-specific outliers. We can generate work queues to try to close gaps. But the data does have to be actionable. The practices have to have a workflow designed to deal with that actionable data and improve outcomes. Getting to that point has been a lot of the difficult work. Cerner A lot of the data aggregation feeds are coming into HealtheIntent. The data is being normalized and aggregated, so our process is pretty powerful in terms of identification of individuals, aggregation of the data, and tracking people. We are starting to feel comfortable with that. HealtheIntent pulls data in from a lot of different sources and normalizes it. Conifer Health Solutions Conifer Health Solutions is working on the data mapping and the algorithms, and they are working on integrating with the different EMR and HIE platforms. We want the data sharing to be automated. We don't want the data to have to be sent and then downloaded, and Conifer Health Solutions is already working on that. They are almost there. They have done their homework, and they have been out hitting the pavement and working in the smaller-hospital arena. They have been proactive and are ready for the things that are coming. They are very responsive. Conifer needs to increase our ability to aggregate data from different sources. This is especially critical since we are a large health system.

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We have the technical capability to do data aggregation, which is more mature than physicians may have in their practices. We are getting that out to everyone. eClinicalWorks eClinicalWorks CCMR does the job fairly well, but the ease of use depends on the user’s sophistication. The system is fairly simple, but there are still some quirks with it around how people go from one place to the next. Just the way that we have to try to get records is not something we can automatically do through a patient’s chart or a patient’s hub. The data aggregation is not perfect yet, but we are to the point that the data is a trusted data source, and that is huge. There are many accuracy issues. Language differences make communication difficult at best. We are still integrating EMRs. The problem is getting the data out of each system, then mapping it appropriately so that the data all matches up. All the systems are so different, so it takes a lot of work to get the data out, but once it is in the eClinicalWorks CCMR system, it aggregates fine. Epic Healthy Planet gives us a snapshot view of the patients and their quality metrics. Healthy Planet's data aggregation capabilities still need more development. We have spoken with Epic about what we believe is missing. I have access to the entire database, which I think is a big plus, but it isn’t easy to get things from other places. The system is immature. We take in data from outside systems, and that works with relatively few problems. Reconciling the data we get from the various sources goes pretty well compared to similar functionality in other products we use. We don’t really think our program is the be-all and end-all, but it is better than other things we have seen. Evolent Identifi needs a more refined algorithm to better target populations. Explorys

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Explorys is the platform we use for data aggregation for our population health program. We are trying to figure out whether it is better to have Explorys do data aggregation or whether we should bring in a private HIE like a lot of other people are doing. We had wanted to stay away from doing the private HIE because it is expensive and painful. That road is just a big challenge. I am hoping the answer is just to have Explorys do the integrations directly with the EHRs, which is what they do for some of their other customers. I think Explorys oversold the system a little bit. I think they are still gearing up for some of these population health things. They have a couple of individuals who are stellar, but as they have grown, they have hired lots of new people, and I think they are training as they go along. I would say that Explorys is better than other vendors when it comes to data aggregation. We have experience with data aggregation in terms of being able to look at Explorys’ curation engine. We are not pumping diverse data to them, but because we look at other data through Explorys EPM: Explore, I know Explorys’ curation is pretty solid. Forward Health Group Forward Health Group has a fantastic little tool that allows us to look at all of our diabetics and see how many of them are not in control. It can give us the names and IDs of each of those cases so we can call those folks in and get them triaged into moreappropriate therapeutic interventions. Forward Health Group is very good at working through the process of normalizing the data. They look at data that we extract from our EMR via eClinicalWorks Enterprise Business Optimizer. It is an IBM Cognos-based tool. We don’t give Forward Health Group access to our database. We just write the reports and click a bunch of buttons, and then about a week later, Forward Health Group runs all the data and gives it to us in a very pretty dashboard. Occasionally, there are some problems with the data that my people have to get involved with, and I would prefer not to have that happen. The structured documents, like hemoglobin A1c tests, blood pressure measurements, pap smears, and so on, seem to report very accurately and effectively. I think our problems aren’t with the reporting; they are with the system we have and our lack of structured data. Right now Forward Health Group PopulationManager® works very effectively. There are a couple of flaws in the system, like with colorectal cancer screenings, for example. If the data isn’t a structured element, it doesn’t come across. That is the problem with all these EMRs. If a colonoscopy is done by someone else, then

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we have a scanned document, and that is not structured. We are trying to figure out a workaround for that. Health Catalyst Right now we are aggregating data from the EMR and the practice management system. NextGen uses the same database for both systems, but the tables are very distinct. The plan is to bring in our surgery system data, the data from our lab and radiology information systems, the claims data from the Medicare Shared Savings Program in our ACO, and the information in our HR and materials management systems. Most of the source systems for our practice will dump in data and then join. Healthagen HDMS DART is good for aggregating data. It takes in claims from different vendors and aggregates all that data. We send HDMS 40 different files, and they are able to deliver a final product that is pretty good. i2i Systems i2i Systems does a great job. They actually focus a lot on what they call their clinical data integrator, which allows us to map fields from whatever source we want into i2iTracks. i2i Systems does a pretty good job of harmonizing all of the disparate sources, and then they have created some additional custom data-integrator tools that allow us to bring things that are otherwise outside the normal, canned interfaces into the environment as well. We have a robust HIE. It is a great resource, and all of our health centers are a part of that. We are not aggregating data from it, but we can look data up in a few clicks. Right now, health centers are getting reports from each payer. They get a set of reports from the Medicare ACO, BCBS, or others. The HIE is a little hard to deal with because it is fragmented. It is more of an enterprise product made of multiple EMRs. In that sense, i2iTracks seems to be effective. Kryptiq Kryptiq has very excellent knowledge of the GE Centricity data structure. That is why the data aggregation is so good. The data mostly just comes from the EMR. The EMR is a central repository, and all the other systems, like the portal, are connected to the EMR. These other systems don't have any direct communication with CareManager. Everything communicates through the EMR.

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The original idea was to aggregate data from another product, but we were never able to do that. McKesson Data aggregation has been a huge pain, and the McKesson team is not the strong guide we needed for this process. Data aggregation has been a lot of work, and my team has been working hard to get it right. Having the physician offices send hundreds of files through a file transfer has been challenging. McKesson gave us boots on the ground to go into the practices and help set up the technical transfer. They have provided us with great customer support. The challenge is that if there is a tiny change at the clinic level, we suddenly can't get any files transferred. We have had an ongoing challenge to ensure files are getting transmitted from the practices accurately and consistently. We need a way to proactively monitor whether or not we are getting the files we expect to get. I think McKesson has been willing to work with us to figure out how to get data out of some of these EMRs that really werenâ&#x20AC;&#x2122;t built for reporting and how to get it into their system consistently. They have been willing to work with all the labs to bring in lab data. I think they have just sort of taken that on as an obligation of theirs. They want to figure out how to get it done. They haven't just given us a cookie cutter and refused to change anything for us. I think McKesson has been willing to work with us to figure out how to get data out of some of these EMRs that really werenâ&#x20AC;&#x2122;t built for reporting and how to get it into their system consistently. They have been willing to work with all the labs to bring in lab data. I think they have just sort of taken that on as an obligation of theirs. They want to figure out how to get it done. They haven't just given us a cookie cutter and refused to change anything for us. It is a challenge when a vendor has a particular process or a particular mechanism with very little flexibility. McKesson Population Manager feels like two separate tools sometimes. It has a risk manager and a population manager system, and they are two entirely separate systems. So whenever we feed data into those systems, it is literally two separate processes. For example, if I have a claims extract from a third-party administrator, I have to send it in through two separate processes, and that drives me crazy. McKesson Risk Manager has done a pretty good job. It has done what McKesson said it would do. McKesson Risk Manager is good at data aggregation. I am not going to say they are fantastic at it, but any vendor that is attempting to take feeds from a diverse group of Population Health Performance 2014 I 163

sources is going to find that very challenging. So I can’t beat McKesson up too much. We have a very complex model; they have a pretty daunting task. McKesson is working through the issues, and I give them a lot of credit for partnering with us and trying to work through all of this. The overall product gives us a significant ability to do data aggregation, but it also takes a significant amount of our own resources to do that. McKesson has some key end reports that are nice but not exactly what we need, so we have a lot of reports that we generate with our own analytics people going through the back door. From a registry standpoint, the data aggregation for the front-door reports is not as much a part of it. Data aggregation works on more of a patient-by-patient basis than a population basis. Using McKesson Risk Manager is so painful, and it takes so long to get any data into the tool. We missed so many opportunities just waiting for it to get implemented. Medecision The product is new to us, so I think some weaknesses might be the users’ faults at this point. I haven’t been able to make that final determination, so I want to be fair. Part of it could be the product’s newness to my team. It is one of those products for me that just by playing around with it, I can figure most of it out myself without even having to look at documentation. It is very intuitive. Weaknesses at this point are probably more on us as users than on the application. I think we are still trying to figure out all the things we can really do with it. We use ColdLight Neuron, and it has been great. All of the heavy lifting is done by Neuron. Neuron gives each patient a level and presents lists of patients separated by level to Medecision Aerial for Population Health Management. Optum Optum does a good job of pulling the data together from several different sources. Optum does a good job. They have a team that helps normalize the achievement data. They basically take the grunt work from us. They are really trying to do the lab components, the flow sheets, and some similar concepts that they group together, especially the implementation. I thought Optum did a good job with normalizing data from different sources and different fields, not just from our system but also from fact files from the hospital. Optum would pick the data up and put it in. Optum has done a very good job with data aggregation. Humedica is a good product. We haven’t had any major problems getting it up. The users like it. They are looking forward to being able to use the enterprise version of Optum One. From the ambulatory perspective, they are very satisfied customers.

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Optum has listened really well to people in the ambulatory world about ambulatory products. Optum’s language is right. Everything seems to be pretty well normalized. We have not had any issues with spurious data. Optum seems to clean things up. We occasionally run into instances where Optum misses something. For example, a blood test was checked somewhere, but it came up in their list as a gap. That is extremely rare. Optum also benchmarks data against a bunch of their clients. We can slice and dice that a bunch of different ways and compare ourselves to academic centers, nonacademic centers, big systems, little systems, regional systems, or even the whole country. It is really nice to be able to do that benchmarking. That ability is not exactly normalizing the data, but it is really a helpful feature of Optum’s system. Optum is great at data aggregation. I just wish they could do it more in real time. The data is accurate. Optum pulls our data on a daily basis, but we get refresh data on a monthly basis from our Epic data tables. Right now, our providers are operating three instances of Epic, and Optum is able to pull all of our data into one source and have it still be accurate. So we aren't stepping on each other’s toes. Sometimes there are discrepancies, but Optum has a process for that. For example, this is a very minor discrepancy, but if a physician resides in more than one instance of Epic and is designated as an internal medicine specialist in one and as an infectious disease specialist in another, Optum has to go through a deciphering process to determine which specialty to display in their program. They have a logical method for doing that, and the data is aggregated and presented in what we consider to be an accurate way. What Optum has done here has been awesome. They have helped us realize how messy our data is. Phytel Based on the data we have given Phytel so far, I would give them a hesitant nine, with the caveat that I have only seen them across our entire platform so far. I am not sure yet how strong the data aggregation is; we are just getting into the deep functionality. I don't think Phytel Atmosphere is perfect, but it works pretty well for us. Phytel Atmosphere seems accurate, and it pulls all the information. I have not seen anything that leads me to believe it is not accurate. Phytel Atmosphere's ability to extract the data that already exists in the EHR is great. We use both our ambulatory EMR and practice management systems. That is kind of key. We don’t pull any information from Epic through Phytel. Our system is really centered on PCPs. We are not pulling in patient information. Population Health Performance 2014 I 165

Premier It seems that the accuracy is pretty solid. We don't have trust issues with the data, so it seems pretty reliable. The data Premier has been utilizing with Verisk Health has strictly been the claim data that we get from CMS. CMS is sending Premier and Verisk Health a direct file on our member attributions and claims files. In our own disease registry, we are pulling some hospital data, but we are not using it for our disease registry. Siemens CareXcell is a one-stop shop. It offers a single repository for everything we need. Valence Aggregating data is one of Valence's strong suits. But the one thing people need to understand is that Valenceâ&#x20AC;&#x2122;s approach around data aggregation is not a big-data approach. There are vendors that take the big-data approach and deal with both discrete and nondiscrete data elements. But Valance is very much about just discrete data, and they are still very good. They have a plethora of different data-integration capabilities around different types of data. Valence does data aggregation for everything, including claims data, billing data, and lab data. Valence VISION is excellent at aggregating data and looking at an overall view of how we are doing as an organization, but it is a little bit lacking in real-time data. How updated the data is depends on where the feed is coming from because different EMRs or different practice management systems feed in at different times. Some of them donâ&#x20AC;&#x2122;t have the ability to hit the system every day; some can only send data in once a month, for whatever reason. That creates lag time. Verisk Health I donâ&#x20AC;&#x2122;t think that I personally or my team has unleashed all of the capabilities yet. They are high. I think this is a great product. It is easy to use. Once the information Verisk Health has to show us is done and accurate, Verisk Health Medical Intelligence is great. It can show us all the way down to the individual provider what their utilization is and how many people are in and out of network on these different populations. Verisk Health Medical Intelligence has been very helpful as I sit with providers. We drill through and can map down to a person. It gives a nice visual of

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all the times patients were in the hospital, when they had outpatient visits, and how many scripts got filled. The data aggregation score will probably go up in the next month with more experience and effort. We are getting all of the claims data that Medicare gets. We get hospital data, laboratory data, and ER data from Verisk Health’s offices. Verisk Health gives us some pharmacy data, but claim that it is not comprehensive. Wellcentive All the data that comes in helps populate an overall picture of each patient’s health. We can see patients’ disease diagnoses, all their medications, and any tests and labs that have been ordered. Most providers contribute to the data, and that puts together the total picture to support estimates of the illness burden and true utilization cost of the patient. At a high level, Wellcentive is doing a very good job with data aggregation. For the care summary and report card, the system takes all the data from multiple sources, aggregates it, and puts it all together in a very usable format. We have used the summary report forever to manage patients; it has been very effective with year-over-year increases, our incentive return, and our quality scores. At this point we are still working on getting the aggregation process correct. We essentially have not completed that step at this point, so the data in our EMR is not accurately represented in Wellcentive. No matter where the data comes from, it looks the same to us. So I would say that Wellcentive does a pretty good job of normalizing it. We can’t tell whether it is claims data or lab data or data from somewhere else. There are always issues with interfaces, so we run into problems all the time with things that didn’t go over. Data transfers don’t flow smoothly. We use the Wellcentive Advance Outcomes Manager tool and the interfaces with it to pull together a really nice dashboard and various kinds of reports on patient-level data. Those reports are available on demand. People can set the system up to show them all the patients for a provider for a scheduled day and which patients on that list need what. Or we can run reports to find out where there are gaps in care and how specific providers are performing across all of their patients, across specific payers, or across all payers with regard to any of the measures we build. We are actually starting to capitalize on that ability and are reporting that information out across our organization.

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xG Health We go over the data every month. The data is pretty good, but there is a bit of a lag on getting it. I mean, we don't want to have a meeting in June with December's data. The next quarterâ&#x20AC;&#x2122;s data comes several months later. But once we get data, it is good. There are problems when we want more data about something else. We get a set group of data, but we also want data for flu shots, pneumonia, mammograms, colonoscopies, and other things. That is still a question, and it could take upwards of six months to get a response.

