Dr. Terri Steinberg shares how Medecision’s Aerial platform helped ChristianaCare’s CareVio program achieve success.

By Terri Steinberg, MD, MBA, FACP, FAMIA, GSVP, Chief Medical Officer, Analytics & Population Health at Medecision, former Chief Health Information Officer and VP, Population Health Informatics at ChristianaCare

As the chief health information officer and vice president of population health informatics at ChristianaCare, I was able to share the perspective of two types of healthcare organizations—a large health system in the small state of Delaware and a care management company.

When ChristianaCare, a network of private, nonprofit hospitals headquartered in Delaware, began its virtual health journey in 2012, it was with an Innovation Grant from the Centers for Medicare & Medicaid Services (CMS). The grant’s purpose was to design an electronic care management program—a patient portal and personal health record that would enable patients to better communicate with their care management team. We set out to find the best-in-class care management application—and we chose Medecision’s Aerial solution in 2012.

The patients who came to the ChristianaCare emergency department received care at facilities across the state, so it was very important for us to break through barriers and silos of data. We built a data structure that included claims data and clinical data, and then we expanded to include socioeconomic data. Finally, we implemented a machine learning, big data platform, so that we could segment our population and really customize care plans to those members or patients who are at the highest risk. We used predictive analytics to coordinate care, identify at-risk populations, and help prevent the need for hospitalizations or emergency department visits through preventive care. Today, our nationally recognized care management program—CareVio—manages more than 100,000 patients, most of whom are not ChristianaCare patients. We wanted an industrial-strength care management application to help drive these efforts, and that’s what we got with Aerial.

Finding Our True North

In 2012, when we first dipped our toes in the value-based care pool, we quickly learned that the most impactful services we can provide are the ones that you can’t bill for—like food security, transportation, affordable medications and providing excellent medication reconciliation. These things are critical to the health of a population—but when we started this journey eight years ago, there were no billing codes for these services.

We’ve long believed that the future of healthcare is virtual, and that population health is ChristianaCare’s true north. We firmly believe that anything that can be done in the home should be done in the home—and this really drives the need for a virtual platform. Does this mean that doctors should abandon their electronic health records or that care managers need to jump ship from using the Aerial platform? Of course not. Providers should stay in their native foundational workflows—in fact, everyone should work in the system that is suited for the work that they do.

But what it does mean is that it’s essential to develop a technology that surrounds and augments these foundational workflows so that a patient can be managed over time and across venues of care in an integrated, longitudinal manner—instead of the old, episodic method that has been used to care for patients. That’s what interoperability is all about: allowing everybody to stay in their own system, but breaking down the transactional barriers separating healthcare systems, types of providers and types of services.

For example, with CareVio, our care managers partner directly with providers. When a result hits the CareVio database, it doesn’t matter whether it is the care manager or the doctor’s office making contact with the patient. What the patient knows is that the person reaching out is part of the care team and has full knowledge of what has happened to the patient. And this knowledge is obtained within the provider or care manager’s foundational workflow! You can’t have people on the phone with patients, flipping between screens trying to find the right information, or doctors working from spreadsheets or in their offices making lists of calls. We know that doesn’t work. But with Aerial, its integrated system allows care managers to stay in their foundational workflow and support the care managers and providers best.

The Importance of Data

With CareVio, we look at four types of data: claims, clinical, social/economic, and transactional (ADT). CareVio receives real-time data alerts. For instance, say a patient goes to an emergency room at a hospital 100 miles away from home. The care manager gets an alert—when the patient is still in the waiting room! Very frequently, a care manager will pick up the phone and call the emergency department to say, “Mr. Smith is well-known to us. Here’s some of his medical history. If he’s able to come home today, we’ll make sure someone is at his house to assist him.” You can imagine how critical this is in terms of avoiding readmissions. Similarly, when a discharge transaction occurs hundreds of miles away, the CareVio care managers can see that and immediately begin to transition care.

Finally, there is the new world of socioeconomic data. Knowing that an individual has changed addresses 10 times in a year helps us address a really important risk factor in healthcare. Having access to socioeconomic data helps us identify individuals who may have untreated conditions like hypertension, which could lead to chronic renal failure—a very expensive outcome. Identifying those individuals earlier could help them avoid expensive and debilitating long-term outcomes.  One of the questions we would like to address is, when you have comprehensive data as we have, are there any data sets that are duplicative or less important.

Care Management Is the Glue

It bears repeating that all of us at ChristianaCare and CareVio truly believe that anything that can be done at home should be done at home. We believe that healthcare should be continuous, longitudinal management—not disconnected episodes of care. Care management is the glue connecting the annual physicals, the visit to the surgery center, a check-in with a specialist. Care managers will gradually become the go-to individuals as they surround and augment the work of providers and others, making patient outreach frictionless and instantaneous, and making patients feel connected to this healthcare ecosystem.

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