By Joe Eberle, Chief Analytics Officer

Millennium’s Cerner Population Health Management platform is on line and delivering major features including:
• Predictive risk identification and stratification.
• Identification of potentially preventable Emergency Department visits and hospital admissions.
• 40 wellness, chronic disease management and Accountable Care Organization registries.
• Care coordination solution.
• Risk stratified high impact lists of patients that will enable immediate outreach and intervention.

The platform is also providing Data Coverage including 134 million laboratory observations with 6.5 million added per month. (This represents approximately 65% clinical coverage for our Medicaid lives and is improving every day.)

More specifically, as 2019 begins, activity highlights include:

  • We are continuing to engage our key partners in developing data-sharing agreements to create the most comprehensive view of our Medicaid members’ clinical encounters in Western New York.
  • The HealtheIntent platform is functional including HealtheCare, HealtheRegistries, HealtheEDW, and HealtheRecord.
  • Early adopter rollout has started with Niagara Falls Memorial Medical Center and the Erie County Medical Center ECMC.
  • Kaleida Health rollout in progress.
  • Valuable new data assets are flowing into the platform and validation efforts are ongoing.

First early adopters are providing feedback regarding the platform including generally finding available information extremely useful but wanting even more complete data. (The Team is working on responding including adding new sources of data, such as unadjudicated claims, to help meet these customer inputs.)

The Data and Analytics Team is adding functionality to the platform such as cost and utilization, MIPS, and social determinants, etc. in support of Great Lakes Integrated Network, Value Network, Federally Qualified Healthcare Centers, Community-based Organizations, and other Partners.


A “Population Health Scorecard” provides a snapshot of over 167,000 patients.

The Millennium system is receiving data feeds from multiple key sources including HEALTHeLINK; ECMC – Meditech; ECMC – Allscripts; Medicaid Department of Health; Olean – Meditech; Patient Activation Measure Scores; Kaleida Health; and Niagara Falls Memorial Medical Center.

Overall, our ultimate objectives are to assure a high level of data quality and consistency to lay the foundation for delivery of actionable insights to our Performing Provider System network to improve care delivery and health outcomes for our attributed members. We have a great deal of work to do, but are very grateful for the early positive feedback we have received including the following:

“The ability to view a patient’s complete encounter history is fantastic! On one page we can easily see how many different ED, hospital, and outpatient visits a patient had, across numerous systems in WNY.”

“At the push of a button we can narrow our entire patient population down into a specific registry, regardless if our practice EMR has that specific condition listed or not. There were numerous instances where patients had a diagnosis of COPD that were given during IP stays that were never communicated back to primary care. Primary care visit summaries were pulled up for those patients and no mention of COPD was found. We will be able to effectively manage these patients, for the CORRECT diseases, with this new system.”


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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

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