Many healthcare organizations at the MGMA annual conference in San Diego, Calif. have been moving forward with their population health initiatives. At the core of these initiatives are a number of common elements, one of them being the ability to provide physicians in practice with real-time data on their patients.
Martin’s Point Health Care, based in Portland, Maine, is a provider organization with three health plans and nine health centers spread across the Northeast. In 2000, at a time when most healthcare organizations weren’t investing in data management and informatics, Martin’s Point built a data warehouse in an attempt to better understand the data it had, says David Howes, M.D., president and CEO of Martin’s Point.
Moving forward, Martin's Point needed the right data at the right fingertips at the right moment—a system-wide standard solution—that would allow providers to see their data at all levels. Without that capability, the goal of effective practice-based population health management was not possible.
Enter the Madison, Wis.-based population health management solutions provider Forward Health Group (FHG), which deployed its PopulationManager tool at Martin’s Point, allowing the organization to “unfreeze” its patient population data and see it from any altitude.
According to FHG officials, despite working with many of the big names in the healthcare policy circles, only Martin’s Point could walk the walk when it came to having its data there. The other organizations simply talked a big game but didn’t deliver, according to FHG.
Martin’s Point has advanced the idea in looking at performance improvement, FHG officials say. “They have measures they have to report on, called reporting measures, defined by a PDF somewhere. But they also have opportunities to do better. These opportunity measures are a second shot, and that is where Martin’s Point is unique,” FHG officials say.
At the MGMA annual conference, HCI Assistant Editor had a chance to sit down with both FHG and Martin’s Point’s Howes to talk about the organization’s population health vision, the key aspects and challenges to it, and effective population health management strategies. Below are excerpts from that interview.
When did you realize you needed to step up your population health management efforts?
We are a medical group with about 50 physicians and 20 mid-level [providers]. We have been in business as an independent medical group for about 32 years, and have had a long-standing set of manual processes that we use to keep track of our medical risks. We weren’t doing bad work relative to the rest of the market, but there were still a lot of gaps and weaknesses.
In 2000, we began building a data warehouse, before we had the ability to put electronic health record (EHR) data into it. Then six years into it, we put all the granular EHR data into it, and built a form set that included all the frequent diseases. Even with that, we weren’t very successful.
So then, we decided to hook up with Forward Health Group. We were set up well to use their services because we had a data warehouse with all the granular, clinical data in it. We had a culture of population health in place because we were an at-risk entity. It’s been a lot of fun, too. We really know every diabetic we have, for the first time now. At the organizational level, we have a good picture of who’s in good control, and who’s not. At the level of the front line, physicians know the list of people they have with each chronic disease and which people have overlaps, allowing them to identify highest-risk folks.
Our quality committee has come to recognize that managing this well is probably the most powerful tool we have in reducing the total cost of care. And as an at-risk entity, that matters. Our health plan partners are demanding that, in order to collect our risk savings, we meet our quality standards. And our board wants to know what our numbers are like. At the macro level, it’s the board. At the micro level, it’s the physician who wants to understand the condition of the patient and what needs to happen in order for his or her care to be optimally managed.
It sounds like having the data is the underlying aspect. Would you agree?
I’m a family doctor and a son of a family doctor, in a rural practice. Our performance data was always locked up in handwritten charts that were in our offices. So by the time I came to Martin’s Point (I came as physician and wound up being the president quite by accident), it struck me that we had to build standards of care, and that we had to collect the data in granular enough form to display it back to clinicians.
In 2000 when we built the data warehouse, we only had business data. But we built it because we wanted to understand how to manage a data warehouse before we had the clinical data. When we put in the EHR, we collected all the granular data and had an infrastructure in place to collect it. Now, all of the EHR data is dropped into the warehouse daily and then goes into the PopulationManager tool. That’s an enormous contrast from where most clinical practices are, as the health plans give them the data. They’re taking it out of billing records, not clinical records. With that, it’s very hard to get really specific, and the claims lag is three months.
But this is timely, it’s as accurate as can be in a real world, and it’s actionable. Our nurses go through PopulationManager each day and they look at what’s in the hopper, who needs to be seen first, where the largest gaps are, what are the oldest gaps, etc. And they begin to plug those people into physician practices with a conversation either electronically or face-to-face with a physician, discussing what needs to be done for each patient.
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