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The 2015 Healthcare Informatics Innovator Awards: Third Place Winner—Bon Secours Medical Group

March 17, 2015
by Gabriel Perna
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Navigating the bumpy roads of population health

To know where Bon Secours Medical Group (BSMG), a growing multispecialty organization that includes more than 600 Richmond, Va.-area physicians, is going on its journey to value-based, population health management, you have to know where Thomas Auer, M.D. and Robert Fortini, R.N. have been.

Dr. Auer, the CEO of BSMG and Fortini, the group’s chief clinical officer, came to the organization in 2009 from the Queens Long Island Medical Group. They went from a heavily capitated environment to nearly 100 percent fee-for-service. The goal was to build value-based patient-centered medical homes (PCMH) and introduce the concept of team-based care to “our fiercely independent practitioners,” according to Fortini.

Under the guidance of Auer, Fortini and other leaders at BSMG, they’ve come a long way in a few years. Certainly, there is a ways to go, but as Fortini says, “We’ve moved the dial a bit.” In total, 27 BSMG sites have achieved PCMH recognition by the National Committee for Quality Assurance (NCQA), and seven are in the midst of applying. Furthermore, the organization has accountable care organization (ACO) contracts with many of its commercial payers and was recently accepted as a Medicare Shared Savings Program.

Thomas Auer, M.D.

The medical group has created a PCMH environment where advanced information systems are gathering data from different sets of clinical and payer data to provide preventive care for high-risk patients. Technology alone though is not enough to create change. BMSG has invested in employing dozens of nurse navigators, who work at large and at individual practices and help to appropriately navigate the care for specific high-risk patients.

“We’re very dedicated to population health and the transition to a different view on, how, particularly, primary care and then specialty care, is used and interacted with the community,” Dr. Auer says. “It all starts with advanced patient-centered medical home. Finding the patients that we’re not seeing and getting them in for care. It’s easy to take care of what we see. It’s not as easy to take care of the patients we don’t see. It’s an aggressive outreach philosophy to find the patients we are seeing and not seeing and take care of them appropriately. It sounds easy, it’s not at all.”

The depth of BSMG’s work to make the difficulties seem easy is why the organization stands out in a field of pretenders. Like everywhere else, the challenges of changing the culture and properly evaluating performance metrics exist at BMSG. Yet, not everyone can say they’ve invested as much resources, time, and energy as they have.

Layering Pop Health Capabilities on Top of the EMR

From a technological perspective, everything begins with the organization’s Epic (Verona, Wisc.) electronic medical record (EMR) system. Both the inpatient and ambulatory sides of the organization are on the platform. This allows for a “longitudinal perspective,” according to Fortini. “Knowing what happens with a patient from the hospital to the home is great,” he says.

Robert Fortini, R.N.

Built on top of that EMR, BSMG has implemented population health capabilities to mine high-risk registries (35 in all) as well as multiple streams of payer data and various diagnosis codes (a capability from the Dallas-based Phytel) that ultimately helps stratify risk. The different sets of data can identify the risk category of a patient or the gaps in preventative care that another patient may have. The software has the ability to push a message to the provider when a patient is in need of a service.

“The scalability of that [technology] is really powerful and something we couldn’t afford to do in man hours,” Fortini says. “It’s really important to leverage that technology to essentially capture the at-risk segments of the population.”

Once this is done, the communication element comes into play. The nurse navigators then call then patient and with a few simple questions, identify the risk for readmission or worsening of illness. However, this doesn’t always work. That’s where MyChart, the patient portal built within its Epic EMR, is a benefit. According to Auer, one-third of patients communicate with them through it. The tool allows patients to book appointments, renew prescription orders, or communicate securely with a provider if they have a question on something.

Joyce Rusincovitch, R.N., nurse navigator for an internal medicine physician practice at BSMG, says it can prove to be a vital form of communication between the two parties. Patient reminders through this platform can save on outreach calls.

“We can send messages to them if they we are having a hard time reaching someone through the phone, you know a lot of people are on the phone all day. We can just send them a MyChart message and let them know what we are trying to get a hold of them for,” Rusincovitch says. “The younger population really appreciates that.”

Not only can the nurse navigators, and other members of the care team, communicate with the patients through electronic means;  they can also talk with each other. Rusincovitch and Angel Daniels, R.N. the clinical manager PCMH at Bon Secours, say this coordinates care, much faster in real time and more effectively.

Care-Traffic Controllers