Hixny 2015 Annual Report

2015 Annual Report

S U PP O RT I N G T R A N S I T IO N S O F C A R E Page 21

2015 Hixny Annual Report p. 4

Letters from the Board Chair and the CEO

6 Proactively Supporting an Ever-Changing Landscape

10 Supporting Enhanced Care Collaboration

14 At Risk Populations

16 Proactive Care Delivery

21 Supporting Transitions of Care

26 Supporting Patient Engagement

28 Strategic Planning for 2016 30 2015 Board of Directors

Hixny

15 Cornell Road Latham, NY 12110

Design: id29, Troy, NY

Š 2015 Hixny

Always at the forefront of innovation, Hixny is continuously expanding its services in order to meet the needs of the healthcare community.

Much more than your average RHIO and HIE, Hixny offers solutions for improved care coordination and population health management.

In order for customers to better understand how Hixny is supporting population health, the brand has undergone some strategic changes; a refreshed logo, a new services structure—Hixny360, and a productized patient portal— Hixny For You. Our goal is to reflect what we are already doing in a much more compelling and persuasive manner by strategically polishing our existing brand in a sharper, more differentiating position.

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Letter from the Board Chair John D. Bennett, MD, FACC, FACP, President & CEO, CDPHP

M

y former life as a cardiologist taught me a few things about the importance of connectivity, interoperability, and having the right information at the right time.

The large practice I was running had an electrocardiogram (EKG), a nuclear imaging machine, and an echo imaging system, all of which had to talk to one another in order to provide a complete picture of the patient’s heart functions. Communication with other providers was just as vital. Often, I would receive phone calls in the middle of the night from emergency department physicians looking for EKGs for my patients, which I would then have to fax. I knew there had to be a better way.

As Chairman of the Board for Hixny, as well as President and CEO of CDPHP, I am gratified by the role I am privileged to play in building that better path forward. I am proud of all we have accomplished, as a RHIO, and as a community striving to achieve the Triple Aim of better health, better care, and lower costs.

I believe that healthcare is as much a public service as electricity and water, and requires the same type of connectivity to be effective and affordable. Hixny spent the first several years of its existence building the infrastructure for this vital utility in our region, and our link this year to the Statewide Health Information Network of New York (SHIN-NY) means that we now have connectivity extending across the state. No matter where a patient seeks care in New York, there is connectivity. And this means there is deeper, more meaningful exchange of health information.

This past year has been a momentous one for Hixny, in large part because we moved past building infrastructure and focused on improving the value of what that infrastructure is delivering. As a former physician and the head of the area’s largest health plan, I can see the benefits of these changes to the community quite clearly.

Hixny 2015 Annual Report

By expanding the types of data Hixny can accept and deliver, it is possible to share EKG tracings with emergency department physicians. This will make those middle-of-the-night phone calls and faxes a thing of the past. Physicians are also now sharing their progress and consult notes, providing a more complete picture of each patient’s history and taking some of the guesswork out of critical medical decisions.

This past year has been a momentous one for Hixny...

Health plans have been a part of Hixny from the beginning, but 2015 was the year we really became connected. CDPHP is now receiving alerts when members go to the emergency department or are discharged from the hospital. These are proving extremely helpful in our effort to achieve value-based care, and I know others engaged in that quest, including Performing Provider Systems (PPS) formed to carry out Delivery System Reform Incentive Payment (DSRIP) program initiatives, will find them equally indispensable.

Achieving the Triple Aim, and ensuring that high-quality healthcare is as accessible and affordable as electricity, demands that we work as a community.

But it also requires each of us to do our part as individuals. Hixny’s tools and services have evolved to support both collaboration and individual preference.

A prime example of this is Hixny alerts, which share vital patient information according to the perimeters set by the physician’s practice.

We have come a long way from my days as a cardiologist. I am proud of our collective accomplishments and I am excited to see what happens next.

Letter from the CEO Mark McKinney, CEO, Hixny

I

hope you notice, that our annual report has a different look this year. We have selected a magazine format as the best way to share the many remarkable stories Hixny has to tell about the ways in which healthcare in our region is positively impacted by our services.

This has been an important year for Hixny from a number of perspectives. We were one of the first RHIOs to connect to the Statewide Health Information Network of New York (SHIN-NY), the establishment of which opened doors for both providers and patients by enabling care coordination across regional boundaries.

Our certification as a Qualified Entity ensures that we will bring the same high standards of privacy, security and data quality to the SHIN-NY as we have to our own exchange.

As you will read in our story about At Risk Populations, Hixny has been actively involved in population health research through our participation in two research projects—a cancer control study and a continuation of the Million Hearts Campaign we began in 2014. We learned a great deal from both of these ground-breaking efforts, not only about our ability to support public health initiatives but about our technology, services, and data quality, which will help us improve our offerings moving forward. Notably, the projects gave us the opportunity to tap into natural language processing. We know that as much as 85 percent of healthcare data is in text, as opposed to the coded, structured data typically shared through HIEs. Progress and consult notes give context to the information stored within a patient’s record, and sharing them enables providers to make better, more informed care decisions and improve patient outcomes.

This is why we devoted considerable resources to advancing our ability to receive different types of data, and making available data more complete and clean.

I am happy to report that at the moment, 16 percent of participating practices are contributing their progress and consult notes. We’ve added scheduling data and can now accept EKG tracings, which creates a huge opportunity for emergency department personnel

who will have access to previous EKGs simply by logging into Hixny.

In 2015, our systems were accessed by Hixny users on average 3.5 times every minute of every day—more than once every 20 seconds. This is due in part to a 200 percent increase in event notifications, a 114 percent increase in direct messages, a 61 percent increase in documents delivered, and a 24 percent increase in records pulled. This significant growth in use is a result of our investment in account management resources that has allowed us to spend more time in the field working closely with our members and participants.

