Oklahoma's largest health system builds medical home model with health IT

INTEGRIS Health links with Phytel to fulfill CMS grant
By Diana Manos
10:47 AM

INTEGRIS Health, Oklahoma's largest health system, announced Thursday it will incorporate Phytel's population health and care management tools to help build a medical home model.

The partnership marks INTEGRIS' latest effort to adjust to the emerging value-based system of health, which rewards providers commensurate with the quality of care they deliver, according to a news release. To succeed in a value-based environment, the health system's leaders say they realize they need population health and care management tools that enhance the capabilities offered by their electronic health record.  

INTEGRIS' use of Phytel also will help meet the requirements of a grant from the Center for Medicare and Medicaid Innovation. This federal funding is part of a $20.8 million Health Care Innovation Grant that CMMI announced last June. Provided to a collaborative that includes Phytel, VHA, and TransforMED, the grant will fund a three-year national project involving health care systems, hospitals and provider practices in 15 communities.

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The CMMI project's goal is to expand the concept of the PCMH to the "medical neighborhood," including specialists, and to connect hospitals with physician practices to improve the quality of care and lower health costs, according to INTEGRIS. The health plan’s first step toward that goal will be to create PCMHs in its 22 family care practices in the Oklahoma City area. Five INTEGRIS practices will be included in the program's initial phase, and INTEGRIS plans to roll out the PCMH model to the other practices in the future via the project.

Officials say the addition of population and care management solutions will help the health system speed its deployment of the patient centered medical home model, which uses team-based care delivery led by a physician to provide comprehensive and continuous medical care to patients. Designed to improve health outcomes for large populations of patients, the PCMH model is fast becoming a critical component of accountable care organizations and other arrangements that tie provider reimbursement to quality metrics and reductions in the total cost of care for an assigned population of patients.

[See also: Analytics take on population health.]

"Our deployment of Phytel solutions will help us successfully manage our patient population toward improved health outcomes, strengthen our already high quality care and increase our overall patient and physician engagement and satisfaction levels," commented Natha Norman, director of project management for INTEGRIS Health in a news release. "(The technology) will enable our care managers to reach out to patients who have fallen out of compliance with their physicians' care plans and need preventive or chronic care. In addition, the care managers can use the applications to track the health status of high-risk patients and to intervene and improve their overall health status."

Steve Schelhammer, CEO of Phytel, commented, "INTEGRIS Health's decision to build patient-centered medical homes positions the organization to succeed in the world of value-based care. Phytel's care management tools will provide INTEGRIS's primary care practices with the technology support they need to redesign their work processes so they can fulfill their commitment to coordinate care better for their entire patient population."

The practices designated as medical homes will rely on the technology to help their care managers and other staff members improve the coordination of care, especially for patients with serious chronic conditions. The technology utilizes a Web-based registry and analytics to identify patient care gaps and generate actionable data to ensure patients receive necessary services on time. Care management is then automated by identifying care opportunities, producing work lists and generating pre-visit care plans. The data for these applications will be extracted from INTEGRIS' EHR. 



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