In Dallas, UT Southwestern’s Leaders Push Ahead on their Ambulatory Quality Initiative | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

In Dallas, UT Southwestern’s Leaders Push Ahead on their Ambulatory Quality Initiative

November 3, 2017
by Mark Hagland
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UT Southwestern CMIO Dr. Duwayne Willett shares updates on UT Southwestern’s pioneering AQO initiative

Things continue to move forward at the University of Texas Southwestern Medical Center health system (UT Southwestern) in Dallas, where that organization’s Ambulatory Quality Outcomes (AQO) initiative has been pathbreaking in many ways—so much so that it led the editors of Healthcare Informatics to name the UT Southwestern team as the first-place-winning team in our 2016 Innovator Awards Program.

As we reported in our January/February 2016 issue, UT Southwestern leaders there have succeeded in creating a clinical quality initiative that has been broad, deep, fast-moving, substantive, and agile—and replicable. Indeed, at UT Southwestern, clinician, clinical informatics, IT, analytics, and administrative leaders have come together to create the AQO Project, which is improving processes and outcomes across 40 medical specialties, and using rapid-cycle improvement processes to improve care delivery and care management, physician collaboration, and the capability to participate in meaningful quality outcomes benchmarking. And all of this work continues to be supported by intensive development work on the part of IT and analytics leaders at the organization.

And, as part of our report on the AQO initiative in our January/February 2016 cover story package, we noted, “One very broad specific goal of the initiative was to create robust patient registries in all the specific medical specialties. To date, the leaders of the initiative have built 58 specialty-specific patient registries, created 134 process and outcome measures covering 77 primary and 44 additional medical conditions, created 111 new clinical decision support tools within the EHR, and created 97 new workflows across 40 specialties.  Very importantly, 58 patient registries have been created, with over 16,000 patients documented to date, in those registries.”

Among the several leaders of the initiative have been Duwayne Willett, M.D., UT Southwestern’s CMIO; Jason Fish, M.D., the health system’s assistant vice president for ambulatory quality and associate CMIO; Mark Rauschuber, UT Southwestern’s CIO; Jacqueline Mutz, R.N., assistant director of ambulatory quality; and data analysts Ki Lai, assistant vice president for enterprise data services; and Vasihnavi Kaanan EHR [electronic health record] and clinical decision support specialist.

Recently, Healthcare Informatics Editor-in-Chief Mark Hagland reconnected with Dr. Willett to get an update on the AQO initiative. Below are excerpts from that interview.


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Dr. Willett, it’s great to reconnect with you regarding the evolution of your team’s work at UT Southwestern. How has the AQO Initiative evolved forward since we spoke at the end of 2015

It’s continued to move progressively forward. Obviously, we’ve been learning lessons as we’ve progressed, and have been able to apply those. We initially did a single registry, and they’ve gotten an appetite for more. We had initially started out with 43 registries; we currently have 81. And 52 of the registries have quality measures associated with them. Sometimes, we’ve just wanted to identify populations for care-gap closure. As a project at first, it’s turned into an ongoing program, and leadership-driven, tied to incentive programs for physicians. And a big push into patient-reported outcomes. We just did an update yesterday, actually. We had representatives of MD Anderson Cancer Center visiting us. And we noted for them that we’ve had 3,200 patients who have completed one or more questionnaires, so something like 225,000 questions have been answered. Over 80,000 of our patients have been put onto registries. In fact, most patients in practices are on at least one registry.

How has the standardization of process and documentation, which were key elements in the initiative at its outset, played out, over the past two years?

We’ve been very thankful we’ve done things in that standardized way. We now have fewer FTEs connected to [the day-to-day management and operations of] the program, but have continued to expand outwards in terms of activity. And we know the set of tools in the toolbox to use. What’s more, the code to calculate the quality measures has been templated out, so they literally now do a “save as,” and so we have a single power-BI [business intelligence] dashboard that can look at all the registries, all from a single data set. So that’s been very helpful.

What kinds of lessons have you learned, as a CMIO, broadly, in the past two years?

One lesson is that there is always this presumption that if you feed people data, esp. physicians, that it will stimulate action. And it’s been very confirmatory of that, that doctors like data, use data, and are willing to take action when they receive data they believe in. And because physicians have been involved in selecting the conditions for the registries, and designing the tool, they’ve been very supportive. One example was in our rheumatology department. The guidelines for care are that they’d like to have them on a disease-modifying rheumatic drug. And it turns out they were actually doing a very good job of that already; were not doing such a good job of assessing patients’ symptom burden—how the patients rated their levels of symptoms. So they set up two measures—one was a process measure. They wanted to know, were they prescribing the right medications?

