You’ve got the SAMHSA PBHCI Grant… Now what? (Webinar Recording)

February 20, 2016

You’ve got the SAMHSA PBHCI Grant… Now what? (Webinar Recording)

With PopulationManager®, Forward Health Group offers awardees of SAMHSA’s Primary and Behavioral Health Care Integration (PBHCI) program a toolkit to meet the specific requirements of the PBHCI program. This webinar was held on January 20, 2015 at 2:30 PM CST.


Hello everyone. Welcome and thank you for joining us this afternoon. I’m Joe Zeimentz, I’m a consultant with Forward Health Group and I’ll be our moderator for our time together today. Also joining me and presenting we have Michael Barbouche, who’s our founder and CEO, Amy Mosher-Garvey, who’s both a practicing clinician as well as our account manager, and Jake Moskol who’s also part of our consulting team.

Before we jump into our presentation we thought we’d take just a couple of minutes and cover some logistics. If you’re having any issues with the volume or the audio or being able to see anything if you want to try calling in using the call in number that way you can listen in for the audio and use the computer link to be able to view the presentation. If you have any issues or challenges you can send us a chat through the chat box. Just send us a note and we’ll see if we can offer a couple suggestions. You can also send us an email if you run into any problems and you don’t have access to that chat box and you can email us at the

We are going to have a Q and A session as part of our time together today so we would ask that you go ahead and job down your questions as you think of them and hopefully you guys have lots of questions for us. Send those to us via the question box in the webinar control box or again as a backup you can send those via email and we’ll get those for our Q&A.

The last thing I’ll mention is the webinar is being recorded so we will have this up on the website and we’ll send a link out to you once we know that everything’s in place and you can share with any colleagues who weren’t able to join us today.

With that let’s go ahead and get started. We’d like to congratulate all of you for getting this award and for being part of such a wonderful program. We know some of you have been involved with it now for the last year or two, we’ve been talking to many of you. Many of you on the call today are getting into this for the first time. We know that somewhere along the way you’ve asked yourself this question, “Great, we got this award? Now what?”

There’s a lot of work to be done, a lot of work you have been doing up to this point, and certainly we’ve learned a lot in the time that we’ve spent meeting with and talking to many of you recently.

We do know as far as the grant program goes that you have some pretty specific requirements including things like budget categories that you have to work within. Those can cover things like technology, infrastructure, program assessment. We know that you have to get your primary care services operational in short order, whether you’re doing that internally or if you’re working with an FQHC partner, there’s a lot to be done there. If you’re working with partners then we know you’re dealing with multiple systems. You might have your own EHR and you’re working with you FQHC EHR. You may also be working with an access database or an Excel spreadsheet. You have data coming at you from a lot of different places.

We know that the information that you’re capturing and reporting on includes things like physical health indicators. You’re NOMS interviews and assessments. Your wellness goal tracking programs and that you’re reporting a lot of that to SAMHSA but we also know that you want to have access to this information and be able to use it within your operation to ultimately improve care, especially in the physical health side.

Then long term, we know that one of the goals for this program is really to create something that’s going to be sustainable as part of your operation beyond the term of the grant.

We wanted to make sure that we had an opportunity to introduce you to Forward Health Group. We think we have something here that can certainly simplify your lives when it comes to this project and this program, but also create something that can contribute to the long-term success and sustainability of it.

We’re going to go ahead and introduce you to our business. Michael will take you through how we got started, where we came from, and what we’re all about and then Amy’s going to talk a little bit about integration and sustainability as it relates to the area health providers who we work with. She also has perspective as a practicing clinician in using the toolset for her own practice. Michael will then take us through population manager and do a full demonstration so you can see what the toolset looks like. Once we get through all of that we’re going to spend a little of time and just talk about that Fast Start toolkit and what’s included in the toolset and the services surrounding it. At that point we’ll go ahead and open it up for a Q&A and Jake will moderate that and that should take us to the end of our time together.

With that I’d like to go ahead and introduce Michael Barbouche, our founder and CEO who will talk a little bit about Forward Health Group.

Good afternoon everybody and thanks for joining us today. It’s a lovely beautiful day here in Madison, Wisconsin where we are based. I’m very proud to be here with our great team talking to you today about the work that we have done and we continue to do in and around primary care and behavioral health. A bit about us and a bit about where we come from. Our team came together about 12 years ago and really was at the forefront of building something for the country that hadn’t been done before.

