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.
So yes, it’s about the data. You have to capture the granular, critical data elements. If you don’t know the lab studies on a patient with renal failure, or you don’t know the medications for a patient with congestive heart failure (CHF), you won’t be able to do this. The data needs to be in the warehouse. You need to capture it and care about it. That’s been a mantra we have followed for a long time, and if you’re not there, you better be going there.
And how do clinicians feel about all this?
They’re good with it. Clinicians are anxious to do better work and improve the care of populations, but they don’t have the time. They have an overwhelming amount of people flowing in the door for their acute needs. We use the data to report back to them about where their gaps in care are, what their percentages are, who’s doing well, and who’s not doing well. They’re competitive fellows, and they really want to be successful.
What are the IT challenges you face?
Well I’m a country doctor by trade, so I’m not an IT guy. From my perspective, the IT pieces of this don’t seem to be the largest challenge. There is much harder work. We began running the data warehouse 13 years ago when we were very small. Replicating what we have today would probably be a challenge. We have invested a lot in informatics for a little organization such as ourselves—I believed it would be our competitive advantage down the road.
What is Martin’s Point vision going forward when it comes to population health management?
I would say first that the healthcare value proposition is entirely changing. You wont succeed without the data in the next generation. You have to collect the data at a granular level, you have to warehouse it, and you have to extract it. If you don’t start today to begin the process of data transparency within your entity, you’ll be in trouble in five years. That transparency will be the law of the land. It motivates clinicians and clinician teams, and it makes a monstrous difference in performance.
It may not be the right data—we have measured the wrong things a lot of times and have had to junk it and come back. But getting something relevant out there and beginning to discuss it, beginning to build processes to improve it is where you have to go right now.
Between now and the end of 2015, we have determined we are no longer going to try to grow our practice in terms of patients. We are instead going to try to close all gaps in care. What is so striking is that in order to close all gaps, we estimate that we will have a 40 percent increase in visits. There are just to many gaps.
It’s a unique way to think about it. We have a health plan system where we have 70,000 members of whom 40 percent are over the age of 65. In that population, we have roughly 3,500 gaps in care around CHF alone. For instance, there are people who are not getting their ACEs or ARBs, or people who haven’t been educated around managing their weight. The list goes on and on. Hospitalizations can be reduced, quality of lives can be improved, and in fact, even in a fee-for-service world, the economics can be beneficial to a practice that is offering that.