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Rate your PHM solution’s strength in risk stratification. Advisory Board Advisory Board works relatively well at measuring risk factors. For example, they will look at the risk factors for a patient and say that ultimately we will need to deal with the patient’s diabetes, but the diabetes is related to the fact that the patient is overweight. But we can only do one thing at a time, and weight is a hard thing to tackle right away. The patient has gotten into that problem after years and years of misuse. Some risk factors are interesting, particularly those of people in the healthcare industry. Just looking at the data for the number of people in the healthcare industry on antidepressants is an eye-opening experience. The risk factors are really very well defined. We can run the data and see that these people’s four highest usages are hypertension, diabetes, and anxiety. Crimson Population Risk Management takes the payer claims and processes them. The Milliman benchmarking and analytics platform enables us to do risk adjustments on a permember, per-month basis. We are also able to see metric and gap reports on quality measures. We can also track costs per episode so we can know the cost for a total episode of care, like for a knee replacement or a hysterectomy. We can see how much it costs when one doctor is in charge of that care versus another doctor, and which facilities the doctors go to. The big advantage with Crimson Population Risk Management is that it is claim based. We get all of our claims for our population. Crimson Care Management only pulls claims from facilities with which there is an HL7 feed. Crimson Population Risk Management is far more inclusive and offers much more meaningful data, to me. It is really robust. I like the system. And I can say it is easy to use because I taught myself how to use it. There are so many nuances in the source data that making adjustments to clear things up on Advisory Board’s side is a lot of effort. There needs to be a little bit more flexibility in the assessments that lead into the risk stratification. Allscripts Risk stratification is one of those projects we have in development. It is not live today. I am hoping to get this pilot going in the fall, and then we will make our decisions based on the pilot about how to move forward. athenahealth athenahealth has one good way to look at things, but that does not always give the whole story. We need to figure out how to take that perspective and find a better way to Population Health Performance 2014 I 169

do it. athenahealth does what they are supposed to, but we have to give them time. We have to decide whether their grouping and logic are identifying the right people. That will take a little trial and error. athenahealthâ&#x20AC;&#x2122;s tool is consistent with the health plans, and the reports make sense, but it would be better if it were an in-house tool. athenahealth is still trying to figure out how to stratify patient and population risk levels to make the software useful in more cases. It is simple enough to give a list of patients and their risk scores, but taking the next step and juxtaposing that with different populations, like showing us which of our diabetic patients are the highest risk, is something they are still working on. They are trying to make the system more useful for the folks in the practice, the care coordinators, and the care managers. CareEvolution Unify has excellent tools. We use CareEvolution for risk stratification, but I do believe they could do more for that. We are not using them in a widespread manner, like to risk stratify all of our outpatients for medication noncompliance or high risk of anything. We have algorithms with CareEvolution for the early detection of substance candidates and for frequent utilization of the ER. We also have a program tracking our top 100 high-risk patients so we can try to understand the medical needs of that group and how we might impact those. We are contracted with Evolent Health, who is really helping us build the population health infrastructure. But the clinically integrated network and our need for data and analytics drove us to CareEvolution, who was a natural fit because we used their longitudinal care record already. We basically had that on top of our prior electronic record. It aggregated data from the EMR and other data sources, and we could reach it through an accessible button in the electronic record, so we had an easier longitudinal view of the care and all the testing. So CareEvolution was a natural fit for us when it came time to do the registry part. My understanding is that their origins really were in HIE. And they have been able to develop their system based on our needs. So they have a really nice program for us. Cerner Cerner is feeding the registries. Conifer Health Solutions Conifer Health Solutions is excellent at this.

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I think Conifer Population Health Intelligence Platform is really strong with the claims information and the risk stratification. I think it isn't as strong when it comes to the quality reporting and some of the registries. We are focusing on employee health. We can download all of our health risk assessment and biometric information into Conifer Population Health Intelligence Platform and do risk stratification on that information. The other piece we are building out to enable us to segment our population is our community screening. We do a lot of blood pressure screenings. The Conifer system does a really good job with risk stratification. eClinicalWorks eClinicalWorks CCMR is an open box. There are no preset risk algorithms. It will automatically calculate each risk we tell it to and give a score. It is fairly simple to set the tolerance levels to start the patient at low, medium, or high risk, but there is nothing premade in the system. We assigned the questions and appropriate risk rates on our own. The engine just runs those for us. People have to create all of that the first time, and then it keeps running. I like the flexibility and that it is easy to use our logic to set everything up. The product is good for risk stratification. It is easy to find the reports and any information we need off of any certain population. The risk stratification in eClinicalWorks CCMR is very accurate because it is based on the Resource Utilization Bands and the Johns Hopkins predictive modeling algorithm. It allows us to identify the high-risk, rising-risk, and low-risk patients and get down to the claims level for each one. We focus on the sickest patients, and the high-risk ones are enrolled in interdisciplinary team conferences. The rising-risk patients are stratified by chronic disease condition or multiple disease conditions and become the focus of officebased nurse care managers. The risk stratification is a strong point. For every patient, we get the ACG risk score from Johns Hopkins. We can then do an average risk for each provider. We have a permember, per-month cost associated with each doctor. The ones that are high cost inevitably say they have the tougher patients, even if they do not. So we actually plot the average risk score versus cost. For the most part, it is a straight line. We do have a few providers that have fallen off the line, and those are the ones we need to look at. But our most expensive doctor actually does have the riskiest panel. He was correct. We thought he was just a whiner. So it is very useful to have that risk scoring. eClinicalWorks CCMR helps us do risk stratification and find people that are high risk so we can better manage their care. There are several ways we get people into care management. For one, they show up in the ER or are admitted into the hospital.

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We are actually getting ADT data from both hospitals. It is not integrated into CCMR yet, but it will be. We are getting a file from both hospitals, and our care managers work off of that. We get information on frequent fliers to the ER with our claims data from CMS and from some of our commercial contracts. Aetna, for example, does a very nice job there. There is one especially cool thing that I have not seen with anybody else. When my dashboard pulls data up and graphically shows me all of the patients and their risk parameters, I can just grab a group of them and send a note or an action on that group of patients back to the providers. Then that note will show up in those patientsâ&#x20AC;&#x2122; charts. There are accuracy issues. Epic I think that Epic has given us the tools to do what we need to do for risk stratification. We need to get those tools implemented and use them. I think Epicâ&#x20AC;&#x2122;s tools are good. Risk stratification is not available. The deep functionality needed is just not there yet. We are not doing as much risk stratification as we are aggregation and work-statistic reporting. We aren't using any Epic tools for risk stratification. We have flagged all of the ACO patients and published the reporting workbench, which is a component of Healthy Planet. We showcase that in the Epic context. We use our simpler in-house tools to stratify the ACO patients based on whatever claims data we have and whatever inpatient fact files we can get, and with the data in Epic, we give the patients a score and then flag them differently in Epic. Those flags basically tell us which patients are eligible for a highrisk clinic, and then we push the patients out to doctors. We use a combination of Healthy Planet and homegrown tools in order to do that risk stratification and follow-up. With Epic Healthy Planet, we are able to go in and get discrete data. For years we looked at claims, and now we can see how many of our diabetics are out of control with their A1c levels. We can see who is at a level greater than 8% and just get those people to come in. Evolent Evolent Health has been able to help us contract with the MSSP. That was a big step. We now have the opportunity to demonstrate that we can deliver added value across quality metrics, cost metrics, and patient satisfaction. It is way too early to know what the outcomes are. Those will happen over the next one to three years. We first have to get our foot in the door with the agreements. Then the outcomes that are associated with those agreements are going to be measured across quality, cost to the consumer, and 172 I Population Health Performance 2014

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patient satisfaction to the consumer. The outcomes related to those agreements are going to take years to fully understand and develop. Identifi needs a more refined algorithm to most appropriately capture those at the highest risk. We are only six months into using Identifi, but I think it is working fine for the population it is serving. Evolent Health Identifi is meeting expectations. I don’t want to say it hasn’t had any bumps, because Evolent Health is growing. They have a good service to offer, but I also think they are learning on the fly. I don’t think Identifi is quite a totally mature product. It is not without bumps, but we have worked through those, and I think it is working fine. Explorys Explorys is still working on the predictive part. The system’s ability to take data and then spit it back out as predictive reports and modeling is still a work in progress. I think Explorys will get there as they move into care management and patient engagement. They will figure out how to take the risk scores and present them to us as the patients that we need to be acting on. Explorys puts the risk stratification functionality into their platform, which is different from other vendors who allow the user to go and license that piece separately from a vendor like Verisk Health. We don’t have the risk stratification tool up yet, but Explorys does have it. We are just implementing it right now. We have looked at Explorys' risk model. Most risk models are proprietary. We are still in the beginning stages of looking at all of the vendors and understanding how risk affects our data and how we are going to operationalize it. Forward Health Group If variables are consistent, the PHQ-9 depression index is a really good way to rate where patients are at for depression and whether they are at higher risk for suicide. PopulationManager® does things I have never seen anything else do. I can actually select patients with a blood pressure above 140 and A1c above 9, and I can find all the patients who fit into that high-risk group. I can then select diabetes and hypertension, and the system will show me the 22 patients who meet all of the criteria and their insurers. I have never seen a product that works so quickly to allow me to aggregate high-risk patients.

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The dashboards sort the data by patient condition and by measure, and then they tell us for each measure which patients qualified and which didn’t. The dashboards are good, and they target specific patients with needs. Health Catalyst Our medication therapy management pharmacist is doing risk stratification with the diabetes patients, but I don't have enough experience with that function to rate it. Our plan is to be able to get a cost for every little thing we do right down to each encounter so we can see what is going on from the business end. Concerning quality performance, ACO measures, and insurance company requirements, we want to be able to see where the high-utilization, high-risk patients are. Health Catalyst’s risk module uses three models, which are the Charlson/Deyo model, the Elixhauser model, and a pediatric model, to do risk scoring and find people with comorbidities. We actually know the number of patients with comorbidities. We identified that number after we did the first data load and ran the models. i2i Systems i2i Systems doesn't really purport to do risk stratification at this point. They do have some very modest acuity waiting and age and gender waiting algorithms, but they don’t really have anything that counts as full-on risk stratification. People can customize the system to their own way of looking at things. It is pretty easy to do risk stratification by diagnosis, and we do have an ACO and look at a couple of key diagnoses like COPD or CHF. We have used i2iTracks for that. But we have other reports that identify those diagnoses from claims data we get from Medicare. There is always room for improvement, but i2iTracks does a great job with the tracking we do for population health. We give providers a patient-summary sheet straight out of i2iTracks for patient visits. The summary easily gives the providers a very clear view of our protocols, what is due, what is not due, what needs to be done, and what has been missed. The tracking allows us to follow everything, from our referrals to labs and anything else we set up. We can test and set up any tracking measures we want. I think i2iTracks is a great product. Kryptiq I did hear feedback that the product was sometimes unclear. It didn’t clearly notify the clinicians of the risk categories. So they had to go in and build the logic for identifying patients in risk categories. That wasn’t automatic. The module itself is designed specifically for COPD. We expected the system to have some knowledge about the risk factors related to COPD, but it was really up to the clinicians to define those.

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It would be better if Kryptiq could provide more filters. Kryptiq does a good job with risk stratification. CareManager is pretty good. I think it is magic. It is very cool. McKesson McKesson Population Manager isn't very strong on the clinical side for risk stratification. Once users are through all the pain of implementation and have data in the McKesson Risk Manager tool, it does help aggregate and normalize the data so users can manage their populations. The tool is extremely powerful, and we have run across people who have been using it for three years and have only scratched the surface of what it can do. At the same time, there are some obvious things that it should do but can't do natively. For example, McKesson Risk Manager requires custom queries against the data warehouse, so for the attribution report, it attributes, but it doesn’t give users a report. It doesn’t generate anything. We are limited to a few quality metrics, so the system cannot be used by all the physicians, and that was our intent. Medecision All of the data is running through ColdLight Neuron. Neuron comes up with smart predictions and passes those onto Medecision Aerial for Population Health Management so that the care managers can act on it. We are not using risk stratification. We haven’t fully used the product in this area, so I think at this point, this question wouldn’t apply to us. NextGen NextGen Population Health doesn't have risk stratification currently. We feel we can determine our sickest patients on our own. We utilized the American Academy of Family Practice risk logic and built that into NextGen ourselves. It supports our risk-stratification mechanism. We have practices that have 100% risk stratified their patient population.

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Optum I might give Optum a seven out of nine on risk stratification. I think theirs is as good as anybodyâ&#x20AC;&#x2122;s, but I think risk stratification is a little overhyped in terms of what users can truly predict and the value of that prediction. I think Optum has done a reasonable job with the Charlson scores. There is still more Optum needs to do from the Humedica side. I know the Optum side has some stronger components. Impact Pro is a really good product. We have had a lot of good experiences with it. It takes a while to get all the anomalies worked out in terms of the claims data. It was a heavy lift to get that sorted out properly, but after that was done, we were able to have good success using Impact Pro. The thing we like about it is that it is very powerful and flexible in terms of our ability to define our own patient cohorts and work any anomalies into that. It is very easy to create a very targeted, discrete population. Optum does the Charlson score and Medicare RCC score. They have done some cool population health measurements for us. They identified nine cohorts of patients right out of the box, and I could immediately start asking questions about whether patients were on the right medications and getting the right physiological parameters, so that was very powerful. Optum has a really nice tool that does predictive analytics. We can go by cohort, and I can drill down to the data that says so-and-so is going to be admitted within the next six months because of the following things that are going on with him or her, and I can point that out to physicians. A lot of times the tool depends on the percentage of risk stratification. Our practicing physicians feel that the risk stratification is fairly accurate. We have chosen to further stratify to make sure we are paying attention to the patients who will need to be readmitted to the hospital. So we definitely use the reports to help with our risk stratification, but we add additional criteria to them. I think the tool is as good as any other out there, if not better. Our risk stratification needs to be in real time since I am always behind. The biggest thing we have found to be helpful has been Optumâ&#x20AC;&#x2122;s risk predictor of future hospitalization or future ER use across four or five different categories. Optum divides their efforts into what they call cohorts, which are chronic conditions that are best treated in the ambulatory context. We use Optum Population Analytics to extract the top 5% of the highest-risk patients. Then we focus our clinical conferences on that top 5%. We engage our care guides, a community health worker with a panel of patients to manage, and the primary care providers in the top 5% and 10% of the riskiness of each of those

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cohorts. Figuring out who to engage is probably the most extensive way that we use the product. Using Optum Population Analytics and Crimson Population Risk Management, we identify high-risk patients. We have done a pretty good job of identifying them, but we need to do a better job at figuring out what we are going to do with them. Optum doesn’t give us good information about high-risk cohorts. We need to look at a population and tell which patients, no matter what problems they have, are most likely going to get admitted in the next year or three months or some other period of time. Optum is still too modular. I have given them that feedback, and I think they are getting better. Optum has a new product where they pull together a population-analytics product, a claims-based analytics product, and a care-management product to form a whole population management suite. I think the model was good and the vision is good, but it is just really early. Optum is modular, but they have been very receptive. When we first started talking to them, we said they needed a Charlson score, so they put in a Charlson score. Then later we said that was a little passé and we needed a different kind of score, so they put that in there. They have been very responsive. The problem is that Optum is not as good across the entire population. They have been very disease specific. Phytel One thing worth noting is that Phytel typically doesn’t do the claims analytics. They have partnered with Verisk Health to do that. Verisk Health has their own solution for that purpose. The Verisk system produces five types of high-risk flags for things like risk of admission, risk of ED visit, and risk of high cost, and then those flags can be taken over into the Phytel suite with the medical record data. We can look at those patients who have high A1c or LDL levels and a high probably of future admission. Phytel Atmosphere shows where the risks and care gaps are. They are literally right there in front of our faces. What we do with the information is up to us, but it is right there. There is an interesting story with risk stratification. One of Phytel's modules, Coordinate, is used by our care coordinators. Its purpose is to take all of the data and filter it or stratify it by provider, clinic, or disease. It has a tool that is used every day by all of the care coordinators to allow us to view in a dashboard format those patients that are the sickest of the sick. That way the care coordinators can go after the patients. So Coordinate does that, and it does it great. We have been using the heck out of it. The next level is to get to real predictive analytics and that more advanced layer. Phytel has partnered with a company called Verisk Health, who is bolting onto Phytel, consuming all of the Phytel data that we are giving them, and adding in claims data from the payers so that they have all the claims data from the payers that are participating Population Health Performance 2014 I 177

with us. That piece is actually in the works, and we expect to have that rolling out by the end of the year. We use Phytel for patient stratification based on claims and clinical data within our systems, but that will go to a whole new level once the Verisk Health piece is bolted on and we are getting that very sophisticated behind-the-scenes logic to really help us identify the patients that need to be dealt with. We are talking to Phytel, but their solution is still not completely able to have a good risk stratification tool. We are using one of Phytel’s products so that we can do risk stratification at some of our practices. We have to manually identify those patients and risk stratifying them ourselves. We don’t have a risk-stratification tool built into Phytel. We do our own risk stratification. Phytel is working on risk stratification right now. We have been doing some additional processes with them and trying to build in risk stratification, but right now, we risk stratify our own patients. Phytel captures the information we need, so we can see it in our care-coordination tools, but we still do our own risk stratification. They have a partnership with Verisk, but we haven’t considered getting that platform. Part of that is because of the cost for claims data. We aren’t ready to spend the additional money for that piece. We have received strong feedback from our clinicians, our CMO, and different users in the market. Premier It seems difficult to get the definitions of the risk scores and determine how they were ascertained. Siemens The risk-stratification tool is not yet 100% in place. Some improvements are still needed, but we are using the tool the best we can in its current state. The tool offers a robust algorithm in terms of risk assignment, and it is more detailed than the LACE assessment tool being used in our hospitals. Valence I have reports that let us do risk stratification on a patient population, but some of those are more limiting than others. Valence is working on that. In the first quarter of next year, I believe there is going to be even more opportunity to look at that data from different perspectives. I can look by disease management population, but I would like to look at the data at different levels. VISION will get there.

