The leaders at Lancaster General Health in Lancaster, Pa., which in August became part of the Philadelphia-based Penn Medicine system, have been moving ahead on population health management initiatives recently. Their two main areas of focus have been the organization’s participation as an accountable care organization (ACO) in the Medicare Shared Savings Program (MSSP) for ACOs, and its universalization of the patient-centered medical home (PCMH) model across all of its medical clinic sites. Among those helping to lead the charge in Lancaster General Health are Michael Ripchinski, M.D., the organization’s chief quality and medical information officer, and Douglas Gohn, M.D., its physician executive for population health. With regard to ACO development, LGH is managing the care of 18,000 in the MSSP program and 70,000 in some sort of risk-based contract. LGH is also participating in the Bundled Payment Pilot Initiative out of the Centers for Medicare & Medicaid Services (CMS), doing cardiac stents, bypass surgery, pacemakers, hip and knee joint replacements, and some spine procedures as well, Gohn reports. Gohn is a cardiologist who continues to practice one day a month.
Drs. Ripchinski and Gohn were among the healthcare leaders interviewed this summer by Healthcare Informatics Editor-in-Chief Mark Hagland for the magazine’s September-October cover story. Below are some excerpts from Gohn’s interview with Hagland. Excerpts from Dr. Gohn’s interview appeared in an article published last month.
Do you report to the CMO of your organization?
I report to the CEO, primarily because of having oversight for quality for the organization. We’ve been trying to achieve a high level of profile to the quality—we’re bringing both results and action plans to the board.
Michael Ripchinski, M.D.
What would you like to have happen at Lancaster General health, with regard to population health, in the next year?
We’ve spent the better part of our efforts since early 2013, first getting all of our primary care sites NCQA Level 3 certified [certified as patient-centered medical homes by the National Committee for Quality Assurance]. That has been a monumental undertaking, and we were moving towards HIMSS Level 7 [a Level 7 designation on the seven-level HIMSS Analytics EMRAM EMR Adoption schematic] at the same time. We were the first in Pennsylvania to achieve HIMSS Level 7 at the hospital and clinic level. And so a lot of this was preparatory work to do gainsharing and then eventually risk-based payment to the physicians; we’re still in the gainsharing mode. We’ve taken on gainsharing contracts with private, commercial, and Medicare payers. Our structure for accountable care was built on the PMCH certification and HIMSS Level 7 structures. We needed those infrastructure foundations for this work.
And can you describe the direction of this work, overall?
The future state is the maturation of those tools from that foundation to do population health. The HIMSS 7 work has been one step on the journey. We’ve basically proven that we can engage our medical staff and physicians and our staff in the journey of transformation to electronic health records, and to use those EHRs to improve performance. Now, in the next year to two years, I see the continued maturation of those tools to identify care gaps, transparently present metrics to the physicians, and give them the ability to improve their performance, and as a result, the outcomes of their patients. We do this in a number of ways, including extensive pre-visit planning, including through huddles.
There are numerous process elements in all this, correct?
Yes. There’s the pre-visit piece; there’s also the same-day process element. I’m a family physician by training, and Doug is cardiologist. The pre-visit planning is the work we do before the patient even shows up. One week before a patient has their visit, we make sure they get their hemoglobin a1c and their LDL numbers, and other data, to follow up with Dr. Ripchinski about. With regard to the same-day preparations, I as a family physician sit down with my nurse and look at care gaps every morning before patients come in. We use the patient registries and population health functions within Epic, checking which patients might be missing their colonoscopies, breast cancer screenings, etc. We’re contacting patients just the way a payer would. And the patient portal plays an important role in helping patients with all of these tasks. But it requires multi-factorial efforts to close the gaps; the efforts have to be multi-factorial and multi-tiered.
What has your journey been like around data and analytics?
It’s very difficult to manage both claims data and clinical data. There are companies trying to merge clinical and claims data to create a path forward, but we’re early on that journey. And as part of setting up the MSSP in January 2014, we started to get claims data and began to do typical payer analysis—what’s the pharmacy spend, who are the high ED users, who are the chronic condition patients?
And aligned with our claims analysis work, we’ve also done risk stratification of patient populations using the clinical data in the EHR. And we’ve timed these so one method of analytics can use the other. For example, in the EHR, we will find out a particular patient is in seven different disease registries, they’ve had claims for eight different conditions, they’ve been in the ED five times.
What’s more, because we have a large share of our local market, our clinical data can have a significant proxy for a claims database. And it’s much closer to real-time. But that’s not going to work in downtown Philly, where they shop between Penn and another system. So we’ve been able to use registry information in the EHR, and we’ve been able to use multiple registries to look at patients by chronic disease states, but we also have a registry that looks at what we call our managed lives; using it, we can track utilization metrics as well as care gaps.