We’ve built the country’s first public reporting website, something called the Wisconsin Collaborative for Healthcare Quality. What you need to know about that is that the initiative was really one that said, “Let’s bring together all stakeholders public and private.” Wasn’t just a government based initiative, it was commercial insurers. It was also the employers and the community, community leaders, and clinicians like all of you. What we wanted to do was really get the data to have value first and foremost to the clinical practice.

That work pushed us into very interesting conversations. We got to meet very new and dynamic people and what we learned along the way and what lead to the formation of Forward Health Group was that a lot of people were interested in having you collect data for them, but they weren’t always interested in having data collected that was for you. We said, “I think we need to invert this. We need to change the flow. We need to have the data collection be first and foremost about supporting the practice.”

By marriage, my wife is a practicing general internist so I saw firsthand how the advent of electronic records became a great data entry challenge for her. She wasn’t getting a lot of information back. With my colleagues sitting with me here in the room today in 2009 we launched our company. Perhaps not the best finanical time to set our on a journey, thinking about the economy back then, but our mission then and our mission today was quite simple. We wanted to be at the forefront of yielding clinical data and bringing it back to the forefront for practices, thereafter helping the practices leverage that data. In a moment I’ll give you a quick tour of how we started and our approach to using data and what we’ve put together to support this very wonderful initiative you’re all participating in.

A couple of quick guiding points. We care a ton. A lot. More than I can put in words, about data security. Data privacy. Our first initiative out of the gate as a company was working in the HIV space. Soon after we moved in behavioral health. We care deeply about how important and how safe this data is. We’ve completed something called a SOC2 Type II audit. We did so with no exceptions. What that means, basically, is that our approach to data security is right now without peer in the market and it’s the most important part of the work that we do here. We believe this data is critical for your work but we also believe it’s very, very privileged and sensitive. We work steadfastly everyday to make sure it is protected.

We’re very fortunate as a company to have garnered the collaboration and the recognition from our partners like the American Diabetes Association, American Cancer Center, American Heath Association, AMA and others. The work that we do for them is really quite like the initiative that you’re all participating in. Bring the practices together. We have a large federally qualified health center network for example. What’s their greatest challenge along with diabetes and hypertension? It’s depression. We work on those things day in and day out.

One final point and then I’ll hand it over to my peers. We are recognized as something called a QCDR. Basically, we’re on the CMS website and what we can do is basically submit your data for any of these pesky programs that really drive you nuts. In fact, we were visited today by members of ONC, the Office of the National Coordinator, asking us specifically for guidance on how to shape the new program called MIPS, which is under MACRA. You’ll be hearing all about that as a replacement.

The point for your thoughts today and the notes today is that at Forward Health Group we view our job as one that supports you in driving improvement in the practice and helping you coalesce and submit the data on a turnkey basis to all the people that are asking you for it.


Thanks Michael. This is Amy. I am not only an account manager for Forward Health Group, but I also am a practicing clinician. Like many of you on the phone I have my degree in clinical social work and own a clinic here in Madison, Wisconsin. I do run the Population Manager platform in my clinic.

My experience is a broad range of mental health practice across a number of behavioral health populations. My training is in both substance abuse and mental health. I actually came out of the physical medicine world and was a hospital social worker in an emergency room for a long time. I’ve run addiction services for a number of healthcare systems in the area and eventually settled in my own practice here in town.

I was attracted to Forward Health Group when Michael originally demoed the platform to me because it really fit with how I saw quality improvement in behavioral health and it really solved a lot of the problems that we encounter specifically within our space.

The first thing I want to say is that what you are all embarking upon is hard work. The idea of integrating information and making it usable across a number of systems is something that is a little bit foreign to us and if you are in a typical behavioral health setting you probably are a part of that culture of, “How do we even begin to measure whether or not we’re helping the people that we see?”

I think this thing about Population Manager in terms of integration and sustainability is that it helps us justify and get credit for the good work that we’re already doing. I think the other thing about Population Manager as a product is that it helps us to work smarter and not harder. We’re already experts in motivating our clients for behavioral change. That is nothing but value added for our peers across the aisle in the PCP world who are trying to exact change around medication management for hypertension or making sure that their clients are adherent with their diabetes care.

