What is the Right Level of Data to Improve Health Outcomes?

The Importance of Having the Right Level of Data

When it comes to quality improvement, we have all experienced one of the highest sources of frustration at some point or another.  I’m talking about the level of data not being sufficient for the those that are accountable for results.

Each level of an organization requires specific levels of information.  This seems very basic and is generally understood, however, most systems struggle to deliver tailored report to meet the different needs of key stakeholders throughout organizations.

Most organizations seem to start with very high level reports.  They then spend a great deal of time focusing on going wide rather than deep.  This is a mistake.

There are Levels of Reporting Needed to Improve Performance

Let’s start with the executive leaders, which could include service line and clinical program administrators.  This group is looking for service line or practice level performance at a high level.

Next, we have the front-line leaders and physicians.  This level is looking for overall and peer performance within a particular group.  It allows them to look at individual providers and identify best practices.

Finally, other team members such as health coaches, nurses, and medical assistants require another drill-down into patient-level data.  This allows them to develop specific interventions to address specific needs for specific populations.

Well, if it’s so straightforward then why do so many systems struggle?  The reasons are usally:

  • Real-time integration of EMR and claims data requires advanced data capabilities 
  • Multiple views for multiple users requires building different levels which is labor intensive
  • Patient data raises concerns about security which triggers compliance and legal team input

Next, a look at the importance of including Physicians in the conversation.

Partnering with 23andMe for a Population Health Initiative

Renown Health’s recent partnership with 23andMe and the Desert Research Institute has been an astounding success. Just little over a month ago we announced the program which offered free personalized health and ancestry information to over 5,000 Northern Nevadans. We expected it would take two days to get that many people to sign up. You can imagine our surprise when the day after the launch of the event, all 5,000 slots has been filled up! So we decided to open up another 5,000 slots, which filled almost equally as fast.

Some reasons to which the success of this event could be owed would be the cost (it’s one hundred percent free for participants), the perks of genetic analysis (it’s something that many people are curious about, but would not think of paying for), and the simplicity of our system (all that is required is that participants show up, watch an informational video about the project, sign some forms, and spit into a tube). There’s also the additional incentive of knowing that those who participate are contributing to the overall benefit of the Nevada community.


via Renown Health

Through our work with 23andMe, Renown Health now has access to over 10,000 samples of genetic analysis. By combining this data with our data on the medical histories of over 300,000 people, we will have a better overall picture of the health of those in Northern Nevada. The Desert Research Institute will draw even more insights out of this data by looking at it in conjunction with a number of social and environmental figures. The overall goal of all of this data-crunching is to figure out how different environmental, demographic, and environment factors interact. Once we have a better idea of this, we will be able to better allocate resources to those who need them most and may even be able to stop illness before it happens.

This data-gathering, data analysis, data sharing, and all around cross-organization collaboration truly epitomizes what population health can become. I’m very proud of everyone who has been involved in this initiative–from the participants, to the researchers, to the countless administrative workers who have made this possible. Additionally, this project would not be possible without the generous support of Governor Brian Sandoval and the rest of the government of Nevada.

I’m also taken aback at how warmly the community has received this project. For instance, KUNR gave Joe Grzymski of 23andMe a great interview and the Reno Gazette-Journal has provided us with some glowing press. We’re taking steps toward the future of medicine.

Mark Behl

MACRA: The Road Map to the Future of Healthcare

One date marked on the calendar of many individuals at the management level of health organizations is January 1, 2017. To some 2017 is being viewed as a “year of reckoning“.  Although this sounds ominous, most negative effects on health organizations can be easily avoided as long as providers are prepared for MACRA. Since 2015, MACRA has been slowly integrated into the operations of medial organizations across the country. In 2017, the performance of medical organizations that qualify as MIPS will be tracked and these results will determine how providers are paid in 2019.

This may sound a bit confusing. It sounds like money’s on the line. It sounds like big changes are coming. But what exactly does MACRA mean and what exactly is a MIPS? To answer these questions I’ve put together a brief starter guide to MACRA and what it means for the healthcare industry.

What is MACRA?

In a nutshell, MACRA is new set of rules and regulations that will reshape the way that medical organizations receive government funding, handle Medicare, and ultimately function. The government MACRA with bi-partisan support back in 2015. Given that MACRA is such a large overhaul of the healthcare system, adoption to the rules and regulations of MACRA has been generously spaced out over a timeline of many years.


