Independent physicians are under the same mandates as their employed counterparts to offer the best possible care for their patients at the lowest possible costs. Yet independent practices often lack the IT infrastructure and tools to achieve those goals. In the Denver, Colo. area, the integrated Physician Network (iPN), a physician-led quality improvement collaborative formed in 2004, maintains that it offers the resources to make sure that independent practices are not left in the dust when it comes to meeting the “triple aim” goals set out by the Institute of Healthcare Improvement: improving the health of populations, enhancing the patients’ experience of care, and reducing the costs of care.
At the HIMSS14 conference last month, Healthcare Informatics met with two iPN executives, Hans Wiik, president and CEO, and David Ehrenberger, M.D., chief medical officer, who explained their organization’s vision and structure. iPN consists of about 30 practices and 260 providers, about 150 of which are primary care providers and 100 are specialists. It is sponsored by Centura Health, northern Colorado’s largest not-for-profit healthcare system.
Ehrenberger acknowledged that independent providers operate in a challenging space. He said that it is important to understand the cultural vein of physicians, whose sense of autonomy is strong. “What we are saying you can have part of that, still have your own business, and you can be in charge of how you excel, in terms of performance and data and how you care for your patients. We are here to help you do that,” he said.
According to Ehrenberger and Wiik, iPN offers its member practices a value proposition based on data analytics, which has allowed them to achieve better care and lower costs, while enabling the network to negotiate favorable shared-savings agreements with payers in behalf of its members. Wiik said that iPN has shared-saving agreements with manjor payers such as Cigna, Aetna, UnitedHealthcare and Anthem. All member practices are on a common electronic health record (EHR), which allowed the member practices to share performance data, setting the stage for performance-improvement benchmarks. In addition, iPN performs administrative tasks for its members, such contract negotiations, and takes care of the IT infrastructure management.
As a regional accountable care organization that aspires to deliver systematic improvements in quality, safety and patient experience while increasing value, iPN has needed to master what he calls “deep data,” which he explained is deep down to the primary-source level. He said a major analytics challenge for the independent practices was the fact that a huge segment of the network’s patient population is managed from outside the walls of a hospital or a fully integrated health system.
SETTING UP COMMON PLATFORMS AND GOALS
Ehrenberger explained that many independent physicians do not have the resources to deliver what government and payers are demanding: “show me your quality, show me your data, show me your cost-effectiveness.” He noted that while the typical EHR is a great transactional tool, it is a poor analytics tool. “We provide a great transactional tool with local training and support. We take care of hosting, we take care of all the enhancements, and we make sure that the tool meets the quality demands and efficiencies of the office practice. We marry that with professional level analytics,” he said.
In 2005, iPN put all of its independent physician practices on a common EHR platform (supplied by NextGen, Horsham, Pa.), and enterprise-wide database. “The enterprise record piece is critical, so there is only one patient record per patient in our community that everybody shares,” Ehrenberger said. He added that the EHR is quite sophisticated, with 26 interfaces in addition to a health information exchange (HIE) interface. “We have got a patient portal that has been in operation for three and a half years. Those are key pierces to making your electronic health record perform at the highest level,” he said.
The EHR platform is being combined with data analytics tools: iPN is currently implementing a national business intelligence service with Cleveland-based Explorys, a partnership that Ehrenberger said will allow iPN to be faster on its feet understanding analytics and understanding data, and will help the company develop tools for quality improvements.
To support quality improvements, iPN offers IT services, produces registries and provides decision-level supporting data to help physicians manage their patients, according to Wiik. “The majority of our practices in primary care are level 3 NCQA [National Committee for Quality Assurance] certified PCMH [patient-centered medical home], and we support that,” he said.
Participation in quality improvement efforts is a requirement for all member practices, Wiik noted. “We literally have it in our bylaws that say, if you do not perform and you do not have a remediation plan, we can take you to the board,” he said, noting that three years ago the group ejected a practice that wasn’t serious about improving its quality.
Wiik acknowledged that physicians are very competitive by their nature. “We put practice managers and providers together, and they sit down together and look at each other’s practices,” he said. “We float all boats by having people understand that the tool becomes the utility to help them really manage their chronic disease patients.” He referred to the iPN as a “multi-specialty clinic without walls.” Physicians are all heavily invested with working together, because the specialists get the referrals from the primary care doctors; they get better care coordination and can see all of the data; and they all work together in terms of security and privacy of the data, he explained.
According to Ehrenberger, “Data governance is really important here, because what you want is great, reliable, valid data, that’s real time, and that shows how well you are caring for your populations of patients.” He noted that payers, employers, and the government, are all demanding value. He said iPN brings what he termed relevant market value that is tangible to the market. “It’s not good enough just to measure performance; you have to be able to improve it, and it doesn’t change all by itself,” he said.
One of the key leverage points of iPN is transparency: the ability to track performance of providers and practices, and provide them with the knowledge of quality improvement and how to change behavior and systems. “Then you can start to move those dots,” he said. “What’s important in terms of change management is for physicians to be aware of the performance within their own practice, and to compare their practice to others. It’s highly motivational and results in incredible changes over time.”
A FOCUS ON CUTTING COSTS IS KEY
Ehrenberger said that while quality goals are important, they must be accompanied by reduction in the costs of care. “Market relevance is, you provide a less expensive service and you provide quality,” he said. He noted that iPN was recently recognized by Cigna as saving $2.2 million on a population of 9,000 patients over a one-year period, against risk-adjusted comparisons in its market. By proving that it is reducing the costs of care with better care transitions and systematic reductions of morbidities and complications from chronic disease allows it to make its value proposition, “because payers know well we are saving them money.”
Wiik said that sometime in the future it is possible that iPN will apply for an insurance license. “I have got to be successful for our medical community; and if we have an insurance license, where I can get full access to claims data along with our quality data, then I know where our costs are and I can act on it,” he said. Both he and Ehrenberger said that iPN has patient-centered medical home pilot data that demonstrates the network has reduced ED visits and readmission rates significantly, on the order of 15 to 20 percent a year.
In its latest iteration, iPN is now part of the Colorado Health Neighborhood, which also includes employed physicians under Centura as well as iPN’s independent practices. “That’s the next layer up. We do believe size is leverage, so we can work better with larger employers and payers,” Wiik said. “Independent physicians and the employed can now come together in an even bigger construct, to leverage the payers.”