By Jon Phillips, Chief Analytics Officer 

For health care providers to survive and thrive in today’s market and regulatory environment, they must improve quality, reduce unnecessary service utilization and cost while accepting increasing levels of revenue risk based on their performance.  Everyone must rise to the challenge of “doing more for less,” but how do we get there from here?

The answer is complex, but one thing is for sure; our health providers need more information to answer their important questions about their patients.  These questions include the following:

  • Who hasn’t had an appointment with a primary care provider for over a year that I need to reach to schedule a wellness checkup?
  • Which patients are at significant risk of a preventable hospital admission or ER visit?
  • What gaps in care does that patient have that I need to address in the next doctor’s appointment to reduce their risk of a poor health outcome?
  • How can I improve my performance on key measures that I am responsible for?
  • What social barriers to health (i.e. lack of housing, food, transportation) do my patients have that I need to address?

The answers to these and more vital questions can be found in patient data, but it is spread across multiple different patient record systems in hospitals, primary care practices, behavioral health agencies and managed care organizations.  Pulling this patient data together into a singular longitudinal patient record is vital.  That is why Millennium has taken the following steps to transform data into actionable information for our healthcare providers.  This includes:

  1. Acquire and integrate patient information from electronic medical systems and claims sources in our population health management platform to create the most robust actionable patient record available in Western New York.
  2. Identify and stratify patient risk into manageable groups and apply evidence based interventions to improve their health status and reduce risk. These groups can be established based on multiple criteria such as one or more chronic diseases or level of risk of high utilization of health services based on past encounters.
  3. Create key performance indicators that monitor organization and physician performance on the selected measures. These measures enable providers to identify actions that they need to take with their patients to improve their performance.  Performance can be trended and bench marked against similar organizations of physicians within organizations.
  4. Create advanced analytic models that identify the key factors in a patient group’s care that either result in positive or negative impacts on the health of the group and their cost of care. Predictive models can provide the information providers need before the health of patients declines.
  5. Generate actionable insights from patient registries and analytic models that Millennium care coordinators can share with our PPS network organizations to further evolve or improve their plans for care for specific patient groups to improve or prevent deterioration of their health status.
  6. Finally, based on our performance measures we can access the effectiveness of our multiple initiatives to improve care and use our data insights to further refine our processes of care as needed to achieve our performance objectives.

We have established why turning data into actionable information is so important to meet today’s challenges of delivering better care at lower cost through effective population health management. So, what has Millennium done to help our provider network be successful and create unique value for our partners to maintain Millennium as a financially viable service now and into the future?

  • Our data strategy is coming together. Over the next few months it will become apparent to our Western New York  health care providers that we have a unique and comprehensive view of our patients that creates significant insights into how to better manage patient populations to achieve better outcomes.
  • We are implementing a leading population health management platform branded as Cerner HealtheIntent. With all our available EMR and claims data, the platform will provide over 40 chronic disease and wellness registries, a care coordination and planning tool and an enterprise data warehouse to support our reporting and analytic needs.
  • We are generating performance reports for our network organizations and individual providers on the key measures most important to our organization’s and network’s success. These reports enable analysis of various groups of providers and patients to identify and monitor trends and root causes of performance outcomes to continuously improve our service quality and cost.
  • We have hired a top-notch team of population health data and analytic professionals. These highly skilled and experienced resources have knowledge of both EMR clinical and payor claims data and how best to turn data into actionable information to achieve targeted health outcomes and value based performance.  Our Data Analytics team can partner with our network organizations to provide for their reporting and analytics needs.



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

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