MACRA Timeline

MACRA Timeline from eptechview.ttuhsc.edu

In brief, MACRA will change how Medicare pays medical providers.

Yes, but what does MACRA stand for?

MACRA stands for Medicare Acccess and CHIP Reauthorization Act of 2015.

And what does CHIP stand for?

Children’s Health Insurance Program. Basically the program that provides states with matching federal health insurance funds for families with children.

OK, so getting back to MACRA…

Yes, getting back to MACRA…

How will performance be tracked?

That depends. There are three different classifications of medical payment models: MIPS, APMs, and e-APMs.

More acronyms?

You bet. MIPS (or Merit Based Incentive Payment Systems) will effect the majority of providers. APMs (or Alternative Payment Models) are a bit trickier to qualify for. E-APMs (eligible alternative payment models) are basically a subset of APMs. APMs are still subject to MIPS, but will receive favorable scoring, with reimbursement rates that reflect accordingly.

Wait, Scoring?

Just like a building might need to reach certain benchmarks in order to be certified as LEED or an Olympic diver has to be mindful of technique and style in order to win a higher score from the judges, so will medical organizations need to meet certain benchmarks in order to receive more favorable payment rates.

That means that medical organizations will need to make sure they are reaching to achieve a slew of metrics pulled from PQRS (Physician Quality Reporting System), EHR (Electronic Health Record), and the VM (Value-Based Payment Modifier) outlined in MACRA’s performance measures.

MIPs from Impact-Advisors.com

MIPS model from Impact-Advisors.com

So what happens once all of these measures are taken into account?

Based on how an organization meets these metrics, they will be given a MIPS composite score that is either positive, negative or neutral. Each of these will adjust the base rate of a provider’s Medicare Part B Payment, which is money that an organization qualifies to receive from the government when a patient uses Medicare for services covered under Part B. And these incentives really do add up. Larger medical organizations stand to lose or gain 15 to 20 million bucks depending on whether or not they receive favorable scores.

So if hypothetically a lot of identical organizations are performing well, will they all get the same amount of money?

Not exactly. This system will be budget neutral.


That there’s a fixed pool of money available for medical organizations. Those with higher scores will in effect take away money from medical organizations that perform more poorly.

Sounds kind of harsh.

Admittedly, MACRA does pose some big challenges for the healthcare industry, but the overall goal is something that we could all agree on: better value and better outcomes for patients. The thing is, the healthcare industry is heading in that direction anyway. There are so many medical organizations out there right now that it’s less a matter of if someone can get to a healthcare provider, it’s which one should they go to. In order to stay in business, providers need to step up their game and really show patients that they value them.

So why is MACRA being introduced if we’re already seeing better patient-centered care?

At the moment government money is provided to healthcare organizations with much more lenient standards on the efficacy of care given. Basically, organizations that are continually doing a poor job of putting patient’s first are still being kept afloat by government money. MACRA will push these organizations to either improve or yield to nearby healthcare all-stars.

Sounds great, but I’m not interested.

Like it or not, MACRA is coming and all providers will need to adapt in order to stay afloat.

OK. So what should I do?

Learn all you can! One thing that is recommended is to see if your organization can qualify as a PCMH (Patient Care Medical Home). This will help getting qualified as APM a lot easier and also carries some rewards of its own. Renown Health was the 1st provider in Nevada and the 4th in the country to adopt the PCMH model.


Good luck!


Mark Behl

What Coffee and Population Health Have in Common

Coffee, refrigeration, the internet. One constant throughout history is that people often fear change. Specifically, people fear the advent of new technology.

A cup of coffee with a sugar cube and a pile of beans

I recently read a fantastic piece by Steven Overly in the Washington Post that explores just this concept. In brief, Overly boils down humanity’s hesitations into 8 conclusions:

  1. People sometimes oppose innovation even when it seems to be in their best interest.
  2. Technologies that are vastly superior to their predecessors, or don’t have any predecessors, are more easily adopted.
  3. Resistance to new technologies comes from three key constituents, including the average consumer.
  4. Humans make decisions about new innovations with their gut rather than evidence.
  5. People flock to technologies that make them more autonomous and mobile.
  6. People typically don’t fear new technology, they fear the loss it will bring.
  7. Technologists often don’t think about the impact their inventions have on society.
  8. Innovation is not slow, linear or incremental — but the government doesn’t realize that.