This has also given us valuable insight into your needs and helped us refine our technology and services.

Our accomplishments have positioned us well for future growth as we continue in our mission to improve healthcare in our community amid an ever-changing landscape.

Another key accomplishment is our work with the three main payers in our region—CDPHP, MVP Health Care, and BlueShield of Northeastern New York—who have been part of Hixny from the beginning, to give them better access to information.

And so, we will enter 2016 with better tools, improved customer service and more people aware of everything Hixny is able to provide. We will be able to leverage that information in new ways and put those tools to better use to deliver data in the way, where, and how providers want to receive it. Our accomplishments have positioned us well for future growth as we continue in our mission to improve healthcare in our community amid an ever-changing landscape.

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Proactively Supporting an Ever-Changing Landscape As 2015 draws to a close, Hixny finds itself at the forefront of a statewide population health management effort. In order to support the everchanging landscape of healthcare, Hixny has strategically positioned itself by focusing efforts in connecting to the Statewide Health Information Network of New York (SHIN-NY), population health research and development, and advancing our services to support new models of care.

Connecting to the SHIN-NY This past year, the SHIN-NY established statewide connections between Regional Health Information Organizations (RHIOs), with Hixny among the first three RHIOs to connect. The state is investing in the SHIN-NY over a three year period to enable this connectivity. Hixny completed a stringent certification process to be designated as a Qualified Entity (QE) in order to connect to the SHIN-NY. “We think the SHIN-NY is a vital tool in healthcare reform,” stated Pat Roohan, Director for the Office of Quality and Patient Safety at New York State Department of Health (NYSDOH). “[It] provides clinicians with tools and information about patients that they didn’t have before.”

Hixny 2015 Annual Report

David Acker, CEO of St. Lawrence Health System, is excited about the possibilities the SHIN-NY presents. He says St. Lawrence is “the largest county in the state most isolated from tertiary care.”

St. Lawrence Health System, parent of CantonPotsdam and Gouverneur Hospital, serves about 66,000 patients. About half of them go to Syracuse or other cities outside of the region when in need of advanced care. Because of this, hospital personnel spend precious time making calls and sending faxes to obtain this critical information. The SHIN-NY has alleviated this problem, by breaking down barriers and connecting large providers outside the Hixny region.

“One area in particular it would help in is surgical procedures,” Acker said. “Right now we are reliant upon a patient’s recollection and phone calls to tertiary hospitals to obtain information about previous surgeries. Sometimes that information shows up, sometimes it doesn’t. Sometimes it’s complete, sometimes it’s not. And that sort of information is just invaluable—to know, for instance, what the patient’s reaction has been to anesthesia.”

Hixny’s tools and services are designed to enable providers to engage and support all consumers within the community...

Like St. Lawrence Health System, Bassett Health Network, in Cooperstown, is on the fringes of the Hixny region and shares patients with providers in other regions. Dr. Scott Cohen, Chief Medical Information Officer for Bassett, said the system’s region is covered by three RHIOs, although it has only been a member of Hixny.

Therefore, “aggregating those RHIOs into one [network] ought to offer some tremendous value.”

Rob LaPolt, Senior Director of Information Management at Bassett, said the SHIN-NY should also make obtaining patient information less expensive.

Jorge Grillo, Chief Information Officer of CantonPotsdam, agreed that there are economic benefits to the SHIN-NY. “But I think the biggest benefit is not necessarily to us as a hospital, but to the patient and the New York health system overall.

That is where the true savings are going to be seen.”

Pat Roohan said the SHIN-NY is making “significant progress” on many fronts, although there are areas where work is needed. Key among them are adoption, data quality and standardization—all of which are vital if the network is to support coordinated population health efforts and bend the cost curve.

Population health research & development This past year was also the time in which Hixny continued its groundbreaking work with the Bureau of Chronic Disease Evaluation and Research within NYSDOH. This work, founded on the Million Hearts pilot research, has expanded to include grant work for obesity, diabetes, heart disease, and stroke. Hixny also worked with the Bureau of Chronic Disease Control to study the ability of a robust HIE to support cancer screening surveillance and post-screening follow-up among Medicaid patients.

Roohan stated, “We are actually pulling data out of EMRs to see: Who is hypertensive? Who is pre-hypertensive? [We are] working on the definitions, working on the data quality,” he said.

“We are trying to get standardization around these things to be able to say something about a region. So I think Hixny is really pushing the envelope on the analytics side. That is something other RHIOs can learn from.”

James Kirkwood, Director of the Bureau of Health Information Exchange at NYSDOH, added “We need all the RHIOs to be at that level of success to support the coordinated care activities we are working on across the state.”

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Advancing our services to support new models of care

“We have made great strides across New York State with the completion and realization of the Statewide Health Information Network (SHINNY) this year,” said State Health Commissioner Dr. Howard Zucker. “Thanks to the leadership of Governor Cuomo, all electronic health records connected to the SHIN-NY can now be accessed throughout the state. We have done this through a statewide collaboration in working with all of the state’s Qualified Entities to break down existing ‘barriers’ to exchanging electronic medical records.” — Dr. Howard Zucker, NY State Health Commissioner

Proactively Supporting an Ever-Changing Landscape And it was a year in which new models of care, such as risk-bearing entities, continued to develop and shift focus from quantity to quality care.

The Delivery System Reform Incentive Payment (DSRIP) program officially got underway, with healthcare organizations all over the state forming partnerships to reduce unnecessary hospital admissions and improve care. Hixny is at the forefront of this industry shift and collaborates with several risk-bearing entities to support their population health program requirements.

