Medical Informatics World’s Fifth Annual

Population Health Management, Risk Modeling, and Patient Stratification

Using Technology and Analytics to Predict Outcomes, Target High-Risk Populations and Improve Quality

Population HealthWith the growing availability of health data, healthcare delivery is moving beyond individual care to population health management. Using technology and analytics, population health management shifts care from immediate treatment to predictive and preventative care.

Cambridge Healthtech Institute and Clinical Informatics News’ Fifth Annual Population Health Management, Risk Modeling, and Patient Stratification, taking place May 22-23, 2017 at the Renaissance Waterfront Hotel in Boston, MA, will bring together thought leaders from the payer, provider, healthcare finance, analyst, technology platform and vendor communities for insightful discussions on implementing a population health management strategy.

Final Agenda

Monday, May 22

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7:00 am Registration and Morning Coffee



 John_MattisonJohn Mattison, M.D., Assistant Medical Director, CMIO, CHIO, National and Regional Leadership, Kaiser Permanente

 Andrea_IppolitoAndrea Ippolito, VA Innovators Lead, Department of Veterans Affairs Center for Innovation

 Saurabha_BhatnagarSaurabha Bhatnagar, M.D., Innovation Specialist, Medical Director TBI/Polytrauma, Harvard Medical School

 Patrick_McIntyrePatrick McIntyre, Senior Vice President, Health Care Analytics, Anthem, Inc.

 David_SheinDavid Shein, M.D., Medical Director, The Mount Auburn Cambridge Independent Practice Association (MACIPA)

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10:10 Coffee Break in the Exhibit Hall with Poster Viewing


10:55 Chairperson’s Remarks

Albert Villarin, M.D., CMIO & Associate CIO, Director, Division of Quality Analytics, Staten Island University Hospital

11:00 Co-Presentation: Why Population Health Is a Contact Sport: A Doctor and Mathematician Tag Team

Harry_SaagHarry Saag M.D., Medical Director, Greater New York City Practice Transformation Network, NYU Langone Medical Center

Simon_JonesSimon Jones, Ph.D., Professor, Department of Population Health, Division of Healthcare Delivery Science, NYU Langone Medical Center (NYULMC)

Population health management provides insight and improvement opportunities for both populations and individual citizens. We will discuss our experiences of how it is beginning to change the way healthcare is delivered and the major opportunities this opens up. We will draw on international examples and illustrate the impact from a clinical and epidemiological perspective. We will discuss the power of segmentation, how stratification is starting to have an impact, how the interdependency of a care system can be described and what the prospects are for system reform and citizen engagement.

11:30 Leveraging Predictive Analytics to Inform Care Planning and Coordination across the Healthcare System

Haley_BoltonHaley Bolton, Manager, Business Operations, Patient Access, Emory Healthcare

Harnessed sophisticated analytics to predict patients’ likelihood to no-show for clinical appointments, to detect patients’ risk for readmission, and to estimate patients’ medical complexity. Overcame operational and cultural barriers to implement dashboards and change the care planning process. Improved the clinic’s no show rate and improved patient outcomes. With the evolving nature of the healthcare landscape, it is critical that healthcare organizations position themselves to leverage data to gain insight to patient health status and to better plan for patient care. My talk will provide the audience with key takeaways and recommendations to interpret patient information, organize data, and implement predictive models within their organization.

12:00 pm Co-Presentation: Population Health Accountability: Promoting Organizational Process Standards and Dashboards

Donald_LevickDonald Levick, M.D., MBA, CMIO, Lehigh Valley Health Network

Michael_SheinbergMichael Sheinberg, M.D., Medical Director, Medical Informatics, Lehigh Valley Health Network

The challenge to population health is transforming millions of individual patient encounters and service at a micro level to an organizational standard that aims to positively affect outcomes at a macro level. We’ll discuss the process standards, EHR tools and accountability dashboards used to maximize success over the shortest time. We will demonstrate measurable results of these efforts along with lessons learned for other healthcare organizations. LVHN utilized ongoing provider-facing performance metrics to drive behavior and improved accountability on quality metrics, leading to successful year one MSSP / ACO performance, and a risk-sharing payment of over $5 million.

