Medical groups of all types and sizes stand collectively at a crossroads in the evolution of the healthcare industry in the United States at this point in time. Faced with a welter of issues, from reimbursement concerns to mandates coming out of federal healthcare reform and the American Recovery and Reinvestment/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act and other legislative and regulatory developments, and competing to better serve the needs of both patients and payers and purchasers, the CEOs, CIOs, and others leading physician groups are working assiduously to find ways forward that meet the demands of stakeholder groups while also meeting the needs of their practicing physicians.
In order to get a sense of where the leaders in the field are at this point in time, Healthcare Informatics Editor-in-Chief Mark Hagland gathered together several leaders of pioneering medical groups nationwide through a “virtual roundtable” process late this summer, in which he interviewed successive leaders and “shared forward” their thoughts with the others around this “virtual roundtable.” Below are excerpts from the progressive interviews. Capsule profiles of the leaders and their organizations can be found below.
Among the many issues facing these leaders: how to plan for the development of accountable care organizations (ACOs), the patient-centered medical home model, bundled payments, and other federal policy requirements; how to make progress towards meaningful use, under the HITECH Act; how to plan for ongoing infrastructure, interoperability, and mobility development; and how to prioritize a variety of disparate efforts aimed at fulfilling different types of needs. No one medical group leader has all the answers; but our panel of leaders certainly has many important and useful perspectives to share.
V.P., Advocate Health Care, and Sr. Medical Director, Advocate Physician Partners, Mt. Prospect, Ill. 3,900 physicians across N.E. Illinois, affiliated with Advocate Health Care
CIO, Muir Medical Group IPA Walnut Creek, Calif. 700 M.D.s across three counties in Northern California
CIO, Hill Physicians Medical Group San Ramon, Calif. 2,600 M.D.s across several counties in Northern California
CIO, Cornerstone Health Care High Point, N.C. 200 M.D.s across 75 sites in the Winston-Salem/Greensboro/High Point Triad region of North Carolina
CEO, Southeast Texas Medical Associates (SETMA) Beaumont, Texas 32 physicians in Southeast Texas
Healthcare Informatics: What are the most important, urgent strategic IT challenges facing you right now?
Tina Buop: I really think there are four top components involved, and they're all equally competitive with one another. The first is developing a strategic approach to identifying and implementing quality metrics, such as those required for meaningful use, those that have already been required for pay for performance, those required for evidence-based care, and those required for CMS Star [a program created under federal healthcare reform and administered by the federal Centers for Medicare and Medicaid Services (CMS) that pays Medicare Advantage health plans differentially according to their beneficiaries' experience of care and quality of care].
There are also accountable care organization metrics; there are existing PQRI [the federal Physician Quality Reporting System, still referred to as the Physician Quality Reporting Initiative across the industry] metrics; and then there are metrics to measure against compliance, such as the [federal] e-prescribing cutoff that happened in June. And in 2012, there will be 1-percent penalties under Medicare-and though it's not a quality metric per se, it's a compliance metric in that case.
HCI: That's a lot of items to think about at once.
Buop: It's daunting. Then you look at our core menu of measure sets for meaningful use, and the existing pay-for-performance metrics, and there is then the challenge of creating a crosswalk between those two areas. With all these different metrics, we could customize them to our hearts' content, but then you'd lose hundreds of thousands of dollars on each customization, because of the data feeds, etc., for each measure. For example, if our organization chose to customize a hemoglobin A1C measure, we would have to customize all our reports in that area, and doing so would make the task of maintaining the system daunting.
WITH ALL THESE DIFFERENT METRICS, WE COULD CUSTOMIZE THEM TO OUR HEARTS' CONTENT, BUT THEN YOU'D LOSE HUNDREDS OF THOUSANDS OF DOLLARS ON EACH CUSTOMIZATION, BECAUSE OF THE DATA FEEDS, ETC., FOR EACH MEASURE.-TINA BUOP
HCI: What are the top issues for you at Hill Physicians Medical Group?