And second, were they documenting effectively? And what they did was, they said, we have a gap of 3 or 4 percent, in terms of patients who weren’t on optimal medical therapy for their conditions; and they got that percentage down to about 1 percent. And in terms of patients doing self-assessments—in other words, providing us with patient-reported outcomes—essentially, that’s increased.

And that would be particularly valuable in rheumatology as a medical specialty, correct?

Yes. The symptom burden is really key, in terms of patient quality of life. So that was another process—are we collecting this patient information? And then, how are patients doing? So we’re starting to see a shift, with patients reporting fewer symptoms. That’s what we’re hoping to get to. And the challenge coming from our leaders was, process measures are good, but we want to get to outcomes measures. And we see patient-reported measures, we see that as a really fruitful area in terms of determining where we are with all this.

What are the key elements of success in designing, building, and executing on a broad strategy such as the one you and your colleagues have executed on, with the AQO program, from your perspective as a CMIO?

To me, there’s a key technical aspect, and a key sociocultural aspect. On the technical side, what’s important is just thinking through when there’s important real-world information about patients, and asking, where do we want to store that? And being consistent about that. It saves so much reconciliation work—just to store things in a particular location. And among physicians, there’s all this angst about EHRs [electronic health records]. So the tack that I’ve found helpful is, one of the only ways we’ll get more efficient with EHRs is when we record information as soon as possible, and use the heck out of it. So the ability to reuse data, and analyze it, is key.

Meanwhile, and on the sociocultural side, it really is all about simply having the people who actually do the work, being involved in the design of the initiative. That was a major lesson we had learned earlier, when we did some initial projects in which a physician leader made a decision, but that physician was less clinically involved; and those became more difficult to actualize. So Dr. Fish and his team really insist that he and his nurses be involved all the way. Being involved in the quadrad [as the quadri-partite group of stakeholders is known inside the organization]—the actual specialists themselves—has been incredibly important.

That speaks to the classic adage in the business world that “culture eats strategy for lunch.” One of the ingenious elements of your and your colleagues’ strategy at the outset with the AQO initiative, it seems, is that you designed a strategy that acknowledged culture and how human beings think, correct?

Yes, that’s an important point. And while we believe the general principles are replicable, you’re spot on—how this would be accomplished would need to be tailored to culture. And our culture is a very physician-centric culture. And our clinical departments and divisions have traditionally been fairly autonomous. It would not have worked to develop this in a top-down fashion. And it’s not that the central organization isn’t strong; that’s who challenged us to do this. But driving this top-down, would not have done as well here.

So you have to figure out how to use the existing physician culture to change itself, essentially, correct?

Yes, exactly: you have to figure out how to use the culture itself as a strength, rather than battling against it. And most cultures, unless they’re toxic, have real strengths. And tailoring your approach to your local culture, optimizes your chances of success.

What would you say to encourage others to try something like this, organization-wide?

Framing the issue in a positive way, I think, was helpful for us. There had been some cultural weight around the idea that, well, I’ll only deal with the problem list, things I’ve put on there. Our consistent message was to make this patient-centric: if a patient has diabetes and endocrine issues, they still have that when they have other issues as well. And it’s important to create this registry, particularly around trying to move people to accept a standard place to create data, because we want the patient’s record to be complete and accurate, to help their patients. There’s altruism in terms of doctors wanting to do the right thing for patients. That was a helpful way for us to do this, to emphasize that these were patient-centric registries. And you’re the expert in this area, and we want to learn from you, how best to do this across organization.

What will happen in the next couple of years, going forward with the AQO initiative/

We have a couple of challenges to face. Over the past couple of years, we’ve gotten to nearly all the specialties; and we’re building on additional registries. So the two main challenges for us are, one, moving to outcomes measures—our leadership is committed to sharing clinic outcomes with patients. And we’re in a clinically integrated network now with Texas Health Resources. And they’re largely a community hospital network, which is very complementary to us as a tertiary/quaternary medical center. And we have a very large cachement area in the Dallas-Ft. Worth region. So, expanding geographically, and organizationally outside UT-Southwestern to our partners, will be a major focus of work going forward. And once culture and buy-in will be big elements in moving towards success; and they’re very excited about it at THR.




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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”



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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.


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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.



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