At the Middletown, N.Y.-based Crystal Run Healthcare, a multispecialty group practice with 35 locations and 375 providers (300 of whom are physicians), all of the senior leaders are absolutely committed to a population health strategy as their organization’s core organizing strategy going forward.
Scott Hines, M.D., chief quality officer, Jonathan Nasser, M.D., chief clinical transformation officer, and Gregory Spencer, M.D., CMIO, of the group, are helping to lead a full-court press into population health management at Crystal Run, and are leveraging IT to facilitate a broad range of activity.
In that context, the three physician leaders spoke with Healthcare Informatics Editor-in-Chief Mark Hagland this summer, as he interviewed medical group leaders for the magazine’s September-October cover story. Below are excerpts from the interview they gave to HCI this summer in the preparation of that cover story.
Tell me about Crystal Run Healthcare’s overall strategy around population health?
Scott Hines, M.D.: When we first really started leveraging data to improve outcomes, our first steps were looking at creating registries to identify patients who had gaps in care, and then distributing those registries to every doctor and their nurse, to try to close those gaps in care. But we realized over time that primary care doctors in particular were becoming overwhelmed by tasks, and that that approach wasn’t the best use of their time. So we took a step back and what we could take off their plates.
Scott Hines, M.D.
So we developed our Care Optimization Team, led by a nurse and staffed by four non-clinician staffers. And each person on the team is assigned to one or more patient-centered medical hoes, and their job is to reach out to patients with gaps in care for process measures, such as immunizations, breast cancer screenings, colon cancer screenings, necessary labs, etc., so we leverage the data from the EHR or reports from payers, which are often months behind reports we can generate internally, so can we reach out to patients as soon as possible. We built our Payer Quality Scorecard, which allows us to track internally what we’re doing in terms of quality performance for measures for each payer we have a risk-based contract with, and we’re able to respond. Everything was developed in 2014. Prior to that we were using registries but relying on the PC doctors and their staffs to reach out and close gaps in care, but since then, we’ve built this team. So doctors can concentrate on performance measures like blood pressure control, that kind of thing. So that’s one way we’re using technology to improve the quality of care.
The other is through our Variation Reduction Program. We’ve developed a tool that tracks charges per patient per year by physician for a particular diagnosis. So for endocrinology, let’s say we look at thyroid cancer, so it would show for each endocrinologist what their charges per year for patient are, based on professional, lab, imaging, and procedure charges. And there’s always a four-fold variation among docs when you begin, and we’ve shown it has nothing to do with the quality of care or sickness of patients, but the degree to which quality of care guidelines are being adhered to. So John and I meet quarterly with each division to perform on a guidelines adherence exercise.
And ahead of time, we ask the division which diagnosis they want to tackle, and then we assign one or two physicians in that division to research what guidelines or evidence exist in the literature, and so they come to that meeting armed, so let’s say, we ask how often do you do ultrasounds or tumor markers for patients with thyroid cancer? And we’ll always have a lot of variation in the frequency of what the physicians do. But one doctor will say, actually, the American Thyroid Association recommends X. So we walk away from those meetings with a guideline we’ve developed, and over time, we see improvement in quality outcomes, and improvement in access to care because we’re standardizing follow-up intervals based on consensus or evidence in the literature.
And you wind up having fewer visits per patient which then allows more access for more patients to be seen. And the last outcome is that overall cost per patient goes down, because you’re eliminating unnecessary tests, procedures, and visits. But in some providers, cost actually goes up appropriately, because they were underutilizing before, but the people over-utilizing always ends up going down, so cost goes down overall.
How do you manage the people processes involved in these initiatives?
Jonathan Nasser, M.D.: There are sort of two ways we divide this up. One is the things that happen outside our physician group, such as hospitalizations and ER visits, and the care in nursing homes and reducing readmissions—that’s one group; and then there’s the care delivered within our organization; and both have different ways of using data. And we also try to accomplish as much as possible for the patients who are in front of us.
Jonathan Nasser, M.D.