Group Prac­tices

IT is cru­cial in suc­cess­fully tak­ing on more risk.

Health Data Management - - INSIDE FEATURES - By Mag­gie Van Dyke

Physi­cians rely on IT to make the shift to value-based care.

Physi­cian groups that have been ag­gres­sive in their pur­suit of value-based care are mak­ing progress to­ward the In­sti­tute for Health­care Im­prove­ment’s Triple Aim of im­proved pa­tient ex­pe­ri­ence, lower to­tal costs and en­hanced pop­u­la­tion health.

Pro­gres­sive physi­cian groups say sev­eral key com­pe­ten­cies aided by IT, rang­ing from care man­age­ment to data an­a­lyt­ics, must be honed to sur­vive and flour­ish as fee-for-ser­vice pay­ment shifts to fee-for­value.

With the in­tro­duc­tion of the Qual­ity Pay­ment Pro­gram in 2017, Medi­care is ty­ing a por­tion of physi­cians’ fees to their per­for­mance on qual­ity and cost met­rics. QPP also en­cour­ages physi­cians to move into Ad­vanced Al­ter­na­tive Pay­ment Mod­els, which re­quire physi­cians to take on down­side fi­nan­cial risk, or cover some or all costs that ex­ceed pre­de­ter­mined spend­ing tar­gets for a pa­tient pop­u­la­tion.

Pre­par­ing for risk-based pay­ment takes a com­bi­na­tion of con­vic­tion and data, says Jeff James, CEO of Wilm­ing­ton Health. “Our strong­est point is that we have peo­ple with dif­fer­ent tal­ents who are re­ally com­mit­ted to what we’re do­ing, and we use the data as the main tool to do it.”

A com­mit­ment to value needs to be­gin at the top, says Scott Hines, MD, chief qual­ity of­fi­cer and chief med­i­cal of­fi­cer, Crys­tal Run Health­care, Mid­dle­town, N.Y. “To do this well, you have to re­ally re­con­fig­ure the way that you do things in the prac­tice, to fo­cus even more than be­fore on qual­ity, ex­pe­ri­ence of care and cost of care. You can’t just form an ACO com­mit­tee. You have to go down to the grass­roots level, con­vince the physi­cians

that this is the best way to de­liver care.”

Lead­ers at Crys­tal Run, an in­de­pen­dent, mul­ti­spe­cialty group, are con­tin­u­ally sell­ing their vi­sion to the prac­tice’s 400-plus physi­cians. In 2010, Hines and an­other se­nior leader met with small groups of physi­cians to ex­plain why the prac­tice needed to tran­si­tion to value-based care. “Since then we con­tinue to beat the drum,” Hines says. Quar­terly meet­ings up­date physi­cians on the prac­tice’s progress; di­vi­sion and depart­ment lead­ers at­tend a Lead­er­ship Academy to learn key per­for­mance im­prove­ment com­pe­ten­cies; and new physi­cians go through an ori­en­ta­tion on the prac­tice’s value-based ap­proach.

Physi­cians also need to see that the prac­tice is in­vest­ing in key re­sources that will help them man­age pa­tient pop­u­la­tions. A re­cent Amer­i­can Med­i­cal Group As­so­ci­a­tion sur­vey found that “hir­ing care co­or­di­na­tors” was the most-cited in­vest­ment among AMGA mem­bers pre­par­ing for risk-based pay­ment.

Other key in­vest­ments re­volve around us­ing data an­a­lyt­ics. “Busi­ness in­tel­li­gence is re­ally im­por­tant,” says Marsh­field Clinic’s Kori Krueger, MD, med­i­cal direc­tor, In­sti­tute for Qual­ity, In­no­va­tion and Pa­tient Safety. “It’s hard to be strate­gic about where you’re go­ing, un­der­stand what your clin­i­cal out­comes are, and achieve fi­nan­cial tar­gets if you don’t un­der­stand the cur­rent state and how that dif­fers from the state you’d like to achieve.”