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We used Valence’s risk models and financial solution to identify and target the highestrisk and highest-cost patients. Valence’s risk model is both external and internal. It allows members to use things like the CDPS and Optum’s Episode Treatment Groups. The internal models are in development but are to include predictive capabilities such as the likelihood of admission, readmission, or an ED event so that we can target specific interventions. Verisk Health I would give Verisk Health an eight for risk stratification. Their models are very, very good. The problem is that they are just based on claims data. Risk stratification is a Verisk Health strength. Even though they do claims only, we keep them around to help us understand where the patient risk levels are. Risk stratification is one of Verisk Health’s main strengths. Verisk Health has their relative risk score using different models for different purposes. They explain very clearly what each model is supposed to do. I stack them and look at the relative risk score versus the cost efficiency index and how the care data relates to compliance with the quality measures. I have all that data right at my fingertips. The risk stratification seems pretty good because Verisk Health seems to have some pretty good algorithms for creating risk scoring. There are 50 different risk models, and we can choose 4. We use a Verisk Health system as well as an Optum system for risk stratification. What we see in the tool for risk stratification is that it will take groups of patients or individual patients, and for every individual patient, it will tell us predictive risk scores based on some intuitive things that have been built into the program as well as a large database. It tells us about the patient’s condition and tells us the patient’s chances of having an ED visit in the next 30 days, a readmission, or an admission. It also analyzes the patient’s clinical data to tell us on a scale whether that patient has gaps in care. The higher the score, the more gaps the patient has, and that is where we focus. We need to look at these care gaps and reduce those to both reduce our medical spending and keep that patient as healthy as possible. Wellcentive The Johns Hopkins risk scoring is the most valuable piece we have been using. We are not fully live with risk stratification. We are working toward turning this piece on fully. We can use the tool as is, but we can’t get a complete picture because we just have

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the EMR and lab data so we might be missing pieces. Once we get the claims data in, we can get a better picture. We don't really use risk stratification at this time. We aren't that deep into the product yet. We will be jumping into risk very soon. That is one reason we are looking into external sources of data. We want to get beyond our organization’s information. xG Health I don’t have an absolute. For comparison, xG Health says that our patients are 30% sicker than the average population, which sounds about right because of what our population is and the environment we are in. I think that is correct. But I don’t know whether or not that score should be 30% or 26%–29%. But I would say xG Health is pretty strong.

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Rate your PHM solution’s strength in care coordination. Advisory Board In our care management software, we actually look at patient risk scores from Crimson Population Risk Management as well as other facts, like whether the patient has good family support and his or her economic situation, to come up with a risk score for the patient. I think the key is having a system that helps the care managers understand what they need to do with each individual patient to help the patients stay compliant with their care plans. The care managers need a place to document their work. They need to know how to scale up their efficiency as the organization goes from 30,000 lives to 300,000 lives in two years. The most precious thing any worker has is time. They need to know where to focus their time to get the best bang for the buck. Maybe they should focus on the transitions, like when somebody gets out of the hospital and gets tied up with the PCP. Maybe they should look at medication lists to make sure patients are not on drugs they shouldn’t be on for their ages. Maybe they should create a strong diseasemanagement outreach program for diabetes. Those are the tough questions people have to ask when ramping up care management teams. The last six months have been a little rough with Crimson Care Management. Our biggest limitation is the reporting. We can put all of our information in it. We can set up an HL7 feed from a facility to prepopulate a bunch of things, and that is great. We can use Crimson Care Management as part of the workflow and alert care managers. That is all awesome. The limitation in reporting comes from the gaps in the record because of the number of data fields that aren’t mandatory. There isn’t a good workflow for our care managers. Since we can’t mandate which fields they have to enter data into, it is hard to make sure we are capturing everything we need. Not having information in all fields makes the reporting a little rough. We have to build a custom report anytime we want to pull something out, and that can take a while. There are still tons of variables we have to filter for, and the process is clunky. We will use Crimson Population Risk Management to fill in the gaps of our other products. Allscripts From an HIE perspective, our care coordination is done by dbMotion because they are part of Allscripts, but they are not using any of Allscripts’ care coordination applications. There are no duplicates because the system brings up aggregated information and coordinates care using its knowledge of tests and procedures that have already been done. The system coordinates activities through the EHR agent so that both sides know the other part of the patient’s care. We will be using the Allscripts products to help the care managers and senior leaders really understand and manage the continuity of care for patients. As we aggregate more Population Health Performance 2014 I 181

data, the goal is to make intelligent decisions about how to position ourselves and how to negotiate with our payers. The Allscripts products are very young, and although we were promised a lot, we havenâ&#x20AC;&#x2122;t been able to get a lot of functionality out of other systems. Allscripts is trying to be all things all at once. They are becoming diluted, their resources are stretched, and they canâ&#x20AC;&#x2122;t focus on any one product that will provide solid value. They are getting overly stretched. We are nine months into the implementation and still trying to get the product to work. The product is just not ready. Allscripts says they will do better, but we have considered just throwing it out. One of the mistakes we made is that we have stakeholders that have fallen in love with Allscripts. athenahealth We havenâ&#x20AC;&#x2122;t been using athenahealth for care coordination. We are using an Allscripts tool for that, and we are evaluating whether we should make the move to athenahealth. CareEvolution Evolent Health will help us with care coordination. Their Identifi program is a care coordination platform. In our view, Epic has the ability to do care coordination, but we would have to sort of jury-rig their system a little bit. We would have to develop template notes or something that could be pulled up by a variety of folks in the system. This Identifi platform is an across-the-continuum kind of care platform, so there are basically different data sets going in. For example, an issue with claims data may bring up a question, and the next question about the patient could be about a clinical lab condition. Identifi brings everything together in one common platform, and then the work can be distributed to the appropriate people and things like that. Conifer Health Solutions Conifer does a decent job of helping our care coordinators communicate and work with patients to increase positive clinical outcomes. Conifer Population Health Intelligence Platform is not a complicated system. It is very user friendly. We can send alerts to the coordination teams within the community to tell them where we need them to go. Ideally, we will have it so that the coordination teams can navigate patients back to our nurses here, and then we will have the transition-care nurses see these patients. That would close the loop because we would have a central location in which to track the clinical notes of each of the providers who touches a patient. The system does a really good job of reaching out to everyone when there is an alert for a patient and of documenting that alert. We use it with our wellness coaches, nurses, and doctors.

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We are still building care coordination, but Conifer Population Health Intelligence Platform is a working tool. eClinicalWorks eClinicalWorks CCMR is not good for case management, care coordination, and utilization management. We have to do all of that by ourselves. CCMR is good for people who want a simple, bare-bones structure to create their own questions and risk scores. It works well but is only for people who have simple needs and who can create the architecture inside CCMR by themselves. If they cannot do that, CCMR will do nothing for them. For a regular group practice, CCMR is of much less value. It is good for larger organizations that know how to do the performance rates and workflow. I like that eClinicalWorks CCMR is good with care coordination. It is easy to track and test things that need to be done annually like mammograms and things like that. It is just really easy to track and keep in the patient’s chart. There is some work to do with care coordination. eClinicalWorks needs more integration. The analytics tools need to be improved as well. We had to design our own care-coordination templates. Nothing comes out of the box. Epic Epic could improve their usability, but I think that need will be addressed in the new upgrade. There are limitations in what we can bring into the registry. The documentation tools in v.12 fell a little bit short. I think we will mostly just need to build out more clinical content. Epic plays a big role with our care coordinators. We follow the really sick patients. We do house visits and do all sorts of annual assessments. The patients are followed very closely, and the provider may be seeing them every three months depending on the acuity. The care coordinators reach out to the patients very frequently. We get most of our Epic data once a month, and it is all coordinated and integrated. Healthy Planet's care coordination piece does most of what is expected but is cumbersome to use. Humedica and Optum clearly have a lot more analytics and data intelligence than Epic does. But Epic’s big advantage is the workflow. The physicians don’t have to go to another system or do anything else. We decided to implement pieces of Healthy Planet; it gives us lists of high-risk patients, so we can do some outreach and document that in the chart. With the analytics part, we are going to start small and give Epic some time to create some out-of-the-box reporting.

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We are documenting everything that we are doing, which I think is hugely valuable. We haven't used the care-coordination tools in Healthy Planet yet. We are looking at those. We have built out some of our own tools, and those are getting us by for now. The tools we built ourselves were built within the Epic platform. We use them to automatically send out material to patients based on their information. We have also worked with the Social Security administration and done some work around transitions of care. Evolent Evolent Health is basically handling the care coordination. They coordinate with clinicians on the care delivery to patients that are at the top of the risk stratification results. Identifi is not very intuitive. It doesn't think at all outside of the box. It is very basic. Apparently we are supposed to be getting an upgraded model. Explorys Explorys does an excellent job of helping us understand gaps in care. They really help us coordinate care. Initially, we expected physicians to utilize the dashboards in Explorys Platform &amp; EPM Suite to assess how they were doing with the ACO measures and assess gaps in care. We discovered that physicians only want to log into the EMR and not another clinical tool, so we had to reevaluate that implementation. We do have the dashboards, and some physicians may use them if their clinic is falling short of some ACO measurements to target patients that need certain screenings or tests to get those numbers back in check. We also use Explorys in the clinics to research incoming patients on the schedule for gaps in their care. We are using Explorys to coordinate care only for individual incoming patients, so we aren't using it so much for population health management. We are using the system more reactively than we would like because we only research patients if they have an appointment instead of proactively looking for people who might need an appointment. Our care-coordination efforts are very early. We had a very small pilot last year. We are coming from an Epic shop. Explorys EPM: Explore is good. It isn’t perfect because I don’t like that people have to go in and out of two different systems. I don’t want to have information in Explorys EPM: Explore that doesn’t get into the medical record.

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Forward Health Group I don’t think that Forward Health Group has a care-coordination offering. It would be really good to have one. The one thing I would ask of Forward Health Group is to add that functionality if they don’t already have it. It is easy for the clinicians to get around in PopulationManager®. It is user friendly and makes it possible for clinicians to access the data. PopulationManager® makes sense to clinicians. They can display things in visual form that is easy for a patient to see. PopulationManager® doesn’t monitor care coordination, but it allows us to understand who needs care coordination. This product gives me information about which patients fall in certain high-risk categories. I can see who in that group has not been in the last three months, and that is care coordination. So PopulationManager® allows us to identify the high-risk patients who have to work with a care coordinator. Now PopulationManager® doesn’t tell me whether a patient has gone out and completed a colonoscopy, but the key thing is to find the high-risk patients that the coordinator needs to work with. The clinicians are using PopulationManager® to see where the patients are at with their drug and alcohol use and risk and protection from use. Those are all broken out and reviewed with the client. The tools we are using and how PopulationManager® shows those results over time are really helpful in assessing where a client is in specific ways. Health Catalyst Our hope is that alongside our care managers, we will be able to tie the data in and reach out to people before they get sick. Healthagen We use ActiveHealth ActiveAdvice to reach out to patients so we can understand what their goals are. It is much more than just a tool that helps us identify patients. It also helps us manage them once we have identified them. i2i Systems I think that i2i Systems has other solutions that do better with care coordination, but i2iTracks is more of a disease registry and an outreach tool than it is a care-coordination, care-planning repository. Kryptiq We are just trying to get used to using the data, and it seems that sometimes there are a couple of issues with the next appointment versus last appointment and so forth. One of Population Health Performance 2014 I 185

the big issues is that our practices use midlevel providers that also see the patients, but their next appointments aren’t showing up in the system. So sometimes the patient management isn’t clear. We are using the system for exam and test reminders, especially for chronic patients. We also use the previsit planning. We plan to use the system for patient outreach in the future. We really had to figure out workarounds. For us, the whole idea behind Kryptiq CareManager was to coordinate care with the hospital, but that was never really successful because we weren’t able to aggregate the patients’ data. Lumeris When we build risk-based systems, we are looking at guidelines and building campaigns for wellness. McKesson Care coordination is an initiative we are interested in. We are hoping that the McKesson product can help us, but we are still having issues with the population management side having actionable data. I wouldn’t say we are advanced users yet, but we are using McKesson Risk Manager today to support care management and identify high-risk patients, patients who have been readmitted or are candidates for readmission, emergency frequent flyers, and so on. We feel pretty confident that as our maturity along the population management spectrum grows and we keep ratcheting up quality indicators and cost management that the tool is going to be able to support us in our growth. We can’t just jump to that nirvana state of measuring quality and cost without going through a bit of a journey with our physician population. We have definitely started on that journey, and McKesson Risk Manager is supporting us well so far. McKesson could improve the population health product a lot so that it guided our caregivers when they are working with patients. The tools don't really help improve overall patient care. McKesson does not play a role in care coordination. They do what we call light patient touches. Our care managers or clinicians who are focused on bringing in patients to close gaps in care can create customized-form letter templates and things like that for identifying that they called a patient or sent a letter to a patient to get that person to come in. For patients who really need to be more aggressively managed, the care managers leverage technology called Click4Care, which is now offered by HealthEdge. It helps them create those more-aggressive plan-of-care actions, like follow-up calls. The

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population health tool set that McKesson has does not have very robust, defined care management. It really is more for registry management. We are developing a care management module. The system can tee up gaps in care, but that is about all it can do. It doesn't really have any of the workflow or care coordination pieces to it. We are not doing much right now within the PHO. The care coordination was focused on chronic diseases, and we had explored the use of the tool to create outreach to patients. The tool certainly has the capability to tell that a patient hasn’t come in or needs to have a visit or get a lab test done. I would say we didn’t find any obstacle to using the tool except in the practices themselves. We are just not there culturally. But I don’t think that was a problem with the tool. Now the focus has shifted away from the PHO, so for the last year I would say we haven't been going down that care coordination path at all within the PHO. We are not doing much right now within the PHO. The care coordination was focused on chronic diseases, and we had explored the use of the tool to create outreach to patients. The tool certainly has the capability to tell that a patient hasn’t come in or needs to have a visit or get a lab test done. I would say we didn’t find any obstacle to using the tool except in the practices themselves. We are just not there culturally. But I don’t think that was a problem with the tool. Now the focus has shifted away from the PHO, so for the last year I would say we haven't been going down that care coordination path at all within the PHO. We use some of the data in McKesson Population Manager as a piece of the puzzle, but we need an additional module for care coordination. Medecision Because Medecision is asking whether we can do care coordination, I would rank them very highly on that metric. Medecision does a good job in helping with care coordination. I do think that the population health market is a new market for them. It means a new workflow and a new business process. They don’t manage things like lists the way an EMR needs to manage them, so they are more transactional then they are longitudinal. That doesn’t really work for the sort of care management that our people are doing. Medecision is only as good as the physicians and staff who use it, but from what I know and what I have seen and from our regular meetings, I would give it high marks. NextGen Care coordination is part of NextGen and part of the EMR. I would give that part of the product a five because it is still being developed.

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Our care coordinators love the dashboard and the drop-down area. They look at that and within seconds, they can see everything about where a patient stands. Looking at the dashboard is a quick reference, as opposed to clicking through the patient record to look at individual files. Users can tell immediately whether a patient has had a mammography or colonoscopy, so that saves them time. We are not using NextGen because they didn't have what we needed. We have built our own tool on the platform. We have almost everything we need with our platform. Optum At first we started looking at 80% to 100% of higher-risk patients. The doctors were all aware of those patients and said most of them are on care coordination, and if they weren’t, the doctors put them on care coordination. When we drilled down into closer detail, we identified areas where we needed to pay attention and which patients we needed to monitor closely. That is what we got out of Optum. For care management, Optum Population Analytics puts out a graph by the patient that can be exported to Excel and given back to the customer for patient outreach. Optum Population Analytics does not really work seamlessly with our EMR. I could use the data in an Excel spreadsheet and talk to the patients, but I am trying to get everybody to present the data in the Sunrise products because that is what the doctors use. We have actually not used the care coordination modules. We still have our own tools that we have had for a long time. We have our own proprietary software for care coordination. As far as I know, we haven’t switched over to anybody else’s product because we have been doing this a long time and have developed our own. We use Crimson Population Risk Management. Phytel I think some things are missing from Phytel in regard to care coordination. There are some calendar functions that we think would be really helpful, for example. Phytel is working on those components. We have had a lot of input into where they are headed, and we have given Phytel a lot of feedback. Phytel is building these new components, but we aren’t using them right now. Once Phytel makes some additional changes, the product will be exceptional. Phytel Atmosphere gives all the necessary information to be able to effectively coordinate care for the patients.