We touch those patients much more than our physical medicine colleagues can and so we have more opportunity to use our specific skill sets to create change in the physical medicine world, maybe than some of our primary care colleagues have. Population Manager allows us to integrate our data with the data from the primary care world so that we can all see up-to-date data for our patients and help to further the goals of both the primary care and behavioral health worlds at the same time.

I think some of the things that I would point out to you and that you should look for as Michael moves into the demo, is that if you have ever had to do data collection before you know that if you’re going to spend the amount of time it takes to do data collection, you need to be collecting things that are meaningful, actionable, and usable to the patients that you are seeing. I’m guessing that many of you are in that world where you are doing double and triple entry of the same data into different data repositories. You’re probably collecting data in Excel, you’re probably putting things into a physical EHR through the primary care world, and you’re probably also keeping some things in your own mental health or behavioral health EHR. You also have claims data. You have pharmacy data. You have laboratory data. Getting all of that data to work together in a cohesive fashion to improve the outcomes of the people that we serve is quite a monumental task.

Population Manager really allows us to pull all of that data into one streamlined source which allows us to easily sort through patients, diagnoses, physical characteristics. We can identify gaps in care that stretch across multi-cultural settings. We can identify which patients we’re reaching and which ones we aren’t and we can target our efforts in a way that is more streamlined and more efficient.

I think for me my mantra is measure what’s important, record it once if you can, not multiple times. Use it to improve. Make sure that everyone has the information and drive outcomes. I think that the tool that you’re about to see is going to show you how you can increase your provider engagement in the process. Introducing outcome measurement to the behavioral health world sometimes is a cultural change for people, and I think that the tool itself drives engagement by putting the data back in the hands of the people who are capable of effecting change.

I’m going to turn it back over to Michael so he can show you the product. Go ahead and jot down your questions in that chatbox on the webinar as they come up for you and we’ll do our best to answer them during the Q&A session.

All right. Thanks Amy. Just a guiding principle here for everybody as I walk through these screens. Just a couple of quick points. All of the data that we’re going to look at today is really good but it’s really fake. We’ve built out simulated data so if I click on a patient it’s not a really patient. There’s no HIPAA here. As I mentioned before we care a real lot about data protection and data security.

I’m going to take you on a quick tour through what our progression was to be in position for PBHCI. We really started in the physical health world. I mentioned HIB. We also did a lot of work upfront with primary care. I’m going to take you on a quick walking tour here of what our original approach was on primary care and in particular try to drive home the point that Amy just made, which is it is our job to work with your messy data. The different sources you have, your practice management data, the nascent electronic record, stuff that your patients are bringing in, and put together the right strategy to collect and capture that information.

I’m logged in here as the fictitious Ellen Driggins of the entirely artificial Spruce Valley Health System. For those that are on the phone that come from a larger clinic or a larger environment one of the things that will be very important is the ability to drill down and look across different structural elements by location, by clinic, or the like.

We do a lot of work with systems where they have different branching. They have owned or affiliated or residents and fellows or part time or full time. The idea of being able to parse apart and look at different cut points, fully customized to the unique structure of your system and your community. The ability, obviously, to drill down and look at an individual clinician levels, and I’m going to log into Dr. Driggins panel.

We’re able to zoom through, so we’ve got her diabetes population here and a whole smorgasbord of measures. I can quickly go and see how here hypertension patients are doing. I can toggle through and look at heart disease. As I do this the measures and the metrics connected are changing. If I toggle into something like here heart failure population. Now we’re down to 38 heart failure patients that Dr. Driggins is managing. If I come down here and look at the ejection fraction assessment there are 10 patients in Dr. Driggins panel who haven’t had an EF, it’s called. There they are. I can zoom in on that list and get to work.

I can also come back out to the home page and say, “I might want to look just across the entire enterprise.” 1148 heart failure patients being managed in the system and now 377 who haven’t had an ejection fraction. With a click I’m able to see that entire group.

What we’re trying to do is make the data very ready, very available, very fast. As I’m clicking through, although this is simulated data, this is exactly the speed and the performance that our practices have. This is what they find when they’re working with the data. I’ll drill back down into Dr. Driggins panel. Look at something like different groups, so different areas of patient responsibility, emerging risk. She has 4 heart failure patients who are in the ACL risk group and here’s how they’re doing.

