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.
And we arm physicians and teams with data, and ask for suggestions for improvement and we try things out through PDCA cycles or meetings; and then when patients aren’t in front of us, we’re also involved in their care through care optimization, and we also utilize care managers who help to facilitate care for our sickest patients, and looking at telephonic outreach etc. We’ve got large utilization events we’re looking to improve upon that happen outside the practice, and then there’s the care inside the practice, which is easier for us to impact. But care outside the practice is more challenging, but data through scorecard reporting, team analysis and individual reports, helps us, and we come together to determine things we need to improve and how we go about doing them. But that’s the structure of how we take a look at the population health work.
What have been the biggest challenges in these processes?
Gregory Spencer, M.D.: Always, the biggest challenge really at the end of the day is getting the patients to take your advice and get the test or do the thing, the patient engagement piece is always something people struggle with. Other than that, we’re starting to get the pieces together to have the organizational infrastructure to be able to identify the cohorts of patients, the list of patients who need to be worked with to close the gaps in care and identify the rising-risk patients. There are a lot of different ways to do that and it’s a matter of building the system, hiring the people, etc., but at the end of the day, nobody’s exactly got the patient engagement thing down yet.
Hines: I think one of the other challenges is just trying to define the ROI on these things. I think that many of these initiatives that we’ve put in place, frankly, we’ve had in place for many, any years even before value-based or risk-based contracts were offered to us, we have had an EHR since 1999; we’ve had care managers since 2004, we were one of the first Joint Commission-accredited medical groups in New York state, and were in 2009 one of the first medical groups to be PCMH-accredited. And as we scale and scope all these projects, one challenge is, what is the ROI above and beyond, it’s the right thing to do for the patient?
And are you finding out what the ROI is in population health work?
Hines: Slowly, yes. I think it’s challenging. Some contracts pay for quality independent of shared savings, while others require shared savings, and quality is just a gate to shared savings, so we have to look at tools to impact utilization. But overall, and we have our own insurance license; and if you’re at a percent of premium with commercial payers, it takes time to see a return on investment in quality, because you’re not going to see a return on investment in reducing long-term complications of diabetes in a year, so how do you monetize and value that?
What have some of the key lessons learned been around the blessed cycle of data gathering, sharing, use in performance improvement, and cycling back to data collection and analysis?
Spencer: I don’t know that any of our learnings have been terribly profound. Getting the data as right as you can at first is important; getting all the stakeholders in early to participate in the overall process, is really important. And having an iterative workflow so that people can see that there’s an end to the means, showing that you’re picking things that make a difference, so there are tangible real, a sense of purpose and gravity; those are the most important things. And, the variation reduction process that Scott alluded to is a really good example of that.
What is it like for physicians to examine their practices and really engage in assessing their clinical and other performance?
Spencer: You’re really alluding to the fact that we’re on our Lean journey. We’re replicating Lean on a number of levels, and are getting consistent results. With regard to the pushback that happens with some people around standardization of practice, you have to bring them back to the question of what value they add [to the care delivery process]. You have to bring them back to the whole concept of modern medicine and scientific thinking, because people do get defensive when they feel their autonomy is threatened; so making sure they buy into the process is essential. It’s nothing magical, and it takes time, and takes more time for others. And we have a larger organization, with people in practice a long time, and sometimes they can be resistant to change.
What advice do you have for your peers nationwide?
Spencer: Involve doctors early and often in the process. Get started with something, and don’t wait ‘til the thing is perfect. Use whatever you have in your systems now: you don’t have to invest in some large analytics platform; there’s probably a lot of stuff you can do with what you have.
Hines: I would say that you need to spend the time to explain to physicians why you’re doing it; that’s important upfront, because if they understand why it’s important and better, you’re more likely to help them get it done. And it always has to come back to how it’s going to benefit the patient. That’s lost a lot of times in trying to check certain boxes and meet certain benchmarks. So what is tangibly better for my patient if I do a fall-risk assessment? Well, because I can identify substantial risks and avert a fall, which can cause significant morbidity and mortality.