Looked at together, these reasons can be cited for the slow adoption of wider spread population health methods. Fortunately (like coffee, refrigeration, and the internet), we are starting to see these methods gain more and more favor.


Mark Behl

A Population Health Crash Course

The field of “population health” is one of the most exciting developments in healthcare in the last last 15 odd years. However, actually describing what population health is can be a little tricky. Although I’ve broken it down before in other blog posts, I thought I’d compile some videos that make the meaning of population health a bit more accessible:

For starters, here’s a general overview:

So, you might be thinking, “That sounds a lot like public health.” Here’s the difference:


A great video that looks at the social determinants that are so critical to consider in the population health paradigm:

Thanks for viewing.

For more population health updates, follow me on Twitter @MarkBehl.

Confronting Zika with a Population Health Paradigm

With the arrival of the Zika virus in the United States, the nation and its medical organizations are mobilizing to prevent its spread. Integral to this process is sound population health practices.

Seemingly Innocuous

image of a mosquito on skin

Meet Aedes Aegypti, the main courier of Zika / WHO

If you haven’t heard, the Zika virus is one of the biggest infectious diseases to roll into the states since the likes of West Nile and H1N1. Although the disease can be sexually transmitted, what’s more troubling is that it is known to spread via Aedes aegypti mosquitoes.

At first glance, Zika doesn’t seem like that threatening of a harbinger. The initial symptoms of the virus are for all intents and purposes relatively innocuous: headache, muscle pain, fever, rash, conjunctivitis. In fact the symptoms are so mild that in many cases those infected with Zika are completely unaware of it. The thing is: it’s not those who are infected that are at risk. It’s their offspring.

Zika is known to cause birth defects such as microcephaly, in the children of mother’s who’ve conducted the virus. The danger is not just for our generation, it’s for future ones.

Not Enough Funds

The United States government recently started putting funds towards combatting Zika. President Obama initially asked for $1.9 billion to combat the disease. The House of Representatives instead opted for a bill that wold send a meager $622 million, most of which is currently going to other Health Department like programs like those that are confronting ebola. The Senate’s package on the other hand proposes $1.1 billion, which will not only give the Health Department ample funds to educate and prepare Americans, but also will give the CDC the amount of funds they’re asking for research–research that includes the discovery of a vaccine.

image of Dr. Frieden speaking at Senate.

Dr. Frieden urging the Senate to approve more funding to combat Zika. (AP Photo/Manuel Balce Ceneta)

Today Dr. Tom Frieden of the CDC urged the nation’s officials to act and act soon: “We have a narrow window of opportunity to scale up effective Zika prevention measures, and that window of opportunity is closing.” But with the House and Senate empty during Memorial Day weekend holiday, the unofficial start of mosquito season, it looks like any action is to be delayed.

Population Health in Action

For instance, in New York, Governor Andrew Cuomo has initiated a state-wide initiative to prepare for Zika. In addition to aggressively pursuing methods of staving off Zika by deploying mosquito traps and staying vigilant for any outbreaks, the state has put forth a number of initiatives that directly assist residents. Such as issuing Zika protection kits to pregnant women who recently traveled or lived outside the country.

Of course the strength of population oriented health program is not just in having the care-providing agency (in this case government) provide aid itself; it’s in training individuals to be Zika-fighting agents on their own. In New York this is being seen in efforts that educate residents to reduce standing water, use larvicide tablets where standing water does exist, and assiduously utilize mosquito deterrents such as mosquito repellant. Most importantly, the state is asking residents to point out large outbreaks of mosquitos. Granted, it might be hard for the average person to figure out what a large outbreak is, in comparison to an average outbreak. But by putting out feelers, by activating more individuals to report data, the state is enacting the fundamentals of an effective population health campaign.

New York is not alone in gearing up for the arrival of Zika. Bringing further aid, the CDC has made it possible for states and province to apply for additional funding to combat Zika locally.

