In Eastern North Carolina, an MD-Run ACO Shows its Success | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

In Eastern North Carolina, an MD-Run ACO Shows its Success

September 10, 2018
by Mark Hagland
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Stephen Nuckolls, CEO of the New Bern, North Carolina-based Coastal Carolina Quality Care, shares his perspectives on why some physician-led ACOs are making huge breakthroughs on quality and cost

It’s not just in the well-known advanced managed care markets that the accountable care phenomenon is making progress these days; indeed, there are accountable care organizations (ACOs) whose leaders are pressing ahead, all across the U.S. Some leaders are operating ACOs in collaboration with private health insurers; a significant number are participating with the Centers for Medicare and Medicaid Services (CMS) in one of its several ACO programs.

One organization that has been making exciting strides forward in the Medicare Shared Savings Program (MSSP), the largest of the Medicare ACO programs, is Coastal Carolina Quality Care, an ACO based in New Bern, North Carolina, a community of about 30,000 people located about two hours east of Raleigh, that state’s capital, and an hour west of the Atlantic coast.  Coastal Carolina Quality Care is sponsored by Coastal Carolina Health Care, P.A., a multispecialty group practice located in New Bern, and which provides care to its community at 16 locations, involving 43 physicians and 20 allied healthcare professionals. Coastal Carolina Quality Care was created in April 2012 and chartered as one of the first 27 MSSP ACOs; it currently has 11,500 Medicare enrollees attributed to it.

Recently, Stephen Nuckolls, Coastal Carolina Quality Care’s CEO, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland regarding his organization’s ongoing journey into and through value-based healthcare delivery and payment. Below are excerpts from that interview.

Your organization has now been participating in the MSSP program for six years, correct?

Yes, that’s correct. We are ending our second contract cycle in December. We will renew, under the new proposed Pathways to Success regulations; there will be a six-month period where we’ll stay in our current track, but starting July 1 of next year, we’re planning to enter their Enhanced Track, the equivalent of their Track 3 under the current regulations. That includes downside risk. We’ve been in Track 1 Plus; we came into that starting January 1 of this year.

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In other words, you’re already taking downside risk?

Correct; it’s a limited form of downside risk based on the revenue standard. Eight percent of our Medicare fee-for-service revenue, is the maximum we’d have to pay back. The maximum gain would be 10 percent of benchmark, which for us would be $12 million.

What’s your sense of how your organization is doing in the program this year?

Well, for 2016, we achieved a little over 4 percent savings, and a little over 6 percent savings for 2017; and through the second quarter of this year, we were a little over 8 percent savings—so far.

That’s really great. What do you see as the secret of your success so far?

It’s hard to pinpoint any one thing. There are several things. Number one, it takes time for some of these strategies, such as population health, to pay off. Another thing that’s going on is that our care management program, I give credit for keeping our costs low and getting things in place. And in addition, we really made a lot of strides in our first contract cycle, specific to our market. All of our annual wellness visits and preventive care, we made our marks there and that positioned us well in our second contract cycle. And it just takes time, when you focus on the quality of care, for… when a greater percentage of your patients have their blood pressure under control, you’ll have fewer adverse events. And when you work to lower a1cs, that will avert events over time. And annual wellness visits, vaccinations, screening services—it costs money for screenings; and once you get things set up, that’s then in place. And care management services—when you go into your second contract cycle, you have some of those costs worked into your contract cycle the second time; so it takes time to achieve shared savings, and to get the staff to focus on the sickest population.

With regard to the electronic health record and data analytics, in the context of population health work, what learnings have you and your colleagues achieved so far?