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Phytel has other modules called Insight and Coordinate, so they can drill into not just the billing and scheduling data but also the EMR data. We make our clinical data accessible to them, and then we can start drilling down even more precisely. So instead of having all diabetics come in every 6 months, we can look at their A1c levels and have those who are above a certain threshold come in every 30 days instead. It allows us to laser in on patients. We can do 3D and 4D graphics that show us things as specific as all the diabetic patients who also have hypertension and who have an A1c test over a certain number, an LDL over a certain number, and a BMI over a certain number. We can see all of that displayed on a scattergram and then go contact all the patients in the upper right-hand quadrant. We can give that information to our care managers, RNs, and health coaches so they can do house visits, check the patients’ food pantries, check their medications, make sure they have an appointment scheduled, and make sure they are fully educated. The ones in the lower left-hand corner are doing fine. We don’t want to ignore those patients, but they don’t need as much oversight. We might just send out a monthly coaching tip via text message. We can run campaigns on the data we get from Insight and Coordinate, and those systems are instrumental to our ACO initiatives because the 80/20 rule applies in population health; 20% of patients drive 80% of the costs. We need to know who that 20% is. So the Phytel tool is not really designed for clinicians like physicians to use like an in-theirface dashboard in real time. It is really more of a care coordinator effective tool, people whose job it is to sit there and scrape through the patients that need to be seen that are not on the schedule. So for that, Atmosphere does a really good job. It is currently not a tool I would give to doctors so they can see a snapshot of their population. Atmosphere could do that, but it is not catered for that. So for the teams that use it for care coordination and all of that, it is just fine. It is just not a physician tool. The information is right there in Phytel Atmosphere, so we can coordinate patients’ care. We can see that patients are due for their mammogram or their pap smear or whatever else they need. The Phytel Transition product is basically for every hospital discharge or a patient that hits our ER. It is an automated follow-up that asks a series of five or six questions to inform us how to escalate a particular patient’s needs. We can find out whether the patient needs to go to a care coordinator, whether the patient’s pain is worse than the day he or she was discharged, whether the patient is having trouble getting medication, and those types of things. We are not implementing that product here, or we at least haven’t to date. We are satisfied with Phytel Atmosphere because it allows patients to schedule appointments for their chronic conditions. We are able to better prepare for the visit knowing what patients’ needs really are. We have not used the product for care coordination yet; we just started to roll that out, and we have to do that in partnership with the hospitals. The problem with that is we Population Health Performance 2014 I 189

have 3,600 affiliate physicians and 2,000 who are employed at our hospitals. From a political standpoint, our hospitals are hesitant to use the product for care coordination out of the acute care setting for fear of alienating our 3,600 affiliate physicians. We don't want to give the impression that we are favoring our 2,000 employees. So we have not used a lot of Phytel’s care-coordination tools yet. However, from the standpoint of chronic disease management, I would give Phytel a nine. That has been phenomenal. Siemens CareXcell allows communication between nurses and provides a way for nurses to offer input on patient care. The physicians also have a tool, but they are not using it yet. Valence My wish is that information were pushed to the providers so they didn’t have to retrieve it themselves. That is limiting. But I know that an HIE would probably help in that area. Verisk Health Care coordination is an interesting issue. We hired a separate group, who I personally think we overpaid for. I think Verisk Health is going to help us to see whether or not we are getting what we paid for with this other group because they have a care gap index that tells how well each practice group, and even each individual, is complying with the quality measures. Once we do the risk stratification that facilitates reaching out to that patient, there is no task list in Verisk Health Medical Intelligence. We need a population management casecoordination platform or something to use for complex case managers that are helping the primary care doctors take care of these complex patients. The care coordinators need to do a risk assessment to keep track of that. They need to contact the high-risk patients periodically. They need to make sure the patients are adherent. But to do that we need a tickler file list, and we don’t have that in Verisk Health Medical Intelligence, so we are sort of cobbling some things together because we are trying to make the best decisions we can on our EMR strategy. Verisk Health does do gaps in care, but because it is claims data, it is a month old. People come and go, and we can’t figure why they went in and out of the population. That data is a little harder than the clinical data. Verisk Health provides us data to share with our care coordinators and to guide their actions. We are using Verisk. We segment out the highest-risk patients based on some of the predictive modeling that is in the system. Those patients then make up our care manager’s worklist. We look at probably the top 10% of our patients really needing 190 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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intensive care management and assign case managers to them. Then we take that middle population, which is the 60%â&#x20AC;&#x201C;90%, and really do outreach and disease management with those. So we use the tool to really design our care management workflows. Wellcentive Our care coordinators are not able to utilize the tool at this point without doublechecking the validity of the information in Greenway. To some extent I would give care coordination a one out of nine. The tools are there, but the underlying data is the issue. Our care transitions program previously managed patients by pulling data from our acute care HIS systems into an Excel spreadsheet and looking manually at patients who fell within a 33-day window so they could reduce readmissions. We have taken away the Excel spreadsheets and interfaced the hospital IS system with Wellcentive so they can do their reporting and clinical documentation and also track outreach and staff productivity. Right now, we are running the first round of reports to submit to our state health commission. Our care transition nurses and community health workers are managing outreach, and to date, they have reported that their workflow time has been cut in half since we went live with Wellcentive. They are tracking data to get some official numbers on readmission rates, but since they effectively have twice as much time on their hands, they have been able to go out into the community and identify uninsured patients who need care. We have a care transitions partner program that primarily targets the uninsured and underinsured population, which is largely composed of Hispanic patients. There are language and culture barriers, so now our people are able to reach these populations in the most comfortable situation and help manage their care. We don't really use the product for care coordination right now. We just went live, and we are starting to work through the care coordination process. I can say that so far Wellcentive has certainly been better than average as a partner. Wellcentive Advance Outcomes Manager has the functionality to do care coordination, and the templates look good, but we don't use it across our system for care management because it doesn't interface directly with our EMRs. Our care managers do not have the time to document in both the medical record and Wellcentive. The reason we don't use the care coordination functionality is not a functionality issue within the tool; it is a process issue. This area is an opportunity for Wellcentive to work with customers and their EMR vendors to make interfacing a seamless process. xG Health xG Healthâ&#x20AC;&#x2122;s training was excellent, but we are now doing the care coordination. We selected people and sent them for training to xG Health for a couple of weeks and then they came back to us. They had phone access when they got back, but we are doing all of the care coordination. They are still meeting with us regularly to review the data. Population Health Performance 2014 I 191

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Rate your PHM solution’s strength in patient engagement. Advisory Board Advisory Board doesn’t have any solutions for patient engagement. That has to be their next frontier. And if I am contacting a patient in some unique way, I want a record of that in Crimson Care Management. We work with Dialog Health, a texting service, right now. There is goal setting for patient care, so we use that alongside the care managers and homecare agencies. There are symptom management guides and reminders that we can print off for patients to put on their refrigerators so the patients can self-direct and manage their own care. There is still a lot of manual work that we are doing to engage our patients. It is yet to be determined what solution we will use to try and automate patient engagement. We have some patients involved in the ACO, and we have had very few patients opt out. But we are not really pushing involvement yet because our main goal is to try to get our own healthcare costs under control and then have a story to tell. We want to be able to show ally providers that we can manage our own practice before we go in and say that we think we can manage their practices for them. That is why we started work with our own organization. We have had a lot of growth in this area. Our town has been down on its luck for a number of years, but lately there has been a lot of growth of businesses. We are really helping some of these businesses manage their own colleagues and their health better. athenahealth athenaCoordinator Enterprise’s biggest limiting factor right now is that the data source for everything related to patient contact is lacking. That is because athenahealth relies on data that comes from the payers, which is often wrong or outdated. There is no interface to keep that information updated or to add more information. There is a missing link there, and that affects our patient outreach. Because the contact information in athenahealth is not comprehensive, if one of our care managers wants to reach out to a patient, he or she may have to access other systems to get the correct information. And once he or she has that correct information, there is really no way to get it into athenahealth’s system for future reference. This is one of the bigger limitations. Everything is based on payer data, and there is no way to augment some of that information. Conifer Health Solutions We got approval to purchase Conifer Health Solutions’ participant and provider portals. We started to use these awhile ago, but there was a problem with our physicians getting on board because we had so many different portals at the time. Population Health Performance 2014 I 193

eClinicalWorks eClinicalWorks has made patient engagement very easy. eClinicalWorks CCMR is easy for patients to access and navigate and easy for physicians to explain and talk about. Patients can understand how to use the system. Results are very accessible, and patients love that. In 12 months from now, I expect the patient engagement will improve. There are things not out right now that we are working with eClinicalWorks to put together. As we monitor patients, we send them an app that is hooked directly into eClinicalWorks CCMR. In the app, patients can show that they have taken their medication, show their glucose levels, and so on. Then those vitals come back to the care coordinator, and the coordinators know what is going on with patients. The coordinators can then proactively reach out to the patients to say that they need a visit because, for example, their glucose is too high. We are engaging patients through the care managers. Those are the people, the nurses and social worker type people, that actually use the software and track what they are doing. Right now there are not any automatic tools. We are engaging patients through the care managers, who are the nurses and social-worker types of people. They actually use the software and track what the patients are doing. Right now there are not any automatic tools. We are working with eClinicalWorks to develop active care planning that can be done side by side with the patients. Epic Epicâ&#x20AC;&#x2122;s ability to document a care plan is getting better, but it is still weak as far as objective-based care plans go. We have several clinics that provide specialty mental health services, and we have built some custom functionality in Epic to support that sort of care plan. There are a fair number of care planning areas in which Epic is still weak. They don't give us a good enough set of tools to do care management or build care plans the way we need them in order to have high patient engagement. Their web-based tools are good and work very well. The tethered portal works very well, but if we choose to go outside Epicâ&#x20AC;&#x2122;s world, it gets a lot harder to provide that kind of integration. Healthy Planet's patient engagement piece is somewhat difficult to use. I really like Healthy Planetâ&#x20AC;&#x2122;s capabilities to send out communication both to its work portal as well as by paper. It can also route things to telephone queues, and it updates what the provider sees at the point of care.

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I think we are doing very well with patient engagement. We are really tapping Epic’s MyChart. We are trying to be better at using technology to automatically engage patients. We are leveraging what Epic would call Healthy Planet to automate reaching out to patients. We have actually been very satisfied with Epic for patient engagement. Evolent Identifi doesn’t really allow us to do anything; it actually creates more work. Explorys Explorys has many other modules, but we haven’t touched them, nor do we plan to. The Engage tool is almost competitive to the EMR or case management tool. Engage allows us to send out letters. For example, if I have a pharmacy recall, I use my EMR for that, but I could use Explorys for that as well. Or if I had 100 patients that needed such and such, I could send them all out a letter or some other type of communication telling them to call their PCP and come visit us ASAP. Explorys is doing patient engagement with Explorys EPM: Engage, but we don’t have that, so I don’t know how well they do there. The thing that is interesting is that in two or three clicks, we can look at the entire population of diabetics without current A1c levels, draft the letters, and then send them out. That is amazing, but then we can’t capture orders sent from Epic to the lab. When Epic releases Healthy Planet, we will have everything in one system. For us, this is a barrier right now because Epic is so functional. In other products like GE Centricity, this area is wholly underdeveloped, so Explorys is great. We are not sending letters out. Explorys EPM: Engage can do patient engagement, but we are not utilizing it because we need to hit our meaningful use numbers. We are all sending our letters out of our own system. Forward Health Group Because we have ability to track over time and display data, patients quickly realize that the information they fill out goes into a database and that they can see it from time to time. That knowledge forces self-reflection and is a self-correcting mechanism for the client and clinician to look at hard data historically. It has been a little difficult for the clinicians to weave the patient engagement part of PopulationManager® into their practice. That is not a reflection of the product, but more about how they have to do extra things. One clinician said it took her a while to figure out that she had to do the patient engagement at the beginning of the session. Clinicians Population Health Performance 2014 I 195

have to spend time to get to the right screen before they invite the patient to view it, so no other patient names are visible. When my patients come in, I get separate screens that are red or green depending on whether the patients meet the guidelines for diabetes and so on. When patients come in, I can go through all the red flags and ask patients whether they are still smoking and all that. PopulationManager® allows me to do a detailed analysis of where patients fit within the guidelines for certain diseases. i2i Systems The i2iTracks system doesn’t actually grab the patient data itself, but it does great with letters for campaigns and things like that. It is very easy to use for recalls, and we can easily automate the tools to get the recall information and other information out to the patients so they will come in. The i2iTracks system fosters a huge amount of patient interaction. We haven’t used i2i Systems i2iTracks for patient outreach. It doesn’t seem like that is going to be one of its purposes. Kryptiq Kryptiq CareManager is not really designed for patient engagement. For our pilot, we had a clinician go in, pull the population data, review it, and make the connections himself. Kryptiq CareManager just provided the list of names. It didn’t do any automated engagement. So far, CareManager has been a good product for patient engagement. However, the problem is getting the patients to engage. Some of our physicians use CareManager for patient engagement. They would like to see improved presentations of the patient summary and detailed information. The patients actually love their scorecards. McKesson Other than helping identify candidates for outreach, we are not using McKesson Risk Manager’s campaign management capabilities, which are basically printing and sending letters. We are not using the system for campaign management. We are using it to help identify candidates for outreach. Patient engagement is primarily handled by us as part of our care management process. Whatever payers patients have their benefits with are also involved.

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Patient outreach is certainly not direct to patients. I can print out a patient’s summary when I see the patient in the office and use that as a teaching tool, but it takes a significant amount of work on my part to do that. There is no patient interface with the system. We are able to compile letters and things like that, but the system is not strong on patient engagement. We don’t have a patient portal or application or anything like that. Medecision I have not seen those kinds of member usage numbers anywhere else, so 20% to 30% is stellar. I think questions about patient engagement don’t apply to us because we are part of an integrated delivery system and a lot of that work is really done through Epic. NextGen I would give NextGen a seven out of nine for patient engagement because the system does cause patients to come to us. However, it is a push mechanism and not necessarily engaging. It is more of a reminder tool. We are utilizing NextMD, which is NextGen's patient portal. We developed another solution in conjunction with NextGen where we give patients a previsit health form when they walk through the door. CareSentry is a provider-facing solution. It provides lists for patient outreach, but it is not designed to directly engage the patients. It can generate a patient list of all the smokers so we can do outreach, and in that regard, the solution works very well. Optum I am not sure Optum actually has a patient engagement module, but we don’t have that either. I had Optum come in and present the other modules, but there wasn’t a whole lot of bite from the outpatient side. Phytel I don't think Phytel Atmosphere does anything to engage the patient. The system gives us the information to talk to the patient, but I don’t know whether that necessarily equals patient engagement. Phytel has a phenomenal outreach component. We use that with advanced protocols that scour the data and identify the patients. For example, a simple scenario might be identifying males over 50 years old who have not had a colonoscopy on record, a result, Population Health Performance 2014 I 197

or an order. One of our protocols is to identify those patients and make sure they do not have a future appointment already booked. Then Atmosphere makes a phone call or texts out to the patients asking them to call to make an appointment. We get statistics on that, and we can see how well the system is doing and how much revenue has been generated because the system has done its outreach. There is a clear ROI, with the Phytel investment showing us that just that component alone pays for the whole thing and then some. Phytel has enabled us to identify the patients, but I don't know that they have any engagement tools available. Phytel helped us put together a patient education kit to put in our practices. It helps explain to the patients what the product is, why they are receiving calls, and why we are providing population health management as a value-added service to the patients. Patient engagement has been phenomenal because we have been able to contact noncompliant patients who havenâ&#x20AC;&#x2122;t visited the practice in over a year; further, Phytel has given us the material necessary to educate those patients once they come to the practice. They have been a strong partner. Phytel is known for patient engagement. Phytel Outreach is one of our fundamental building blocks, and it works with the PM data, the billing data, and the scheduling data. There are well over 100 clinical protocols around preventive care and chronic disease follow-up. So for example, once patients turn 50, they are supposed to have an endoscopy, and the women are supposed to get a mammogram. It can also alert diabetic patients that it has been more than six months since they were seen by the doctor. The system just runs in the background, and we can change what we focus on depending on the patient population. Most physician practices are slammed in the middle of winter during flu season. The volume goes down in the summer, so that is when we crank up the number of calls that go out. We limited our outreach protocols until we understood how they worked and exactly what the patient feedback was, and then we began to expand our outreach protocols. We use a product that is reaching out to get patients in for care. It is working for us. Siemens We can use CareXcell to push out surveys, reminders, and so forth, but we are not using the patient-engagement piece yet. Valence There are outreach capabilities within the VISION system. Those are great for the providersâ&#x20AC;&#x2122; ease but not for engaging patients. The providers reach out to patients 198 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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through the VISION portal. Valence has made that very, very easy. The outreach is amazing. But the patients are not engaged with anything that is going on within VISION. VISION works really well for the practice level, but the patients can’t log in to the portal, so they can’t get any information out of VISION. It is utilized more on a provider, network, or care-coordinator level, and the patients benefit from it that way, of course. Verisk Health I think there are a bunch of other services Verisk Health provides that we should tap into, but I wanted to put what we have together first because if we buy other services, we are going to have to convince our finance department that they are worth it. I think we are getting close to that point. Wellcentive A few years ago I would have rated Wellcentive the very highest for patient engagement, but as users work, they find other things that work better. The Wellcentive report card functionality is downright perfect. It is simple enough and promotes health literacy and patient engagement, but there is an opportunity for the care summary to be more useful for patients. The format is more clinician focused. Wellcentive’s partnership with Emmi Solutions is going to get them to best of class regarding patient engagement in areas like shared decision making, health literacy, and overall patient awareness and knowledge of how to manage medical conditions. We haven’t purchased the solution yet, but it is very exciting. Advance Outcomes Manager has a report card feature that some of our offices use and that actually can be shown to the patient. If we are looking at blood pressure, Advance Outcomes Manager can show the last four blood pressures that the patient has had so that he or she can see their blood pressure right on the report card that they take home with them. That is a really nice feature. xG Health I don’t know how to rate that. I mean, our nurses call and ask if they can call again. xG Health is not doing it for me.