We can toggle into something like a screening measure. Broader group of patients. Now we bring a presentation up that says, “Okay, who needs a colonoscopy?” There are 235 patients and those are a click away and we can pull that list up. Here they are. More importantly as I go back out to the home page there’s thousands of [inaudible 00:18:45] sitting down here. You know what? That represents what the electronic record thinks right now. There’s where your false alerts and your false positives and other things come about.

Very important thing that we care about is the ability to get to a very clean, accurate list and until this red bar and this red bar are the same size you’re going to have a lot of alert fatigue and other challenges. What we work with you is to help the data go from this red bar down to that. We’ll produce both numbers and work with you to try to, in your native system, bring it down.

I’m going to take a quick hop over here to the patients tab and just show you some of the different ways that you can navigate through the populations. I’m still looking at Dr. Driggins panel. She has 2140 patients total that she manages. I’ll begin to explore real quick here with you. Here are her patients with diabetes and we’ll toggle in and show her patients blood sugar control and now we can really start to accelerate the surfing so we’ll narrow in on those in decent control or not. I’ll zoom in on more clarification around the payer and the source.

I can pretty readily get down to 10 patients who are in Dr. Driggins’ panels who are medicare eligible. We can look at the ACL risk group. We could toggle into a different pair and you see by these made up names that it’s all simulated but we have 4 patients who fall into that bucket for help first.

Again, I mentioned before, I’m married to a primary care doc. I don’t get very with her talking about these categorical results. We actually have behind our numbers the actual clinical metric, in this case the actual AO1C. Down from 2140 patients to 2 overall patients who have diabetes, Help First insured, in the ACL risk group with an AO1C above 9.

I’ll do one more quick view on this page in the primary care demo then I’m going to move more into the behavior health side and show you that. Because your patients don’t just have diabetes, they don’t’ just have depression. They may in fact have diabetes and depression and the ability to be able to canvas and look at that and see precisely that intersection and then pull up that specific list of patients and say, “Okay, I want to look just at the 44 that have both diabetes and depression.” Now here’s that group and I can take that group and now take action.

We’ll call this the sunny Wednesday cohort. Now I’ve taken that group. I’ve just saved it, saved it in something that we call an action list. This is really where Amy and her practice were some of the pioneers in helping us learn saying, “Okay, now we need to track and monitor the work that we’re doing together about getting the meds reconciled, about really looking at patient adherence, about getting the appropriate follow-up care and the like.” It becomes a very important way to track and monitor the intermediate actions that people in your system are able to take. When we end up in a situation where we end up with challenging patients or difficult obstacles the ability to see that as well.

I can take this list, I can send it to my team, I can begin to leverage it with other tools you might be trying in this initiative or on patient engagement and the like. We have some behavioral health practices that have a little button we helped them build right here that sends automated text messages around employment reminders. Whatever it is the tools that you need to leverage the data to get you where you need to go, that’s a very important part of the work that we want to do with you.

I’m going to jump out of the primary care world here. That’s where we started and really worked on honing the toolset and the materials. Now I’m going to jump over to where we started with Amy. I’m still Ellen Driggins and the data is still made up but I’m going to walk you through now how we started in that community, in that world. The idea was again to really focus on measures of interest, so populations that would be quite familiar to all of you on the phone. We really began to mix things up when we began to think about the different cut points that were going to be required to really track and monitor the populations.

It should go without saying that the challenge we face as a country, heroin and other opioid abuse makes something like IV drug use an important marker. The ability to come in and check on the BAM or the GAD-7 or the TSQ or the like and then cut that further by things like housing status. These become the important markers that Amy and her peers have taught us are the data elements needed to begin to track and monitor the work that you’re doing day in day out.

Again, it’s one thing to say who’s been assessed, it’s another thing to actually be able to pull up the metrics. We can get down here real quick, real fast and say, “Where are we with our cohort? Which are the patients meet the criteria we’re after and again get to that action list and move forward?” That’s how we started in the behavioral health community. Real nice symmetry.

