Ascension St. Mary’s Physician Hospital Organization


The mission of Ascension St. Mary’s Physician Hospital Organization is to deliver excellence in patient-centered care for patients that reflect our faith-based values, is high-quality, and cost-effective. It is a steward of sound fiscal responsibility and develops capabilities to take and manage financial and performance risks for covered populations. The organization will provide innovative care delivery solutions across the continuum of care.

The makeup at St. Mary’s PHO consists of 50% of hospital-employed physicians and 50% of East Michigan physician organizations, which consists of independent primary care and specialty practices. The PHO has contracts with Blue Cross, Blue Care Network, Meridian, Molina, United Healthcare, Priority Health, and others. The makeup as an organization is 75% Ascension Medical Group (AMG), and 25% is the community-based independent practice providers who provide services to Ascension. As a large group, there are a total of nine different electronic medical records systems (EMRs) which supports data capture and attribution of covered lives. The organization currently manages roughly 42,000 covered lives.

Alma Enderi is the team manager for the analytics group, has a bachelor’s degree in computer systems and administration, and has been with the organization for ten years. Ashley Agnew is a clinical data analyst supervisor at St. Mary’s PHO, has an associate degree in business administration, and has also been with Ascension for ten years. Both are based in Saginaw, MI.

Why a Registry

The organization had a previous data registry vendor relationship but discovered that the platform was being sunset. So, Saint Mary’s needed to find something different as having a registry tool is required nowadays to manage patient populations and operations effectively. A registry platform is necessary for the Patient-Centered Medical Home (PCMH) model through Blue Cross/Blue Shield. Additionally, it is essential to have a registry for data analytics and reporting to effectively close performance gaps and manage the cost of care along with the ability to data sharing with payers. Another critical requirement of the registry was the ability to interface clinical data into a single system so that we can manipulate and track the data in different ways, which supports improved clinical and financial outcomes. Monitoring and managing readmissions within 30 days, transition to care outreaches, looking at financial analytics for high cost and high use, and issues like this. Ashley says: “We use and manipulate reporting to a maximum.”


They simply used Google search for a registry vendor to find alternative vendors. Ashley states that they did a functional assessment and evaluated four different vendors. They had stringent parameters that they were looking for. Saint Mary’s developed a scorecard and weighted the vendors based on their ability to meet organizational needs. The functional assessment included population health reporting for PCMH, providing disease and chronic condition management, reporting, and tracking. The vendors had to have the ability to submit an acrs (Active Care Relationship) file to MiHIN (Michigan Health information Network) MIHIN. Also, the vendors were required to receive and display ADTs, which is admission, discharge, and transfer statewide from MIHIN ).

Ashley says: “We were also looking for medication, allergy, and problem list reconciliation. So, we were dealing with clinical document exchange. We needed functionality within care management and care coordination tracking, which ties into provider-delivered care management, which will be referenced as Provider Delivered Care Management (PDCM) risk stratification capabilities for HCCs and ACGs, which is adjusted clinical groupers as risk stratification; it’s very common these days among payers to flag the level of illness burden. We had to be able to submit supplemental data to payers, and that requires a two-way street. So, sending our data outbound to close quality gaps in care, along with receiving inbound information. We looked for the ability to ingest a common key, which ultimately is a patient identifier number that would be used across the state using a 12-digit number associated with the patient versus having to deal with name variations and spelling and corrections that we get from everywhere.

She adds: “A big one was ad hoc reporting capabilities. We like to be able to customize, and we’re familiar with building our own reports, so we had to have that functionality. Along with financial analytics abilities, the ability to take payers’ claims data and slice and dice it to make informed decisions. Another important criterion was the ability to connect with multiple types of EMR vendors since we use a large variety of them. We wanted to make sure that we’re able to receive from the practices, the scheduling data, the clinical data along with the claims data because anything we can get in real time is great versus waiting three months for delayed data from payers, laboratory and radiology and then of course MIHIN. The last two factors we looked at were the cost and implementation timeline.”

The Decision

HealthFocus offered a very compelling solution right out of the gate for the data analytic team. Ashley says that they did have another vendor that was a close competitor. The Saint Mary’s team ended up asking both vendors for references of clients extensively using the system. We received contact information and scheduled meetings to learn more about their successes and what they liked about the products. The reference calls helped seal the deal for Saint Mary’s to move forward with HealthFocus. Ashley adds that she could immediately tell that HealthFocus was founded and managed by people who grew up in a physician organization. She also shared: “They knew the issues personally and knew what to ask and how to deal with things effectively. That comes from hands-on experience.”