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Of all the technology currently used to drive your population health strategy (not limited to your PHM products), which one vendor is driving the most value for your organization and why? Advisory Board Cerner is so ingrained in our environment, and we have such a close relationship with them. Our methodology is to get the best of cluster, not best of breed. We can leverage Cerner to provide the functionality we need, so we thoroughly consider Cerner before we consider others. Crimson Population Risk Management is a better product than the Allscripts tool. I would say Advisory Board is probably the premier vendor for us; we use one other vendor who does a lot of claims data. Advisory Board is a very popular vendor that I am sure everybody in the universe knows about, but the problem is that Advisory Board talks about predictive modeling, and predictive modeling is at its best only 30% effective. We are dealing in a system that is real time. It allows us to interact with community-based providers and hospitals and everyone else so we have actionable information in real time. We are so Advisory Board centric that it is basically Advisory Board or nothing for us. For our workflow evaluation and population health, we are a total Advisory Board shop. So they bring the most value for us. And of their tools, Crimson Population Risk Management drives the most value for me because we can see all of the claims data through it. It is inclusive. I like Advisory Board's methodology for identifying patients. That comes down to a single member. It is not a very complicated methodology. It looks prospectively and takes all claims into account. It is a better, more sensitive methodology that comes through Advisory Board's partner Milliman &amp; Robertson. Because it is a proven thing, I donâ&#x20AC;&#x2122;t have to go in and figure out how they are figuring things out. We use almost all of the Crimson suite of solutions for our population health strategy. On the inpatient side, we are a Cerner shop, so we are looking at Cernerâ&#x20AC;&#x2122;s population analytics tools, but those have some room to grow still. I think Cerner has a big partnership with Advocate out of Chicago for some of those population health tools that look very interesting to us and for some of the standardization across EMRs. So we are looking at Cerner. But we really are a Crimson shop. Alere We are in the middle of an Epic implementation for ambulatory and inpatient, so right now we arenâ&#x20AC;&#x2122;t really focused on how our products are driving population health.

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Allscripts I am not as familiar with what some EMRs are doing. I know that there are workarounds and that EMR vendors try and do some things, but to be honest, I think there is a ways to go. We are looking to dbMotion Population Health to be the answer for population health along with building enterprise analytics. As we run these population health engines and build the different disease packages, dbMotion Population Health can flag patients as part of a population, and those flags can go out of dbMotion Population Healthâ&#x20AC;&#x2122;s clinical analytics gateway into our big data warehouse and then from there do population health. We are trying to do population health on the aggregated platform. Today, doing that just within an EMR would make us miss a lot of patient information. What we plan to go live with by the end of the year is really our first push at population health management. athenahealth Eclipsys is the center point. It is where we identify the gaps between athenahealth and where we need to be. The more consolidated data people have, the better off they are. Epic has the ability to interface across hospital and physician systems more easily. CareEvolution Care Evolution is our warehouse for everything. We looked at Evolent, Optum Health, and Navvis from Healthways. All three of them had appeal. Optum came from United, so it had a very strong insurance plan and insurancecompany orientation. That had some appeal. The Healthways option had quite a bit of functionality for wellness and for disease prevention, and it was employer oriented. Diabetes was the big one there. Evolent came across as having a provider orientation. But we have been clients of The Advisory Board for a number of years, and Evolent had that connection. And we knew that UPMC's being a provider-based organization with a large health plan would add to the content and expertise involved. Cerner So far the registries are the first tangible output from the process. Conifer Health Solutions athenahealth is doing some really cool things. Our providers love their system and are looking to implement athenaCoordinator Enterprise for population health. I am really excited about that one because the integration piece is already built in. Population Health Performance 2014 I 201

I have been able to talk directly with the president of Conifer Health Solutions. The company is very dedicated when they bring someone on as a client. They want to make the system work for the client. They are very up front about what they are good at and what they can do. They have a lot of integrity, and they have such compassion to do the right thing. They are in the business to do the right thing; everybody needs to make money, but sometimes Conifer Health Solutions is willing for us to just pay cost so that they can get our innovative ideas up and running. They do that because the ideas are the right thing to do. I can’t say enough about their integrity and compassion. We are still establishing consistency. I don't know what I am getting out of vendors other than Conifer Health Solutions, but I am happy with what I get from them. eClinicalWorks eClinicalWorks CCMR is going to be the backbone for our population health management strategy. eClinicalWorks is probably the vendor that drives the most value for our population health strategy because the structured data that is in eClinicalWorks' systems is what we need to do population health management effectively. It is not our intention to take on risk and be our own ACO, so I don't see our group trying to go to a much higher level in the next five years. eClinicalWorks is the only vendor we use. Neither NextGen nor eClinicalWorks has a solid understanding of how to use the claims data from CMS and other vendors. We have had to rely on expensive, but accurate, analysis from Milliman. Our data analytics team has used Access to make a big difference. We are providing care coordination information to the physicians. The physicians get their reports and information through the data analytics department. To properly deliver care management, we are using a different vendor. Nobody stands out as a clear leader or as exceptionally good. eClinicalWorks CCMR is not even in the picture if people are looking for premade workflows because eCW doesn’t have any. There isn’t any clear leader, especially when people talk about monetary value. We could maybe get more things with Epic, but the price is prohibitive. We currently are only using eClinicalWorks.

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Epic Conifer has a very mature system that does what we need it to do, and they are very good at merging claims data with clinical data. Epic is driving a lot of value for us because we have everything on one integrated solution. We want to move forward in the long term to get everybody on a single system. That system should be Epic because Epic has products that work in a large number of clinical and operational spaces. Our strategy with these things moving forward is not getting our dream system or even the best in the market. Rather, we want a system that meets all or most of our basic needs. In the long term, the integration efficiencies, overall support efficiencies, maintenance efficiencies, and even training efficiencies are so much greater. I would say that Epic is driving the most value for our organization in regards to our population health strategy. That is where we have all of our patient data. We use everything Epic has. If we want data on population health, that is where it is going to come from. We even have our health plan on Epic. There are a lot of different tools available in Epic Healthy Planet. We are using pieces of the system right now, and we are looking forward to upgrading sometime next year. We have plucked out the registries we can use, we use some of the ordering functionality, and we use some dashboards. We donâ&#x20AC;&#x2122;t use Epic's documentation piece or their casemanagement module. We have been told that the piece for documenting care coordination will be much better in the newest upgrade. Most of the documentation templates we have used are templates we have developed. We have pretty much built all the registries in the Epic software. Epic has built out one custom registry for basically chronic-disease management for patients who have multiple diseases, and Epic has done some risk stratification for that. We are finally starting to see more traction with the web tools and patient-engagement tools. That has largely been driven by the requirements of meaningful use, not by the ease of implementing the Epic tools. We are only using Epic. We use a lot of Epic Healthy Planet for registries and everything. We get certain reports out of Cogito - Clarity in Epic that help us. We can see who hasnâ&#x20AC;&#x2122;t been in, who hasn't been in in over a year, and who has null values. That is neat. We can sort our registries to look at, then tackle them to improve our scores. If I had to say which vendor is helping us the most today around population health, it would be Epic.

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Evolent Every vendor in the world is trying to get into population health and figuring out what population health is. I think Epic has a lot of focus in that area. But the challenge with Epic is how to aggregate data from non-Epic physicians. Epicâ&#x20AC;&#x2122;s Cogito data warehouse is outstanding, but I need to determine whether it will be able to aggregate that data. If everything were in Epic, I think Epic would do population health very, very well. They are even now touting their Healthy Planet application, and I am working on setting up a demo for that. We donâ&#x20AC;&#x2122;t have a lot of exposure to other vendors. Right now, Evolent Health is driving the most value for our organization with Identifi, which is actually an outgrowth of a joint venture between the University of Pittsburgh Medical Center Health Plan and The Advisory Board Company a number of years ago. Both organizations agreed to commercialize Identifi through Evolent Health as a provider-based solution rather than a payer-based solution for population health. Evolent Health as a vendor stands in contrast to Epic or Siemens. Our system needs to be provider-centered, meaning we develop the software as a healthcare provider rather a commercial payer trying to develop its own software. To us, it is somewhat of a conflict of interest to have an agreement like that for software with a third-party payer when we are going to have agreements with multiple payers. We are discussing several other options, and it is just somewhat odd for us to have relationships with all of those payers but say we are going to pick one of them to run the software through. We would rather have the software through an independent third party, and that is what Evolent Health brings to the table. Explorys Explorys' data warehouse is still the place we are gathering our own information from. Explorys helps us somewhat get some of our claims data together. We have several tools, and we could probably use several more tools because we still have some gaps around risk scoring, for example. But from a sustainability perspective, we are trying to bend the cost curve. We need to maximize our usage of the tools and get to fewer tool sets. When we can control everything, which is typically what one does in a warehouse and the tools on top of it, the warehouse always seems to be the crutch we fall back on. We can get pretty creative about how we manage our data in that space. We are reevaluating where we want to head because the demands are so high. My concern is whether we are nimble enough in the management of our data. I want to change something. I can't wait six months to get data from the system. For the patients we have in our Epic database, Epic will certainly drive the most value. Our go-forward strategy is to launch Healthy Planet next year. I am putting a lot of faith in it, and I know it is going to be version 1.0, but that is where we are putting our energy. I could see Epic and Explorys coexisting through the end of this decade, with Explorys filling in what Epic can't do. When Epic does have the functionality, I will just take the 204 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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beam of light from Explorys and direct it elsewhere. It could be really beneficial for processing claims data or data from other EMRs when there is shared responsibility for a patient. We use two different EMRs for orthopedic care and rebound orthopedics here. Outpatient care is done on one EMR, and inpatient surgery is done on our surgery system. I need another tool that can manage cases across the Epic boundaries, because Epic does not do that. There is a very legitimate opportunity with Explorys. We use a mixed bucket of technology. When I think of claims-based analytics tools, Verisk Health obviously comes to mind. Using their system requires a large amount of claims data, and there is a lot that can be done with claims data. When I think of disease-registry data, I think of vendors like Wellcentive and Advisory Board. And coupled with that are the more analytics-based programs, like those from Optum and Truven Health Analytics, who has tried-and-true, higher-level analytic reporting. Forward Health Group eClinicalWorks has some special tailored reports, but the problem is that each one of those requires special program knowledge and special reporting and structure. eClinicalWorks has been supportive in what we do, and then Bridge IT has been able to provide some of the reporting processes we do. Hands down, Epic is driving our population health strategy more than anyone else. That is just because we use Epic for everything. PopulationManager® involves such a tiny scope of what we do that it can’t compete. Much to my chagrin, our clinic has not made as much use of the PopulationManager® tool as they could have. I am hoping that will change over the next year, and I am driving an initiative to use the tool more. PopulationManager® is the only product we are using to work on population health. That is why we are transitioning into an electronic health record. Healthagen We have now set up the infrastructure and are continuing to modify and refine it. Cerner set up the infrastructure in HealtheIntent to match the EMR claims data that comes through from our hospital systems, physician offices, laboratories, and so forth. We are able to match that data up with the claims data that comes from the payers and our own claims shop to get a more complete and comprehensive look at a patient. We are potentially able to identify patients quicker so we can understand some cost and utilization things in a more timely manner. Ultimately, I think HealtheIntent is going to be the most helpful tool. Everything we use serves a different purpose, so I guess it is all beneficial in its own way, but I think HealtheIntent will be the most helpful in the future.

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i2i Systems eClinicalWorks has an enterprise EMR system that basically has a lot more functionality than just population health pieces. i2i Systems is driving the most value of any population health vendor at our organization right now. A lot of that is because we have invested significantly in the system. I think we are going to stay with it. We have no reason to change right now. At first we tried a custom data warehouse, but we were unsatisfied with the company running that. We tried to hire another company to fix the custom data warehouse with a reports suite, then ended that relationship and went with i2i Systems. We are smarter the third time around. We chose i2i Systems because we had experience with all of the EMR vendors in our group. i2i Systems actually specializes in federally funded community health centers, which make up a specialized group. Kryptiq I can’t think of one vendor that is really valuable to us for population health. We are not doing much population management; we are really doing more patient management. The one place where we are managing a population of patients is with GE. We are doing recalls for colonoscopies with our GI doctors. If a patient has a colonoscopy, polyps are found and biopsied, and the doctor wants to see the patient in three years, we use GE to manage that recall. We have no other products that help with PCMH aside from Kryptiq and GE. Lumeris We are considering using Lumeris across our organization based on our success with the pilot program. We are using a separate analytics as a vendor service now as a bridge strategy. The Healthy Planet tool suite has been out a year and is being rapidly improved just like the Cogito suite. We were just on the phone with Epic today about Healthy Planet. We really think it is going to answer 90% of our needs, and roll that in with a fully expressed Cogito, and it will meet 100%. However, that will take dedicated project resources and commitment on our end. We are excited about what we see in Epic's tool set. Lumeris has a lot of expertise in Medicare Advantage. They have their own delivery platform, and they will continue to rise and tell customers to forget about developing other things because their way is so easy. They will just take the raw data. I think the advantage of the Epic tool set is that because I am inside the transactional system, I can apply the analytics in the operational workflow. I don’t have to open two systems; I don’t have to know two systems. I can get dashboards with actionable items from within Epic.

