As the road to the new healthcare continues to lead patient care organizations into new and uncharted waters, healthcare system leaders are increasingly targeting defined patient populations to improve health outcomes. Population health management programs are a set of interventions designed to maintain and improve people’s health across the full continuum of care—from low-risk, healthy individuals to high-risk individuals with one or more chronic conditions.
In Buffalo, N.Y., Catholic Medical Partners (CMP), a network of more than 900 independent primary care physicians, pediatricians and specialists, along with hospital partners at Catholic Health System in Buffalo and Mount St. Mary’s Hospital in Lewiston, N.Y., have fruitfully navigated the granular healthcare landscape with effective wide-scale population health management.
Members of the first-place winning team in the HCI Innovator Awards program, from the Buffalo, N.Y.-based Catholic Medical Partners. Left to right: Michael Edbauer, D.O., chief medical officer of Catholic Medical Partners and chief clinical officer of Catholic Health; Paula Conti, coordinator of clinical transformation; David Nielsen, director of IT and internal operations; Sarah Cotter, director of clinical transformation; and Dennis Horrigan, president and CEO of Catholic Medical Partners.
At the core of its population health initiative, CMP has made significant investments in technology to help foster the effective and efficient exchange of clinical information between physicians, and to help engage patients as active participants in their own care. Beginning in 2006, CMP provided its physician members with incentives to implement Certification Commission for Health Information Technology (CCHIT) certified electronic health record (EHR) technology. It was at this time when the leaders at CMP—including Dennis Horrigan, president and CEO; Paula Conti, coordinator of clinical transformation; and Sarah Cotter, director of clinical transformation—felt that every doctor in its network should have an EHR.
As part of its technology investments, CMP has focused on primary care and EHR quality reporting to help physicians understand how to better take care of their patients, and help facilitate better relationships between primary care providers, specialists, and hospitals within their network for better continuity and shared information, says Cotter. To date, CMP has more than 50 practices submitting EHR registry quality data on a quarterly basis, she notes.
Practices are provided physician and group level comparison data to help assist them in implementing and monitoring their quality improvement practices for diabetes, coronary artery disease/ischemic vascular disease, congestive heart failure (CHF) and preventive services such as mammography, colorectal screening, flu vaccine, and pneumococcal vaccine, Cotter says.
According to Cotter, CMP started with a small group of medical practices with the goal of trying to get the physicians to understand prevention rates within their practices. “We started with baby steps, and we realized in the beginning that there was a big learning curve, as it takes nine months to a year for the process to be less about data improvement and more truly about quality improvement,” Cotter says.
From those core preventive measures, the practices have expanded to all measures around diabetes care, CHF, childhood obesity, asthma, etc., with the vision of expanding more in the future, Cotter says. “When you only have paper charts, it’s very easy to feel like every patient you see you treat very well,” she says. “Only when everything is brought to your attention can you can really highlight and see where improvements can be made. All providers want to provide the best care and get A+ ratings, so if you give them the information and tools, they’re on board and willing. That’s where population health management is highlighted.”
Providers should know how well they treat blood pressure or CHF, Horrigan adds. “They should know their rates in preventative medicine, immunizations rates, and flu vaccine rates. The idea of every doctor having an EHR was step one in this whole process.” Currently, Horrigan says, 95 percent of CMP membership has implemented EHR technology.
EFFECTIVELY MANAGING POPULATIONS
CMP has trained and embedded more than 200 care coordinators in its attempt to transform the way care is delivered, Cotter notes, adding that these care coordinators use the EHR quality reports to target their interventions to their patients who need the most assistance. CMP was also one of the first 27 organizations across the country chosen to participate in the federal Medicare Shared Savings accountable care organization (ACO) program. Cotter feels that CMP’s selection as an ACO was due, in part, to its technology infrastructure.
“As we moved into the ACO, we began to extract information out of the EHR on all of the patients of a practice; we figured the best information from the doctor would be on their entire population,” says Horrigan. “That was the vision, and then along the way, we found that people had EHRs but weren’t putting data in properly, making reporting less than accurate as well as interoperability problematic. Our idea was to empower the practices to have the kind of data so they could manage the population.”
To achieve successful population health management, the first issue is to stratify the population to determine which patients need the most services, and also which patients are being treated, but not being treated optimally, advises Horrigan. “We started with the group of patients at the highest risk who have the highest burden of illness, and then worked our way into prevention,” he says. “While prevention pays off in the long run, the greater opportunity from a personal and human perspective, as well as a financial perspective, is to try to make the interventions with people most in need.” Another aspect of this is that there is a good percentage of the population that doesn’t see a doctor, he adds. “So we focused on getting practices to realize the portion of their population that hasn’t been in for one reason or another, and to be proactive.”
An additional strategy for a network with more than 900 physicians involves working with its primary care practices in becoming patient-centered medical homes (PCMHs), Cotter says. Currently, more than 40 primary care practices have achieved Level 3 National Committee for Quality Assurance (NCQA) PCMH certification.
“We work on helping them change not their whole practice operations, but proactively reaching out to their patients, making things easier and more accessible, and using health information technology to manage their population, which is what the standards around PCMH are about,” she says. “I really think those standards help give us a framework for working with practices on doing population health in their practices. Our goal is to have all our primary care practices become PCMH’s, or follow PCMH principles.”
In several cases, applying these principles has paid off in very concrete ways. In 2013, CMP saw a 4-percent reduction in readmissions from 2012; and in spite of the high volume of respiratory illness early in the 2013 flu season, prevention quality indicators (PQI) avoidable admissions have not increased from the 2012 baseline. CMP has also seen improvements from baseline for blood pressure, diabetes, and CHF, Cotter says.
While the leaders at CMP have put together the elements for a successful population health management foundation, there have been roadblocks along the way, specifically around interoperability, says Horrigan. “We originally wanted to put everyone on one EHR, but that wasn’t going to happen since independent practices have their own ideas on what they wanted to do,” he says. “So the question became, can they talk to each other?”
To this end, CMP received a million dollar grant from the Medical Society of the State of the New York to essentially design a technology for interoperability using what it is called the “connect” method, which is an elegant way for exchanging information, says Horrigan. “It was elegant, but also complicated. An alternative to that method eventually became the Direct method, which is secure messaging. This shift is something we’re still working through,” Horrigan says.
Physician education posed another challenge, notes Conti. “Older physicians are not as comfortable with technology as younger employees who are coming in and grew up with technology without fear of it. Changing that personal preference with how you perform at your day-to-day job can be a struggle,” she says.
But as Cotter adds, “Technology investment without investment in people to use the wide breath of information that technology can create will not result in success for population health management. We believe that our investments in technology and people will help improve the quality and satisfaction of care that patients receive. But it takes education, time, and a willingness to get there.”