Through the use of technology, analytics, and interoperability, this workgroup recommends practical, patient-centric outcomes that improve care for patients with chronic conditions. Specifically, the workgroup is trying to create a seamless integration of data and information sharing for patients with diabetes and heart conditions, two chronic conditions with significant impact to all stakeholders in the healthcare ecosystem.

LEADERSHIP:

• Brian Ahier, Director of Standards and Government Affairs, Medicity an Aetna Company
• Al Kinel, President - Strategic Interests, LLC
• Patrick Sauer, MHA, FACHE, CMPE, Innovation Officer, Optum Corporation
• Theresa Wilkes, MS, RHIA, CPHI, CHTS-PW, Medical Informatics Strategist, Alliance for eHealth Innovation, American Academy of Family Physicians

GOAL:

Use the patient persona "Oscar" to render a more friction-free care experience for both patients and providers in the longitudinal health of patients with chronic conditions. Oscar represents a patient with heart disease, diabetes, and depression. Challenges and solutions will be identified for Oscar's care journey. Discussions in this workgroup center around closing gaps in data, removing barriers to sharing information, educating patients and providers about consent around data sharing, potential uses for labs and lab data, incentivizing patients and providers to share data, remote patient monitoring, and patient engagement.

About Oscar

• Oscar goes from primary care provider (PCP) to a specialist (cardiologist, endocrinologist, etc.) for his heart condition and diabetes) and back to PCP
• The PCP and/or specialist orders diagnostic studies (labs, imaging, etc.) to understand the whole picture of Oscar's health
• Oscar had an event and was hospitalized (either in a hospital within his home network/health system, or in a hospital outside his home system)
• When Oscar comes back to his PCP’s data / information on his hospitalization is missing, niether the PCP nor Oscar has the information
• Oscar needs help to be linked to community services for his active conditions (members of his broader all encompassing “care team” that support his longitudinal health and quality of life)
• Oscar and his entire care team need ALL the data from any of his medical encounters so all are aligned or re-aligned on the care plan, patient activation, etc.  
• Oscar is asked by his providers to capture bio-metric information from devices periodically, such as glucose readings, blood pressure, activity, pulse-ox, etc, so they can better understand his condition between appointments, and identify changes required

PRIORITIES:

• Improve patient consent to data sharing
  • Educate patients and providers about the implications of patient consent, the exchange of data once consent has been granted, and the policy implications of data sharing
  • Identify resources, methods, and tools that enhance patient’s ability to access, control, and share their data with authorized providers, including economic and business models, legal and data sharing agreements, organizational models and communications guides
  • Incentivize and remove barriers to data sharing; close gaps in provider data
  • Automate patient consent and promote the ability of providers to access consent information
  • Possibly address challenges associated with disparate state policies
• Use data, analytics, and digital health tools to help providers and payers improve population health; link critical measures to actions which identify patients most-at-risk
• Identify and close associated gaps in care, and enhance patient engagement and compliance
• Align this workgroup with priorities, approach, findings, and content of other workgroups

 

MEETING HIGHLIGHTS:

February 2018	Highlights from eHI's Executive Summit, the Roundtable on Technology & Analytics
April 2018	Begin to develop the 'Oscar' persona, the patient with a chronic condition on which to model best practices and address priorities
May 2018	Review of best practices with Oscar as the frame of reference
June 2018	Policy Steering Committee Updates
July 2018	Optum presentation: Artificial Intelligence Used to Predict Atrial Fibrillation
August 2018	NeHI presentation: Analytics Journey; 4Medica presentation: Solving Patient Identity Matching
September 2018	Rochester Regional Health Presentation: Best Practices in Interoperability
October 2018	Point of Care Partners presentation: The Role of Standards in Value Based Care
November 2018	Interoperability Standards Advisory (ISA) Overview by Brett Andriesen, ONC; Maintaining a Value-Based Care Model with Innovative IT Infrastructure by Dr. Raul Vasquez and Dr. Chet Fox of Greater Buffalo United ACO.