Orlando Health’s customized Epic comprehensive health record (CHR), known as ELLiE, has its own population management application embedded called Healthy Planet. The Healthy Planet application ingests medical and pharmacy claims data along with other external data feeds allowing the network to analyze information on its value-based care (VBC) lives and better perform care management and quality reporting functions.
The network’s quality performance team utilizes Healthy Planet dashboards to track and trend performance across all VBC arrangements. These reports are capable of incorporating clinical and administrative data sources to create a holistic view of an individual patient and, consequently, present more accurate performance information. This reporting also allows for better identification of patients requiring more care coordination due to their complex care needs while simultaneously providing a common platform for communication between care team members. Lastly, the quality team can summarize performance across all measures on aggregate or individually to understand both network and provider-specific areas of opportunity, respectively.
The care coordination team uses the Healthy Planet platform to identify, stratify and assign cases to the network’s clinical resources. Cognitive risk modeling identifies at-risk patients and seeks to enroll those who may benefit most from the network’s myriad clinical programs, such as disease state management or transition of care services. Care management dashboards update in near real-time and allow for summary and granular views of the patient, including access to more than 40 unique quality measures. Orlando Health Network providers can leverage patient “pursuit lists” to identify members overdue for preventive and maintenance care services, offer scheduling options to see providers capable of managing their condition needs, and, ultimately, close all gaps in care.
ELLiE also features a special analytical tool known as Slicer Dicer, which allows users to filter, sort and analyze data in various ways to glean important insights across the network’s vast patient population. This self-service tool readily provides actionable information from exceedingly large sets of data, thereby shortening the time it takes for providers to receive the information necessary to improve healthcare outcomes and contain unnecessary healthcare expenditures.
Orlando Health| InNote is a physician performance enablement application that allows providers to receive pertinent real-time insights on their patients within their practice’s electronic medical record. The application serves to consolidate all data from multiple electronic health records, payer systems and other sources to automatically surface the most meaningful information to providers at the point of care. In essence, this mitigates the time-consuming challenge practices routinely face in searching for patient data across disparate and fragmented systems, allowing for more time to provide better care to their patients with the most relevant information at their fingertips, in their own medical record.
The InNote application natively integrates into various medical records to provide a seamless workflow experience for clinical and administrative teams. Network-aligned practices have two different installation options, one allowing for access to all external data insights without their own medical record integration and a second more advanced option that interfaces with their medical record and scheduling system for enhanced insights. Under either option, the application can be installed in just a matter of hours with minimal configuration, and training on the application is quick and simple.
Using the insights generated through the platform, such as care gap listings, cost and utilization reporting, and risk coding analytics, providers can make the most informed decisions for their patients. This ability to provide the holistic view of the patient is what simultaneously improves practice operations and patient outcomes. Additionally, while the tool is largely built to be used in real-time during the patient encounter, it also can be leveraged by office staff to proactively plan for upcoming appointments and outreach to patients. From a performance perspective, InNote users have experienced greater practice efficiency, better patient outcomes and marked improvements in their value-based program results.
The value-based care (VBC) team launched an interactive patient engagement module this year with its population health data partner known as InConnect. This automated platform offers bulk messaging and patient outreach functionality to further support network physicians in driving quality care, improving outcomes and encouraging patient participation in their care (e.g., medication adherence).
Utilizing various channels of communication, such as text, email and phone messages, patients can receive notifications about overdue/upcoming visits, outstanding screenings and prescription refills, among many other targeted messages. The InConnect platform also allows for two-way patient interactions in response to all outreach campaigns, thereby allowing for greater patient interaction and more tailored care plans. In 2021, 11,865 aligned members were successfully contacted and took the necessary steps to close their care gap(s) in the plan year.
Telemedicine and Remote Patient Monitoring
Orlando Health’s Telehealth service line offers a variety of virtual medical services including on-demand and scheduled visits using the virtual visit platform. Providers are able to virtually perform patient rounds, provide consultations, support after-hours nurse triage programs and even offer remote patient monitoring services. The platform also has been expanded to provide additional ancillary and diagnostic services, such as virtual appointments for physical, occupational, or speech therapy.
Orlando Health also deploys remote patient monitoring technologies to better follow patients after they leave the system’s hospitals and provider offices. These remote devices are used to track health outcomes and alert providers if vital sign abnormalities are indicated. The biggest advantages of remote patient monitoring from the patient’s perspective include a greater sense of independence by being able to remain in the home, more confidence in managing their chronic conditions, and improved access to a care team standing by to support them. Patients who use the technologies also experience improved quality outcomes, reduced overall medical spend and higher patient satisfaction scores.