Medical Early Sign12:30 Leveraging “Ordinary” EMR Data with AI Today to Identify Tomorrow’s “High Risk” Population

David_YavinDavid Yavin, Ph.D., President, North America, Medial EarlySign

David Yavin will discuss how applying AI and know-how from market-proven financial algorithms to standard EMRs can identify those individuals at highest risk of harboring cancers and other life-threatening diseases, flagging them for further evaluation and potential intervention. Such an approach can ultimately save more lives, while enabling healthcare providers to prioritize and allocate resources more effectively.

Philips12:45 Luncheon Presentation: Enabling Cloud-Based Clinical Analytics to Enhance Workflow

Ivan_SalgoIvan Salgo, MD, Associate Chief Medical Officer, Patient Care and Monitoring Solutions, Philips

The rapid adoption of EHRs has resulted in a large volume of clinical data that needs to be analyzed for actionable insights at the point of care. Solutions that have access to curated and un-curated, real-time, low lag data are valuable in acute care settings with high intensity monitoring of critically ill patients. This presentation will describe a cloud-based data platform that enables the secure collection, integration, and analysis of health data.

1:30 Session Break


2:05 Chairperson’s Remarks

Donald Levick, M.D., MBA, CMIO, Lehigh Valley Health Network

2:10 Informatics, Analytics, Clinical Efficiency: Integrating the Trifecta on Your Path to Population Health Superiority

Albert_VillarinAlbert Villarin, M.D., CMIO & Associate CIO, Director, Division of Quality Analytics, Staten Island University Hospital

The 2015 MACRA healthcare legislation has unified meaningful use, core measures and Medicare reimbursement for all clinicians. By 2017, navigating the complex ambulatory workflow to achieve MIPS incentives will require a concerted effort from EMR vendors, evidence-based content providers and business intelligence integration. The population health practice of the future demands accurate clinical data capture, decision support automation and on-demand patient portals to facilitate care management beyond the scope of our human clinical capabilities. Reliance on technology requires us to ‘up-grade’ our practice and embrace a new world of healthcare automation.

2:40 How to Interface Technology with Workflows to Drive Outcomes

Adrian_ZaiAdrian Zai, M.D., Clinical Director, Population Informatics, Laboratory of Computer Science, Massachusetts General Hospital

As we attempt to improve outcomes and efficiency, healthcare organizations have turned to data more than ever before. Big Data & Analytics have emerged as a strategy to help solve the industry’s toughest challenges. But without proper alignment between technology, provider workflows and organizational structure, investments in data and analytics alone will not achieve the desired outcomes. Dr. Zai will discuss how to bridge data analytics to the rest of the population health story to drive clinical outcomes. Specifically discussing strategies on how to combine clinical workflow, data and technology to create effective interventions (based on clinical studies conducted at MGH).

 3:10 Shifting to Value and Risk Sharing with Disruptive Analytics

Mark_HiattMark Hiatt, M.D., MBA, Executive Medical Director, Regence BlueCross BlueShield of Utah;
Co-developed by Richard Popiel, M.D., MBA, Executive Vice President, Healthcare Services & Chief Medical Officer, Cambia Health Solutions & Regence Health Insurance Company 

How are we as a healthcare system going to improve healthcare outcomes and reduce cost by shifting to value and risk sharing? This presentation will share some ideas on how disruptive analytics and analytical approaches to cost trend monitoring and containment can be part of the solution.

