Enhancing Collaboration and Insights

Northwestern Medicine is a leader in quality healthcare and service, bringing together faculty, physicians and researchers to support and advance care through leading-edge treatments and breakthrough discoveries.


Northwestern Medicine was transitioning their care delivery model from one based on fee-for-service to a value-based care (VBC) delivery model. VBC is a healthcare reimbursement model based on the value of services provided rather than the volume. The goal is to lower healthcare costs and improve quality and patient outcomes.

Northwestern Medicine recognized that, in healthcare, organizations have access to an abundance of data. The problem is not how to get it – it’s bringing it together and knowing what to do with it once we have it.

As a leader in healthcare, Northwestern Medicine is always looking for new ways to collaborate across the health system enterprise to increase efficiencies and elevate patient care. To this end, they established Northwestern Medicine Physician Partners (NMPP), a population health management program built on the foundation of a shared physician-hospital platform. It is designed to utilize collaboration and leadership to meet the future needs of healthcare.

Northwestern Medicine did not have a central repository to perform enterprise-wide analytics, and their infrastructure, business rules, and processes were not defined or robust enough to support the new VBC model. They lacked the dashboards and tools necessary to provide a complete view of their patient population and to track physician performance as it relates to ACO measures.

Information must be managed so it is useful, operationally relevant, insightful, and secure, driving the ability to gain a complete view in order to deliver better care, meet regulatory requirements and improve overall decision making.

Improving Compliance and Performance with Analytics

Perficient implemented Epic’s Cogito as the foundation for the data warehouse model in order to provide a complete view of both Epic and non-Epic patients throughout their entire journey. The central repository housed all patient data, physician rosters and claims files including MSSP, ACE, and BCBS data.

Northwestern Medicine selected Epic Cogito because Epic was the Electronic Medical Records (EMR) platform already being used. Leveraging the native capabilities of Epic allowed Northwestern Medicine to have a single platform for both care management and analytics. By expanding the Cogito analytics platform to include the data warehouse, Northwestern Medicine could seamlessly load native Epic data into Cogito.

Additionally, Northwestern Medicine found value in the following:

  • With Epic Cogito, the MSSP interface was already written by Epic to ingest CMS files.
  • They were able to develop smart data elements (SDE) to send information from the Cogito data warehouse to Epic hyperspace.
  • Reports were already available/used via Radar and workbench.
  • The system had scale.

Perficient implemented Epic’s Smart Data Element (SDE) functionality to populate patient measure information into the Healthy Planet chronic disease and wellness registries for help manage population health. Perficient developed data link actions that move the information to the SDE so the registry information is automatically updated on a weekly basis.

To help proactively monitor physician performance, a series of clinical integration (CI) physician progress reports were generated monthly. These reports indicate whether physicians are compliant with ACO and Northwestern Medicine performance measures.

Achieving Population Health Management

  • Care managers can now proactively manage population health via the use of care planning and coordination tools such as patient outreach, and longitudinal care planning; population analytics and reporting, and patient outreach & care management workflows
  • Physician dashboards serve as the central repository of reports, designed to instantly provide physicians with an overview of the performance of their patient population across all registry-based measures.
  • The enterprise is able to import, store, and analyze external data into Epic (i.e., payer claims, patient satisfaction, hospital quality, training, clinical, and non-clinical measures, etc.).
  • Custom processes were built for the NMPP program. The patient attribution process analyzes claims and eligibility files to assign patients to 1 PCP, and multiple specialists.
  • The patient matching process creates patient records for new patients. The external claims process analyzes external claims, removes duplicates, and structures the claims data for analysis.
  • Cohorts of patients with chronic conditions, or those whom qualify for wellness screenings, can be identified based on a specified inclusion and exclusion criteria.

The goal was to truly establish one program with one set of measures and clinical protocols, one set of administrative procedures, one infrastructure for care management and one set of incentives for our physicians. Rob Desautals - Director, IT, Northwestern Medicine

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