Data analytics are key with this. We have a dashboard right in our Allscripts EHR. We’ve really used that dashboard, and we’ve used that module to track things; we’ve done things around opioid abuse disorder, and tracking things. Most people don’t associate that crisis with the Medicare population, but there is a good number of people on Medicare for disability. And we’ve really used our EHR to help track prescriptions, and to pinpoint patients to make sure they’re getting the right care and support. And with regard to point-of-care dashboards, we’ve just found those to be incredibly helpful. And focusing on tracking outcomes, at the individual physician level; doctors are competitive, so that helps. And we’ve used Allscripts’ reporting package that allows things to print out well and that works well in meetings, and that helps get the point across about how these numbers relate to the day-to-day practice aspects. That’s what drew us to the program: if you give good care to the patients and it keeps them healthier, it’s good for the practice’s bottom line.

What have been the most difficult challenges in the journey so far?

We’ve had many. One is around physician engagement. We did not achieve savings during our first contact cycle, and that was disappointing, because we felt we were doing a good job. So, maintaining engagement, and making sure we were making good investments in the program. Now, we have reached the point where we’re financially successful, and our projections are looking good for this next contract cycle. Some of it had to do with the vagaries and complexities of establishing this new benchmark. They’ve fixed a lot of those things.

Another challenge is around care management, just getting up to speed on chronic care management, and how to bill for that and set up that program, so it can show itself as a break-even center in a fee-for-service world, cost-justifying that, and training and educating, that was a real hurdle, but I’m proud of that now. It’s a little more than care management, some would call it practice transformation or team-based health. But there’s a lot about how to pay for setting all that up.

Many ACO leaders have commented on what’s popularly known as the “one foot in the boat, one on the shore” problem of having to manage both fee-for-service and value-based payment realities at the same time. Your thoughts?

We’re actually fairly fortunate in that we’re what Medicare considers a low-revenue ACO. Our doctors comprise a low percentage of the overall dollars. When we see patients and are keeping them healthier, we’re at least breaking even.

So you have low overhead, and that keeps you in a good position, in that context?

Correct. We do have our own processes, where we give certain kinds of injections, for example. Now that we’re looking at a 75-percent shared savings track—when you move from 50 percent to 75 percent, you get past what you’d call incremental revenue. You can really start to look at some of the internal costs. If you’re in a 50-percent shared-savings world, and let’s say we get paid $100 for an office visit; if you don’t do that office visit, you increase your shared savings by $50; but you have to look at incremental costs. For example, a shot of Porlea that costs $600. The point is that when you get to 75-percent savings, it makes the math a bit different in terms of your incremental costs of providing a service. You get closer to saying, if I can provide this drug or see the patient, it makes more sense to move to virtual visits or not always bringing the patient in for an in-person visit—when it’s someone we’ve seen three or four times recently and know the patient well—the doctor may handle it over the phone, for example. It changes the calculus as we go forward.

What should CIOs, CMIOs, and other senior healthcare IT leaders be thinking about, based on all of this?

As far as population health management and trying to get the numbers together, make it simple for the physicians to use; make sure they have enough resources at the point of care to use; and make sure you’ve answered the question of what’s in it for them to use it. So a CIO might buy a big, fancy system, and it’s wonderful, but the doctors may not use it unless they know what’s in it for them. Unless there’s an incentive for them to use it, the human behavior is, I’ll just generate as many RVUs as I can, as I’ve always done, and this slows me down. So I’d tell a CIO or CMIO to set up a system that’s simple, that encourages the physicians to use it, and provides incentives to use it. In some cases, we had to hire scribes.

And what has your experience with scribes been like?

It depends. In some practices, we’ve crashed and burned, and then some practices couldn’t live without them. It depends on the number of patients the doctor has, and their comfort level for having someone in the room. Our doctors with larger patient panels and not so particular about how their notes looked, FPs, they’ve done well with scribes; with general internists with smaller panels, they’ve had less success because there’s not so much of a need for it.

What do the next two years look like for you and your group?

