Expanding core platform capabilities enhances population health management program, offers 'a full picture'

Case Study | OnPoint Family Medicine
  • ""

    67 providers

  • ""

    8 family internal medicine clinics

  • ""

    2 OB/GYN clinics

  • ""

    4 pediatric clinics


  • Growing value-based care programs
  • Lack of visibility into data
  • Manual reporting, outreach processes
  • Small population health staff
  • Care gap follow-up


  • athenaOne
  • athenahealth Advisory Services


  • Better visibility into metrics
  • Enhanced visibility into determining, addressing care gaps
  • Progress toward streamlining common quality reporting measures
  • Growing toolkit allows small staff to be nimble
  • High patient satisfaction rate
  • 50% reduction in effort associated with manually managing quality data
  • 4 care gaps on track to receive 5 stars

     Colorectal cancer screening 7% improvement

     Breast cancer screening 8% improvement

     HbA1c control 13% improvement

     Controlling high blood pressure 7% improvement

Transitioning from a larger health organization to a smaller one gives Katie Egan the opportunity to feel like she’s making a greater impact. But it also gave her the perspective to know that when she joined the OnPoint Family Medicine team as its population health manager, she needed a platform that would connect OnPoint’s contracted payer rosters to her practice, and provide metrics at a per-clinic level.

As an existing athenaOne customer, Egan described the chance to pilot a new analytics-driven services model for quality management — and expand core platform capabilities and functionality for value-based care population health management — as “music to my ears.” She cited several reasons. Other population health data platforms proved too expensive for an organization of OnPoint’s size. Other platforms also would have required double documentation for OnPoint’s 12-payer mix. “We want all of our stuff to live in our EHR and be able to pull our information out of our EHR because that’s our full patient population,” Egan said. “We see the value of athena being able to pull in payer data from all programs and produce for us quality reporting to say, this is what the payer shows for you — we know because we got it from them. But this is also what your EHR is showing because we know that this is what you documented. It’s a full picture.”

That portrait is even more robust thanks to the athenahealth Advisory Services experts collaborating on OnPoint’s engagement. “I really can’t say enough about this team being very understanding of exactly what it is that we’re trying to do. I don’t have to do a lot of explaining. We developed a quick trust in each other,” said Egan of her Advisory Services team. “I can’t believe how quickly we moved from saying what we needed to ‘I know exactly what you’re saying, here’s all of the information.’”

Initial engagement yields success

As part of the engagement, that information initially included four common care gap measurements across Medicare Advantage and several commercial payer contracts: screenings for HbA1c control, controlling high blood pressure, colorectal and breast cancer screening.

Incorporating the analytics and perspective of the Advisory Services team has helped address transparency challenges when it came to workflows, for example. Many OnPoint clinics perform their HbA1c diabetes measure testing in-house, which was reflected in the EHR – but most clinicians’ processes meant OnPoint did not get credit for performing those tests. “One of the things that would happen is, we would get payer data telling us one thing, and then we’d look in our EHR and we’d see something else,” explained Egan. “That was one of the things athena called out early for us.”

The initial end-of-year engagement also yielded data that OnPoint was able to use for patient outreach, putting the organization on track for a full 5-star rating across all four of the care gaps they targeted.

Other ongoing initiatives will eliminate manual reporting, like a separate list matching all patients with mammogram flags with those who’ve had double mastectomies, in order to exclude them. “Without any kind of data advancement on our side, we’ll be doing the exact same thing” in two years, says Egan. “If we can leverage the tools of athena that are looking to learn and help pull out reports in these ways, our workload would be substantially less.”

Projecting short- and long-term quantitative and qualitative enhancements

Using the data from OnPoint’s initial engagement, Egan projects that her team will save an estimated two minutes per measure per month. Through the alignment of athenaOne and payer data, automation of analytics, and proactive management of OnPoint’s patient population, the organization projects a 50 percent reduction of effort associated with manually managing quality data. Egan expects that automating the care gap process analysis reports will mean one full-time employee can be repurposed to perform higher-value quality management tasks. Those include driving increased attribution across payer contracts to continue to evolve OnPoint’s value-based care program; working on process improvement efforts across the organization; and strategic planning.

OnPoint sees additional benefits with clinicians being able to selfserve and utilize athenahealth’s advanced capabilities to extract their own patient data, as opposed to using spreadsheets generated monthly. “They’re all identifying that the level of awareness is so much higher when you have this kind of data,” Egan said.

She sees advancing OnPoint’s population health program also has a positive effect on patients in terms of pre-visit planning, and ongoing enhancement efforts will enable clinicians to proactively manage their own patient populations through analytics. Once care gaps are identified, follow-up for services can be automated. “All of this effort is creating very specific targeted efforts to patients who are getting one-to-one follow-up by their provider on things that still need to be completed,” she said.

Katie Egan, OnPoint Family Medicine population health manager

These results reflect the experience of one particular organization and are not necessarily what every athenahealth customer should expect.