While widespread adoption of electronic health records has generated new streams of actionable patient data, John C. Lincoln has taken data mining to new levels to enhance performance of its accountable care organization (ACO).

Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).

In this 25-page report, Karen Furbush, business consultant, and Heather Jelonek, chief operating officer, accountable care organization, John C. Lincoln Network, describe the sources combed by the ACO to address operational and technological challenges during the pre-launch period, and how these efforts and resulting data enhanced quality measurement and reporting for the JCL ACO.

This HIN special report provides details on the following:

• Workarounds for data gathering that help to reconcile disparate EMR systems;
• Creation of a care transition team that tapped a valuable and underutilized worforce segment and the team's impact on readmissions rates;
• Immediate changes made to workflow processes;
• Enhancements made to the patient health questionnaire;
• The challenges of scouring CMS claims data to highlight gaps in care;
• Enlisting physician practices to help fill in care gaps and provide feedback via a new Physician Network;
• Leveraging monthly ACO reporting calls;
• Updating its Medicare Wellness Template to identify care needs for its aging population;
• Analyzing integration opportunities;

and much more.

Table of Contents

• Performance Quality Measurement and Reporting for Accountable Care
  • John C. Lincoln ACO Structure and Team
  • JCL Transition Coach Program
  • Tactics to Reduce Avoidable Utilization
  • Addressing ACO Operational and IT Issues
  • Responding to CMS Quality Reporting Requests
  • CMS Reporting Vs. Performance
  • Addressing Care Transition Measures
  • ACO Patient Navigators
  • ACO Quality Reporting Calls
  • Parsing Quality Measurement and Reporting
• Q&A: Ask the Experts
  • Reporting Quality Data to Physicians
  • Workflow Changes to Boost Prevention
  • Accounting for Out-of-Network Patients
  • Comparing Care Transition Coaches to Patient Navigators
  • Salaries for Care Transition Coaches
  • Scanning Records for Quality Data
  • Candidates for Home Visits
  • Scheduling Medicare Wellness Visits
  • Updates to Patient Questionnaire
  • Contributions from Transitional Care
  • John C. Lincoln’s Physician Advisory Network
  • Impact of Changes to Patient Health Questionnaire
• Glossary
• For More Information
• About the Contributors