Data an­a­lytic needs

A lack of data to in­form pop­u­la­tion health and im­prove­ment ef­forts is not an is­sue among lead­ing-edge group prac­tices, which have had EHRs for years. The op­po­site is ac­tu­ally the prob­lem.

“Our big­gest chal­lenge is tak­ing all the mas­sive amount of data we have and try­ing to boil it down into ac­tion­able in­for­ma­tion,” says Rick Rine­hart, CIO and vice pres­i­dent, in­for­ma­tion tech­nol­ogy, The Carle Foun­da­tion, Ur­bana, Ill.

Two types of ac­tion­able in­for­ma­tion are crit­i­cal: risk strat­i­fy­ing pop­u­la­tions and

iden­ti­fy­ing per­for­mance im­prove­ment op­por­tu­ni­ties.

Risk strat­i­fi­ca­tion

Seg­ment­ing a pa­tient pop­u­la­tion into high- vs. low-risk groups helps physi­cian groups pri­or­i­tize those pa­tients who most need care man­age­ment. “You’ve prob­a­bly seen the Medi­care num­bers where 20 per­cent of pa­tients are re­spon­si­ble for 80 per­cent of the costs—the 80/20 rule re­ally works in health­care,” says John Cud­de­back, MD, the AMGA’s chief med­i­cal in­for­mat­ics of­fi­cer.

So­phis­ti­cated risk strat­i­fi­ca­tion mod­els iden­tify pa­tients when they are be­gin­ning to de­te­ri­o­rate and are likely to be ad­mit­ted to the hos­pi­tal or visit an emer­gency depart­ment in the next six months, Cud­de­back says. By con­trast, first-gen­er­a­tion ap­proaches, which have been used by in­sur­ers for decades, tend to iden­tify high­risk pa­tients af­ter they were ad­mit­ted to the hos­pi­tal or vis­ited an ED. These older mod­els of­ten rely on claims data or af­terthe-fact billing codes sub­mit­ted by providers to de­scribe health­care ser­vices pro­vided to pa­tients.

Physi­cian groups with EHRs con­tain­ing up-to-date bio­met­ric in­for­ma­tion, in­clud­ing blood pres­sure and glu­cose read­ings, can de­velop pre­dic­tive mod­els ca­pa­ble of iden­ti­fy­ing pa­tients who are on the cusp of a down­ward spi­ral. “The big ad­van­tage of in­clud­ing clin­i­cal data in your an­a­lyt­ics is you can see pa­tients as their clin­i­cal pa­ram­e­ters are be­gin­ning to de­te­ri­o­rate, and you can pre­dict not just a read­mis­sion but an ini­tial hos­pi­tal ad­mis­sion,” Cud­de­back says. “This is a great time to in­ter­vene.”

The Carle Foun­da­tion has cre­ated dis­ease reg­istries within its Epic EHR for asthma, di­a­betes and other con­di­tions. The ver­ti­cally in­te­grated net­work, which in­cludes Carle Physi­cian Group and Health Al­liance Health Plans, de­vel­oped its own risk score to help seg­ment these dis­ease pop­u­la­tions. “We have a means of strat­i­fy­ing that sub­set of a pop­u­la­tion to un­der­stand who’s at most risk for dis­ease ad­vance­ment be­cause of their lat­est lab val­ues or be­cause they haven’t fol­lowed up on some of their health and well­ness main­te­nance,” says Suzanne Samp­son, sys­tem vice pres­i­dent for in­for­ma­tion man­age­ment and an­a­lyt­ics, as well as project man­age­ment. “Through that func­tion­al­ity, we can do di­rect out­reach to those pa­tients very ef­fi­ciently.”

Other group prac­tices are in­vest­ing in risk strat­i­fi­ca­tion soft­ware prod­ucts. For in­stance, Crys­tal Run Health­care uses Crim­son Pop­u­la­tion Risk Man­age­ment to iden­tify those pa­tients most in need of care man­age­ment.