When we began to think about the PBHCI initiative we said, “Aha, this is really what we’re after.” This was for us the chocolate and peanut butter moment we were waiting for saying, “We’ve got primary care. We’ve got behavioral health. It’s time to bring these two together.” I’ll give you now a preview of the platform set that we’ve been working on and building out for your initiative and there’s still so much great work to be done by you, the practices, but we’re prepared and ready today to begin to harvest your rich data and get it in here.

I’m still Dr. Driggins and the data is still fake but it’s good stuff. Let’s now have a look. We’ve got our behavioral health population. We talked about that, and we have a lot of new measures and new focus on NOMS and other things. When we get into something like perception of care, and a lot of this will be driven by how you think about the challenges, about how you want to drive your practice forward and begin to look at the metrics that matter and drill into how does the unemployed population perceive our care, or any other of the cohorts of interest that would matter for you to track.

We see that as our job to help you begin to shape and measure this. Then of course what we know is that we’ve got a full, rich set of information, not just the NOMS but in the physical health and the wellness side that we need to begin to track so we can see across the board how our physical health metrics are doing right alongside. Coalescing the behavioral health and the physical health into one common view. Again, the ability to drill down. We can’t forget about at all the wellness side and being able to look and track those measures and of course then the ability, as we had before, to drill down to a specific physician, a specific clinic, or the like and to see the information.

The same constructs I shared with you earlier, the Venn diagram, the selection, everything else. I’m going to focus on two quick things right now, a way for you to begin to leverage the data within your practice, so we’ll look across behavioral health and see how our practice is doing, all of our clinicians. I’m going to click on the computer tab here.

Now we have a layout here. Dr. Driggins is the big doc down here and these are all of the clinicians in here practice. We’re looking at the variation in performance in this case on the bam. We see Dr. Driggins’ doc is one of the lower ones. If I toggle out of here and pick a different clinician, Dr. Henry, he’s here at 55.7. I lieu of just saying, “You’re a 55.7” and sending a PDF we want you instead to have one-click access to the underlying numerator and denominator that made up the result. The ability to then further just drill in to a patient like Greg and really see what’s happening and see what’s going on and look across the spectrum at all of the measures and begin to see where things are.

A very important part of the initiative, your part you’re participating in that matters a lot, is the data submission and that challenge, we know, is very, very significant. We also know that SAMHSA and its partners have really struggled to give you an infrastructure and guidance, might be putting it lightly. We get that. What we know our job needs to be is to essentially that a turnkey process for you, which is to say as the rules continue to shift and evolve as they’re building this up and building this out we are the partner for you to help you endure and really thrive through that change. Moreover, what we want you to do is think about the data and your use rally as Amy teed it up, as something that’s first and foremost there to help your practice. Our job is to take and package and form and format the data you’re using to manage your patients, to drive improvements in care, and then put it in the structure and the dialect and the format that SAMHSA has dictated so that we can get it out.

Amy, do you want speak a bit about how when we started this journey in the state of Wisconsin what it was like trying to solve that reporting riddle?

Sure. It might have been more entertaining if it weren’t so cumbersome. Initially when we installed in a pilot project on outcome tracking for behavioral health in the state of Wisconsin, we had to train the state of Wisconsin in how to receive data from the sites that were participating in the pilot. For example, we had a site that was about 5 hours away from Madison who had their data in our platform and wanted to submit it to the state of the Wisconsin and the state asked us to pull it back out of the platform and submit it to them in an unsecured email attachment via Excel. We had to shepherd people through the process of what exactly does HIPPA mean and how do we secure your data and how can we help educate you about the most proper way to pull data and submit it for reporting purposes.

We have quite a bit of experience doing reporting for our channel partners like the American Heart Association, American Cancer Society. We’re pretty savvy at being able to assist people in meeting their reporting requirements. One of the things that we are attempting to do within this particular platform for PVHCI is to actually give you the opportunity to do that track reporting right through out platform.

Think again about reducing workload. If you could enter it once and then you could have it immediately available to you to use for analysis and for program planning what would that be worth to you in terms of both time saving for your staff and program improvements in being able to use that data right away?

Thanks Amy. Joe, hand it back to you.

