Jon Phillips, Millennium’s Chief Analytics Officer, center, with Cerner team members James Kanary, Senior Director, left, and Dane Sutherland, Senior Account Executive, right. at MCC’s May Population Health Conference.

By Jon Phillips, Chief Analytics Officer 

Over the past year, we have been working with our service providers to unlock the patient data they capture in their electronic medical record (EMR) systems and share it with Millennium to help improve population health.

This is being done in one of two ways: either by sending clinical document summaries to HEALTHeLINK, or by sending their clinical records directly to Cerner HealtheIntent, our population health management platform.

HealtheIntent aggregates the data and provides the tools to help our network manage the health of our Medicaid members. This is done through chronic disease and wellness registries; a care management tool and an enterprise data warehouse that we can use to build reports and perform data analysis. Ultimately, it is Millennium’s responsibility to turn this vast web of disparate clinical data into actionable insights that our providers can use to improve the health of our community residents.

What kind of actionable insights will we be able to generate?

One example is leveraging our patient data to determine how we can reduce potentially preventable hospital admissions, readmissions and emergency room visits; a key goal of the Delivery System Reimbursement Incentive Payment (DSRIP) program.

We want to answer the following questions.

  • What are the causes of these preventable events?
  • What chronic conditions are contributing most heavily to these preventable events?
  • What gaps in care are most important to address to prevent these events in the future?
  • Are there geographic areas that are more heavily impacted that need special attention?
  • What leading practices can we find among our health providers?
  • What actions can physicians take to reduce their preventable events?

With the answers to these questions, we can share these insights with our health providers to develop effective strategies that reduce these preventable events that increase cost and utilization and negatively affect patient health.



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