3:40 Refreshment Break in the Exhibit Hall with Poster Viewing


4:10 pm Find Your Table and Meet Your Moderator

4:15 Interactive Breakout Discussion Groups

Concurrent breakout discussion groups are interactive, guided discussions hosted by a facilitator or set of co-facilitators to discuss some of the key issues presented earlier in the day’s sessions. Delegates will join a table of interest and become an active part of the discussion at hand. To get the most out of this interactive session and format, please come prepared to share examples from your work, vet some ideas with your peers, be a part of group interrogation and problem solving, and, most importantly, participate in active idea-sharing.

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5:00 - 6:00 Welcome Reception in the Exhibit Hall with Poster Viewing

6:00 Close of Day

Tuesday, May 23

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7:30 am Registration and Morning Coffee



 John_HalamkaJohn Halamka, M.D., MS, CIO, Beth Israel Deaconess Medical Center

 Maxine_MackintoshMaxine Mackintosh, Chair & Ph.D. Student, HealthTech Women UK & University College London

 Trishan_PanchTrishan Panch, M.D., Co-Founder and CMO, Wellframe; Lecturer, MIT

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10:10 Coffee Break in the Exhibit Hall with Poster Viewing


10:55 Chairperson’s Remarks

Ivan Salgo, MD, Associate Chief Medical Officer, Patient Care and Monitoring Solutions, Philips

11:00 Case Study Co-Presentation: How Atrius Is Integrating Behavioral Health Data to Improve Clinical and Financial Outcomes

Sam_NordbergSamuel Nordberg, Ph.D., Director, Behavioral Health Informatics and Innovation, Atrius Health

Jacob_KaganJacob Kagan, M.D., Director, Behavioral Health Specialty, Harvard Vanguard Medical Associates, Atrius Health

Research indicates that co-occurring behavioral health problems can increase total medical expenses for patients by 200% - 700%. Providers can benefit from systems designed to identify patients with underlying behavioral health problems, and to stratify those patients by risk and treatment needs. We will describe an initiative at Atrius Health to integrate data collection and risk stratification into the clinical routine. We will discuss the importance of multidimensional measurement that can capture patient complexity, and review the barriers and facilitators to implementing data collection in routine settings, based on experience rolling out a standardized system to 15 sites, serving over 30,000 patients.

11:30 Screen & Intervene: Leveraging Social Determinants of Health and Putting the Population Back in Population Health

Joel_ReichJoel Reich, M.D., CMO, Eastern Connecticut Health Network

As the US health care system transforms from fee-for-service to a value-based care and payment system, there is growing recognition of the importance of identifying and managing social determinants of health (“SDOH”) including housing, food, finances, transportation, personal safety, and environmental hazards. Most of the nearly $3 trillion in annual US healthcare spending goes towards direct medical services, while little goes to screening and meaningful interventions to alter the SDOH that significantly contribute to poor health status and a majority of deaths.

12:00 pm Case Study: How Blue Cross Blue Shield Is Integrating Lifestyle-Based Analytics with Traditional Clinical Markers

Divyes_PatelDivyes Patel, Manager, Information Delivery Innovation, Blue Cross Blue Shield, TN

The majority of wellness incentives offered to employees have been generic to their entire employee populations. Blue Cross Blue Shield TN has created an innovative app that integrates Human Capital, Medical/RX claims and Population Health program participation data that demonstrates the value of stratifying employees not just by traditional clinical markers but by integrating lifestyle, job type, salary and wearable device data and visualized in an interactive application that can help to tailor & model specific value based incentive structures for employees to maximize their participation and effectiveness of wellness programs for employees.