Micro to Macro

At the core of modern population health practices is the triple aim:

  • Increasing the prevalence of evidence-based, preventive health services and behaviors
  • Improving care quality and patient safety
  • Advancing care coordination across the health care continuum

It doesn’t take that much of any eye-squinting to see how the fundamentals of the triple aim can been seen in the government’s mobilization against Zika.

  • Increasing the prevalence of evidence-based, preventive health services and behaviors

By educating people on the risks of Zika and empowering them with the means to prevent it, the government is using the research at their disposal (evidence-based knowledge) to spread preventive health services and behaviors.

  • Improving care quality and patient safety

The more that the government learns about Zika, the more empowered it is to combat it–one of the reasons why additional funding for government agencies is so important. The ultimate boon here being a vaccine.

  • Advancing care coordination across the health care continuum

Similarly to the first aim, this includes empowering citizens to take on Zika themselves. However that this just one point on the healthcare continuum. Under the the larger government’s guidance, we are seeing individual government agencies (like the CDC) collaborate, in addition to a number of private sector organizations (including Gilead Sciences Inc., Inovio Pharmaceuticals Inc., and Intrexon Corp. With the government’s oversight, these organizations are acting less in silo, and more as individual fingers of the same hand.

an infograph depicting what people should to protect themselves from ZIka

An example of the sort of materials being circulated by government agencies, in this case the CDC, in order to educate.

As idea of population health grows in popularity, we’re seeing more and more hospitals take health to the people. It’s not just enough to wait and see who comes. It’s a matter of going into the community. It’s about seeking an integrated, holistic and widespread approach.

Mark Behl

Mentrics: Redefining the Possibilities of Population Health

IBM Watson is one of the most exciting developments in population heath. It has an unprecedented capability for processing high volumes of data and turning that data into natural language answers. IBM Watson is like Siri on steroids. Through partnering with a number of organizations, IBM has been able to increase the range and power of the Watson. One of the most recent partnerships in this direction has been its partnership with ODH Inc. The progeny of this collaboration is called Mentrics.

Mentrics gives Managed Care Organizations (MCOs) and Behavioral Health Organizations (BHOs) like Renown Health the ability to “understand the whole population, segment the population needing intervention AND manage and monitor the key determinants of health for each segment.” Not only will Mentrics give population health organizations more data to work with, it will make providing healthcare cheaper and more streamlined–specifically when targeting those segments that suffer from a chronic comorbidity.

The Cost of Comorbidity

When patients have a physical and a comorbid (coinciding) mental health disorder, treatment becomes more costly and often less effective. For instance, a patient with diabetes and depression has a 200% higher mortality patient compared to a patient who only has diabetes. Furthermore, individuals with coronary artery disease and depression are 2 to 3 times more likely to incur a future cardiac event. Those who fall into this segment of comorbidity of chronic physical and mental health cost 300% more than those with only only chronic health condition.

Bottom line: the greatest healthcare expenditures are going to a small group. We need a way of addressing this specific group. Big data, population health, and specifically Mentrics is the answer.

image of mentrics logo

Mentrics in Action

HITConsultant.com has identified three specific areas in behavioral health that Mentrics will benefit

1) Behavioral Health Population Management

Using 22 dimensions including a model for behavioral health specific risk stratification (the only commercially-available one on the market thanks to IBM Watson), Mentrics will be able to create clinically meaninful poplulation segments.

Bottom line:  This will help medical professionals to identify which segments will most likely benefit from interaction.

2) Provider Network Performance

With Mentrics, providers will be able to assess their own effectiveness and efficiency, allowing for a comprehensive comparing of providers and an analysis of the entire provider network. This will in turn work towards value-based payment arrangements.

Bottom line: Money will be allocated more accurately, efficiently, and economically.

3) Patient Care Coordination

Using a user-friendly, “Longitudinal Data Visualization tool”, cross-network providers will be able to notice detailed patterns in medication use and clinical history. Furthermore, providers will be able to receive notifications based on evidence-based care gaps like patients receiving duplicate prescriptions and providers will be able to customize cross-network care via these notifications.

Bottom line: Providers will have a more holistic view of patients and will have an interoperable system in place for communicating with other providers.

Realizing the Vision of Population Health

Years ago, population health was a vague though ambitious field. It promised an integrated cross-network system that optimized patient outcome and reduced patient cost. Yet, it seemed that there was no shortage of hurdles blocking population health from ever realizing its vision.