All right. Thank you Michael. Let’s talk a little bit then about the FastStart Tookit and what’s included when we’re talking about our toolset and the services that would go with that. The first thing is that we’re going to do is sit down and really understand the systems that you’re working with. If you’re doing this in house and you have an EHR or you’re working with an FQHC partner and they have an EHR, we’re going to make sure that we have a system and an approach to get the data out of those EHRs and make that connection so that data comes into population manager.

If you’re working with Access or Excel or if you have other programs that you’re using we’ll work with you and figure out whether or not you think it makes sense to continue to use those systems and if so then we’ll make sure that we make those connections as well and have that data coming out. You may find that in working with Population Manager that you don’t need all of those systems and we’ll figure that out together and at that point we’ll be able to move into the data entry.

The second piece that we’re going to provide are some simple data entry forms for you to be able to enter any information in that you’d like to. As an example, if you’re using a paper form to do your NOMs interviews it may make more sense for you to go ahead and just enter that data right into population manager. You would have immediate access to that along with everything else.

We know as well that all of you right now are having to manually key in everything into Track that gets reported to SAMHSA. What we’ll do right now is be able to get that data extract out of Track that you all have available to you and get all of that information into Population Manager as well.

The main component of this is the toolset itself will provide and implement a PVHCI configured version of Population Manager so you have that integrated view of all of that information coming from all the different sources in a way that really is going to be useful and actionable for you and your team.

Pricing and implementation. The price of the toolset and the services we just talked about is 24,000 to 40,000 per year. That range is really going to be dependent on the number and type of data connections and systems that we’re working with. Again, we’ll sit down and figure out what that’s going to look like for you and what the best implementation plan is and then we’ll provide a proposal that includes all of that within the construct of this range.

We do know that you have some flexibility with this grant project and this is something to really keep in mind as you think about your expenses and itemizing your budget. You have a couple of different areas that this can pull from so that he entire investment here can be incorporated into the funds that you’re getting from SAMHSA. You have up to 20% for data collection measurement and performance assessment. You also have up to 15% for health information technology.

Again, depending on what your situation is and other expenses that you have built in or planning to build in there’s some real flexibility there to include this tool within that. I’ll share an example with you. I know we have some program evaluators on the call and I know many of you are working with program evaluators and that investment and those services are part of that up to 20% for the data collection and measurement and performance assessment. This would be a real nice complement to those services and to that function of the program and again, having that flexibility on where that fits in the budget is going to be very helpful to you.

As far as implementation goes, we’re going to be somewhere in that 6 to 8 week range. Again, it’s going to depend on your situation and what we’re working with on the front end as far as the systems that are involved.

With that I’d like to go ahead and hand it over to Jake who’s going to moderate our question and answer.

Thanks. Thanks Joe. We have a number of questions coming in so let’s just dive right in. The first question is, she asks, “If we put it in Population Manager will you then put it into the Track system or do we have to enter it?” Right now we know one of your limitations, or limitation of Track and of cancer reporting is that there’s no batch upload feature into Track. At the outset what we’re imagining is that we can eliminate at least one of your bill entry manual processes. In other words, if you’re entering something into a fillable PDF form NOMS data, you can instead be entering that data into Population Manager and actually do something with it that’s meaningful, the kinds of things that you saw Michael demonstrate before. Data [inaudible 00:35:59] on that, visualization, pushing stuff to action lists. All of that is going to be really helpful.

Michael has a comment on that also.

Yeah. Folks, we know that there’s a real shift going on here at SAMHSA, and we’re talking to them directly. What we would advocate on this call and make as a pledge is that Track is really a fallback position for SAMHSA. We’re going to work directly with them and support this program so we can get to that batch submission, either through Track or sending it directly to SAMHSA. That’s the pledge that we make to you on this call. We know that there’s work to be done to make that happen but we’re committed to being at the forefront of that. It’s part of the pioneering work that we have done for more than a decade.

Thanks Michael. The second question is along the same lines. It comes from Becca. She says, “Does the platform pull into versus out of Track.” She says, “Can we enter into your platform and import into Track?” I think that’s what we’re talking about here. It’s worth noting, I think, on the export side for Track we can feed Track any other data so to the extent that you can download and export out of Track we can pull that information to Population Manager and treat that some more. Michael?