Craig Lanway: My to-do list keeps growing. And healthcare reform is changing the whole landscape. I wouldn't say that anyone at Hill completely understands this thing or how it will turn out; but I will say that what we've been doing at Hill for years in terms of managing care in terms of cost and quality is where we think healthcare reform is going. Certainly, California has had a lot of experience with that. You're familiar with the ACO-type arrangement we've already created in California, and we realize that we have to have flexibility for new arrangements.
WE'RE GOING TO HAVE TO SHIFT SOME OF OUR CORE COMPETENCIES AWAY FROM HARDWARE AND SYSTEMS AND TOWARDS EXPANDING OUR CONCEPT OF WHAT A NETWORK IS, AND TOWARDS A LOT MORE DATA INTEGRATION, AND DATA DELIVERY IN THE RIGHT PLACE AT THE RIGHT TIME.-TIM TERRELL
So we've been working with a consulting firm for the past five or six months on a plan for an overall care management strategy, because that's our business now. We are now moving into the realm of care management. And who is better-positioned than medical groups to manage the care of patients? It's not hospitals; it's medical groups. At the same time, we have to take care of some mundane things, like the transition to ICD-10; that's got to be completed. We've also got to continue to get physicians to adopt EMRs in their practice.
HCI: You still have a large percentage of physicians who are not yet fully electronic. How does that figure into your care management strategy?
Lanway: It figures in very strongly, because we still have a large number of very small physician practices that are working off paper. And only 20 percent of our patients are seen by PCPs who are using an EHR. And we've got a long way to complete that rollout. So we have a two-part strategy right now. One option is to do a full NextGen implementation [with Hill's core EHR vendor, the Horsham, Pa.-based NextGen Healthcare]; the other is an EHR “lite.” And we're still working on defining that second offering. We've started that process now.
HCI: What about at Cornerstone Health Care?
Tim Terrell: I'd put it like this: our immediate issues have to do with meaningful use and getting the stimulus money. But bigger than that is looking at healthcare reform, as well as industry consolidation, the big trend towards consumerism and consumer engagement, and the whole cloud computing trend. We're seeing that we're going to have to shift some of our core competencies away from hardware and systems and towards expanding our concept of what a network is, and towards a lot more data integration, and data delivery in the right place at the right time.
HCI: But that implies a strong data infrastructure to support all this new flexibility, correct?
Terrell: Correct. The difference, I think, is that for groups like ours, we're seeing this incredible growth in complexity in the systems environment, and it's hard for groups our size to keep up with that, and these new technologies such as cloud computing are coming along that will simplify things on our end-and that's very, very attractive for us. And another thing is that cloud could take some of the administrative burdens off us.
HCI: What kinds of data capture, data collection, and data sharing issues do you and your colleagues face?
Terrell: With healthcare reform, we're looking at integrating a tremendous amount of data across the community. There's all this talk of health information exchanges, and all of that may help a lot; still, our biggest challenge is not connecting across the entire state, but across our community. With the healthcare reform situation, someone is going to have to be the data integrator for individual communities, and we'd like to be that for our community, and we're going to have to learn how to be that in a rapid fashion.
There are all sorts of different tools, too. Everybody's looking at the electronic medical record as the tool, but that may not be the tool that's going to help you do population health management. It will certainly be a part of the solution, but it may not take you to that next level.
HCI: What about at SETMA, where you've focused so intensively on care management and population health management?
James L. “Larry” Holly, M.D.: An increasingly important element for us is clinical decision support (CDS) to support performance improvement continuing medical education, or “PICME.” [Editor's note: PICME involves a feedback loop between a CME-granting organization and an individual physician, assessing that physician's current practice with regard to his or her using evidence-based performance measures, and providing feedback to that physician through the benchmarking of his/her scores against those of peers.] So CDS to support PICME and transformational processes in the ambulatory care environment, to me, is one of the most important things to do. When we take a complex thing and reduce it to a one-second task, to me, that is worth doing.
ONE OF THE BIGGEST CHALLENGES WILL BE HOW TO INTEGRATE THOSE PEOPLE INTO AN OPTIMALLY FUNCTIONING ORGANIZATION, AS COLLABORATORS RATHER THAN JUST COOPERATORS.-JAMES L. HOLLY, M.D.