Data connectivity is the first step to informed, coordinated healthcare. In order to succeed, risk-bearing entities must be connected to all the providers their patients visit. Hixny, a national leader in provider adoption, has connected more than 700 entities and locations, including every hospital in its 19-county region, 274 primary care practices and 284 specialist practices.

“Hixny is a proven leader in this area,” said Roohan. Kirkwood and Roohan agree that Hixny is ahead of other RHIOs in both adoption and analytics capabilities. Roohan pointed to the Million Hearts pilot.

Throughout 2015, Hixny focused efforts in advancing its analytics capabilities to include community disease registries and dashboards, another key component in achieving population health milestones. These tools will enable riskbearing entities to track, monitor, and analyze patients at the population level, in order to administer early care intervention and reduce healthcare costs.

Kirkwood added that analytics will be an important part of the shift from fee-for-service to value-based purchasing and care coordination.

He said having high quality data from sources all over the state will arm providers with the information they need to do that analysis.

Hixny 2015 Annual Report

Hixny’s tools and services are designed to enable providers to engage and support all consumers within the community...

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SUPPORTING ENHANCED CARE COLLABORATION Hometown Healthcare, Brunswick Family Practice, and CDPHP, with support from Hixny, are partners in a unique pilot program, Primary Care Pharmacy, to provide medication therapy management and medication reconciliation services to CDPHP members. The overarching goal of the Primary Care Pharmacy initiative is to show the value—to the patient, provider, pharmacy, and payer—of embedding a pharmacist into a primary care practice to provide comprehensive, personalized medication therapy.

Leo Vovna, a pharmacist at Hometown Healthcare in Watervliet, meets regularly with Dr. James Aram and his patients at the Brunswick Family Practice in Troy. Using records from Hixny, Vovna engages with patients to ensure there are no issues with their medications, such as allergies or interactions, and that they understand and are taking them correctly.

Hixny is a key component to determine if there are issues with a patient’s medication, supplementing data from CDPHP and Dr. Aram’s own patient records.

Hixny 2015 Annual Report

In one case, an asthmatic believed his Flovent inhaler was not working, so Dr. Aram prescribed a newer, more expensive medication called Respimat.

After talking with the patient and checking refill records, Vovna realized that the patient was not using the Flovent inhaler regularly, as prescribed, but only when he felt he needed it. Correcting this meant Respimat, which had a much higher cost to the consumer and insurer, was not needed.

In another instance, Vovna discovered that a patient was taking her Doxycyline at the same time as her calcium supplement, rendering the antibiotic ineffective. By advising her to separate them, he improved her outcome.

Phase one of this pilot program began in June, and focused on the most at-risk patients. These patients are identified as those taking five or more maintenance medications a day, and have been selected for one-on-one counseling from Vovna.

As of late September, Vovna worked with dozens of patients, primarily CDPHP Medicare patients with one or more chronic conditions such as diabetes, asthma, coronary heart disease or dyslipidemia.

Casey Toomajian, CEO of Hometown Healthcare, said one of the theories behind the pilot is the idea that when a pharmacy organization collaborates more closely with a physician practice on patient care, the pharmacist can focus on trouble-shooting and disease management issues, enabling the physician to focus more on diagnostic issues. Vovna’s consultations take place immediately after the patient’s visit with Dr. Aram and are billed as part of the visit. Once, he spent 90 minutes helping a newlydiagnosed diabetic understand how and when to test his blood sugar.

“It is rewarding because you are making a difference in a person’s life, and hopefully that will translate into better outcomes for the patient,” Vovna said. “The pharmacist in the community setting, who is constantly focused on filling prescriptions, does not have time to sit down and talk with the patient.”

“As a patient centered medical home, we believe in a team approach for the delivery of healthcare,” Dr. Aram said. “With the number of drugs which are available, potential for drug interactions, the complexity of the prescribing process, and the relevance of transitions of care in a small office, we feel that the addition of an in-house pharmacist

brings an added value to the services we offer.

Hixny provides us with information about which providers the patient has seen, what encounters they may have had either in the hospital or emergency room, and what may have been prescribed at the time of those encounters. At times, this may be the only information that is available before a relevant document, like a discharge summary, arrives from Hixny.”

Every patient asked to meet with Vovna has agreed to do so, meaning the pilot has a patient engagement rate of 100 percent, surpassing the goal of 70 percent, and far exceeding regional and national averages.

In phase two, which is slated to begin in mid2016, Hixny will alert Hometown Healthcare when transitions of care occur for Dr. Aram’s patients, triggering a series of care coordination activities.

The pharmacy will, for example, look at changes in medication to correct any potential problems.

Eileen Wood, Chief Pharmacy Officer for CDPHP, said the insurer believes such efforts can help achieve the Triple Aim of lowering healthcare costs, enhancing the quality of care, and improving the health of populations. “We are very excited about working with Hometown Healthcare and Dr. Aram because it is the first time a pharmacist, who is in the medical neighborhood already serving these patients, can partner with primary care in a profound way,” Wood said.

Dr. Aram is part of CDPHP’s Enhanced Primary Care (EPC) program, meaning he is incentivized to improve efficiency in six areas, including pharmacy. He is also part of the Comprehensive Primary Care Initiative,

11

a Center for Medicare & Medicaid Services (CMS) program whose primary goal is to reduce emergency room visits and hospitalizations, in part through better medication management.

Wood said CDPHP will apply the same analytics to the pilot as it does to its entire medication therapy management program. This includes looking for any changes, such as hospital admissions and emergency room visits, in the patient cohort. The insurer will also look at how many elderly patients are taking medications considered riskier for them, something also measured by Medicare and the Healthcare Effectiveness Data and Information Set (HEDIS).