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McKesson High Line Health is a data aggregator that does risk stratification and helps define target populations that the case manager ought to go after. It doesnâ&#x20AC;&#x2122;t do the case management itself, but it gives us the information we need to go after the patients and figure out what patients to go after. I think High Line Health is reasonably new and started in the last three years or so. High Line Health is a tool that came to our attention when we were involved in discussions with one of the commercial health plans about doing a shared savings agreement. We have a Medicare shared savings grant, federal agreements, and three commercial shared savings agreements that cover about 100,000 lives. One of the health plans has been using High Line Health to do some of their shared savings analytics, and they did a demo with some data for us using High Line Health to help us see where the population we would be responsible for was and what it looked like. We entered into a conversation with High Line Health about doing that same kind of work for us, so now they do it for all our payers as well. High Line Health provides a service. Essentially they use technology and create reports, but they actually organize the data into a database that we can query using their tool. In all of our experience to this point, TigerText has been the most valuable to our organization. It is simple, easy to implement, low cost, and has low barrier to entry. It has really helped to facilitate something that amazingly is just not prevalent in most markets. I am sure there are many markets and organizations that are better, but for our market, the facilitation of communication between physicians so they can have very quick, asynchronous discussions about patients is the most valuable thing because it helps us avoid another visit, a thing that would cost money and waste time. Physicians can make quick exchanges. They can be specific and frank and share photos or images. They can take a photo of a lab result or something and come to conclusions and then move on. TigerText has been the first major game changer we have seen that is a really big deal here. McKesson is our partner, and we haven't used anyone else. We did take a look at dbMotion, but we decided to stick with McKesson. They have had the biggest impact on our population health efforts. No one vendor is driving the most value for our organization. McKesson is our goforward solution. Hopefully we will have better experiences in the future than we have had so far. Orion is our private HIE that just came live, but it looks very promising. Our goal with Orion is to reduce test repeats. We know there is already good data out there, so that should improve the coordination of care. Instead of perpetually scrounging for records and faxing documents back and forth, we can know, for example, that at the very least Population Health Performance 2014 I 207

our patient has seen the gastroenterologist or the radiologist, and even better, we might be able to access the notes. There are still challenges with that approach if users are trying to bring in foreign data from outside their organization, but the nice thing about the HIE is that everything is foreign, so we are not trying to be an EMR. We are basically trying to provide as much community information as we can. That is our approach and our strategy. McKesson Population Manager is the largest contributor, but FRG uses AccuReports, and they are giving us data aggregation. That is showing significant progress. FRG is a small outfit, so they are very nimble. They got us up and running in no time with different types of reports that are useful. We have financial metrics to determine which patients go where as well as which patients go inside the network and which go outside the network. And we can figure out how to try to keep patients in our networks. Right now Epic is driving the most value because even though we are not using the Healthy Planet tools, that is where our care coordinators are doing their work. They are running reports and reviewing patients. The two products we have really looked closely at are Lumeris and Conifer Health Solutions, and of those two, Conifer Health Solutions is the most promising. We really only have McKesson. To select another vendor, I would have to go back and reevaluate who is out there in the market now to see whether anyone would be able to do things any easier or quicker. We have to have our McKesson data aggregation tool because we don't have just a single vendor. If all of the physicians participating in our clinically integrated network were owned and operated by us, they would all be on Epic and I wouldnâ&#x20AC;&#x2122;t need a population health system. But we are working with multiple organizations that have their own EMRs, so we have to do things practice by practice. Medecision There is not one vendor. We are struggling with finding one vendor who drives population health. I would say that the problem is that there is no one good vendor. What I am finding are fragments across the data acquisition side and the intelligence reporting analytics side. I have not found a good number that can put the two sides together. Without those two sides together, the system is worthless. We use a DST MHC as our core operating system. We havenâ&#x20AC;&#x2122;t integrated Medecision's disease management and case management applications, but we understand that Medecision has a fairly robust integrated system for case management. Based on the initial strength of the product, we are looking very closely at integrating that case management piece with Medecision instead of the product attributable to our core operating system. All of this depends on how we integrate the data and how the bridges and transitions work. Our Medecision product is probably the strongest tool we have right now. We are really talking about a more contemporary architecture as far as the 208 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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way the product is set up. Users can point and click and get data they need. The Medecision product is by far one of the most user-friendly tools we have. It has been by far our best tool. Without a question, Medecision is driving our strategy for population health. Medecision allows us to jump-start the business process of population health. The act of using the software makes us better at the act of care management. The value of the software comes less from what features the software has and more from the fact that the Medecision people installing the system know how to do care management. NextGen I am not sure which vendor is driving the most value because we are actually working with multiple vendors in different capacities at the moment. Simbiote is driving the most value. We could argue that the vendor is NextGen because Simbiote is a bolt-on tool for NextGen. It was written by a practicing physician just for NextGen. We have NextGen deployed to offer us an enterprise chart. The goal is interoperability. All of the providers are working from a common care plan for the patient. That is shared across the community, so they can all know exactly what everybody else is doing and provide efficient and effective care. The NextGen platform provides us with the tools, but we had to build it. Still, that is the one piece that has provided the most value to us for our triple aim. Optum I created a whole separate dashboard to support our medical home because nothing else was really set up to do that the way I thought it needed to be done. Creating that was a ton of work, but it sure has been nice because it does exactly what we need it to do. I built a dashboard myself because so much data from medical homes is in our EMR that we basically have a separate Oracle database. Its charts are awesome because there is a chart that says how we have tracked mammography, colorectal cancer screening, and so forth month by month. There is at least one button on there for everything that we need it to do. We built problem-listing models for every practice where hitting a button shows us all the patients ranked by health care scores. We can rank them and sort them all in different ways. I can tell you which patients are most likely to be admitted in the next six months. I can rank them by mortality risk. We set this system up all by ourselves because I didnâ&#x20AC;&#x2122;t know how to get any of the other systems to do that. If I go to Optum and ask for something, they will tell me they can build it for me. But I can't go to them and ask them to build something every time I need something. That is the frustrating part for me.

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My impression is that Optum has really good products. A company that can actually marry clinical data analytics to claims analytics will strike gold, and Optum is promising to do that. Optum is taking the right steps in the right direction, but they are not marrying the database yet. They have got to be working on that, but I do not see anything indicating that they have actually put the two databases together so that claims data is integrated with clinical data out of EHRs. Optum would need to rewrite all their predictive analytics and their reports. But if they could do that, they would hit gold. With what Optum is offering right now, they pretty much took some of their old groupers and risk adjustments and just brought them over into their new population health system as a set of reports. Then they can run the existing reports against what we get out of the grouper and the risk-adjustment methodologies. We can look at the data in the same program, but we have to change windows or tabs. The system strikes me as not being really integrated. We looked at a bunch of vendors a couple of years ago. The John Hopkins ACG System is another system out there. It is really mature; it has been around for 15 years. It gets better every year. However, it is limited in that it is only good for older people and does not help with kids at all. That is a huge deficit, and I have not seen anybody enter that space. There is a big gap in the market for claims analytics for children. Another vendor is Advisory Board. They were way behind Optum in terms of being able to do clinical analytics. That just did not seem to be a space that they were very adept at. Even if the registry function within the EHR is poor, it is a huge advantage that we are in the same space and can send a list of patients to contact or directly schedule them if we are working a list. The advantage is so huge that I cannot imagine independent vendors are going to last very long against Epic and other EHRs that have that. But I am very skeptical that Epic is going to be a master of the analytics space as well. They are going to really talk like they can. They usually make a promise and then actually deliver on that promise two versions later. That is my experience with Epic. I would guess the 2018 version of Epic will have some pretty amazing population health analytics but still struggle on how to incorporate claims information from non-Epic systems. That will be an ongoing opportunity for other types of vendors that can actually take claims and analyze them independently. Optum is driving our population health strategy the most. We also have Precision.BI, which we are migrating into the clinical intelligence side, but it has more flexibility in that we can write inquiries on any ICD-9 diagnosis. We don’t know whether Precision.BI is pulling from the same fields or whether it is just as reliable as Optum in terms of accuracy, but there isn’t as extensive of a data validation process. We are looking for the Optum platform to integrate better with the EHR. We can’t find that easily. We were disappointed that Optum hadn’t integrated at the point of care yet. That is on Optum's road map, and we are interested to hear whether they have accomplished that. They are trying. 210 I Population Health Performance 2014

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Optum is really our only vendor other than Epic, and Epic is used more at the point of care. We would not bring in any additional vendors. That would just confuse our data. We are discussing which is our most valuable vendor right now. We have got a few big players that all want to deliver that same tool for us and tell us they can do the different tasks. We are trying to figure out the best spot for business intelligence, ACO management, and population health. Several of the vendors overlap into all three buckets and say they can give us an ACO dashboard so we don’t have to go anywhere else, but none of them do it quite right. We have a couple of other initiatives from an analytics perspective that may change that over time, like standing up Health Catalyst, but at the moment we feel comfortable that Optum is a good strategy for us. We have seen a bunch of vendors, and I think Optum Humedica is probably one of the best out there. I have definitely continued to be impressed with Humedica through its merge with Optum. I think in terms of products, they are definitely high up there. The combined cost is a lot higher than the cost of other vendors. We don’t completely know what we really want in population health, and we would rather not throw money into it until we can define what we want. We don’t want to let perfect be the enemy of good enough. We need to start simple by making lists of reports of what patients we need to see and getting them in for super visits. We need to do some basic risk stratification based on chief admissions and some claims data we have. I think we are adopting a walk-before-we-run approach. It is hard for me at this point to say what tools we are using. We have decided to not get bogged down by all the tools because every vendor says they can do magical things for a $1.5 million or $2 million price tag. We know who the tricky patients are because we can do a basic stratification. We want to minimize the cost of our group and find out what we really want. We will hopefully learn what vendor we want to go with through doing. Phytel From a population health perspective, Phytel has brought the most value for our organization. The other platforms make it easy for patients to find us or schedule appointments, but in terms of reaching out to noncompliant patients and getting them to be proactive about managing their health, Phytel wins hands down. I would tell other Epic providers that Phytel Atmosphere allows us to get registries, contact patients, and identify patients who are behind in their care. It does those things in a way that the Epic system can’t do today. I have talked about what the system can do to several other Epic and non-Epic providers in our area.

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If there is a population health vendor out there that can provide more value than Phytel, I haven’t met them yet. Phytel is definitely driving value. I don't know if I can say that about my EHR. Phytel is helping us get answers and enabling us to actually implement solutions to decrease the cost. Phytel's biggest innovation is the ability to extract data from our EHR and display it in a format so that we can actually do something with the data. The fact that we don't have to manually go chart by chart and are now are able to look at all of our patients in a single report is fantastic. Phytel is doing a lot of the heavy lifting. The hardest thing to do is what Phytel’s doing in terms of the data mapping. The only other vendor that is part of our population health strategy is our EMR vendor. The reason we went to Phytel was that our EMR wasn’t capable of doing the things we needed it to do. Today Phytel drives out population health strategy the most, but that might change. We are looking at all sorts of different things, but Phytel reaches the farthest throughout all the organization with all the different components. It does appointment reminders and the outreach, so clearly it is sort of the tool for our population health strategy right now. We are only using Phytel products and our EMR for our patient population health. We really only use Phytel and Allscripts. We could not survive without Allscripts, but we are not comparing apples to apples when we compare Allscripts and Phytel. The EMR helps us capture the information, but Phytel helps us do something with the information. Phytel only brings value because their product pulls the information from Allscripts' product. I don't think Phytel Atmosphere could do what it needs to alone. Premier For our disease registry, we are using a company called Symphony Health Solutions. For our back-end analytics, we are just in the process of trying to roll out Truven Health Analytics. Siemens We are a Siemens shop. Almost everything we have in IT is a Siemens product.

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Valence No vendor is driving our population health strategy right now because I am not connected to Explorys and Valence is not providing any value. We have such a wide variety of vendors in our network, and they all have their pros and cons. None of them really stand out at all. Verisk Health I think the Verisk tool is a powerhouse. It can take claims data and make it usable information that can point physicians, care teams, health coaches, and all of the new roles that are rolling out with value-based care in the right direction. It can give us a highlevel look or an intense look at what is happening with our population. The other systems are just support systems for that, I believe. I would definitely say Explorys is driving our population health strategy. They are flexible and are able to quickly deliver value. Our population health management system revolves around Verisk Health and athenahealth. We do go outside and get publicly available data as well, and we get claims data from the state so that we can do some work and have comparison groups. But as far as all the applications go, there are over a hundred health systems that need support, and that is a big task. I think I will have better insight once we get clinical data because we will see some of the problems with Verisk Healthâ&#x20AC;&#x2122;s back-end systems when we review the clinical data. I think there is a lot of value in that data for referral management and referral patterns. That is a big driver of cost and quality. So if we get the data, we will be able to look at those very important patterns. We will be able to create better subpopulations based on biometrics than we can now with gross risk scores. The high-risk group is great, but even within that group there are high-risk patients who are stable and some who are unstable, and we need to really key into the ones that are unstable at a particular point in time. Having the clinical data that would be a huge advantage for doing that. The Verisk Health tool is getting very discrete claims data and providing a very valuable role. Today, most of what we do in population health involves a patchwork quilt of vendors. My internal data team runs our payer claims data through the Optum system. We take the resulting output files and put them in PremierConnect Enterprise and lay Tableau Server on top to do reporting. I can't say who provides the most value in that scenario. We have to have all three in order to make that use case happen. I think that has been Population Health Performance 2014 I 213

one common theme with everybody I have talked to. There is no one size that fits all. Everybody ends up being held together with a little bit of duct tape and bailing wire. The component pieces together create the analysis or the output that the organization needs. Nobody is doing it in a single-source way. We use PremierConnect Enterprise for data aggregation. I would rate Premier very high on dimensions like vision, road map, resourcing, and my confidence in their ability to execute. I would not rate them very high on existing capability. From a platform perspective, they have great capability, but from an application perspective, I think that is still emerging for them. I think Verisk Health is good in terms of third-party payer claims and population health. I wouldn’t say they are as advanced in terms of vision and strategy. They have nice capabilities at an individual patient level and not as nice capabilities when it comes to ad hoc analysis, which is something we do a lot of. We use Verisk Health Medical Intelligence to look at relative risk scores, cost efficiency, imaging-use indicators, and utilization. It is very helpful, and we can show the doctors real numbers. That makes it hard for them to say their patients are sicker than they are. A couple of people from Verisk Health came to our place at least a month or two ago and sat down with us all day to train us to use the system. They got partway through their workbook, and they are coming back probably next month to finish up or go through more of the workbook to show us more things that we can do. But from the first course we had, I was able to dig in and get a lot of use for prevention. Then I sent what I put together to Verisk Health and asked for them to comment on or criticize whatever should be added or deleted. They liked what I had, and they added one thing they thought would be helpful, so we have had a good relationship. Wellcentive Advance Outcomes Manager is really the only product that we use. It is hard to say who is driving the most value for us because all of the vendors we are currently working with are failing miserably. They are going too fast, they are unable to keep promises, they can’t do anything in a reasonable amount of time, they don’t communicate, they miss dates, and so on. It is interesting that KLAS is asking me this. It is just like choosing between bad and badder or dumb and dumber. I can’t even answer the question. I mean, I wouldn’t want to buy us something from a vendor when the vendor is not doing what they are supposed to be doing in the first place. Of all the technology we are using, Wellcentive's product is the one that is most helping us drive our population health strategy because it is pulling everything together in an actionable format. That enables us to engage our patients and make changes to our

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workflow to impact the outcomes of our interactions and close gaps in our patient care. It is the tool that pulls everything together for us. Our EHR vendor is the vendor that most affects our population health strategy. Wellcentive can't be the best because Greenway doesn't pass all of the data over to them. Wellcentive gets only what Greenway is willing to send. That means that Greenway has to be our number one repository for data. Greenway has a lot of ideas, but I haven't seen anything come to fruition yet, particularly for a practice of our size. When Greenway rolls out a BI tool, it usually crashes when we try to run a report. I think Greenway is headed in the right direction, but they aren't quite ready, especially not for a practice our size. Relatient is actually a vendor we arenâ&#x20AC;&#x2122;t currently working with, but we have worked with them in the past. Relatient is a communication application that allowed us to do targeted outreach through basic patient outreach applications. Outside of that, our EMR is probably our most valuable population health system right now. It is the most reliable source of patient information so we can make clinical decisions and view a wider subset of the patient population and make global decisions. Wellcentive drives the most value for us. We are working with our corporate sponsor on the Verisk solution and understanding that tool, but that is driving contracting and actuarial strategy. Those things are a portion of population management, but they don't fall on the provider side. We see the CareEvolution solution as a big data aggregator that can produce high-level reports. That might be helpful at a state or regional level, but we would require a registry tool with care management functionality and specific patientoutreach functionality to support a comprehensive strategy. We also worked on an Explorys pilot that was not successful. The functionality was not useful in providing population management and clinical integration at the regional or local level and certainly not at the provider level. We have tried a number of these tools, but Wellcentive has brought the most value. From an administrative, clinical, and IT perspective we have not found a tool that exceeds the capability of Wellcentive, nor have we found a tool that has as much functionality. xG Health xG Health helps us get the data we need to drive change.