And the AAFP [American Academy of Family Physicians] said back in August 2010 that every family physician should every five years calculate one of the 12 Framingham risk calculators [calculations around cardiovascular risk, from the six-decades-old Framingham Heart Study] for each of their patients. We now do all 12. These kinds of efforts are now central to our work. And we've created additional dimensions, involving our patients' participation. Automation is central to such work.
The second biggest element is that, as the stress on physicians increases, they're going to be looking for safe havens, for opportunities to join or merge with an organization that already has solved the problems around things like billing, ICD-10 coding, SNOMED nomenclature, EHR adoption, etc. One of the biggest challenges will be how to integrate those people into an optimally functioning organization, as collaborators rather than just cooperators.
We're in conversations with a number of physicians. And we've spent nearly $7 million so far on IT infrastructure; and they won't have to spend a penny on that infrastructure. But we want their minds and hearts engaged in this; and finding those people, rather than just people who want someone to solve their problems, that's another huge problem.
HCI: Dr. Shields, as the leader of a bridge group between physicians and a multi-hospital system, what are your most important issues and priorities around leveraging IT strategically?
Mark C. Shields, M.D.: The major ones we're faced with involve our positioning ourselves for value-based payment systems; and we have a long history at Advocate Physician Partners with our clinical integration program. Advocate has 12 hospitals in northern Illinois, and also owns a home care agency, and has 900 physicians in salaried positions. Meanwhile, Advocate Physician Partners is a joint venture between Advocate and 3,900 doctors, with 3,000 of them in private practice.
We have for over seven years done a clinical integration program, to drive quality, patient safety, and cost-effectiveness across our network. And because of that, we are able to jointly negotiate with commercial carriers; and we have contracts with all the commercial payers in the northern Illinois market. We feel this provides a good base for value-based care delivery. We're actively looking at the Medicare accountable care program; and we're already engaged with an ACO-type program with Blue Cross Blue Shield of Illinois [BCBSI], which went live on January 1 of this year. So we feel we have a good base for these value-based contracts; but we are actively enhancing our IT to do a better job in these areas. And we're doing it in two ways. We've accelerated the rollout of our EHR among our independent doctors; about 250 are live now, whereas 90 percent of our owned practices are on the EHR.
HCI: How quickly will your remaining non-automated private-practice physicians go live?
Shields: We have hired 30 full-time employees to help us supplement what the vendor provides; and we think that we can probably do about 250 physicians a year. So it will take several more years at the current rate. We are currently doing it on a voluntary basis, while addressing the question of whether we should mandate EHR implementation for participation in our network. Doing so would enormously accelerate the pace of adoption across our network. The answer depends on whether we decide to move ahead with an accountable care program; and if we do in fact do so, we would likely make EHR implementation mandatory.
WE USE A LOT OF ANALYTICS, BASED ON CLAIMS AND PHARMACY DATA, TO PROFILE OUR PHYSICIANS, AND FEED INFORMATION BACK TO THEM. WE'VE INSTITUTED 70 FULL-TIME OUTPATIENT CARE MANAGERS, WHO ASSIST WITH THE MOST EXPENSIVE 2 TO 3 PERCENT OF PATIENTS.-MARK SHIELDS, M.D.
HCI: Would you agree that it's too difficult to really do accountable care or value-based contracting without a live EHR?
Shields: I wouldn't agree, because we are actively pursuing that program with BCBSI; we have disease registries for both chronic conditions and wellness, and those are real-time, web-based tools with information for doctors coming from multiple sources-claims, pharmacy, lab, into those sources. We use a lot of analytics, based on claims and pharmacy data, to profile our physicians, and feed information back to them. We've instituted 70 full-time outpatient care managers, who assist with the most expensive 2 to 3 percent of patients.
In fact, we've implemented an electronic care management tool for our nurse care managers, which helps them target high-risk patients and then provide prompts and reminders for the care of those patients, as well as counseling for them. And we have an online referral management system that has protocols that drive care decision-making, for pharmaceuticals, for imaging, for other expensive interventions. So we have a lot of electronic tools that are not an electronic health record; and in fact, the electronic health records, as currently deployed, don't accomplish a lot of what I've just described. So to think that an EHR is the Holy Grail for accountable care and value-based purchasing is incorrect; you have to implement a lot of other tools.
