The art of managing patients in an Accountable Care Organization (ACO), Managed Shared Savings Program (MSSP) involves the ability to intervene as quickly as possible to offer the right care at the right time in the right setting. The key, and the challenge, is getting information about a patient’s needs in time to make a difference. With so many ways for a patient to access care and with some of them outside an ACO system, care providers often don’t find out until long after the fact that a patient received care elsewhere.

The Health Collaborative is pleased to recognize Mercy Health’s Care Management Team as a finalist for the 2017 Informatics Solutions Award, for its work to improve patient care through the use of its hb/suite line of technology products and services. The award will be given as part of the Inspire | Healthcare dinner and awards celebration, planned for November 1 at the Renaissance hotel in downtown Cincinnati. The Informatics Solutions Award recognizes an individual, team, or organization that has applied products from the HealthBridge technology suite – either data services, notification products, or business intelligence – to create an innovative solution to an ongoing challenge.

Leveraging data to inform care management
Mercy Health physicians treat more than 115,000 patients as members of a Mercy Health “at-risk” MSSP ACO. Mercy Health is accountable for both cost and utilization for these patients. There is a care management team in place to ensure these patients are monitored for hospital admissions. Previously, when any of these patients arrived at a Mercy Health system hospital, an alert was generated and sent to the care management team, creating an opportunity for the care team to get involved and manage the prescribed follow-up and prevention. The system broke down when patients arrived at other health systems’ hospitals within the region. When that happened, there was no way for the care management team to know what kind of follow-up or prevention would be needed because they didn’t even know an episode has occurred.

hb/notify to the rescue
Mercy Health’s team members realized they could do a better job supporting patients, as well as managing cost and utilization, if they could get timely information about these patients presenting at other hospitals. That’s where hb/notify, a service within The Health Collaborative’s hb/suite of data and informatics tools, came in. Mercy Health employed hb/notify to generate notifications when patients from the Mercy Health “at risk” cohort presented for care at other health systems.

Amy Frankowski

Dr. Amy Frankowski

Integration into workflow
Mercy implemented an innovative workflow to integrate hb/notify with their internal notifications to provide care managers with what they needed: a single patient worklist regardless of where the patient was admitted. This focus on automating the collection of this hard-to-capture information and integrating it into the workflow allowed the care management team to focus their efforts on the needs of the patients, with the goal of improving on all three aspects of the triple aim: healthier people, better care, and lower cost.

Amy Frankowski, MD, FACP, System Medical Director Health Strategies of Mercy Health, will represent the Care Management Team as it is recognized at the Inspire | Healthcare event on Nov. 1.

Please join The Health Collaborative in congratulating Informatics award finalist Mercy Health and its Care Management Team, for using tools to reach outside its own data system to gather the information essential to helping patients receive the care they need, when and where they need it.

About Inspire | Healthcare:
Inspire | Healthcare is the Greater Cincinnati and Northern Kentucky region’s premier annual healthcare event and awards celebration. The awards seek to recognize innovations by individuals, teams, and/or organizations in the areas of informatics, quality improvement, and population health. Other awards given annually include the Inspire Champion Award and the Hoxworth Blood Drive Awards, with separate nomination and judging processes. For more information about Inspire | Healthcare, visit

About The Health Collaborative:
The Health Collaborative strives to lead data-driven improvement initiatives that result in healthier people, better care, and smarter spending. Based in Cincinnati, we work with those who provide care, pay for care, and receive care, to find mutual solutions to healthcare’s most challenging problems. For more information about The Health Collaborative, visit