On average, 8,344 Hixny users are accessing 37,000 clinical summaries per month— That’s a

24% increase in 2015 alone

Dr. Aram said he will be measuring medication adherence and compliance, as well as tracking the number of high-risk drugs his patients take, and how many were switched to appropriate generics.

“In addition, we would be interested in looking at

Hixny 2015 Annual Report

Dr. Aram (left) and Leo

outcome studies in terms of total pharmaceutical Vovna (right) see an costs attributed to those patients participating in improvement in patient the program, as well as information about hospital satisfaction and outcomes. admission rates,” he said. “Hopefully, pharmacy costs would be reduced through a comprehensive medication management program, and similarly, errors that contribute to hospital admissions would be reduced.”

Hixny will be even more important in phase two, as it moves from being a data point to a “driver of activity” through its alerts, which will expand the pilot beyond those patients currently targeted for Hometown Healthcare’s services.

Hometown Healthcare will utilize Hixny alerts to trigger a series of care coordination activities.

For example, the pharmacy will get in touch with the patient’s case manager to find out which medications are being used to stabilize the patient in the hospital.

It would then cross-reference with CDPHP’s formulary to ensure those medications are covered. If not, it would address the issue before the patient is discharged. This should ensure the patient will fill their prescription knowing it is of covered by their health Number transactions Hixny processes insurance, thereby reducing hospital readmissions caused by not taking the medication, and significantly improve the overall patient experience.

/ 60 Second

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At Risk Populations Achieving the Triple Aim requires identifying, tracking and intervening in the lives of at-risk populations. This, in turn, requires a clinical information system with robust, valid data on these patients as they move through the entire healthcare system, and the tools to turn that data into actionable information. In New York’s Capital District, Northern Region, and Mohawk Valley, that clinical information system is Hixny.

1.25 Million patient consents out of 1.62MM people in Hixny’s region

“A cloud platform of patient-centered data is just part of what makes Hixny the right partner for stakeholders looking to improve the health of certain populations,” said Ian Brissette, Director of the Bureau of Chronic Disease Evaluation & Research at the New York State Department of Health Brissette has worked closely increase(NYSDOH). in alerts delivered in 2015 with Hixny on a new grant focused on preventing obesity, diabetes, heart disease and stroke, as well as continuing work to support the Million Hearts Campaign—a national effort to prevent one million strokes and heart attacks by 2017 by changing the way providers engage at-risk patients. The project team has included NYSDOH, Hixny, InterSystems, and researchers from the University at Albany School of Public Health.

200%

77%

Hixny 2015 Annual Report

Patients 77

%

Brissette said Hixny has proven itself as an organization whose leadership is willing to listen and understand the priorities of stakeholders, whether those stakeholders are policymakers, health plans, risk-bearing entities or the federally qualified health

In our region

Dr. Brissette is responsible for overseeing performance measurement and evaluation of chronic disease prevention programs in the New York State Department of Health.

100% 100%

centers involved in the grant projects. “So it is all of of hospitals are connected FQHCs are connected those things together—the data, the leadership,ofthe human and IT connections within Hixny’s region— that would lead Hixny to be a great partner if the goal was to track information about at-risk populations across an area,” Brissette said. of specialists are connected of PCPs areHixny’s connected Over the past two years, strategic focus patient out of 1.62MM has beenconsents on developing a technology platform that people inpopulation Hixny’s region supports health efforts with patientlevel disease registries, smart alerts, rapid-cycle analytics, dashboards, and billboards. These tools will enable providers, health plans and risk-bearing entities such as Delivery System Reform Incentive Payment (DSRIP) performing provider organizations,

1.2575% Million67%

200% increase in alerts delivered in 2015

In o

10

of hos

75

of PCP

69,032 lab results are delivered per month

Accountable Care Organizations (ACOs), and health homes, to convert Hixny data into actionable information.

By applying their own application logic to the data, providers will be able to identify and segment patients with hypertension, diabetes, cancer, asthma or any other targeted condition, and monitor them radiology patient consents of 1.62MM in out real-time.

With Hixny alerts, case managers are reports are notified if one of those patients visits people in Hixny’s region automatically thedelivered emergency room, is discharged from the hospital each month or has an abnormal lab result, and can intervene as necessary. Having this information in real-time allows providers to act quickly to fight cancer, high blood pressure and other diseases when time is of the essence. Continued monitoring will tell providers if that intervention was successful.

Hixny’s secure patient portal, Hixny For You, gives patients access to their own electronic medical record, as well as information about their increase in alerts delivered in 2015 documents are medications, prevention programs and advised delivered per month; lifestyle changes. Brissette sees all of these tools as an increase having great promise in improving population health. of 61% in 2015 “One of the big responsibilities of the next year is to test some of the tools that exist within Hixny to help support the control and diagnosis of hypertension. In the next year, we will begin to

1.2510,185 Million

15,027 200%

“Hixny is in a position to, through patient portals and other technology, provide information Patients to patients about their healthcare and help make Second77 % decisions about their number of transactions Hixnyhealth.” processes

60/ 77%

Ian Brissette of—patients in our region have given testconsent how well these tools may support primary care Hixny

providers working on these conditions.”

Now, with the establishment of the Statewide Health Information Network of New York (SHIN-NY), Brissette sees Hixny’s influence expanding.

He said the state’s pilot projects with Hixny will answer questions about the role individual RHIOs PCPs and the statewide exchange can play in population Specialists health, and that the task moving forward will 72 65 %

72%

of PCPs and 65% of specialists are connected and contributing data

be “sharing and spreading” the capacity and infrastructure Hixny has developed.

