Prisma Health’s inVio Health Network Getting More Real-Time Patient Data

The inVio Health Network is Prisma Health’s clinically integrated network that includes more than 5,500 Prisma Health employed and independent community clinicians in the Upstate and Midlands of South Carolina. Healthcare Innovation recently spoke with Anna Kay, vice president of InVio, about infrastructure improvements inVio is putting in place to improve the flow of data and care coordination. 

Kay explained that inVio was started almost 14 years ago as a way to better connect the physicians in their community. The clinically integrated network has grown as value-based care has evolved. “Certainly our primary care providers in the area are much more aware of the opportunities around value-based care and there's quite a few of them now to offer them through our network, so I do think that that has certainly expanded it,” she said, adding that inVio has moved into direct-to-employer arrangements and also expanded the types of providers that are included in the network, including specialists and post-acute providers.

About two-thirds of the network is comprised of Prisma Health clinicians, who use its instance of the Epic EHR, and some independent physicians are on Epic through a Community Connect program. “That certainly helps, but there are still a lot of different EMRs that our practices are on, so we do have several options to connect them and help drive our improvement work,” Kay said.

“Probably the most important of those is a scorecard that gets a data feed from each of our practices’ EMRs. We associate that at the patient level and are able to show providers how they're performing in quality measures, with information from all of those network practices, as well as from claims data, so they can see how they're performing compared to their peers.”

She added that inVio also has centralized data and analytics solutions that it uses to identify areas of opportunity around potential quality or cost improvements and they use that to drive care management priorities.

Prisma Health and inVio are starting to use several collaboration tools from Bamboo Health with the goal of improving care coordination and transitions of care.

Here is how Bamboo Health describes them:

• Pings: Offers real-time alerts for patient care transitions, using admission, discharge, and transfer (ADT) data to assist healthcare professionals in delivering superior care and achieving success in value-based care programs. Prisma Health and inVio Health Network practices will be able to use Pings to be alerted when their patients are discharged from the hospital. 

• Discharge Summaries: Aims to improve communication during patient transitions, addressing common challenges in accessing and sharing vital patient information across different healthcare settings. 

• Spotlights: Provides real-time analytics and a user-friendly interface for tracking key performance indicators, enabling healthcare providers to make informed decisions based on up-to-date data. 

Prisma Health already uses Bamboo’s PMP Gateway solution to integrate multi-state prescription drug monitoring program (PDMP) information into its existing clinical workflows.

Kay said that inVio providers typically have had relatively good information about patients who have gotten care within Prisma or its network. “But if they went outside of that system to another system for care, we really didn't find out about that a lot of times until we got the claims data from the payer a month and a half later, maybe two months later, and they started to pop up in a risk score,” she said. “With the Ping solution, we'll be able to see what happens to those patients when they've had events in other outside facilities, both acute facilities as well as post-acute, which we also didn't have very good insight into.”

She said that's going to help in a couple of ways. “One of the things we found is that our care management team has a phenomenal impact when they're able to engage with a patient. We see that in our data on reductions in readmissions and ED visits, and lower cost of care. However, if you reach out to them to try to get them to engage in care management two months after they've had an acute episode, it's typically too late to unpack some of those things, but they're also just not as interested,” Kay said. “They’ve gotten through their crisis, figured it out or not, and maybe had a readmission or an admission. So we are really excited to see what that's going to do around engagement if we're able to reach out to somebody at the time they really have a critical need during that transition. We think we are going to get more patients to engage.”

The discharge summary is the corollary to that, she said, because if you not only see that the patient has an event, you can also get some information about that event without having to go to another solution or request a medical record somewhere else, that's even better because then the care manager or the primary care provider has that information right at their fingertips.

Kay said that the inVio team feels pretty strongly that they will be able to reduce readmissions as well as unnecessary ED visits. The care management team has a lot of ability to to help them with things that may go wrong during transitions of care. “If they can't get their medicine, we can get them connected; if they don't understand discharge instructions, we can help with that. Having more folks connected with care management, we believe, will also reduce the cost of care because it will help us have more people educated about the right way to care for their condition and keep them from having exacerbations of their illness.”

Kay said that inVio recently moved from the Medicare Shared Savings Program to ACO REACH. One of the requirements of that program involves gathering data on health equity efforts. 

“We are early in our participation with that program, but one of the projects for this year is being able to report back out the required health equity and SDOH screening data,” she explained. “We're in good shape on the Prisma Health side and the folks who are on Epic, because we had already put in place the social determinants of health screening, and are capturing a lot of the information that we'll need to report. I think our challenge will be all of those other independent providers and working with them and their EMRs on how do we not only get that information, but all of their screenings are not exactly the same in terms of form and format. So that really will be our challenge is just getting that baseline set of data from lots of different types of providers.”

Healthcare Innovation interviewed Bamboo Health CEO Jeff Smith in February.