Our favorite part of HealthFocus was our ADTs for admission, discharge, and transfers (ADTs). Ashley says: “We had a very robust process already developed and rolled out to our offices for receiving these and outreaching to patients. We were really picky here on what we wanted and what we needed. HealthFocus was phenomenal here with what they had developed; they call it the TCM (Transitional Care Management) dashboard.”

She adds: “What they offered was nice, but it did not meet the sheer extent we were looking for. HealthFocus did significant customization for us related to the TCM and built it exactly how we needed it. TCMs were the first thing that we tackled with the system. We intended to sign with HealthFocus, since our current platform was dissolving in December, so we signed with HealthFocus in October. We wanted to get on the platform and get things connected and data flowing as soon as possible, especially with the ADTs. So beginning in December, we could meet with our offices and hopefully get them on the new process and not interrupt the current process flow instead just saying, I got to train you on a new system, and we were able to achieve that. We ended up starting training in November on the new platform.

Ashley says regarding their decision process: “It had to go through several levels obviously because we’re using data from several different entities. So obviously, the overall decision came from us at the PHO based on our functional assessment scorecard. From there, we then had to go to Ascension, and then we had to make sure that HealthFocus met all the national legal requirements for HIPAA, data sharing, et cetera. HealthFocus was great, providing documents, materials, and resources that we needed on the legal side. Once we got through Ascension and the national side of things and got the okay and the required approvals, we had to go obviously to our medical directors here at the PHO, present it to them, and then our leadership team, which was done simultaneously. We had to work through the different channels to get the approval from all partners to ensure all of the outlined requirements were met to move forward with the next steps.”


Ashley stated that they signed their contract in October and were using the system effectively in November. “That was an incredibly quick and effective implementation.”

The main issues around the implementation process were connectivity, which was not on the HealthFocus side but more with the EHR vendor side. Ashley says: “I would say, in this scenario, that HealthFocus was very advanced and did adapt well here to push on the EHR vendors, which did help expedite connections. I think the biggest success was our implementation. We broke it down into different phases. Our first objective was getting our membership, attribution, and patient assignments into the system. That allowed us to send our active care relationships (acrs) to the state HIE (MiHIN), stating when a patient event happens. So that provider alignment patient creation piece in the registry happening pretty much instantly was ideal.”

She adds: “HealthFocus tried to accommodate us on several of our needs and requests when we were pushing on them. As you’re coming onto a new system, you know what you previously had with the old system and can identify what is missing and still wish to have. We were a little complicated to work with, and they were responsive and great to work with.”


The HealthFocus system that they use outside of their standard reports is called Meta Base. There were significant expectations from both St Mary’s and PHO for this reporting custom build where we could create and develop their own reports. That’s what all of us were accustomed to in our previous system. HealthFocus offers the capability of creating ad hoc reports and on-request basis, and they have been able to accommodate our requests. We are still learning and working towards independently developing our own reports, and HealthFocus has been very helpful in supporting us to do it ourselves.


Ashley states that the great advantage of HealthFocus is that it was created here locally in Michigan. Their team is very knowledgeable and knows the core performance programs which support PCMH requirements and other payer initiatives through reporting. They also have the capability of creating ad hoc reports, as well as on a request basis, and they have been able to accommodate our requests.

Ashley says: “One of the biggest asks we wanted from this system was the ability to create our own reports, which we could do in the previous system. We are still learning and working towards independently developing our own reports, and HealthFocus has been very helpful in supporting us to do ourselves.

She adds: “Another key advantage about HealthFocus is that they can ingest all the payer’s data we receive, including claims and eligibility files. Having all this information in the system allows us to pull cost reports, financial analytics, quality summary reports, and much more. We have begun to focus more on this front. HealthFocus has many reporting capabilities we didn’t have with the previous system, which was very important to us.”

Ashley and Alma said they noticed they had some increased incentives from our different payer programs and participation. Ashley states that by implementing HealthFocus, they have expanded their abilities to participate in various programs, which increased financial outcomes. They also benefited as HealthFocus was significantly less expensive than expected for all the added capabilities and functionality.

Ashley and Alma agree that they get continuous positive feedback from their user community. They would gladly serve as excellent references for HealthFocus if other organizations were interested. They agree that this is a must-have capability for organizations with “at-risk” business, and both St. Mary’s and PHO give HealthFocus a 10 out of 10 rating. Ashley closes with, “They have been great. What else could we ask for?”