“We want to promote the advances Hixny is demonstrating statewide and there are going to be challenges to that,” he said. “So Hixny becomes an entity that helps teach and spread the innovations that it’s developed. That to me is going to be essential to the growth of the SHIN-NY. But I think if we maintain the kind of collaboration that we’ve had on these projects, we’ll be able to achieve the goals of the SHIN-NY.”

In our region

100% 100% of hospitals are connected

of FQHCs are connected

75% 67% of PCPs are connected

of specialists are connected

While there may be challenges ahead, Brissette is confident in Hixny’s ability to improve care for at-risk populations.

“Hixny is in a position to, through patient portals and other technology, provide information to patients about their healthcare and help make decisions about their health,” he said. “You are in a position where you can influence care teams and potentially, in the future, you have the opportunity to collect and provide information to different types of care providers who are outside the formal healthcare setting. Hixny has connections with health systems, Performing Provider Systems (PPSs), hospitals, and is also providing information to the state decision makers. To me, Hixny is moving information, not data, but information. Information that could inform decisions made by individual consumers, by providers, by policymakers, and that really is what makes Hixny such a powerful tool for improving population health.”

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Proactive Care Delivery Over the past year, CapitalCare has been

Dr. Panneton sees a decline in ER usage among Medicaid patients.

uses Hixny to see if her patients have had

relying more heavily on Hixny’s real-time data to

preventative screenings, such as a mammogram

track its patients and improve follow-ups after a

or colonoscopy. This information allows her to

hospital discharge or emergency room visit. In

engage with patients who are due for preventative

doing so, CapitalCare is hoping to reduce hospital

care. Conn also uses this information to complete

readmissions and improve patient care. It was in

the monthly Healthcare Effectiveness Data and

the 65th percentile for following up within 72 hours

Information Set (HEDIS) reports CapitalCare

of a hospital discharge, or within 7 days of an

receives from insurers. She estimates that using

emergency room visit. Now, it is consistently in the

Hixny, rather than calling specialists for patient

98th to 100th percentile.

information, saves her about 90 minutes a day,

Hixny’s real-time alerts enable a much faster

or 7.5 hours each week. This improves workflow

follow-up, by triggering a chain of care coordination

efficiency for CapitalCare, and allows Conn to

activities. A transitions of care secretary at

be more productive and spend more time directly

CapitalCare stated that Hixny has been very

serving patients.

beneficial in closing that gap. Hixny currently sends nearly 3,000 alerts each month to CapitalCare.

Amanda Conn, CapitalCare Medical Secretary,

Hixny 2015 Annual Report

CapitalCare has also found that Hixny’s realtime delivery of alerts and discharge summaries is extremely helpful in meeting organizational goals.

Conn says that in most cases, the information

or clinical registries. Hixny processes 60 patient

comes faster than it would from a hospital, and

records per second, including lab results, blood

that small window of time can prevent a patient

pressure readings, diagnostic images, and hospital

from being readmitted. “Probably nine times out of

discharge summaries. This might be one of the

ten, something is in Hixny and we don’t have the

largest data sets I have ever used in my life,” he said.

records from the specialist. Having that information

Johnson said insurance claims and clinical lab results are provide the “enormous” benefit registries do not delivered per of real-time data. But with Hixny, users will be able month to create custom patient registries that update

from Hixny definitely has helped CapitalCare engage patients and make sure they are getting preventative care,” said Conn.

This not only allows CapitalCare to better care for its patients, but also to earn incentive payments from insurers for meeting set goals.

“This real-time data is very important because we can hopefully deflect and cause an improvement in trend if we can get to these people in real-time.”

— Dr. Panneton

69,032

continuously.

Kirk Panneton, MD, Regional Executive and Medical Director for BlueShield of Northeastern New York, agreed that Hixny’s real-time data is

10,185

“invaluable.”

“All our data is claims-based,” he said. “It takes at

least three months to run it through, then another period of time passes before it is usable, and radiology providers reportsare aregetting tired of seeing data that is three, six, twelve months old. This real-time data is delivered

said Feng “Johnson” Qian, MD, PhD, Assistant

veryeach important month because we can hopefully deflect and cause an improvement in trend if we can get to

Professor of Health Policy and Management at

these people in real-time.”

“I think a lot of great things are being done,”

the University at Albany School of Public Health.

In 2014, BlueShield started to receive daily

“We are entering a new phase of health delivery—

reports from Hixny, listing member visits to the ER.

patient-centered and individualized—to achieve

Dr. Panneton said that about 70 such visits take

noble goals. And HIE data can be a very powerful

place every day in this region, at an average cost

tool.”

of $800 to $1,000 each. An outreach associate

15,027

Hixny to evaluate population-based hypertension

spends several hours a day going through these documents arefirst for Medicaid members, and reports, looking delivered per month; then identifying avoidable encounters—those with an increase issues considered of 61% in 2015 non-urgent like a cold or sore throat. She calls these members, first asking how

rates in Hixny’s region and determine the degree

they are feeling, and then encouraging them to use

to which hypertension is diagnosed and controlled,

a primary care office or urgent care facility the next

with the goal of developing clinical interventions.

time these issues arise.

Johnson has worked closely with Hixny as lead researcher on a pilot study to test the use of HIE data in population-based health surveillance. The partners are using critical patient information from

Johnson, who was trained as a cardiac surgeon in China and holds a PhD in health services research and policy, is enthusiastic about the potential of HIE data with respect to clinical care, population health, and public health. “First, HIE data can provide comprehensive information for a much broader population than either claims data

/ 60 Second number of transactions Hixny processes

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69,032 lab results are delivered per month

Dr. Feng “Johnson” Qian is instructing a class at the University at Albany School of Public Health

Dr. Panneton said the response from members

10,185

deal with BlueShield’s requests to provide patient

cost savings. “Before receiving these reports we

information. radiology Dr. Panneton reports are said “Really the only way we can get delivered real-time data is through our RHIOs. And each Hixny, ofmonth course, is at the top. That is going to be

had no way of knowing on a real-time basis that

the wave of the future, to get real-time data in the

someone had been to the ER,” he said. “We had

hands of the providers so they can make a big

to wait for claims to come in. Now, when the alerts

difference.”

has been positive, and the program is showing results with a decline in ER usage among Medicaid patients. He says that this will result in significant

come in, in real-time and thanks to Hixny, we can act on them right away. That is why these phone calls are so effective. They are right after the event.”

