This summer, HCI’s Editor-in-Chief Mark Hagland interviewed leaders of medical group organizations from across the country to get a sense of where their leaders are right now with regard to laying the strategic information technology foundations for the “new healthcare,” as it’s being called: the shift away from volume-based fee-for-service patient care delivery and reimbursement, and towards a more measured, standardized, responsive, accountable, and transparent healthcare system. Among the numerous emerging vehicles for that care are accountable care organizations (both within the Medicare Shared Savings Program, and between private health insurers and providers), bundled payment-based contracts, patient-centered medical homes, population health initiatives, value-based purchasing programs, and others.
Fortunately, the Supreme Court’s affirmation in June of the constitutionality of the federal Affordable Care Act (ACA) has created greater policy clarity around many of these vehicles, with the ACA’s provisions for accountable care organizations (ACOs), bundled payment-based contracts, patient-centered medical homes (PCMHs), and value-based purchasing now moving forward with renewed certainty.
In this virtual roundtable, medical group leaders share their views on the challenges they face as the industry shifts from the volume-based fee-for-service model to more accountable and responsive patient care. See the participants’ biographies on page 10.
What are you all seeing as the most significant strategic IT issues facing medical group leaders like yourselves in the current and emerging operating environment at the moment?
Francis X. Solano, M.D.: We’ve been extremely successful in rolling out the electronic record, which is a wonderful tool. The next priority is to utilize that tool to the fullest, so we get maximum benefit. Personally, I think meaningful use is actually forcing us to go backwards a bit in order to satisfy government regulations. Our capabilities in report-writing are already advanced. Our challenge really is in the area of specialty care, which everyone in the industry is struggling with.
You can get lots of crude data on outcomes, including length of stay, etc., but is that really helpful? In primary care, there are a lot of outcomes measures, process measures like controlling hemoglobin A1C, lipid management, blood pressure control, smoking query, anti-platelet and statin use in heart disease care, colonoscopy rates, immunization rates, etc., and we’ve actually done things like ranking our physicians on those elements. Some of the meaningful use requirements were well-intentioned. But in some cases, it’s kind of a step backward for us to spend all the time, energy, and resources, to figure out what the government wants and satisfy those wants.
Jeffrey Weinstein: Our biggest challenge is taking the data that we’ve collected and starting to put it into a format so that we can use it to help manage populations, to improve the health of our communities.
Glenn Mamary: At some point it’s really being predictive in our analysis as well. Because we’ve been on our EMR for so many years now, we’ve got a database that we could leverage, because the tools are so mature out there.
Tim Terrell: Overall, for us, it’s the challenges presented by healthcare reform, in its broadest sense.
From your perspective, what unites all these healthcare reform-related programs in terms of the strategic IT foundations required for them?
Terrell: Number one is analytics, and number two is integration. Those two things will be the biggest elements of it, and both are enormous.
Where are you on those two elements?
Terrell: We’re actually investing pretty heavily in analytics. We’re working with Teradata, one of the three biggest data warehouse vendors (the other two are IBM and Oracle); also, we’ve got Humedica for the clinical analytics and clinical predictive modeling. We’re in the process of implementing the OptumImpact suite from OptumInsight, to give us claims-based analytics.
Are you live on all three yet?
Terrell: Right now, we’re live on one, Humedica; we’ll be live on Teradata by October, and will be very close on the Optum.
Dr. Solano, your umbrella organization, UPMC, has long been a pioneer in leveraging clinical IT to address core issues in patient care delivery. Where do you see the nexus between performance improvement in care delivery right now in the medical group setting, and what IT can do to improve that performance?
Solano: Getting rid of the variability in care is what’s keeping me awake at night. I just don’t realize why so many physicians are so variable in their care in so many ways, or why so many physicians are still not optimally using some of the tools in the electronic record. Some of it has to do with such elements as best practice alerts, preventive maintenance screens, and allergy-allergy checking: if you ignored them in the paper world and you ignore them in the electronic world now, you’re going to be mediocre. The thing is, this transparency train is coming, and physicians have to be ready for it and be aware that it’s coming.
Also, it’s not automatically true that quality care will cost less. That conundrum is out there, and it bothers me if we’re going to be benchmarked based on quality and cost. If you happen to work in a quaternary care center as I do, your costs will be a lot higher, because you’re supporting a teaching institution. We actually did an interesting study: we took our top 50 providers and bottom 50 providers in primary care, and found that it actually cost more money to provide higher quality in a care group; so that’s out there. The newest conundrum that we face is, how do you go from a volume-based payment system, to doing the right thing in a quality-based system? That will be our biggest challenge. How do you start to align yourself to set up what you have to do. You’ll have to make some changes around utilization, around the use of diagnostic tests and drugs.