I’d like to talk about Pathways For Success and this new rule that comes out: while it doesn’t change our decision-making too much, I think that the forcing of more groups into downside risk earlier, is a mistake, I don’t think it will save the treasury that much. There will be a study released next week by NAACOS [the Washington, D.C.-based National Association of ACOs] that will show significantly greater savings than what Medicare has shown to date. This study uses a methodology that MedPAC and the Innovation Center have used—they look at a matched cohort—and it will show almost twice as much savings in the MSSP than has previously been shown. It also speaks to the policy point—organizations are truly saving the government money, even if it doesn’t immediately show on paper. The evidence doesn’t support the idea that ACOs should be kicked out because they have a bad benchmark. The true savings to the Medicare Trust Fund will then be less. And that’s what they need to focus on, achieving true savings to the government.

And where will this appear?

I think it’s going to come out in Health Affairs. I’m familiar with it through NAACOS, which helped fund it.

 


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At the Beverly Hills HIT Summit, APG’s Crane Offers a Vision of the Future of Medical Care

November 11, 2018
by Mark Hagland, Editor-in-Chief
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Don Crane, CEO of APG, a nationwide association of physician groups involved in risk-based contracting, offered Beverly Hills HIT Summit attendees a vision of a coordinated care-based future

The signs are that the policy and payment incentives around value-based healthcare are accelerating now and may soon become much clearer, a nationwide physician leader told attendees at the Beverly Hills Health IT Summit, being held in Los Angeles this week and sponsored by Healthcare Informatics. Don Crane, the president and CEO of the Los Angeles-based APG (America’s Physician Groups), a nationwide association of more than 300 physician groups involved in risk-based contracting in healthcare, though participation in accountable care organizations (ACOs) and in all types of value-based contracting, which his association refers to as coordinated care.

Crane, whose organization counts member physician groups in 43 states, the District of Columbia, and Puerto Rico, told his audience at the Sofitel Hotel Los Angeles at Beverly Hills that he believes that the most senior federal health officials—at the Department of Health and Human Services (HHS), at the Centers for Medicare and Medicaid Services (CMS), and at the Center for Medicare and Medicaid Innovation (CMMI), are planning to move forward rapidly and decisively to push as many physicians and physician organizations as possible into risk-based contracting, through a variety of means. Statements from HHS Secretary Alex Azar, CMS Administrator Seema Verma, and CMMI director Adam Boehler, have made it clear that plans are afoot to accelerate the transition from fee-for-service payment to risk-based and value-based reimbursement, he said.


Don Crane

Speaking of his own organization, Crane said, “What distinguishes us from similar trade organizations is that capitation is the preferred model. Probably half of my members are already there in terms of professional or global risk. And what we’re developing is the antithesis of fee-for-service [healthcare delivery]. We’re very much central to the value movement.” Further, he said, “Capitation is the destination” of the current evolution of the U.S. healthcare system. “Groups everywhere are experimenting with Medicare ACOs, other kinds of programs and projects,” he noted, adding that physician groups are advancing forward organically through a series of phases, “starting with fee-for-service with some sort of bonus-based quality incentives, moving next to some sort of shared savings program, then shared-risk, leading to primary care-based capitation or shared risk, and ultimately to global capitation or full risk.”

Further, speaking of APG’s member organizations, Crane told his audience, “All of us see capitation as the destination; our hair is on fire about it; we’re excited about it. We want to move the system to that model, because it produces higher quality at lower cost. As you all know, we’re at 18 percent of GDP right now, with really poor results, and we want to change that, through coordinated care.”

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Speaking of the mid-term legislative elections that had taken place three days earlier, Crane told his audience, “This election on Tuesday means a number of things: for one thing, repeal and replace is dead, yes,” referring to efforts to eliminate the Affordable Care Act over the past two years. “The big takeaway for us in the healthcare industry is the extent to which the ACA has been cemented into our landscape, right there with Medicare and Medicaid,” he said, referring to the legislation, which had been signed into law by President Barack Obama in March 2010. “So with the Democrats controlling the House, there’s nary a chance that it will be repealed or replaced in the next two years. Also, in three states, initiatives were passed that would expand Medicaid.”