Dr. Panneton said BlueShield is also excited about using Hixny for compiling HEDIS data, which it files with the National Committee for Quality Assurance (NCQA).

“Our HEDIS nurses love it, they love the

15,027 documents are delivered per month; an increase of 61% in 2015

accessibility, they love having everything in one place,” he said. “We don’t have to go out and find charts and do that kind of research when we have it right at our fingertips. That is a tremendous savings down the road in terms of collecting this data, which we really need for quality purposes.”

BlueShield receives periodic HEDIS gap reports that are patient specific and organized by practice.

Until recently, the process involved contacting each practice, pulling charts and locating the data necessary to fill in those gaps. Now, using Hixny, BlueShield Healthcare Quality Improvement Specialist, Robin Gonzalez, can fill in the reports quickly and efficiently. Gonzalez said using Hixny is “invaluable” when dealing with smaller practices, who often do not have the time or resources to

Hixny 2015 Annual Report

/ 60 Second number of transactions Hixny processes

Supporting Transitions of Care.

Hixny360’s Alerts provide members with a unique opportunity to be notified within moments when new, pertinent information exists about their patients, such as in-patient and emergency admissions, discharges, and we can push discharge summaries and ED reports to your organization.

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Hixny 2015 Annual Report

Supporting Transitions of Care “WE DIDN’T KNOW W HAT W E W ERE MISSING.”

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“We didn’t know what we were missing.”

This is how Barbara Shields, Manager of Care Coordination for St. Peter’s Health Partners Medical Associates (SPHPMA), described the reaction to a pilot program with one of their multispecialty practices, SPHPMA Internal Medicine.

This pilot program is testing the power of Hixny alerts in supporting transitions of care.

St. Peter’s Health Partners (SPHP), the Albanybased system, includes four acute care hospitals, a rehabilitation hospital, senior care services, and multi-specialty physician groups representing more than 20 specialties—with SPHPMA being one of the Capital Region’s largest multi-specialty physician groups. Its goal is to ease transitions of care, not only for patients moving within its vast network—which uses several different electronic medical record systems—but outside it as well.

“It is very difficult to track patients through the continuum of care,” said Will Rauch, Director of Analytics and Informatics for SPHPMA. “It becomes very fragmented.”

18,482 alerts delivered per month to Hixny participants

The more fragmented care becomes, the greater the opportunity for duplication, missed opportunities and errors, all of which can be very costly. Hixny works to close these gaps by empowering healthcare professionals with the right information at the right time, to make informed care decisions. Providers have the ability to “pull” from Hixny any information they need when encountering a new patient, while alerts enable them to be proactive with their current patients. By applying the provider’s own attribution logic to its millions of pieces of patient data, Hixny automatically notifies that provider when a patient of interest goes to the emergency room, or is admitted to or discharged from the hospital.

Hixny 2015 Annual Report

“From that starting point we can do our transitions of care,” Shields said. “We can follow through with the discharge, make our followup phone call, make sure their medications are appropriate and they understand them, and that visiting nurses are there.”

She said this pilot has made the SPHPMA Internal Medicine group more efficient than other SPHPMA practices. As patient-centered medical homes, the practices all strive to coordinate care of the sickest patients with specialists, hospitals and other providers. Without Hixny alerts, they must rely on the patients, or their caregivers, to tell them about hospital visits. “Patient information must then be obtained manually by logging in and out of the different EMR systems in the St. Peter’s network, or contacting other area hospitals through phone calls or faxes. It can be rather overwhelming and time consuming,” Shields said.

Jean Potolski, Case Manager at the practice, believes the alerts are very valuable in allowing her to keep on top of what is going on with those patients most in need of her attention.

“Frequently, I catch ER visits and hospitalizations that I would otherwise miss,” she said. “For example, people who have been to Ellis Hospital. I only get those notifications if they come from Hixny.”

3.5x/min.

Hixy provides information to providers at an average Barbara (left) and rate ofJean 3.5(right)times per minute are enjoying an improved workflow thanks to Hixny alerts.

David Skory, MD, Chief Medical Officer for Hometown Health Centers in Schenectady, has had a similar experience. He noted that healthcare is moving into an era where more things—such as emergency department usage—are tracked more than ever before, and with Hixny, “we are getting a better quality of information more consistently.”

Dr. Brooks and Julie were the driving force and first to contribute EKG tracings to Hixny.

He said Hometown Health Centers receives about 2,000 Hixny alerts every month. He has found them, and the information he can pull from Hixny, to be “hugely helpful,” particularly in such areas as medication reconciliation.

“If a patient tells me they went to the ER a few days ago but they don’t remember what they were treated with, I can look that up in a heartbeat,” he said. “The same thing is true of their lab tests and x-ray results. Before Hixny, someone had to get on the phone, call the ER, they had to look it up in their system, and we would go back and forth that way.”

Dr. Skory recently delivered a baby for a woman who had disappeared from his care for 14 weeks.

This gap included the time she should have had a RhoGAM shot, which is given to RH-negative women to prevent severe complications with an RH-positive fetus. Without the shot, the mother’s blood may have produced antibodies which could then cross the placenta and destroy the red blood

cells in the unborn baby or in her next Rh-positive baby. Through Hixny, Dr. Skory was able to confirm that she had the shot elsewhere.

