Analytics Dashboard

OneHealth New Jersey participants will have access to secure analytic dashboard and report services. Report capabilities include:

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High Risk Patient

High Risk Patient dashboard identifies patients considered most at risk for poor health outcomes, high resource utilization and in need of care coordination. Identifying high risk patients can help meet the Clinical Practice Improvement (CPI) requirements under MIPS. For this analysis, high risk patients are defined as patients with three or more chronic conditions and five or more emergency department visits in a 12-month period.

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Preventive Care

Quality Metrics dashboard displays analysis of preventive care procedures commonly required and approved for quality reporting programs for clinic practices. Individual measures are structured to meet NCQA, CMS, and HEDIS requirements. Current reported measures include screening for colorectal, cervical and breast cancers, osteoporosis, and pneumonia and influenza vaccines.

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Readmissions

CMS has identified seven clinical conditions for which hospitals could receive a readmit penalty if a patient is readmitted at the same or any other eligible facility within 30 days of discharge for any reason. Readmission measures include acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, elective hip or knee replacement, stroke, pneumonia, and coronary artery bypass graft.

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Disease Registry

Disease Registries display specific patient populations with certain high or at risk conditions, and sets the stage for physicians to take steps that mirror many of the MIPS CPI activities. The disease registry data provides information about the health status of communities and identifies opportunities for care coordination, referral to community resources, and evidence‐based practices.

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Population Health

Population Health presents opportunities for community resource coordination and planning for at risk members of a defined geographic region. Analysis is currently provided on 11 predetermined criteria selections such as hypertension, ischemic heart disease, pre‐diabetes, diabetes, heart failure, and A1C poor control, to name a few.

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The OneHealth New Jersey data warehouse stores and aggregates clinical data from all OneHealth New Jersey member's EHR systems as well as any other connected HINs. This data is normalized and populated into a standard data architecture which is then delivered in the form of custom developed, web-based dashboard reports. Participants can also request specially created ad-hoc reports based upon desired criteria as long as the data appears in the data warehouse. Access to this information in such a manner will be necessary for successful clinical integration, care coordination, quality reporting and transition to performance-based payment models.

High priority is placed on securely storing data in the data warehouses. All HIPAA rules and regulations are adhered to for all services provided.

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