The Charlotte, N.C.-based Premier health alliance, a membership organization encompassing more than 2,500 hospital organizations and more than 81,000 non-acute care sites nationwide, on June 5-8 held its Breakthroughs 2012 Conference at the Opryland Hotel and Convention Center in Nashville. Attendees participated in dozens of sessions, organized by tracks, and spanning such areas as patient safety and quality, efficiency and cost control, purchasing innovation, and strategic information technology.

On  June 7, several clinician executives from Premier member organizations, some of them conference presenters, sat down for a roundtable discussion by telephone with HCI Editor-in-Chief Mark Hagland. Each discussion panel member spent some time describing what he and his colleagues have been doing at their organization, and then they engaged in a broader discussion with Premier's enterprise-wide chief medical officer Richard Bankowitz, M.D. Below are some excerpts from that June 7 discussion.

I’d like to ask each of you to describe some of the innovations you and your colleagues have been working on in your organizations.

Evan Benjamin, M.D., senior vice president and chief quality officer, Baystate Health, Springfield, Mass:  We’re a three-hospital system; our flagship facility is a 700-bed academic medical center affiliated with Tufts University. We also have an affiliated health plan. And our goal over the past few years has been transforming the way we think about delivering healthcare and the way healthcare is financed. And as you know, we’ve had a few years of insuring 98 percent of the population here, following healthcare reform in Massachusetts. One of the big challenges has been how we continue to insure everyone and improve quality and lower costs. So we’ve been focusing on new ways to align physicians, to coordinate care, and to integrate care. So we started a bundled payments project about two years ago.

Evan Benjamin, M.D.

At that time, the only organization really doing bundled payment contracts was Geisinger Health System [Danville, Pa.], with their ProvenCare program. What we’ve done is that we’ve worked with our health plan, Health New England, which has 120,000 members, and began by focusing on total hip replacement; since then, we’ve expanded to total knee replacement, and we’re currently working on expanding out to other areas, including cardiac bypass surgery. We brought together the hospital, the health system which also included our visiting nurse association, the health plan, and our community orthopedic surgeons. We began planning this in 2010, and created an eight-step approach, and went live on January 1, 2011. It took about seven months of planning prior to go-live, which is pretty typical in terms of the amount of work required to change the model of care, set up gainsharing models with the physicians, analyze the patient population , and set up quality replacements.

How many physicians were involved in the initial total hip replacement pilot program?

Initially, it was just our four orthopedic surgeons who are doing total hips.

And what happened?

We put together those elements I’ve just mentioned—the payment model, gainsharing, quality measures. We wanted to establish a baseline on quality; and we set a bundled price, and we included a warranty like Geisinger, so the plan would feel comfortable. And we used the model of preventable complications, handling those complications without charge, like ProvenCare. And then we set our quality targets, and set up a very simple gainsharing model, so that we would share cost savings. Geisinger at first set up a 50/50 model for ProvenCare. We set it up as 45 percent for the hospitals, 45 percent for the physicians, and 10 percent for the visiting nurse association, because they were doing rehab at home, averting post-acute rehab.

What have the results been?

We’ve been hitting all our quality measurements, and saving about $800 per case. The cost savings have been coming  from two broad areas: one was inpatient medical management, where the surgeons were recognizing some non-standard practice variation. And when they’re all sitting around the room developing a bundled care model; so they had incentives to standardize. We lowered supply costs, and we lowered length of stay about three-quarters of a day, from 3.5 days to 2.75 days inpatient. The overall cost of the bundle was about $25,000 per case, and between the inpatient reduction in cost and the reduction in post-acute care services, it was about $800 per case. We just started total knee this month, June. And we’re working with the Center for Medicare and Medicaid Innovation (CMMI), and Premier on this. Premier has pulled together 18 health system member organizations as a convener, to help apply to participate in the CMMI bundled payment program. We’ll be submitting our application to the CMMI Innovation Center for the federal bundled payments program.

Dr. Wise, please tell us about your organization’s recent activities.

Greg Wise, M.D., vice president of medical affairs, Kettering Medical Center, Dayton, Oh.: We are an eight-hospital system; we have our own college with baccalaureate and graduate degrees. Three of our hospitals are teaching hospitals and affiliated with Ohio University and with Wright State University. My journey has principally been around quality. And we’ve really valued Premier Inc. as a partner in this journey. We were involved in QUEST 1.0, now QUEST 2.0, and in the Partnership for Patients, value-based purchasing, ACO readiness, etc.; Premier has been a critically valuable partner, because no single hospital or even system can address all the issues involved without a partnership with an organization like Premier.

Greg Wise, M.D.