“That is a prime example of how quickly we can close the loop on that sort of information,” he said.

“Hixny allowed us to get the documentation, in a timely and easy fashion, to show that what needed to take place actually did take place. As a primary care provider you are responsible for knowing that, and if you don’t know it, there is a gap in your care.”

Hixny’s ability to improve transitions of care and lower costs depends, in large part, on the data submitted by participating providers. “We need to standardize the things that need to be in structured fields so that they can be passed on from provider to provider. So we may all agree we have to have colon screenings, pap smears, mammograms, we have to have the last flu shot— these are all must-haves. And that list might be 50 items long, it might be 150,” Dr. Skory said.

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“It is time for people to take a second look at Hixny. The more people share, the more valuable it is.” — Julie Demaree For ER physicians at Saratoga Hospital, the list includes EKG tracings. Hixny therefore entered into a project with the affiliated Saratoga Hospital Regional Medical Group in which they send EKG tracings to us from their EMR system.

Julie Demaree, a Physician’s Assistant and Clinical Informatics and Documentation Specialist for the medical group, said ER physicians at the hospital were asking for access to the group’s EMR for patient information. She told them that would only solve part of their problem.

“I explained to them that we need to leverage Hixny because that is really the solution for all of their patients,” she said. “Then the discussion became, ‘What do you want to see when you get in there?’”

One answer was EKGs. Demaree explained that having access to the previous EKG of a patient who presents at the ER with chest pains enables the physician to tell immediately if an abnormality is new or routine for that patient. Often, ER personnel

must call cardiologists in search of a patient’s EKG, but that can be problematic in the middle of the night.

Without a previous EKG, the physician will assume the abnormality is new and subject the patient to a number of expensive tests. Often, the patient will be admitted to the hospital and the bills skyrocket.

Although it was Saratoga Hospital physicians who asked for the EKGs, this information is now available to anyone with access to Hixny.

Demaree’s group is also submitting physician notes and other information that will be useful to others.

Demaree believes that Hixny is ahead of the curve in recognizing the need for real-time patient information during transitions of care. She said that when the exchange started several years ago, many physicians did not understand how it could help them.

“All of a sudden they understand why we need it,” she said. “It is time for people to take a second look at Hixny. The more people share, the more valuable it is.”

Hixny360 Results & Reports Delivery Why wait for the information you need?

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Hixny provides real-time delivery of lab results, radiology reports, and transcribed documents such as discharge summaries.

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Hixny 2015 Annual Report

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+ SUPPORTING Throughout the school year, Brian Austin is an orchestra director at Shaker High School in Latham, NY, and during the spring and summer, he is known as “Sammy Baseball” (below) — representing Uncle Sam for the Tri-City ValleyCats in NY’s Class A Penn League.

Austin is a prime example of the benefits of statewide patient records. He has made several trips to Rochester for care, and expects to be traveling to other areas outside the Hixny region as well.

“I always have to tell the same backstory and list doctors, medications, etc.,” Austin said.

“Doctors I have visited have no records of my

Hixny 2015 Annual Report

PATIENT

interactions with doctors locally. No test, prescriptions or treatment records. It will be an incredible relief not to have to worry about them having enough information or the correct information.”

Population health experts understand that change takes place one patient at a time.

Patients engaged in their own care are more likely to be satisfied with that care—one goal of the Triple Aim—and to take the steps necessary to improve their status. In this way, the other two goals of the Triple Aim—improving the health of populations and lowering costs—can be met.

Already, more than one million people in Hixny’s region have granted consent to securely share their health records with their providers.

A growing number of consumers are creating accounts with Hixny’s secure patient portal, Hixny For You. The portal provides patients secure access to vital information contributed by multiple providers—to be viewed, downloaded or transmitted at any time. Hixny For You empowers patients to manage their and their family member’s healthcare online and in one comprehensive view. It also provides access to an e-library with material on relevant medical topics and answers to common questions.

T ENGAGEMENT+ Now the patient portal is even more valuable with its connection to the Statewide Health Information Network of New York (SHIN-NY).

This connection enables patients who see providers outside the region, anywhere in the state, to share vital information and to access records from those visits.

Austin added that he was not sure how to gather all of his healthcare information but now would “most definitely” sign up for Hixny For You. The patient portal is a critical part of the healthcare community, endorsed by providers, payers, government entities, employers and others with a stake in achieving the Triple Aim. “Hixny is at the center of the healthcare universe,” said Barbara Hess, Chief Administrative Officer of SEFCU, the Capital Region’s largest credit union. “Hixny’s mission aligns really well with our thinking about bringing all the right pieces together toward a common vision of substantially transforming and improving healthcare in our community.”

Hess, who represents the employer class on the Hixny Board, said SEFCU encourages its 700 employees to be active participants in their own healthcare. The credit union’s workplace wellness

program encourages workers’ physical and mental wellbeing and personal and professional productivity to maintain a culture that supports a healthy lifestyle. This includes education, encouragement, and targeted programs and services which address lifestyle-related health choices.

“The Hixny patient portal is a critical tool in that equation since information leads to empowerment,” she said. “[It is particularly useful for] those who see multiple medical providers because it aggregates information from disparate providers into one holistic view.”

She said the patient portal is especially helpful to employees who are caring for elderly parents, as all of their medical information is accessible and in one central place.

Hess agreed that Hixny’s connection to the SHIN-NY, “makes the data in the patient portal more comprehensive and useful.”

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Strategic Planning for 2016 Hixny is well positioned for the coming year, and will focus efforts in developing new capabilities and expanding its services.

