Application Overview

The EDH Application is comprised of four primary modules – Perform, Inform, Navigate and Empower.

Underlying all the modules is an integrated data warehouse, sourced from clinical, claims, costs, and patient generated data. In addition to the core features, the modules are also able to leverage a variety of shared services that are available throughout the application. Specific details and requirements regarding module descriptions, functions, features, and use cases are described in the module subsections.

The primary modules are:

PERFORM
Provides leaders in health care organizations with the information needed to make decisions and take on risk in an environment that is shifting from volume to value. The module will provide analysis of claims files and provide insights on key cost drivers, variation analysis of physician practice patterns and create a road map to cost savings stemming from reduction in variation. This module also provides analysis of claims data to create a detailed map of out-of-network revenue (often referred to as “leakage”), allowing organizations to enhance access and communication to improve quality and reduce revenue escaping to out-of- network entities. The Perform module will also allow analysis of physician performance across clinical quality, patient satisfaction and financial benchmarks. Another unique feature is the capability to calculate the distribution of an ACO’s contracting incentives across a provider network in a transparent, understandable format. The ability to track Resource Utilization across the organization is included in Perform. There are over 16 utilization parameters such as admissions, readmissions, emergency room, images, scripts, etc.

INFORM
Provides practice population overview, condition registries, metric performance and gaps in care, and patients not seen. Inform enables comparison of performance on quality metrics between organizations, practices, and individual physicians over time and across multiple metrics and parameters. All information can be viewed at an aggregated enterprise level or with drill down can be viewed at the practice, individual provider or individual patient level; this flexibility offers intense analytics insights. Inform allows geospatial representation of patient populations disease registries and condition control. The capability to compare metrics and attributes across similar entities, as well as the ability to trend these results over time are core functions of Inform.

NAVIGATE
This module provides all the data and analytics tools required for care managers in their day-to-day work. It provides multiple risk assessment tools that can be applied to individual or groups of patients to risk stratify them, allowing the appropriate allocation of care management resources. Transitions of Care information is presented based on Admissions Discharges and Transfers (ADT) as reported via an HIE or RHIO. Gaps in care disease registries and performance against metrics are presented in a manner that is relevant to the care manager’s workflows. A pre-visit planning tool facilitates prospective view of practices schedules so that gaps can be closed prior to patient visits. The Navigate also provides extensive information regarding patient risk flags which provide insight not only into high risk patients, but more importantly the most appropriate care management interventions. A longitudinal care record will be a tool to provide a continuum based view of all care that a patient has received as evidenced by clinical, claims or ADT based data sources.

EMPOWER (future release)
Is the patient engagement module, that is patient facing. Patients are provided with a view of their clinical information, which allows patients to compare themselves to a de-identified group of patients in the same practice. In addition, patients can obtain a detailed analysis of the changes they need to make to perform better on clinical parameters, such as diabetic control, improvement in cholesterol levels, weight and physical fitness, etc. Multiple embedded clinical and educational resources can be linked to an individual patient’s clinical parameters. This module is designed to upload and integrate data from personal health wearable devices such as Fitbits as standards progress. A linkage to the LMS may be leveraged to provide patient education (optional and required) based on “prescriptions” by care team members.