Asked by an audience member about the sustainability of the state-based health insurance exchanges, Crane said, “The notion is that, if you don’t get everybody to pay into the risk pool, how can you get everyone covered? The answer is, time will tell. People have worried that the repeal of the mandate would undermine the exchanges; that hasn’t happened. And in fact, premium costs have seen a fairly moderate risk in the past year of about 2 percent.”

Meanwhile, Crane said, moving into the core of his presentation, “Whither and what of the value movement? The value moment got started with the ACA in 2010 with ACOs. More recently, in 2015, MACRA, the Medicare Access and CHIP Reauthorization Act, was passed, and that gave us MIPS [the Merit-based Incentive Performance System] and APMs”—alternative payment models. “So a big tailwind was put behind the whole value movement, where physicians and physician groups would be graded on quality measures, and that so that was brought into the fabric in 2015. And we’re well into the value landscape now.”

Documented evidence of the value of coordinated care

What’s more, Crane told the audience of healthcare leaders, “the announcements that you’re hearing from Alex Azar”—the Secretary of Health and Human Services—“are ones in which he repeatedly says that one of their missions is to accelerate the value movement.” Indeed, he said, referring to the proposal by CMS and referred to as “Pathways to Success,” “We’ve seen a pending rule soon to be made final, that will basically push these 400-plus Medicare ACOs much more rapidly into downside risk. And that’s hard to do unless you’ve got a sophisticated system with rich informatics. Many will be afraid of that, but those who are afraid will be winnowed out, and it will leave a more robust, stalwart cohort.”

And, Crane continued, referring to Adam Boehler of CMMI, “We’ve participated in a number of roundtables with Adam Boehler; in fact, I’m seeing him again next Thursday. We haven’t seen any pending rules yet, but we need to get ready for some bold moves in Medicare, where they accelerate the movement. One thing that’s gotten a lot of attention is delegating large portions of the country to players that want to take risk, and then turn around with physicians and hospitals to deliver care to employers like Google. That would allow for prime contracting that would lead to subcontracting for the delivery of care. Much of it is conjectural, but I think it’s coming. With regard to their request for proposals on direct contracting a few months ago—one can see, coming in from out of the mist, as you read the tea leaves, you can see some profound changes in original Medicare that will accelerate this forward.”

Crane went on to review in some detail the results of a study released on March 1 of this year. As the press release announcing those results noted, “Health care quality and cost for commercially insured Californians varied dramatically in 2015, indicating that where you live affects the care you receive and how much it costs, just one of the new findings from the California Regional Health Care Cost & Quality Atlas. Developed by the nonprofit IHA, in partnership with the California Health Care Foundation (CHCF) and California Health and Human Services (CHHS) Agency, the Atlas is the state’s source of comparable performance information about the quality and cost of care provided to 29 million Californians.”

Further, the March 1 press release noted, “The second edition of the Atlas brings together 2013 and 2015 multi-payer data by geographic region—including commercial insurance, Medicare, and Medi-Cal—on more than 30 standardized measures of health care quality, cost, patient cost sharing and utilization to help purchasers, health plans, and policymakers target performance improvement initiatives. An IHA fact sheet provides more details about the Atlas and measures. In 2015, clinical quality varied across the state’s 19 geographic regions by an average of 25 percentage points and costs ranged from 22 percent below to 29 percent above the statewide average. These differences mean: If care for all commercially insured Californians were provided at the same quality as top-performing regions, nearly 205,000 more people would have been screened for colorectal cancer and 31,000 more women would have been screened for breast cancer in 2015. [And] If care for all commercially insured Californians were provided at the same cost as observed in San Diego―a relatively high-quality, low-cost region―overall cost of care would decrease by an estimated $2.6 billion annually, or about 5 percent of the $55 billion total cost of care for the commercially insured.”

That study’s press release included a comment by CHHS Secretary Diana Dooley, who noted that “Increasing transparency is essential for improving quality, lowering cost and gaining consumer confidence. Atlas 2 shows where quality and cost are trending in the right direction and where there is room for more improvement.”