So we’ve been presenting on our journey with regard to clinical documentation. As you know, all data in hospitals is collected by somebody, and sent to many different avenues; but in the basic quality metrics that hospitals are compared against, such as risk-adjusted mortality, complications, and length of stay, etc., that risk adjustment is done through physician documentation. And this is a highly regulated process through Medicare. Physician documentation in the chart determines risk-adjusted methodology and outcomes so you’re truly comparing McIntosh applies with McIntosh apples across the country. And we’ve built a physician-led physician documentation program, which also includes nurses, coders, finance, and we even have our corporate integrity officer on our committee to make sure we’re doing everything correctly. And we’ve been doing that for 10 years.

So we’ve been doing continuous work to optimize our physician documentation process. At the same time, we’ve been working with a Premier collaborative around mortality, end-of-life issues, and other related issues. And we’ve been using a physician-led process to build and approve the use of evidence-based order sets into our CPOE [computerized physician order entry] system.

What have been the results of all this work?

We have a third-party independent group that comes in to audit our documentation process. We look at the response rate by physicians to our queries; there’s  great compliance with our external audit. And the government has been doing RACs as well. And we’ve come out quite well on our RACs. We’ve been subject to five or six RAC audits so far in the last year or so. Some are around sepsis and other low-hanging fruit. The other aspect would be length of stay.

What have the key learnings been from this work?

Probably the major one is that it does take a village, in the sense that it requires a multidisciplinary approach. But we’ve built a unit-based process with our documentation specialists so that we build a relationship with our physicians. Meanwhile, all of these elements [clinical documentation, evidence-based ordering, clinical performance improvement] are related.

And the big-picture question now is, how can we turn data into information that can be actionable? And then we need to form a community to allow all employees in the hospitals to have access to the Premier database.

Dr. Bechard, I know that you and your colleagues have been involved in a quality journey, too.

Douglas L. Bechard, M.D., chief quality and safety officer, Adventist Health System, Altamonte Springs, Fla.: Over the last six years that I’ve been with the organization, the emphasis has been on creating, in terms of improving quality, the infrastructure and the content, and to demonstrate that it improves patient care. We’ve put in the infrastructure for paperless hospitals in all our institutions. For example, on April 23, we turned on 63 applications, including CPOE, at one of our largest facilities, converting them from their current systems which were not integrated to the AHS standard including CPOE. Doing these conversions on an enterprise-wide level has been a daunting task.

Douglas Bechard, M.D.

We have not been with Premier very long yet; we were concentrating on ‘putting the tracks down’ for sustainable improvement with enabling technology. Where we have spent our time is on trying to put into the workflow of nurses and doctors what the best practices are, with just-in-time information. So we’ve worked with Zynx and have developed 650 order sets. We then allow them to take a parent order set, and if they want to make a child out of it, there are certain measures, pieces of evidence-based care, that can’t be taken out. And while we have not been universally successful in that, we’ve been working on that. And with nurses, we’ve developed and deployed  interdisciplinary plans of care, or IPOCs.

We have had data comparing our hospitals before and after CPOE, to look at conditions and risk-adjust them.  Our data demonstrate that patients who have been on our CPOE order sets have 10-20 percent lower costs and length of stay, though in a few cases, costs have actually risen, for good reasons.  We focus on what’s best for patients. Our preliminary data also show improved outcome and process measures.

Listening to all these accounts of work being done in these innovative organizations, what are your perspectives, Dr. Bankowitz?

Richard Bankowitz, M.D., enterprise-wide chief medical officer, Premier Inc., Charlotte, N.C.: It’s actually been great sitting here and learning about what’s been going on in these hospitals. And it all fits in very well with the themes of our Breakthroughs Conference. The first learning is that the transformation has to be provider-led. We believe that providers have to lead the way in lowering costs and improving quality. And you didn’t hear anyone here say they’re waiting for D.C. to tell us what to do. The second theme has been the theme of innovation; we’ve been highlighting a lot of our supplier partners; we’ve been highlighting a lot of the QUEST innovators in our QUEST meeting; we’ve been sharing a lot of ideas. And the last theme has been the power of the alliance. And one of the things we’ve done is to launch an alliance called PremierConnect. Premier has just leveraged its considerable IT resources to help our member organizations connect data, knowledge, and people. So we’re putting all our database applications on this one platform. Premier is trying to help facilitate and accelerate change.

Richard Bankowitz, M.D.

Any last thoughts?

Dr. Benjamin: This is a real time of change in healthcare; we’re going through a lot of transitions. We’re trying to change cultures, trying to move towards team-based care; move towards chronic-based management; move towards bundled payments. And all the population-level care management—this is all really new. So we’ll be on this journey for a long time.