So we’re able to look at managed lives by how many patients have had multiple hospitalizations, or high rates of ED visits, in a two-year period. We can also look at non-traditional things: physician orders for life-sustaining treatment—so we’re tracking patients with end-of-life care plans. And on a broad level, we’re trying to marry utilization metrics, care gap management, and this end-of-life care planning.
Because it’s not just about care gaps; the final piece is beginning to understand social determinants of care. How does their depression interact with their diseases? How does their current living situation interact? So those pieces of the medical care gaps; utilization metrics (ER, hospitalization, urgent care); social determinants of health; and advanced care planning, those four—because we’re able to capture those advanced care planning metrics in our EHR.
And what about merging claims and EHR data for analytics?
We’re absolutely doing that right now. We’ve got to use near-real-time EHR data, informed by claims analyses. You’ll find out a lot. We have a lot of leakage, where patients are going to other care sites in our service area. So we have to make sure that the patient has a plan of care. The patient is seeing seven specialists, and they don’t know where to go.
That speaks to the classic image of the little old lady with the shopping bag full of meds, doesn’t it?
Yes, the classic patient who goes to several specialists. We know there are patients with chronic diseases who see seven specialists. So we’re trying to make this longitudinal plan of care very transparent in the EHR so that anybody who sees them knows what their plan is, right to the end-of-life plan of care.
So we’re taking an early-adopter look at this. People have gone before us, like Kaiser and Geisinger, who have had a head start. But I do think we’re still in the early adopter group on this. We’ve been lucky to have a community that supports us, and a board and executive team that supports us. And with Gunderson and Bellin in Wisconsin, or with us, unless you have communities, as we all do, that support this and are engaged in this work, we won’t there.
What have been a few of the biggest lessons learned so far on the journey?
The very first thing you have to do is to figure out who you’re really taking care of and how you’re segmenting them. We went through a lot of definitions of the managed life—by primary care, by type of patient visit. Before we had gainsharing contracts, we went through work to figure out how we would count and track this population. It sounds like a simple thing, but it’s not. Flip it on its head: if a payer and you sign a contract together, and say, you’re responsible for gainsharing, I’ll say as a physician, well, how many patients is that? And the payers don’t give you the claims data the next day; it’s like months later, if at all. So we’ve taken approaches in the EHR, and we label patients by payer in the EHR, so we can track them and slice and dice their clinical data immediately, so I can tell you the colonoscopy rate or breast cancer screening rate for every population we’re under contract for. It won’t be perfect, but it will help.
So, immediate proactive attribution is very important?
Yes, identifying the population, and then attribution. Which primary care doctor or office is on first? So both labeling them as an ACO patient and attributing them to a specific practice, so they can have up-to-date data on their panel. In that regard, we’ve created metrics on a dashboard inside Epic so that doctors know their panel size. They know at the panel level. We present to the PCPs their entire panel ,regardless of payer. At the executive level, I can segment the populations. So we give them their performance for their entire panel of say, 2,000 patients. So they can see their breast cancer screening rates, colonoscopy rates, for their whole panel. In terms of how physicians treat patients, they’re not going to differentiate one payer over another; they’re going to give excellent care to all of their patients.
And then you need to be able to start to use some of the analytics to say, oh, this practice has higher ED utilization, and how do we help them change what they’re doing? I don’t want to be the guy who just gives them quality data and says, good luck. We need to help them change their practices to improve care for their patients. That’s the win. It sounds like a lot of work, and it is!
What would your core advice be for CIOs, CMIOs, and other healthcare IT leaders? What should they be doing now?
CMIOs are change agents by nature. For my part, I’d look at this as an opportunity for change, because we’ve spent decades rolling out the EHR. But now, CMIOs and CIOs have to put a bold vision out there to help to align operational processes, quality, and IT, so that we can achieve our vision of improving value for our communities, per the goals of the Triple Aim. We’re doing that today: we’re creating cross-functional teams, with a process engineer/Lean person, an IT analyst/analytics analyst, a physician champion, a nurse champion, and an administrative/business operations partner. It’s a clinical and administrative team that has quality and data people in it.
We’re trying to be nimble enough so that if we’re looking at a horizontal process across the organization, like for transitions of care—back from the hospital back to the medical team. How do we effectively do that to avert a readmission? So my advice to the CMIOs and CIOs is, use your change agent skills to create a collaborative force to improve patient outcomes. That’s my call to action, I see that as my role now. I collaborated with so many people in my previous role that this was a natural transition. That’s at the heart of my role, what we need to do. So when I interviewed for this expanded role to include quality, I said, this is the value proposition, to bring the right people to the table to improve outcomes. Make clinicians feel good at the end of the day that they’re improving patient outcomes.