As physician groups move into the arena of population health management and accountable care, not surprisingly, physician organization leaders are adopting a variety of different strategies going forward. One of the organizations moving forward on two fronts simultaneously—both as a Medicare Shared Savings Program (MSSP) accountable care organization (ACO), and in a private-payer ACO collaboration, is the Houston-based Memorial Hermann Physician Network (MHPN), a 2,000-physician accountable care network affiliated with the Memorial Hermann Health System.
There, Shawn Griffin, M.D., chief quality and informatics officer (his title encompasses the organization’s CMIO role), has been helping to lead colleagues in his organization to work to bridge the gap between claims-based data from payers and electronic health record (EHR)-derived data from his organization. In that effort, he and his colleagues launched an MSSP ACO in July 2012. At the same time, they teamed up with the Hartford, Conn.-based Aetna, to launch, in January 2013, a private-payer ACO. And they are collaborating with Aetna to develop and use analytics tools to bridge the claims/EHR data gap.
In the October 2013 Healthcare Informatics cover story, HCI Editor-in-Chief Mark Hagland interviewed a wide variety of physician group leaders and industry experts regarding the journey toward population health management, which encompasses numerous vehicles and organization structures, including ACO development, care management, patient-centered medical home (PCMH) development, and avoidable readmissions reduction work, among other types of initiatives.
For that article, Hagland interviewed at the same time both Dr. Griffin of MHPN, and Charles Kennedy, M.D., CEO of the Hartford-based Aetna Accountable Care Solutions, a division of Aetna. Below are excerpts from the interview with Drs. Griffin and Kennedy.
What have been the biggest challenges leveraging IT for strategic purposes?
Shawn Griffin, M.D.: The Memorial Hermann system has always been an outstanding organization in terms of technology; we’re a HIMSS Level 6, and we’ve been doing CPOE [computerized physician order entry] for a number of years. And we always felt we were extremely savvy in terms of technology. But when you move from a single-patient format to a population health focus, some of the tools are not there in the market right now, and we’re having to use what we can and invent what’s not there. The innovation required for population health management is outstripping what’s available in the market.
So you go into your technology pantry and you look at what you have, and you want to go to the store, but there’s no one there to sell anything to you. And we come at this being excellent in technology. But you either have sort of the payer0version, claims-based analytics, which are very payer-based, or the EHR-based solutions, and each type of solution is trying to grow into that gap. So you have payer tools, but in terms of the sort of physician-based, big medical group-based stuff, there’s software based on those, but there isn’t a set of tools that covers both.
Shawn Griffin, M.D.
So how are you doing it, as you build both of your ACO entities?
We’re working with our payers; and Aetna has been an excellent partner to do things like this with. We had been working on clinical integration and physician alignment for years, so we had excellent physician alignment. And we had certain areas of tools that were existing; but we’ve also invested in development work. The other thing is that when you partner, you have to be patient, and do some workarounds, so sometimes you’re cobbling it together while you get things running.
Dr. Kennedy, what does the landscape look like from your national perspective?
Charles Kennedy, M.D.: Well, Dr. Griffin’s comments are spot-on, and reflect what’s going on nationally. Firstly, in terms of the EMR, it may have sufficient or even exceptional depth of information so that they’ll know in far more depth than a payer like us will have, with what’s going on with individual patients; but EMRs were designed as storage functions rather than data-sharing functions, so it’s exceptionally difficult to pull the data out. And secondly, you run into exceptionally difficult problems with interoperability. How do you get the data to mean the same thing when it’s coming out of different systems?
And thirdly, we have great claims data and expertise in using claims data, but when you try to match up claims data with clinical data, you find tremendous inconsistencies. So for example, some of the things important for an ACO to manage, such as unstable angina and trying to figure out which clinical variables are important to look at, we’ll find agreement in the 10 percent or 15 percent range, between the two types of data. But you have to be very, very careful about how you use claims data, because it could steer you wrong. So the nirvana of this would be to put the claims and clinical data sets together. So we’re working on that with some of our clients. Not Memorial Hermann, though, because they were already pretty advanced technologically.
Charles Kennedy, M.D.
Griffin: I think that there’s this somewhat romantic notion of big data and the usefulness of the information that would be found there, and so often, big data is just making the haystack bigger and not making the needle better.
Kennedy: I see some of big data as having a hollow promise, because you really have to make the information available at the point of care, and I don’t see big data playing a role in those functions.
Griffin: And that’s my second point. As we are engaging our front-line clinicians, there is a filtering and a sharpening of the information you want to deliver to them at the point of care. Taking this from 100,000 claims lives, and to take that and to distill it and sharpen it and communicate it in a meaningful and timely manner to a physician who has seven minutes to visit with a patient and to make it useful and to help that physician close gaps, is a tremendous challenge. We’ve tremendously ramped up our ambulatory care managers. And we have a tremendous variety of practices; I practiced in small-town rural Missouri [as a family physician], and now I sit in Houston. And so what’s the water bottle that you want to hand the physician while they’re on the treadmill of their day?
So from your perspective, Dr. Griffin, what are the critical success factors going to be around all this, as your peers move forward to leverage these different types of data and pull together the analytics, in order to support ACO structures, whether MSSP or private payer-based?
There’s sort of this conceptual triad of people, processes, and technology. And we had our strengths and weaknesses, when it came to technology. So you invest in promising technologies to close those gaps. And per the processes, you find ways to embed health coaches, and interventions, and alignment of your ambulatory and inpatient case managers, to facilitate medication reconciliation, etc., so you don’t have the bounce-backs you want to avoid. And we’ve had to go from two care managers to 25 care managers in the past year and a half, and develop that group of people and the skill set as well, for population health management.
The fact is, physicians are generally great at treating individual patients and at managing their practices, but not at population health management. And in many cases, they haven’t even had the information on patients who need to be reached out to. So it takes something like three information cycles for physicians: you show them information at the beginning, and then they compare that information to what’s in their EHRs, etc. And you do that about three times with the practicing physicians, so you need to improve processes to give them usable information; and you need to sharpen your message, so they can leverage those moments where they can use information.
In fact, we’ve found a tremendous variation in how practices function. It’s a very different thing for a two-physician practice in a rural area to figure out how to do outreach to women who need mammograms, versus at an academic medical center. So, in some practices where you give physicians information on patients who need a hemoglobin a1c, they look at you as though they’re drowning and you’ve just given them a baby. And in other practices, they’re ready to go.
So we’re having to give support to physicians in their practices; for us, that is very important, both giving support to physicians, and understanding their practices, because very practice is different.
What do CIOs and CMIOs need to do in the next few years, with regard to all of this?
Griffin: Number one, they need to take inventory, of the technology, of the relationships, of the people processes—take an inventory of all those in your organization and of the groups you’re planning to work with. You also need to start with a group of tremendous partners such as we’ve found with Aetna. Because this is a process, and we’ll stub our toes. And choose vendor partners who’ve done some of this, but there’s no vendor who’s done all of this. It takes a tremendous commitment on everybody’s part to work out the bugs. And you need to have tolerant physicians who will work through this with you. And the rules keep changing all the time. So you need to take your Dramamine!
Do you believe the vendor tools will soon enough be capable to effectively facilitate this important work?
Griffin: I think the vendors understand some of what they need to do. But unless they come out of their vendor bubble and go that last mile, they risk developing something that’s technologically beautiful but operationally useless.