Why Workflow Matters
How does that translate into what IT implementation can do to support performance improvement?
Jim Venturella: It gets to the workflow and efficiency issues that Dr. Solano talked about. In some of the practices, the doctors are well-educated, and our tools may not be as efficient as they could be, so we’re trying to figure out how to make the tools more efficient; because some of the tools actually make their day less efficient. The other area is looking at devices: how do we use devices more efficiently? How will we use the new mobility tools more efficiently in the clinic setting?
Terrell: Also, you can’t treat every patient the same way anymore. You basically have to divide your patients into the generally healthy versus the chronic with one illness, versus the poly-chronic, versus those in end stages of illness; and you have to treat each category differently. With poly-chronics, you have to work on poly-pharmacy and managing those patients more intensively. With the end-stage people, it will be about getting them to the lowest-cost, best-outcome setting for care. The patient who is terminal with cancer actually lives longer, and at much lower expense, in hospice, versus in the hospital.
In addition, you have to create disease registries. You have to figure out who your most frequent flyers are, and why; and who your most expensive patients are, and why. You have to figure out exactly what your clinical performance is at the individual provider level. The same thing is true regarding patient satisfaction, by provider. You’ll need the analytics to understand the processes at each clinic, to know which things work for each patient and which don’t. You need analytics to determine how you’re performing on your quality-based contracts.
Data Integrity Issues
Mamary: Among other things, we’re trying to move forward on data integrity issues. Some of the issues in that area include making sure that people understand the meaning of the data we’re capturing, and that people are trained to correctly capture the data. Fortunately, we’re all on the NextGen system, so the capture element isn’t that difficult on the practice side. It’s on the hospital side where I find that we have some issues, because of multiple systems and vendors.
The other thing is that, in the hospital, I have to provide data to over 30 outside sources, whether state or federal. They come up with these little state-level names of pieces of data that mean something to New Jersey, for example; and then the information systems are required by our contract to capture those data elements. Inevitably, New Jersey calls something by a name that is different from what it’s called in another state. There are so many points of data entry into the system.
Capturing a piece of data in a consistent way is a challenge, and is one of the lessons we’ve learned. We’ve gone back and made more fields required fields, so people don’t just skip by them. We’re required to say that a patient doesn’t actually have a referring physician, if they don’t. We needed more analytics people to find things out. We’ve got tons of data, but we’re really trying to turn that data into information. We’re using the Ensemble solution in that area. Having a financial systems analyst, a clinical systems analyst, and also working with the customers, you need to put all those systems in place, to make sure you have good data integrity, and to make sure that all your processes are correct.
ACO Challenges and Opportunities
Dr. Cuddeback, when you talk to leaders of medical groups that are your organization members, what are you hearing right now?
John Cuddeback, M.D., Ph.D.: Accountable care organizations are very much a focus for our member organizations, and ACOs are exactly what our association has been focused on. Of course the Medicare Shared Savings Program was based on the Medicare group practice demo that several of our member organizations participated in.
Weren’t most of the practice demo groups AMGA members?
Cuddeback: Yes, nine of the 10 were, and the tenth was not an actual medical group, it was a community coalition. When I first came to AMGA five years ago, medical directors and CIOs of medical groups were talking about the issues around creating patient registries and supporting population health. That’s essentially been the theme, just because this is so important to AMGA members.
Accountable care is about medical groups working collaboratively with insurance partners—not just on their own. With regard to the infrastructure issues, it’s about being able to understand a patient’s entire healthcare experience. If you look at AMGA members, we’re seeing an increase in integrating organizations; and most of these are mergers of different groups. Five years ago, in the heart of the PGP demo [the federal Medicare Physician Group Practice accountable care demonstration, which helped create the model for the Medicare Shared Savings Program under healthcare reform], only about one-third of our members were integrated delivery systems; but now, two-thirds are. Still, data integration remains a huge focus.
What should your colleagues in medical group organizations across the country be doing right now?
Solano: First, you have to get an electronic record in place, one that will support your organizational and national goals, because if you pick a vendor that can’t do that, that will create problems down the road. Then you need to get a leadership group together with strong, forceful, directional leadership, so that you can try to define what your priorities are, which is crucial. You can wander into areas that will just waste your time and resources.
You have to make sure you hit all the national benchmarks for quality. It’s very easy to get sidetracked into pursuing projects that bring your organization very little value and don’t fulfill any of the national objectives. Instead, you need to look at the national objectives of accountable care, the medical-centered home, and value-based purchasing, and align your organization with those, both on a national and local-area level. Aligning with those goals is crucial. Because if you fall off the path, it can be fatal. Anyone who says they’ve never fallen off the path is lying! We’ve fallen off the path many times along the way.