HCI: Craig Lanway, you've been very pioneering in areas around care management and quality improvement, but on the IT side, there's fundamentally no shortcut to any of this, right?
Lanway: Yes, that's right. It's not as though the hospital has a contractual obligation to provide health information exchange. And we're interacting with organizations that don't have financial obligations to us. So it really relies on trust and shared vision; without those, this isn't going to happen.
HCI: Thank you all very much for sharing your information, insights, and perspectives with our readers, your peers. We look forward to providing our readers with updates on your progress in all these areas.
Association Viewpoint: An Interview with MGMA's Robert Tennant
Robert Tennant, senior policy advisor in the Washington, D.C., office of the Englewood, Colo.-based Medical Group Management Association (MGMA), spearheads his association's responses to a very broad range of policy issues and developments. At a time of tremendous change and tumult in healthcare and in the medical group world in particular, Tennant and his colleagues are strongly focused on representing their members' interests to policy leaders in Washington and in the state capitols. Tennant spoke recently with HCI Editor-in-Chief Mark Hagland regarding the challenges and opportunities currently facing MGMA members. Below are excerpts from that interview.
Healthcare Informatics: What seem to be some of the biggest challenges for your member groups around meaningful use right now?
Robert Tennant: What's interesting is that the proposal for Stage 1 of meaningful use included two of the administrative transactions, the electronic claim, and electronic eligibility verification. We pushed back against that, because we argued that those administrative transactions were conducted through the practice management system, not the EHR, and that that would essentially force medical groups to get practice management systems certified. So those two requirements were stripped out of the final rule for Stage 1, but kept in Stage 2 as placeholders. So we've asked again that they review that. But at ONC [Office of the National Coordinator for Health IT], they're looking to drive a lot of policy through meaningful use, everything from privacy and security to electronic administrative processes. Their hearts are in the right place, but that's not what Congress intended.
In fact, CMS has only disbursed incentive monies into about the mid-200 millions of dollars at this point; they clearly aren't giving out the money at the pace that had been expected. One reason is that the criteria in Stage 1 are very challenging. What we've seen is that folks who have achieved meaningful use and have attested so far, were already frontrunners in the industry, early adopters. So the question is, once this sort of blip dies down, how will practices that haven't adopted EHRs, get on this train? And our argument to ONC and CMS has been, don't make moving forward on MU so difficult that it disincents medical practices.
It speaks to such simple things as how you register and attest. They did allow for the designation of a proxy, but doing so is complicated. So we've asked for something simple; if the physician has reassigned his or her benefits through Medicare through PECOS [the Internet-based Provider Enrollment, Chain and Ownership System from CMS], just allow the administrator to do all the attesting for the group. So again, make the infrastructure more streamlined, and eliminate one more barrier to participation in the program.
HCI: Are you hearing from your membership that meaningful use is difficult for them?
Tennant: Yes. The frontrunners have had some time to move forward in areas now covered by meaningful use. But some of the criteria are more challenging than others; there are questions about providing a care summary to your patients, for example, when some patients frankly don't want it; the same goes for e-prescribing and patient participation. And issues like that can create logistical problems with fulfilling some of the MU requirements.
HCI: At an even more basic level, ONC has not even formally recognized medical groups as an entity under MU.
Tennant: That's right. We've asked for a group reporting option, because groups act as a unit. If you have a group of 150 physicians, and you have to require them to all go into a website in a specific way, it really defeats the purpose of having a medical group.
HCI: Is ONC listening?
Tennant: In fact, we had a call with them [late this summer], and they said, yes, we've heard you, and we're in discussions about this. So as they say in Washington, I'm cautiously optimistic. Part of the impetus of that change will be the relatively slow outlay of monies under meaningful use. So if that pace of outlay is not moving forward as expected, that may encourage them to streamline things somewhat.
Healthcare Informatics 2011 October;28(10):10-15