“The intention is to further our technology platform quite a bit, and make the data more intelligent,” said Mark McKinney, CEO of Hixny. “Enhancing data quality is job one, because everything else depends on robust, reliable data. This will include improving the cleanliness of the data and increasing standardization, which is vital to its use in analytics and public health surveillance. We already have a critical mass of data, but want to fill in the gaps.”

This means continuing work with natural language processing in order to include searchable text documents in the exchange, such as progress and consult notes, as well as EKG tracings.

Enhancing the type of data is Hixny’s second major goal for 2016, which includes obtaining claims data.

This, in turn, will drive use by participants, and therefore increase the flow of patient information throughout the community.

Scott Momrow, Vice President at Hixny, said “driving use requires giving participants access to tools and services which will make it easier to incorporate the information into their everyday workflow. Development

Hixny 2015 Annual Report

of a mobile application, which can also extend Hixny’s reach to community providers without certified EMR systems, will ramp up in 2016.”

Improving ease of access includes making the flow of data more intelligent. A primary example of this is smart alerts, which were introduced in 2015. These alerts will be leveraged on various platforms including EMRs, the Hixny provider portal, and the mobile app.

Smart alerts enable users to filter event notifications to the individual patient or member level. Event notifications grew 200 percent last year, and are expected to increase significantly throughout 2016.

“In many cases, these alerts go to the case manager or nurse who looks at them and determines what to do,” McKinney said. “It is our goal to advance these alerts to say ‘when it looks like this, send it to the doctor. When it looks like that, send it to the nurse.’”

Another goal for 2016 is to take the intelligent, actionable information and apply it to patient registries, which are customizable by organization. Program registries include members of a certain program, such as a particular Delivery System Reform Incentive Payment (DSRIP) group. Community disease registries track people with a targeted condition, such as hypertension. Also, providers and payers will be able

Hixny’s Scott Momrow (left), Bryan Cudmore (middle), and Mark McKinney (right)

t),

to maintain their own registries, and contribute to real-time dashboards and billboards to track community-wide trends.

“Let’s say someone’s hypertension is registered as ‘diagnosed and controlled’, but Hixny receives a few blood pressure readings from outpatient visits that indicate it is no longer in control,” Momrow said. “The logic in the registry will convert that person from the controlled group to the non-controlled group and then issue an alert to the primary care physician.”

Bryan Cudmore, Senior Director of Account Management and Sales at Hixny, said “Hixny’s future vision was shaped, in part, by recognizing that every organization’s needs are different. The mission of our newly-formed account services team is to understand the needs of 180 customers, ranging from small practices to large health systems, and provide distinct solutions for each.”

Cudmore’s team will be a driving force to increase participation and connect new types of organizations.

This includes nursing homes, mental health facilities, behavioral health providers, and emergency medical services.

“These connections are really valuable to the collaborative care players in our region, whether payers, accountable care organizations, or DSRIP performing provider systems,” McKinney said. “They need that information, and we will focus on bringing that forward.”

Increasing patient engagement is another focus in 2016. Improvements to the Hixny patient portal, or

Hixny For You, will include giving patients the means to contribute their own health data to the exchange. This will start with simple information about the person’s care team, and grow to include readings from blood pressure monitors, personal fitness devices and so on.

All of the initiatives planned for 2016 and beyond have the overarching goal of demonstrating the value of what will soon be known as Hixny360 to providers, patients, payers, and the population as a whole. With more data, more options and smarter tools, Hixny360 will be embedded in the fabric of care coordination programs, and will be the first place the community looks for critical patient information.

The value inherent in Hixny’s proprietary technology has prompted the formation of a for-profit subsidiary called XchangeWorx, which will market this technology to providers and health plans all over the country and outside of the Hixny region. The revenue it produces will support the further development of tools and services, which will help to accelerate the Health IT services Hixny provides to its participants. Led by Joel Ryba, President of XchangeWorx and former COO of Hixny, it is now staffed with 10 full-time employees and is anticipating significant growth in 2016.

“In 2016, we will experience tremendous growth in use, our tools and services will mature, and participants and patients will access us in new ways,” McKinney said. “We will make great strides in population health management and public health surveillance, and be widely known for all the things we’re doing.”

xchangeworx.com 29

2015 Hixny

John D. Bennett, MD

Paul Macielak

Board Chair

Board Vice Chair

President & Chief Executive Officer CDPHP

President & Chief Executive Officer New York Health Plan Association

Wouter Rietsema, MD

David Kile

Board Secretary

Board Treasurer

Vice President/Chief Quality and Information Officer University of Vermont Health Network – Champlain Valley Physicians Hospital

Director of Continuing Education & Professional Development/Instructor of Pharmacy Administration Albany College of Pharmacy and Health Sciences

Board of Directors Hixny 2015 Annual Report

Bonnie Chavin

Scott Groom

Katherine Alonge-Coons

William Duax

President The Seymour Fox Memorial Foundation

Vice President, Chief Information Officer Bassett Healthcare Network

Commissioner Rensselaer County Department of Mental Health

Vice President – Information Systems Albany Medical Center

Joseph Gambino

Barbara Hess

James Hopsicker

Jonathan Goldberg

Chief Executive Officer Hometown Health Center

Chief Administrative Officer SEFCU

Vice President of Pharmacy Programs MVP Health Care

Vice President, Chief Information Officer St. Peter’s Health Partners

David Shippee

Kirk Panneton, MD

Sumeet Murarka

Louis Snitkoff, MD

Chief Executive Officer Whitney M. Young, Jr. Health Services

Regional Executive and Medical Director BSNENY/HealthNow New York, Inc.

Chief Technical Officer Community Care Physicians

Chief Medical Officer CapitalCare Medical Group

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hixny.org