But recent developments in digital health, such as Mentrics prove that there is indeed hope for an ubiquitous population health model. Mentrics provides providers with unprecedented awareness of the millions of variables that go into a healthcare system. Now it’s just a matter of this brilliant software finding its way into practice.

How Apps and Wearables are Changing the Population Health Landscape

At the center of modern population health practices is data. Traditional forms of gathering data include culling medical records, analyzing ever scrap of demographic information available, looking at medical studies conducted, and gleaning information from other people/systems/organizations that are compiling their own health databases. But the advent of smartphones and wearable apps allows a whole new sort of data collection. It allows access to real-time, uniquely tailored data for an individual, and at the same time (when enough individuals are using the app, mobile apps and wearables) allow access to lots and lots of numbers. Numbers that can change the landscape of population health for a community and for the world.

Health Apps

Image of intellicare apps

Northwestern’s Intellicare app suite opens a new door into quickly and easily collecting data on mental health.

From Apple’s Healthkit to Samsung’s SHealth, apps that help people measure their fitness activity and diet are becoming more and more popular. But we’re also seeing the emergence of a level of unprecedented apps, such as Northwestern University’s Intellicare  app suite that focuses on mental health. Using a variety of approaches to treating mental health based on Cognitive Behavioral Therapy (CBT), the Intellicare suite holds the potential to provide data on mental health from a variety of patients. Although not a complete substitute for face-to-face interaction, the app suite grants patients an accessible and cheap first line of defense resource. Yet another a tool in the value-based healthcare model.


image of a fitbit

Wearables adoption is set to double from from 2014 to 2019.

A recent study in 2015 indicates that patients with multiple sclerosis were much more likely to engage in an activity tracking physical fitness with wearables. Over 24o patients enrolled in the study to track their activity with Fitbits and 77% made it all the way through to the post-study follow-up survey. For starters, wearables are cool. Just like it’s fashionable to have a smart phone, it’s fashionable to have a Fitbit. According to a survey conducted by RBC in 2015, Fitbits are one of the most in-demand wearables out there.

And the wearable market is only going to grow. The investment firm Piper Jaffray expects that from 2014 to 2019, wearable technologies are expected to nearly double in adoption across the world. They point out three trends behind the widespread growth of wearables (which could be attributed to health apps as well):

  1. Health and fitness becoming a growing concern among individuals in more and more demographics
  2. People wanting to be able to quantify and analyze more and more of their activity
  3. Convergence between brands and tech e.g. UnderArmor acquring MyFitnessPal, etc.

Privacy Concerns

As more and more consumers use apps and wearables, more data becomes available. But as the availability of data grows, health organizations and other businesses need to make sure that they are harvesting this data in ethical fashion. There have already been several law suits in regards to companies not being upfront about their privacy policy. Moving forward, companies need to work with consumers’ full awareness and trust if they are to make the most out of the data available.

What are your thoughts on apps and wearables? Is there a particular company or product that you think is making strides? Let me know @MarkBehl.

How IBM Watson is Revolutionizing Healthcare

If you’ve been following big data the past several years, chances are you’ve heard of IBM’s Watson. To recap, Watson is IBM’s revolutionary commercial computing capability that utilizes the cloud in order to process high volumes of data and then turns this data into evidence-based answers when presented with questions in natural language. Put simply, Watson is a cloud-based supercomputer that companies can make use of. Watson’s ability to comb the cloud for data makes it a catalyst for great change in the healthcare industry. In fact, in 2015 IBM launched IBM Watson Health and the Watson Health Cloud platform specifically designed to assist physicians, researchers, and insurers in harnessing the great amount of personal health data being circulated around the cloud.

ibm watson logo

IBM Watson is revolutionizing how the world analyzes health data.

IBM’s recent collaboration with Welltok and and Pathway Genomics illustrate two ways that Watson is revolutionizing population health management.

Welltok and Improving Heart Health

In line with a number of other initiatives this National Heart Month, IBM has revealed plans to team up with the social health management company Welltok and the American Heart Association (AHA) in order to develop workplace technology that improves heart health. The unnamed app will make use of AHA’s Workplace Health Achievement Index, which uses best practices “to measure and rank corporate health initiatives” and give an overall assessment on workplace health culture.

welltok logo

Welltok’s most recent project comes on the heels of a similar workplace health platform developed specifically for IBM offices.