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Additional Comments Advisory Board Advisory Board is a lot easier to deal with up front, but it is a challenge to have them assign resources that are knowledgeable, can make decisions, and are able to help through the implementation cycle. We have been working to create clinical integration networks with the doctors. Legally, we are allowed to get doctors together, form an alliance, and negotiate with payers so that as the quality of the doctorsâ&#x20AC;&#x2122; patient care goes up, the insurance companies of those patients provide additional reimbursement for the doctors to drive behavior. Crimson Population Risk Management gives the doctors the dashboards, their patient orderables, and the patient charges. It lets the doctors see where they are an outlier from their peers and some high-level outcomes related to mortality. Then the doctors have some data to start changing their behavior. We acquired a health plan in one market, and in theory we are going to start creating some narrow networks and offering Medicare Advantage plans in certain markets. We are in the middle of the pack in terms of what other people are doing. We are not on the bleeding edge, but neither are we on the back end. We need some additional tools from a population health perspective, but the first thing we have to do is get our health plan and clinical integration networks up. We use Crimson Care Management for mostly our workflow. It gives us alerts when todos are ready and for episodes. I would love to use it more for reporting, but it is so limited. We are not able to report much out except activity things. We do assessments on patients, like a COPD assessment test, or CAT. We would love to go back in three months and check those again, but there is no way to flag the baseline and what was a change. I canâ&#x20AC;&#x2122;t pull a report that says we reduced the CAT scores by a certain amount once we started working with somebody. Advisory Board is working on allowing this, but it has been over a year. We went live in three months on Crimson Care Management. Advisory Board is responsive, but they are disorganized. They are really struggling. They have a lot of turnover that adds to the chaos. They are almost too responsive. They spend more time responding than just fixing the issue. They will have five people on a phone call and have several on the issue when I just want them to fix it. Advisory Board is incredibly smart; they know their business. It is execution that is killing them right now on these products. The company Crimson Care Management used to be owned by was smaller, and the experience was better. They were more responsive. They would just fix things. Since Advisory Board bought them, things have been rough. Sometimes Advisory Board just gets lost in processes. We are looking at replacing Crimson Care Management. If I could see the COPD assessment test (CAT) score improvement, that would be really valuable. But Advisory Boardâ&#x20AC;&#x2122;s responsiveness in making changes has been the other issue. 216 I Population Health Performance 2014

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Crimson Care Management is very slow. We put it on one screen and do things in the other while we wait for it. Crimson Population Risk Management doesnâ&#x20AC;&#x2122;t feed automatically into Crimson Care Management. We may identify patients who need follow-up coaching because their risk scores are very high, but we have to manually enter those into Crimson Care Management to begin that management. The systems donâ&#x20AC;&#x2122;t talk to each other. It would be really nice if they did. Allscripts dbMotion Population Health offers four out-of-the-box disease populations. The algorithms are built in the background, and we are working to take those into production. Allscripts has population health analytics. It marries up with their disease management system. With it, we can build our own populations as well. The analytics system shows the dashboards with the groups of populations across our organization. athenahealth Overall, our experience with athenahealth has been really positive. athenahealth has really good thought leadership in this area. They have a great platform that does good analytics. I don't think the analytics functionality is much of a differentiator anymore because there are so many solutions out there, but athenahealth is trying to focus on workflow. By combining a strong practice system and analytics, athenaCoordinator Enterprise helps providers engage and schedule patients and really reach out effectively. CareEvolution Looking at what Epic proposes to do in the future, I find it hard to imagine something else becoming the primary population health solution of the future. Epic's technology will be unified. But right now, I am somewhat amazed that some pretty basic, helpful functionality is not yet built into Epic. That is hard to understand because every system involved with the kind of activity we are doing would enjoy the same things. Those features would be really nice to have. I do not know whether the problem is a matter of capacity or priority. But knowing the company to some degree, I suspect the needed functionality is all on the radar. Cerner A lot of the process is getting started in the measurement of outcomes, looking at the results, and comparing the results to others'. Getting into that mentality of being data driven in terms of our improvement process is key. The biggest hurdle is getting our Population Health Performance 2014 I 217

physicians to participate and agree to some standardization and common approaches, such as keeping patients in the network and the value of the network. We have to work on all those things. Our physician group has had a physician leadership structure all through the process. What has gotten them to participate heavily is a pay-for-play group so they can see the rewards of quality. Last year there was a pool of over $100 million, which was distributed back to the physicians to reward them for hitting their quality measures. As physicians, they all want to do well and provide high quality, but a cash reward is a nice incentive. Conifer Health Solutions The drill-down capabilities of Coniferâ&#x20AC;&#x2122;s financial platform are magnificent. The system tells us our top providers, our big claims, and our major categories of care. We can drill down as far as we want to go. That whole financial piece is fantastic. With Conifer Population Health Intelligence Platform, there is so much information that people do need to get some training on how to run the reports and what the reports mean. The system has tons of standard monthly financial reports and is great for reporting, but I would have to dock it some for ease of use. Users need to know what filters they are using, and because the data comes from a data warehouse and because there are so many aspects to the data, users have to make sure the time periods are right and that the population they are mining is right. Users can do a lot of ad hoc report writing, but if they click the wrong box, the system won't warn them of that or doublecheck that they are getting the information they actually want. But if people take the training, they will know the groups and filters, and they should be fine. When users ask the system for data, they have to know what they are asking. There has been movement in Conifer Health Solutions' executive team, and there has been movement in our team as well, so a few things have been dropped, but that doesn't typically happen. Usually, if I feel something is not being addressed, the executive team immediately jumps in. That team is very much involved, and Conifer Health Solutions is a wonderful organization. They are willing to meet the needs of their clients and to work very closely with them. If they canâ&#x20AC;&#x2122;t do something, they are very up front about it and will let the client know. Advisory Board seems to have a similar platform as Conifer Health Solutions, but I like that Conifer Health Solutions has local people and is willing to work with us to be entrepreneurial with our different initiatives. They are very innovative and aren't afraid to take on new challenges. Sometimes the larger vendors aren't able to be innovative because of their size. Conifer Health Solutions might be different now since they acquired InforMed and became a larger institution. But InforMed had such a strong system and financial platform for data warehouses, disease management, medical management, and outcome tracking. When we were considering Advisory Board, they didnâ&#x20AC;&#x2122;t talk so much about the prevention and wellness piece in terms of health risk 218 I Population Health Performance 2014

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assessments, integration, and risk stratification, whereas Conifer Health Solutions was able to meet those needs. eClinicalWorks eClinicalWorks CCMR has a fairly simple architecture. The good thing about that is that we can create any type of evaluation we need. We can create whatever format we want. We can fine-tune the risk engine that runs in the background. It used to be difficult to identify risk, but eClinicalWorks has made it simpler. eClinicalWorks CCMR is a little more capable now than it was a year ago. It is still an early product. It has worked well for us because we have our own way of doing things, so we didn’t need preset options in the beginning. We could create whatever we wanted. eClinicalWorks has helped us build eClinicalWorks CCMR up so we can use it effectively. They have fairly good manuals and training, and their personnel do a really good job. They have enough people on hand to help us set things up and make the system work. We are a small to midsize customer, and the level of support the company gives us so we can really use the technology is good. The trainers are really patient. They take the training down to a simple level. They spend a lot of time going over things, so the system is easy for anybody to understand. eClinicalWorks’ support is good. Their website is fairly comprehensive. We can search through different topics and learn a lot step by step. If we have an issue, we open a ticket. Simple solutions are resolved within a day. Solutions that require more research or modifications get taken care of in a week. When we first started using eClinicalWorks CCMR, we had issues because it was a newer product, and eClinicalWorks resolved those within a week. They get the job done and stay on top of it; people don’t have to call and remind them. They dedicate resources and deliver on the timelines. There are a lot of repetitive, predictable activities and steps in care coordination and case management. If eCW offered a prebuilt feature that let people outline a requirement so that those repetitive tasks were automatically done, that would be very helpful. The problem of setting eClinicalWorks CCMR up ourselves for case management and utilization management was just not worth dealing with. We didn’t want to assess every step by ourselves. That should already be built in when people buy this product. eClinicalWorks CCMR is bringing value for what we use it for, which is data aggregation and risk stratification, but there are still a lot of things we want done. eClinicalWorks needs to map it to the EMR. The data is separate right now, so whatever we put in eClinicalWorks CCMR we have to also put in the EMR if we want to have access to it there too. That is a significant drawback. As a tool for collecting data and organizing it, eClinicalWorks CCMR does enough to be helpful, but it does not do all the things it could do. I would not recommend eClinicalWorks CCMR to anyone. Population Health Performance 2014 I 219

Once our first hospital was live on the HIE, we started collecting data for our quality measures. But it took a while to get our NextGen practices plugged in to the HIE. I would say some sites took nine months. That was a function not of eClinicalWorks, who was chomping at the bit, but of NextGen. They required an upgrade on the first hospital's system. So first they took three months to tell us they could do it but the hospital needed an upgrade. They took another month to tell us which upgrade was needed. Then they said they would have to schedule that upgrade for three months out. It is very frustrating to work with vendors that are on the sending side. We have a Greenway OB/GYN group plugged into the HIE, but they are not able to capture all of the quality data for us. We are getting some of it. The interoperability is incomplete, and getting the interoperability done in a timely fashion was hard. The vendors on the sending side all act like every time is the first time they have done this. They are big boys. I am sure they have connected before. What may be a little bit of an issue is that eClinicalWorks is viewed by them as a competitor. The biggest win of using eClinicalWorks CCMR is that it lets us see the patients who don’t present to us on their own. In population health, we can’t rely on coordinating the care of the patients who present. We have to take care of all the patients, particularly the ones who don’t present or who get their care outside of our system. eClinicalWorks CCMR allows us to have a look at the cost, utilization, and behaviors of all the patients in a physician’s panel or the organization’s panel. We would never have that if we had to rely on just the EHR or the claims data alone. We need both together. We were taking a risk with eClinicalWorks CCMR because we could have purchased an out-of-the-box solution. Instead we chose to help create a custom-designed product that specifically met our needs. That was the right thing to do, but we underestimated the development time. The biggest challenge was getting the data and filtering and validating all the data. The product is very positive now and looks fantastic. eClinicalWorks has been a fantastic partner to work with. They recognized that the application needed a lot of hands-on development, and we have had their attention right from the top. Last year, eClinicalWorks CCMR was really conceptual, and now it is an actuality, so that is a phenomenal improvement. It has improved beyond the projections we made last year for this point. The response time is also much better than it was. Epic Epic has a lot of capabilities, but we haven't implemented all of them yet. Healthy Planet pulls together a bunch of tools that were already in existence and allows for greater ease of implementation and packaging. That is very useful. The tools are well integrated into the core platform, so users don't have to go outside of it to gain access to the registries. The registries are integrated operationally into the things that users want to do within 220 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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the Epic platform. If someone had an outside product, Healthy Planet might not work so well. The integration is key. We are in many different states, and some of those communities are Epic rich and some are not. Epic Healthy Planet is still developing and maturing. Epic appears to have come late to this game. They need to put more time and resources into the software to make it ready for prime time. Currently all of the functionality is embedded in the software; nothing is not being sold as a separate module. And the maintenance for Healthy Planet comes with the purchase of the product. Epic Healthy Planet utilizes multiple preexisting tools that Epic already has. For data warehousing informatics, we have purchased SAP’s advanced tools, and we are in the process of implementing those. They will utilize Epic’s data warehouse that is included in the Cogito product. We are populating the data warehouse right now. Each day, we put in new data as well as a chunk of old data we are back-loading. When that is all done, we have to go through a validation process because the data warehouse gets its data from the Clarity component of Cogito. The data warehouse reformats all the tables, so the validation process is a little more complicated than just validating a number of rows or columns in a table. I think that Epic Healthy Planet is a tool that takes time to fully utilize. Some of the basics aren’t that difficult, but some of the more advanced features take time, and they certainly tie into our reporting capability as well. Healthy Planet is not a typical Epic product in the sense that a lot of it is made of things we already have. We just have to enable or use it. My informatics team has tried to target specific examples to help our healthcare system and show how things can be done. One of the issues that came up is that people say our volumes are down. I look at that and say we are our own biggest referrer. We developed a metric that said how many referrals were completed or scheduled to be completed in 30 days out of all the referrals written in our healthcare system. The maximum level was 48%, which was really surprising for me as a PCP because I thought more than half the time, patients did what I asked. We have processes in place so that any time a referral is written, it gets routed to somebody accountable for scheduling that referral. We have been able to increase our 30-day referral completion rate from 48% to 61%. That is an extra 6,500 appointments per month and an extra million dollars net revenue to our healthcare system. We have the data and the tools, but we need the people and the processes. People look at that 48% number and say that is terrible. There is no value in that. The value is made of the people and processes to improve that number to 61%. We are in a state of transition. We have used other solutions in the past for population health management, some of which were focused on the same population that is being covered by Epic and that would tie to our legacy EMR. We also had comparative databases that we used, one of which we used for population health management. That database focused mostly on the sickest of the sick as opposed to a general population. Population Health Performance 2014 I 221

We used another product to essentially drive position dashboards, and I would say where we are right now is primarily because of the role Epic played. We now have a new data source and a lot more physician practices and hospitals that are on the same EMR, so we are trying to figure out what kind of capabilities we have with Epic. We are in the process of identifying what those gaps are. I think our biggest goal would be to reach the ninetieth percentile in terms of quality benchmark measurements within our organization. Other, more tangible goals at this point would be in regards to the project build. We use Healthy Planet a lot like reporting tools, but the scope of it and the actions we take have changed a little bit. Epic's support is readily available and responsive, but they donâ&#x20AC;&#x2122;t always have an answer. It takes them awhile to find a solution, and they often look for solutions from what other organizations have done with workarounds and so on. Healthy Planet's risk stratification is very young, but we do hope to upgrade to the newer version, which should have some better risk stratification. Healthy Planet is not a module where all the tools are. Healthy Planet is a collection of capabilities in different tools working together. We are basically using the same tools included in EpicCare ambulatory. The difference is that Healthy Planet has a rules engine, and the rules engine is able to take a look at data that we have identified and mapped to certain concepts or terms. Those concepts can be written into rules for inclusion or exclusion criteria to determine who gets into a registry or into a cohort. Those concepts can also be used to identify interventions, tests, or treatments that need to be done for a cohort of patients based on rules by frequency of interval or by goal. I think the overlay is that the clinical rules engine is able to gather all the information flowing into the EMR for a patient, then abstract that information and get an actionable summary-level view. We have worked mostly with Epic technical support and talked to some other organizations who have Healthy Planet to help us through this build process. With any EMR project, we have to expect there will be some building involved. We canâ&#x20AC;&#x2122;t just implement a product and turn it on. We have to build it to our specific needs. We should also first do an assessment of what data we have and what data we donâ&#x20AC;&#x2122;t have. Evolent Applying for the MSSP and becoming an ACO were simply some pieces of the puzzle that we came up with that we felt were necessary to be successful and allow us to start our journey into population health. 222 I Population Health Performance 2014

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Explorys Like everyone else, we have population health as a major part of our strategy for the coming year. We are growing our physician networks, building HIEs, and increasing our data breadth so we can join our professional and acute care data through an EMPI and do population health across the continuum and at the selection, measurement, and performance levels. The thing about analytics platforms is that they take a while to establish. Everybody has them, but they are a big deal to change because they have to be fed the data. After a contract is signed, it takes a while to get the analytics going. Our providers barely log into Explorys even when we show them all the clinical quality measures that are available. It is generally the practice managers and other managers who log in. The truth is that we are not going to be as successful as we need to be until we get single sign-on from the EHR into the population health platform, or until we are actually bringing the data for the risk models into the EHR. We have to do those things before the providers are really going to use Explorys. Surprisingly, Explorys as a whole is going through some growing pains. The reason that surprises me is that the company founders have a strong software background. When they upgrade a module in the production environment and it breaks a previous module, that to me is a sign of growing pains because it shows they are not thinking through configuration and change management and all that. They are struggling with things from IT 101. A year or so ago, I might have scored Explorys higher than we are scoring them now because then we were still excited about building and getting things together. As Explorys has continued to grow and add clients, we are just not really seeing them add the robustness to the system that it really requires to move on. The newer clients are still in the wave of excitement. It isn't that there is no value to the product, but it certainly hasn't reached the potential we hoped it would. Explorys has just about everything, including claims, EMR, and lab data. That includes claims that we have access to. We have access to the CMS claims and our self-funded health plan claims, so we send those there. Some of the claims in our value-based contracts we don’t have access to, so unfortunately we can’t send those. We don’t get data from any HIEs because of some use laws in various states. We had hoped to incorporate some home health or long-term care data from our HIE into Explorys, but we haven’t gotten there yet. Forward Health Group Any behavioral health clinic, especially those without an EHR, wants to be able to do data collection and analysis to see what happens between when patients come in and when

