Population Health Management – INFORM

EagleDream Health’s software provides the actionable data that physicians need to tackle the challenges of population health, supporting a full spectrum of care management activities, while improving clinical outcomes and generating new cost savings.

Our application offers comprehensive population management tools incorporating descriptive and predictive analytics enabling users to visualize data, generate role-based reports and focus scarce care coordination efforts on the patients most in need of these interventions.

Our software will help your organization successfully transition from volume/fee-for-service reimbursement to value-based payment contracts.  Our comprehensive population health management capabilities will assist you in taking on risk in contracting and quality/outcomes management and enable you to create informed, effective, and collaborative providers who together deliver high quality, low cost care that improves outcomes.

INFORM is our clinical population health and care management module that provides:

Population Health Management

  • Practice Demographics such as age, gender, race/ethnicity, zip code distribution including geospatial mapping
  • Condition Registries including geospatial mapping
  • Performance on Quality Metrics with comparisons and trending against benchmarks
  • Gaps in Care including detailed drill down for performance enhancement
  • Initiative Builder allowing the attribution of a patient population and specific quality/performance metrics relevant to a population for measurement and reporting

Care Management

  • Risk Stratification of patients through the incorporation of evidence based predictive risk algorithms
  • Predictive Risk Reports including cost projections and risk stratification across condition registries, both at the individual patient and aggregate population levels
  • Pre-visit Planning Dashboard allowing visualization of gaps in care and facilitating care management interventions

We have put in place extensive processes for the ingestion, normalization, and synchronization of data, ensuring data integrity. Employing a variety of tools and technologies to integrate data, regardless of origination, once the data has been processed into our data model, analytics are performed and the results are presented in a very elegant, contemporary user interface.

In just a few clicks, users have the ability to navigate from the organization’s entire population down to individual patient detail.

Clinical and leadership teams are able to look at dynamic graphic dashboards of performance across an entire organization, with drill-down to the specialty, practice and individual provider level.  Access is securely administered by user permission rights and authentication processes, as set by your organization’s leadership. Users are able to navigate through the software with minimal training, gaining insights spanning their entire population.

Several core functions span across all of our modules and are central to our software’s unique design.  These include comparison, reporting and trending at all levels.  These functions operate across the modules providing capabilities to leverage analytics from multiple perspectives.  Geospatial capabilities are embedded throughout our software allowing analysis of multiple data elements across a geographical area.

Condition Registries

EagleDream Health currently provides a standard library of defined registries “out of the box” with the ability to stand up virtually any customer definable registry to support evidence-based care.

Our condition registries provide users the ability to view multiple conditions and provide comparisons across the network, specialties, practices and providers.  Condition overlap and geospatial mapping of these population snapshots are also provided.

Metric Reporting

EagleDream Health’s software provides access to an extensive metrics library containing approximately one hundred quality measures.  Performance metrics are presented within the software, defined by the customer’s specification and reportable at the system, initiative, specialty, practice, and provider levels. These include HEDIS, PQRS, UDS and other custom measures.  Flexibility is inherent within our software and customers are able to report on their performance according to a single value-based contract across the entire network or for a given specialty, practice or provider.

All metrics are viewable in the aggregate at the system level with performance rates, numerator and denominator information regarding each measure available for review within multiple date range periods.

Individual provider performance across multiple quality initiatives and quality measures is available with drill-down capability to the patient level.

Our software enables our customers to address their care coordination and care management requirements across multiple EMRs.  Metrics are satisfied by any validated data type, affording care management teams the ability to work across multiple platforms.

For organizations involved in risk contracting, it is critical to have clear visibility to your organization’s performance on metrics in order to empower you to negotiate quality targets within your risk contract.  Our solution not only provides you with this performance information, but also has the capability to identify and trend key elements of resource utilization in risk-bearing contract populations enabling timely interventions to ensure successful financial performance on the contracts.

Initiative Builder

A unique feature of EagleDream Health’s software is the use of its Initiatives to manage specific populations.

The Initiative Builder allows the attribution of a patient population and specific quality/performance metrics relevant to a population.  The use of Initiatives allows users to simultaneously report on multiple value-based contracts, programs, and customer defined quality efforts.

This advanced functionality appears throughout our application and is available across all software modules.