12:30 Sponsored Presentation (Opportunity Available)

12:45 Luncheon Presentation (Sponsorship Opportunity Available) or Enjoy Lunch on Your Own

1:30 Coffee and Dessert in the Exhibit Hall with Poster Viewing


2:00 Chairperson’s Remarks

Samuel Nordberg, Ph.D., Director, Behavioral Health Informatics and Innovation, Atrius Health

2:05 Case Study: How Morehouse Choice ACO Achieved $3,850,000 in Shared Savings for the Medicare Shared Savings Program

Michelle_BrownMichelle Brown, CEO, Morehouse Choice ACO

The Morehouse Choice ACO was founded in early 2012 based on a progressive integration model. The presentation will highlight how Morehouse achieved $3,850,000 in shared savings for the Medicare Shared Savings Program for 2015 and received an earned shared savings distribution of $1,675,000! The focus will be on some of the methods and strategies for consumer growth, patient retention, and sustainable relevance among a “co-optative” safety-net, collaborating to share in the attainment of top-tier value-based care. Morehouse Choice is under its second contract term with CMS. The ACO is a reliable simulator with more than 35% dual eligible population and 40% under the age of 65 of the total MSSP attribution.

2:35 A Statewide HIE Offers Predictive Analytics for Population Health

Devore_CulverDevore Culver, Executive Director and CEO, HealthInfoNet

As providers are increasingly asked to take on risk, they need tools and information to help manage the health of individuals and populations. Powered by the HIE’s real-time clinical database of over 1.3 million people, Maine’s HealthInfoNet offers real-time predictive risk scores to help providers improve care coordination and drive down unnecessary utilization. Discuss lessons learned and several use cases for use of predictive analytics tools in both the ambulatory and inpatient settings. Hear how HealthInfoNet’s clinical users integrate the tools into their daily workflows to target high risk patients and reduce unnecessary readmissions and emergency room visits and provide better care coordination for at-risk populations.

2:50 CASE STUDY CO-PRESENTATION: Leveraging Patient Stratification and Mobile Engagement to Improve Health and Reduce Costs in Chronic Low Back Pain

Mary_PakMary Pak, M.D., Medical Director, Unity Health Insurance

Elaine_RosenblattElaine Rosenblatt, Director, Quality and Care Management, Unity Health Insurance

An innovative program designed to improve population health and manage costs in the area of chronic low back pain will be shared. Population health management of chronic conditions is critical to managing costs and access to care. Low back pain is one of the most burdensome health issues worldwide in terms of prevalence, cost, opioid prescription, and impact on disability rates. Powered by a secure web- and mobile-based technology platform, the program employs clinically-validated risk modeling and evidence-based screening to stratify patients. Payers and providers will benefit from learning about how an insurance company and healthcare provider are using an innovative chronic care management program that leverages evidence-based science and technology to reduce costs and improve health for members.

3:05 Next-Generation Analytics for Population and Public Health

Michael_DulinMichael Dulin, M.D., Ph.D., Chief Medical Officer, Tresata; Professor and Director of Population Health Innovation, University of North Carolina at Charlotte

This talk will cover the use of advanced analytics in the domain of public and population health. The overview will include current barriers and resource needs that healthcare systems and related health providers require to improve the value and benefit of healthcare delivery. Content will include discussion of 5 key elements needed to transform healthcare delivery and application of data/analytics within each domain, including data integration, visualization, application development/deployment, and evaluation. Sample case studies using this framework will be provider from healthcare provider systems as well as public health departments.

3:35 Co-Presentation: A Flexible Healthcare IT Platform for Engaging with At-Risk Populations

Vish_AnantramanVishwanath Anantraman, M.D., Chief Information Architect, Northwell Health

Vipul_KashyapVipul Kashyap, Ph.D., Director, Clinical Information Systems, Northwell Health

Northwell Health is a health network consisting of 21 hospitals, 3 skilled nursing facilities and many specialty programs and institutes that recently implemented a Flexible Healthcare IT Platform that enables rapid design and implementation of care management programs for at-risk cohorts with targeted and customized interventions. We will present via a demonstration, real world examples of Clinical Programs at Northwell Health which have been delivered based on the platform – enabling care coordinators to track the progress and outcome of various outreach activities with efficiency and ease.

4:05 Closing Remarks

5:00 - 7:00 Join Bio-IT World’s Grand Opening Reception in the Bio-IT World Exhibit Hall at the Seaport World Trade Center

Day 1 | Day 2 | Download Brochure