Strat­i­fy­ing a pop­u­la­tion by pa­tients who did or did not re­ceive crit­i­cal screen­ings or lab tests is dif­fer­ent from iden­ti­fy­ing those pa­tients likely to be ad­mit­ted to the hos­pi­tal in the next six months, Cud­de­back says. EHRs on the mar­ket can be pro­grammed to send alerts about so-called gaps in care, like missed screen­ings, but fall short of pre­dict­ing out­comes. “When you’re talk­ing about pre­dict­ing risk for poor out­comes, you need more so­phis­ti­cated an­a­lyt­ics,” he says.

Per­for­mance im­prove­ment

Marsh­field Clinic’s pop­u­la­tion health dash­board tracks 160 qual­ity and cost mea­sures, pulling data from the or­ga­ni­za­tion’s ro­bust EHR and data ware­house. Physi­cians can see how well their pa­tient pan­els or in­di­vid­ual pa­tients are do­ing on spe­cific met­rics and com­pare their scores against those of other physi­cians, while se­nior lead­ers can com­pare per­for­mance across dif­fer­ent lo­ca­tions and over time.

“That dash­board is 100 per­cent trans­par­ent to ev­ery­body in clin­i­cal care de­liv­ery through­out our or­ga­ni­za­tion,” says Krueger. “Us­ing a drill-down ap­pli­ca­tion, they can im­me­di­ately see all the way down to in­di­vid­ual provider-level per­for­mance on any mea­sure.”

The dash­board has made it eas­ier to en­gage physi­cians around or­ga­ni­za­tion­wide ef­forts, such as the blood pres­sure im­prove­ment ini­tia­tive that be­gan in 2015. “We used our med­i­cal record and our data ware­house to un­der­stand the pop­u­la­tion of pa­tients who have el­e­vated blood pres­sure and hy­per­ten­sion, and we put to­gether a strong re­sponse for man­ag­ing that pop­u­la­tion,” he says.

The ini­tia­tive has en­listed all physi­cian spe­cial­ists, from der­ma­tol­o­gists to plas­tic sur­geons, in track­ing blood pres­sure rates and en­sur­ing any pa­tient with high blood pres­sure is re­ferred to a pri­mary care physi­cian for fol­lowup. “We de­vel­oped some other dash­boards for our med­i­cal sub­spe­cial­ties where they can see things like how of­ten pa­tients show up in their of­fice with a blood pres­sure out­side the de­sired range and how of­ten staff ap­pro­pri­ately take a se­cond blood pres­sure in those cases,” Krueger says. As a re­sult, Marsh­field Clinic has in­creased the per­cent­age of peo­ple with con­trolled blood pres­sure of 140/90 or lower to the high 80 per­cent range, from the low 70 per­cent range in 2015.

Crys­tal Run Health­care’s busi­ness in­tel­li­gence team has also been en­listed to help guide per­for­mance im­prove­ment. One tool it built helps pin­point vari­a­tion in physi­cian treat­ment ap­proaches, which in­forms best prac­tice dis­cus­sions. “If you had two peo­ple, same age, same sex, same ge­net­ics, who both had hy­per­thy­roidism, and they saw two dif­fer­ent doc­tors in the same or­ga­ni­za­tion, you would think they’d be treated in rel­a­tively the same way,” says Hines. “But we’ve found that’s not the case.”

The vari­a­tion tool com­pares the over­all charges per pa­tient per year for spe­cial­ists treat­ing the same dis­ease. For ex­am­ple, when look­ing at di­a­betes, the tool shows each en­docri­nol­o­gist’s av­er­age charges per pa­tient for the past year.

“No mat­ter what di­ag­no­sis, no mat­ter what spe­cialty, we usu­ally find a three- to four-fold vari­a­tion be­tween the providers on the left and right side of the graph,” says Hines. “The rea­son is not that some providers have sicker pa­tients or that oth­ers have bet­ter qual­ity. The rea­son is a lack of aware­ness of, and ad­her­ence to, ev­i­dence-based prac­tice guide­lines.”

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