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they leave. We are in talks with Forward Health Group to be able to see progress in terms of how the aggregate of our patient population is doing during a certain quarter. Forward Health Group’s service is very supportive and prompt. It was a very good price. They got a resource local to our county that all the behavioral health providers knew, which was very smart. That served their clients well. PopulationManager® is a little less intuitive for navigation and results data entry. There is room for improvement there. There are very simple things that could be easily fixed on Forward Health Group's end, like how the data fields are broken apart and how the data is laid out. If I enter five different entries for BAM, PopulationManager® shows me all of them, and it takes me longer to navigate to make sure I have the right field open. That could be cleaned up a bit. Some of the data fields take me right to a calendar, which is helpful sometimes, but I can’t get out of the calendar. If I have waited a few months to enter data, it is harder and more time consuming to go back. When entering or creating a new patient, PopulationManager® doesn’t track the patient ID, so I have to go through my entire patient list to figure out the next new patient number. It would be nice if that information transferred automatically rather than having me enter it manually. If I am not careful, I could duplicate a client ID. I have had a phenomenal contact from Forward Health Group. The representative is fantastic and very responsive. I haven’t had to wait for anything. If I have an issue, it is resolved within a very timely manner. Forward Health Group is very responsive as a company and great with communication. They give a heads up on what is going on, and they are very supportive in coordinating things. Our experience has been phenomenal. Kryptiq Kryptiq CareManager is a good fit. Kryptiq has been very helpful in terms of making all the forms available to integrate with our EMR. They provide a lot of support for customizing the forms, so we can provide more functionality to the doctors and collect the data needed for reporting purposes. Their customer service is easy to use, and the implementation of the system was very easy. The Kryptiq CareManager dashboard is pretty user friendly. It is all color coded, and I think it is pretty easy for most people to understand. It allows the providers to see our full panel of patients. Kryptiq's clinic team is going to help them with their PCMH accreditation and continuing efforts to improve patient care. Kryptiq provides encounter forms we can use within the EMR that tie back into CareManager. One of the encounter forms has a control panel that gives the providers an overall view of patients' needs based on their diagnoses. Providers can filter the data based on their criteria or what they are doing for an office visit. They can filter it, create one letter, and send out a customized letter to each patient. 224 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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The system lacks functionality to automate the process of reaching out to patients with things like reminders. We actually submitted an enhancement request about that. Also, the reporting could be enhanced. That is what the providers want to see. They would like to explore reports, filter data, and manipulate data. Kryptiq CareManager started as a disease registry, and that is not really a good model for population health, which is really for focusing on individual patients. When we started the implementation, we were focused on the disease registry. Then we realized that it wasn't necessary in a clinical setting because patients have multiple diseases and we cannot isolate a disease from a patient. When we tried to manage patients from a disease angle, we missed things. If a patient had diabetes and coronary heart disease, we might focus on the diabetes and miss things for the coronary heart disease. The software could help with this problem. I heard that Kryptiq is going to develop some functionality around that in a release that is due at the end of this year. We have been communicating with them about the issues we are running into, and they seem to listen and have an open mind. We will know by the end of the year whether we can stay with them. McKesson From a technical perspective, we are struggling with multiple disparate systems and getting data in a workable way that we can share seamlessly. From the clinician side, it will be a challenge for us to weave the systems into the physicians’ workflow. In the past, I have used Epic, and we were all on one system, so having so many different systems is going to be a challenge for us. It is going to be a challenge to get physicians to leave their EMR to log into another third-party system like McKesson or Conifer Health Solutions to see if there is a gap in care. We have to look at a way we can more seamlessly integrate that into the physicians’ workflow, whether it is through a link within their EMR or presenting that data within their normal workflow. It took a year to get live with McKesson Population Manager with a big billing file extraction, and that was much longer than we expected. The implementation has gone fairly well, but we have had issues with the population management and risk side. It was challenging to get ramped up. We are evaluating other vendors to replace McKesson. If we could get the data in a format we could consistently trust we would be able to realize some benefits, but we aren’t there yet. We are still validating accuracy of the data and questioning it. From a customer relations’ perspective, McKesson gave us a resource to help get our physicians’ 837 billing forms uploaded, which was great. As we have tried to roll out McKesson Population Manager and McKesson Risk Manager, we have had challenges getting the support we needed and experienced a lot of delays. One of McKesson’s challenges has been the turnover in their project team. People who are assigned to us have not been with us from the beginning, which makes it difficult to keep things moving. Population Health Performance 2014 I 225

McKesson has been interested in making sure we have the resources we need. Our original license only came with so many logins for our users on the back end to do ad hoc reports. McKesson has allowed us more of those users as an olive branch to continue the relationship. They are interested in maintaining the relationship, but it has been a struggle to get issues resolved in a timely manner. McKesson’s executive involvement has had quite a bit of turnover. We have been through three managers over the last year. The new person we have now is very engaged, and things are starting to move in the right direction. McKesson has done a good job of communicating with us. They just haven't always told us the message we hope to hear. McKesson Population Manager is a little stronger in terms of its quality reporting and some of its registry pieces. MedVentive came from a more clinical background, so the solution is a little weaker on the claims side. I am having far too many conversations with McKesson's executives because I am not getting timely responses from those who are tasked with the day-to-day work. The executives are responsive, but I don’t feel like I should have to talk to them. McKesson seems sort of locked into a clocklike waterfall approach. When we talk to them about changing their cycles or anything, they are not even able to entertain the idea. Our main challenge is that one site decided early on that they were going to use McKesson Population Manager and rammed it down the throats of everybody else. We could not get McKesson Population Manager off the ground. It can’t ingest data at the rate we need. Only one site in our group was able to get the data into the tool and still be able to manage it. So now we have an ongoing fight with McKesson. Some sites tried to send data to McKesson Population Manager. It ingested some of the data, but the data did not come out in validation as being appropriate. We have asked McKesson to extract that data back out. We are reevaluating our strategy as an organization. One of the chapters within our organization is still using the tool. We need to evaluate whether McKesson Population Manager is a tool we need. If we do need it, then we will have to power through. But we want to take a step back and get a road map of what we want to do. Initially, we just got an IT tool and thought it would do certain things for us, which is exactly the opposite of what needed to happen. McKesson Population Manager may end up being our long-term solution. But even McKesson Population Manager cannot be successful if we do not have a clear direction of what our road map is. Much of our struggle predated my involvement, but my perspective is that IT solutions can do a lot for us provided that we know what we want and that we don't get a tool because it looks really cool. We need to know which metric we want to use, how we want to use the tool, and what kind of data we have that we 226 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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want to be able to report on. Then we need to find the tool that matches that as closely as possible. Population health strategies are not EMRs, but what we learned from EMRs is that we cannot tie best-of-breed components together and really get any picture of what is happening with the patient. A nearby provider decided they were going to have the bestof-breed order entry and the best-of-breed documentation, then knit them together. But it turned out they couldn't do that. We cannot get a full view of the patient because we are spending all of our time trying to reconcile between the databases. I completely agree. There are lots of reasons we had a failed implementation of our pathology tool, but one of them was just all of the different databases and how it was actually impossible to actually reconcile them. Our strategies with McKesson have shifted a bit because we are closing down our PHO in deference to a new organization and anticipating moving to a different kind of approach. We didnâ&#x20AC;&#x2122;t really use McKesson for reducing readmissions. We might very well have been able to, but we ended up using hospital-based systems to do that. Instead we focused on the CHF readmission project and intervening to prevent readmissions where we could. Those projects were both very successful. We did reduce readmissions, and there were shared savings in the commercial contract with the health plan on the CHF populations. I think we maybe reduced the penalty or set ourselves up to not have a penalty when Medicare used those years of data as their comparison option for Medicare readmissions. People underestimate the complexity of population health and what it takes to bring up this technology. To a certain extent, I blame some of the vendors that are out there. They come in with their little sales pitches for standard HL7 interfaces and CCDs and tell us that we can bring their data aggregation tools up within six months. They all say that will take six months. Identity management is a major key, as is understanding who the doctors are and being able to reach out to the doctors and their business partners. We are still trying to get claims interfaces from one particular vendor for more than a dozen of our practices. Medecision The Medecision Aerial for Population Health Management acts on the lists generated by ColdLight Neuron. The Medecision system is not very smart. It has some rudimentary predictive analytics, but it is not planned very well, so it doesnâ&#x20AC;&#x2122;t do much of the heavy lifting. We integrate everything with ColdLight Neuron. Medecision Aerial for Population Health Management is a standalone product today. Medecision's contract negotiator was not very good. We did not enjoy working with him.

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Optum In terms of managing a population, the data that is in EHRs will be critical, but not sufficient. We also need claims data for a whole bunch of reasons. It provides information about the costs, but it also gives us a view of things we might not touch. We have EHR data for the patients in my practice. I may have a lot of things from my network, but if my patient ends up across town in a different network that I am not connected to, I may not know that. But claims data that pays everything will have those other views that we may lack. Claims data is important. It gives us the big picture. It gives us the cost information, but that needs to be married with the EHR data. One of the interesting things we noticed as we talked to vendors is that they often try to price their platforms based on certain populations of patients. That doesn’t make a lot of sense to us. Patients are dynamic as they move from one risk stratum to another and back, so it doesn’t make a lot of sense to narrow the use of a product to a specific group of patients or specific risk stratum. We want to be able to consider our entire population and focus in as we desire based on risk stratification and capacity. There aren’t a lot of vendors that have been really successful at taking claims-based analytics and clinical-based analytics and pushing them together into a single analytics platform. If Optum is successful at that they will be in a very good spot and be very helpful to us, but I don't have a clear line of sight yet for bringing all that together. I am critical there because I can't get Optum to articulate exactly what their strategy is. Conceptually, they have really good products on the claims side with their Impact Pro and Impact Intelligence products and with Humedica. It is potentially a powerful set of tools. The jury is still out on that, but I like the platform conceptually. We will be watching Health Catalyst very closely, and if they are successful in this area, we would clearly shift gears. We are still optimistic Optum will be successful at making all this work together. We don’t have any claims data going into the package because we don’t have any at-risk contracts, but we are rapidly approaching that point. One of our frustrations with the market in general is all the insurers who hold the claims data want us to use their reporting package. We are part of an initiative with several payers, so we get one report per payer on the financial side, but none of that is integrated into Optum Population Analytics. Our hope with the integrated Optum tool is that it will finally be the integrator of both claims and clinical data. We have a vision that the moment any patient is in a transition, we want to know what that patient's risk is for readmission. We want to get patients into a patient-centered medical home and have all the information between the hospital and outpatient environment be centralized. We want to be able predict high risk, have the opportunity to intervene, and then have the communications go securely across the network. That is the goal. It is hard because it feels like the vendors are changing the rules. Things have all gotten so merged together that we have to reevaluate all our tools. Optum tells me that Optum One is going to have an HIE in it, which we don’t want, and that it will have care 228 I Population Health Performance 2014 This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price.

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coordination modules in it, which we have already bought. Everybody feels that either we completely do things on our own or we are beholden to companies that keep changing the components. There is a constant change in how our analytics look. Phytel Phytel Transition is a relatively new product. It is a hospital-based system. Hospitals are incentivized to make sure that patient satisfaction is high and that readmissions are low. The most critical health period for patients is the first three days after they are discharged from the hospital. That is when they are most likely to have a bad health event. If they develop some sort of avoidable complication within those three days, they are going to end up back in the hospital, and it is going to be costly. Phytel Transition sends automated calls to 100% of those patients within 48 hours and goes through a battery of questions, such as whether the patients have any questions about their discharge instructions, whether they have gone to the pharmacy to pick up their discharge medications, whether they have made a follow-up appointment with their primary care physician, how their pain level is compared to the previous day, and so forth. The patients respond by punching numbers on the keypad, and based on those responses, red flags are created so that nurses can call the patients and figure out what help they need. That is an essential component to both population health and to some of the hospital-based incentive programs. We looked at every vendor in the population health space, and our decision to go with Phytel was based on a combination of their history in the space because they have been innovators, from my perspective, and the fact that they are a pleasure to work with. When I think of a vendor partner on a national level, I want somebody who will view us as their first customer. By that I mean that beyond the sale, I would like the company to educate everyone from our market operations leaders down to the practice managers or anybody else who wants further training. Phytel provided us with one-on-one training; they gave us a very detailed implementation plan and support every step of the way. That brought tremendous value. We care not just how the product works, but how it is received by our staff and physicians because that will lead to how well it is adopted. In that respect, I found Phytel to be a class-A partner. Our goal is to go for more of an enterprise solution. Tenet started as a hospital-operating company. We started hiring physicians to feed into the hospital, and then we went with an outpatient ambulatory strategy with freestanding emergency departments, urgent care centers, and ambulatory surgical centers. We are now partnering with CVS and Walgreens to support those. We are currently looking at ways to manage our employeesâ&#x20AC;&#x2122; health. Whatever the point of entry is for our patients, we want to make sure we get them the right care at the right time, and once we get them the right care, we want to help manage their health for the rest of their lives. We want to make sure we keep patients in the system from a business standpoint, but from a population health standpoint, we want to make sure we are routing the patients to the appropriate places at appropriate times. Population Health Performance 2014 I 229

We narrowed it down to three vendors and then finally chose Phytel. It was about 52 days from signing the contract to literally ingesting our data from all our different systems. Premier We havenâ&#x20AC;&#x2122;t engaged Premier for any specific kinds of projects. We have just had an ongoing engagement for a few years. We have engaged Premier to help with the development of shared savings models, care management programs, infrastructure, other standalone organizations, and so forth. There are a lot of services included in what we pay. We will continue to use them continually for the same collaborative needs that we do now. Premier will go out to research various products and then offer them up to providers for opportunities to participate. So when the budgets are tight from a data analysis perspective, we have leveraged what we are able to get out of our health plan and a lot of things to that end. I think what I appreciate about Premier is that they can narrow down the list with us really quickly and at least give us some options to look at. And then if we choose the one that they happen to choose, then they typically will be able to give us a pretty good discount because they have been able to do some leveraging with those vendors. What becomes very challenging is when we are very tight on resources and have more projects than there are available time resources. Premier can help us expedite projects, but it takes time to keep engaged with them, and that becomes the ongoing challenge. We have plenty of opportunity to engage with them, but we have got to put in a lot of effort to reap the benefits. If we donâ&#x20AC;&#x2122;t go to the annual conferences or participate in the monthly committee structure, we lose out on a lot of opportunities. Valence The go live was awful. I would say that it took us almost three years to make all the community connections. The registry is in the tool, so I am not using any other registry to feed into the tool. Verisk Health Our issues with care coordination are partly network-composition issues and partly tools issues. Our care coordinators work across our employed and affiliated clinics, and there is currently no single-source platform for their data. They spend part of their time in the Verisk Health system, part of their time in the Epic system, part of their time in QlikView, and part of their time in the 29 non-Epic EHRs in our network.

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Our utilization of Verisk Health Medical Intelligence has really ramped up in the last few months. We finally have all of the data in the system. Getting the data in and validated has been a bit of a challenge. We are getting to where we need to be, but it has taken a little longer than we planned. We thought we would be further along by now. The implementation didn’t come together very well, and the quality of the data was a problem. We would get the data in the system, but the results wouldn’t look right. Wellcentive I would say care coordination has definitely improved. I will have a better gauge of that once we roll Wellcentive out in our second region. In the second region, we have a patient-centered medical home pilot program where we will have two RN care coordinators live in the application and accept EMR data from 16 different practices. The bulk of those practices have different EMRs on different table spaces, so there will probably be about 12 interfaces coming into the application. This will be a hub-and-spoke model with the two nurses coordinating care across all of these primary care practices. The primary care practices will be staffed with ARNPs and other mid-level employees, so each practice can manage their scheduling based on the care coordination of the nurses and their assessment of risk levels and care gaps. We will have claims going into Wellcentive so the RN coordinators can see whether a prescription was filled, whether a patient showed up for a primary care appointment, and whether a patient’s appointments outside the scope of our program were with primary care doctors or specialists. The care coordinators can help the practices follow up and close care gaps. It has been ten months, and our go live still isn't completely done. We are still working through our implementation and data validation. We are essentially going to have to reimplement. Greenway is not a great partner for Wellcentive, so we have to do a lot of digging ourselves to identify the SQL mappings on the backside of Greenway. It is a bit more laborious than we ever had really planned. The EMRs are the source of truth, and data from the EMRs, as well as other primary source data like lab and radiology results, comes into Wellcentive either through direct interfaces, feeds, or files we pull and import into the tool. There is a very specific way we vet data. We check the kind of data we are taking, the primary source of the data, whether the data is valid and reliable, and where the data is mapped in Wellcentive. We do validation maintenance routinely for all the input data. As Wellcentive processes that data for use, there are specific data points identified that are valuable to provide output to appropriate payer partners to assist them with reporting and managing incentive programs. We were one of the first organizations to start on Wellcentive Advance Outcomes Manager, so we were there early on in their adventure of starting this company. Our process was extremely long and very difficult, but I don’t know whether that would be the case for a new client today because of all the changes Wellcentive has made. They have grown significantly since we went live with them. Population Health Performance 2014 I 231

Wellcentive just has trouble executing. They will reorganize and try to change to better serve the customer, but that never works. Each time it just slows things down. They have trouble getting to everything. I have 12-month-old requests for interfaces that I have committed to pay for that Wellcentive hasn't even started on yet. They haven't gotten around to getting the resources together and executing. They need a lot of prodding to execute, meet dates, and respond. I think they are having difficulty managing either their growth or the demand.

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