There’s also an important other view of that question which is you guys are going to want to have some historical data in there. You’re going to want to have some baseline information. Absolutely as part of this build we’re going to work to bring in as much of that historical background information. You’re not just starting at day one. We know you need to go back and see as much history and other things. We’re going to help yield that information, harvest that information from whatever sources you have, including if we can get at Track, which I believe we can. Bringing you a rich view of the historical action of the population so you have something to baseline from and then move forward.

Great. The last question I have on the list here so far from Phyllis, it’s a similar question actually. I think we’ve already addressed it. Let me just ask, just remind you if you have any other questions please submit those through the question box on your control panel. In the meantime maybe I could ask Michael one question around dashboards, because this is something that I’ve seen and the research out there that I’ve been looking at, the literature, [inaudible 00:38:20] building dashboards. We have the patient scorecard as one example of that. How would you envision that rolling up into maybe a further aggregation at the clinic level or enterprise level even?

That’s a great question. I’m going to bounce back over to our primary care world. We had previously made what we had called an action list and there’s the security. I’m going to log back in, one moment. We have rich experience learning with the practice how to create views that resonate across the entire care team. Here’s patient Betty and Betty is a fake patient. In our view here with the reds and greens and the results. We have some practices who go to the level and say, “Hey, time out, who’s on the care team here? I want to list all the actors that are involved. You know what, I want to have a next appointment date on here. I want to have the next refill.” It’s really about customizing this view so we can look across the entire spectrum of care.

Another thing to mention, by the way, is that this becomes a home base because it’s not going to be the case for many of you out there that you’re able to fully integrate the data that you might be getting from a primary care partner or from a hospital. We do want to give you a consolidated view of that information. To the question just presented, we will get the work that you’re doing as the R&D that will drive the entire industry forward. Again, when I said before this marriage of primary care and behavioral health, the excitement to us because we had been working on both independently, but scratching our heads saying, “They really are one.” Now this is where the real innovation comes from all of you.

Where the skill that [inaudible 00:40:19] at crafting the views, the color, and the layout to get at there. One of the things that we would hope and that we would pledge is that should we find a great way to get innovation with one of you as a partner, the ability to then spread that to others so that the community could share in the innovation and the advancement.

Great. Thanks Michael. More questions coming in. One from Lucy. Perhaps Michael, you can hit on this one too. “How does this interface with existing electronic health records?” She’s thinking of Qualifacts or Carelogic for example.

Great question and actually I was just speaking to the Qualifacts folks. I mentioned before that we’re based in Madison, Wisconsin. There’s a small little electronic record company named Epic, it might be based here as well. We look at the electronic record as a rich data source so we can make this commitment too on the webinar today that any version of any vendor of electronic record is a rich source of clinical data that we can work with. We have worked with so many different EHRs. I can try to count them, to Qualifacts, to NetSmart and the others that some of you have been using. Or others might be using things like Amazing Charts or on Cerna or on NextGen. With all of those we’re able to gather the data.

I want to make a very clear point in the answer to this question. We’ve built out a model and we spoke about it in the slides up front and Amy really reflected on that, that said it’s not about an IT list. We’re not going to try to do something that’s very onerous and tie up your IT staff. Those folks are already quite busy as you well know. Instead what we’re going to do is identify the smoothest, most sustainable path to harvest data, extracts of data that are already naturally occurring in your electronic records. It’s not just your electronic record, by the way. It’s the billing data. It may be lab data. It will definitely be patient survey data and other things that come into this. Not all of those coalesce in one place necessarily.

It’s the diversity, it’s the plurality of the data sources that we also need to bring in. That’s really the custom data model we build for each of those.

Wonderful. Another one from Phyllis. Michael, perhaps you can field this one too. “Do you have a contractual arrangement with Westat or SAMHSA?”

We do not have any contractual relationship with Westat, with the government, with SAMHSA, anybody. We are trying to work very closely with HRSA, with SAMHSA, with CMS, HHS, ONC, and the like, and teach them what the needs of practices are, but we have no financial relationship of any kid.

Great. One from Erin. “Is there a limit to the number of data sources, that is EHRs, Access, Track, download, etc, that can be pulled into Population Manager?”