Employees could take advantage of Welltok’s platform by filling out the AHA’s My Life Questionnaire, at the core of which is the AHA’s Simple 7 key cardiovascular health indicators: not smoking, eating healthy, being physically active, achieving and maintaing a healthy weight, managing blood pressure, controlling cholesterol, and reducing blood sugar. Using the data from this questionnaire, as well as that from other of IoT devices–from wearable fitness trackers to wifi-connected scales–Welltok would be able to tailor health recommendations to the individual needs of each employee.

Optimal population health management is all about pooling resources. It’s about pooling data.  In this case, we see how IBM’s computing capability, Welltok’s health platform, and AHA’s metrics would all work together for better healthcare outcomes.

Pathway Genomics

In January, IBM teamed up with Pathway Genomics teamed up to create another personalized healthcare app. Instead of targeting workplace heart health, Pathway’s OME makes use of information from Pathway’s “FIT” Test, which takes a look at a number of metrics including exercise and genetic predisposition, and pulls metrics from a number of IoT sources, such as wearable health monitors and Apple HealthKit.

ipad with OME app on screen

Pathway Genomics’ OME delivers health recommendations based on your genetic traits.

Critical to this platform is the analysis of genetic traits and their effects on health. After receiving approval from a licensed physician, participants receive a saliva DNA collection kit. Pathway uses this to conduct their FIT test, which looks at 75 genes that deal with a number of health factors. The insights gained from the FIT test are then incorporated into personal wellness plans.

More to Come

Both the Welltock and Pathway Genomics collaborations with IBM Watson illustrate the boon of integrated systems in population health. But we’re just scratching the surface. Welltok’s platform focuses on workplace health and Pathway Genomics’ OME focuses on genetic predisposition, but what if the two technologies could work together instead of separately? What if both genetic predisposition and genetics were compared in one’s personalized healthcare recommendations? We’re well on our way to finding out.

Population Health Platforms

The purpose of population health management is manifold: it helps improve the the health outcomes of people by improving the quality of care, increases preventive care, and provides access to better care. The golden promise is that healthcare providers will be able to deliver better care at a lower price. In order for this to happen, caregivers at all sides of a patient need to be interconnected with a digital framework.

As mentioned in another blog post, this past year has been a booming time for digital health companies that harness population health. There are a number of ways that digital health companies can approach population health. Below is a breakdown of the platforms that make up population health management as detailed by Miguel McInnis, the founder of McInnis & Associates, a healthcare management and consulting firm. As with any attempt at categorization, there is some overlap.

NueMd mark behl

Population health intelligence platforms can provide plan administrators and care teams with cloud-stored access to extensive financial and clinical information, and access clinical data from a number of sources. They may also link to other population health platforms like risk stratification, hospital admission data, and referral data. Example: Conifer Health Intelligence

Medical Management systems combine people and information to effective and personalized services for acute care management, chronic care management, etc. These systems use accurately integrated data to identify at-risk patients, track results, analyze care and support wellness management. Example: NueMD

Risk Stratification tools identify different population needs across all levels of risk. WIth this info, providers can determine appropriate courses of action with which to approach the needs of a population. Of prime importance here are demographics, medical conditions, cre patterns and resource utilization. From here, patients can be stratified into five main categories: episode of care patients; high risk patients; chronically ill patients; healthy patients but with conditions; and healthy patients. Example: HExL

Patient Engagement services AthenaHealth mark behlhelp help patients take part in their own healthcare. The goal here is to help create a supportive, long-term relationship with a patient using third-party data to figure out the needs of patients and facilitate more effective relationships with providers. Example: AthenaHealth

Predictive Analytics tools model medical conditions within a population to identify high people who may be risk. By identifying these patients ahead of the curve, predictive analytics can prevent these people from needing to shell out for expensive healthcare. Example: Evolent Health

Better Patient Access platforms help patients interact with providers. This is especially useful when patients have poor access to healthcare. One way of doing this is with telehealth which ties together some of the above platforms in order to provide not only better care to patients, but also better training to providers. Example: Doctor on Demand


For the full article, check out Forbes.com.