There is no limit. I shudder to tell you what the record has been. It’s a big number. We understand if you are a practice of even more than 10 or 15 clinicians there’s going to be some messy stuff there. That’s really how we approach this. What we’re going to do, if I’ll go back to our PBHCI world. We’ve got to get these measures and you’re going to build out others beyond. We need to work to gather the data. Our hunch, our experience, our field knowledge is that some of this data already exists in your system but a lot of it does not. This is really about an improvement and an advancement of your collection of data.

Let me make one very important philosophical point. We want to help you stay long term after the grants and everything else. Our ideal, and what we say to everybody and we need to say to all of you is, over time we want you to be able to enter this data directly into your native systems and that we can harvest it from there. We know as a crutch, we know as an interim step we’re going to have to help you collect that data, but we really want you to begin to gather that data as part of your regular work flows.

Okay. Great. We have a couple other questions. I think they’re starting to develop a theme here so let’s just make sure we have everybody answer. The next one is from Joan and she asks, “We area new grantee and have not started the NOMS or Track. Are you saying Population Manager avoids the entering of NOMS and/or Track because you enter all the SAMHSA data in Population Manager and our EHR provides the physical health data?”

I think that comes back to the question that we tried to answer earlier in that we can’t batch upload to Track anymore than you can at the present moment. We’re actively pursuing solutions to that but they are not currently in place. We could, however, if you have entered into Track, you can get a batch download back from Track which then you can just shoot to us in a data export so that you don’t have to reenter it into population manager. We would love for it to go the other way as well. That bi-directional batch uploading with Track is not currently functional.

I would just say, we work with a large spectrum of federally qualified health centers. If any of you are FQHCs or have friends that are there you know this is the very dark season. This is UDS, the very, very challenging time of data collection. For our federally qualified health centers in a manner that Amy just hinted at, we help coalesce and capture all of the data around their UDS reporting. There is also not a batch process there yet, but we’re working on it. We accelerate amazingly how they can become efficient at doing UDS, by bringing all the data together and making their entry and their tracking much, much easier.

Great. We have another one from Becca along the same lines so Becca, if you don’t mind, we’ll take that one offline and just connect it to you one-to-one. Let me go to Tina. She asks, “Would you be able to pull data from the medicare/medicaid sites for recent hospitalization diagnosis claims, etc?”

That’s a great question. That’s an important question, everybody. This is really saying, “Can we get at payer data? Can we get at other data like that?” I mentioned early on in the slides that we are something called a QCDR. Qualified Clinical Data Registry. I won’t get into all the legislation and the like but when Congress passed the fix to the medicare reimbursement stuff last summer they included language that said QCDRs can serve as that bi-directional conduit to bring claims data out.

It’s a really critical question that was asked. I really want to get this through to everybody. It’s so important that we understand that you get your data in your 4 walls, in your practice together. Then we have the challenge of getting it from your partner, either on a primary care or behavioral health side, but then all the other rich data that’s accumulated and that the payers can see, we need to create as a source. We’re absolutely advocates, huge advocates that what you guys need to think about is capturing and bringing in data that seems far afield right now. The payer data, the medicare data, the medicaid data. Blue Cross data or whatever’s in your market. Absolutely we can bring that in.

Not only can you see what’s happening from a hospitalization perspective but, “Hey, what about other medications? What about other clinicians in the mix and the like?” That real diversity of care that’s occurring out there is something that as well can be very important for you to see and address.

Great. The stream of questions has slowed somewhat, here. I think we are through the list. If there are not further questions we can perhaps go back to Joe to wrap up from here.

All right. Thank you Jake. I guess we’ll go ahead and get things wrapped up. I want to hit real quick on next steps from this seminar. We will send out a link to the webinar here in the recording. Once it’s up on the website you’ll also be able to access it at We’ll get that out again once we have it loaded and you can share with colleagues. If you would like to reach out to us and connect and explore working together the first step in that process really is to schedule a consultation so we would ask that you go ahead and reach out to us using our email. Give us a call at 608-571-4530 number. We really have a simple process to get you from today to having something that’s up and running for your practice. This really is the first step to reach out.

With that, congratulations again to all of you for being part of such a wonderful program. Thank you for joining us this afternoon and we’ll look forward to connecting with many of you here in the short term. We feel like we have something that can not only simplify the process for you but also really contribute to the success of this program for you long term.

Thanks again, enjoy the rest of your afternoon.

Thank you everybody.

Thank you.

Thank you.


February 20, 2016