As Crane noted at the Summit, “This was a meta-study commissioned by the Secretary of State for California and the California Health Care Foundation. It aggregated the data of 29 million Californians participating with 10 of the major health plans in CA, all the physician groups. The study had two purposes: one, it looked at geographic variation; the other focus was to compare and contrast the two predominant models in California and elsewhere—fragmented, fee-for-service PPO, compared to capitated, integrated HMO. They were looking at products, but that’s how they looked at the delivery and payment models under those products.

There were three domains—familiar HEDIS measures in the quality domain, which was the first domain; hospital utilization measures in the second domain; and then third and finally, and this is where this is such a distinguishing study, total cost of care—not just premium, hospital fees, physician fees, but also the patient’s share of the premium pay and of co-pays and deductibles. So you get quality and spend, so you have what you need to get to the question of where the value is,” when evaluating data from all those domains.

“So you see 19 different contracting regions through CoverCalifornia, the California exchange,” Crane noted, as he shared a slide with visual results from Atlas 2. “The chief thing is that you should look at the little blue pyramids, commercial HMO, and the orange dots, commercial PPO results. The HMO measures show HMOs outperforming PPOs on quality—very important,” he said, referring to the slide, which showed all the blue pyramids rising above the orange dots. “The chief takeaway here is that PPO products are costlier nearly everywhere, with a few small outliers; and we’re not talking about premium here, but about total cost of care. HMOs—representing capitated, integrated delivery models—performed better on cost and quality across the board.”

Importantly, Crane noted, with regard to quality outcomes among Medicare Advantage-enrolled seniors in California over those enrolled in basic Medicare, “Medicare Advantage outcomes were all superior to those in original Medicare.” Indeed, he noted, “Medicare Advantage outperforms fee-for-service Medicare on hospital utilization, on all-cause readmissions, on ED use, on length of inpatient stays. In short, all Medicare Advantage is shown to be of higher quality and lower-cost than original Medicare—and, importantly, our APG members outperformed everyone else on all of these measures.”

Further, Crane said, “Capitated, integrated care delivery was found to be 14 points higher in quality, and 9 percent lower in total cost of care in commercial health insurance products. And there was $4,450 less total cost of care PMPY [per member per year] in Medicare Advantage in California.”

As the Atlas 2 report itself notes, “In 2015, HMO products delivered clinical quality that averaged 14 percentage points higher than PPO products at an 8% lower total cost when member cost sharing is included. PPO members paid, on average, $620 more out of pocket for care in 2015 than HMO members. HMO hospital utilization was generally higher than PPO even though total cost was lower. Given HMO products typically offer networks composed of integrated providers to a greater degree than PPO products, integrated care (HMOs) offered superior value.”

What’s more, Crane said, “Atlas 2 confirmed a total spend of $16,000 a year on average for seniors; that’s 25 percent lower than in original Medicare. Think of the savings that would be achieved if we overlaid this across all the seniors in California or the United States. This is proof positive of a better model, the model of the future, and one on which we will depend on your participation and your leadership.”

APG’s initiatives around advanced payment models

Crane went on to describe initiatives taking place at APG; in particular, he pointed to the Risk Evolution Task Force, and Third Option, two programs that he said show the way to the future for physician groups and for coordinated care. “The Risk Evolution Task Force,” he explained, “is essentially a benchmarking program mostly for our Medicare ACO and Next Gen participants. In the past, twice, I tried to initiate benchmarking programs, in which members had to submit data.” The mechanics of doing so turned out to be difficult to sustain those past initiatives, he conceded. “But moving forward, this data will be freely available in Medicare off 1500 forms.” Meanwhile, he continued, “Third Option is our proposal that we think will see light of day in a month or so. A few months ago,” he said, “CMMI issued an RFI on director-provider contracting. We said, we have the model. Direct contracting with CMS and a sophisticated qualifying medical group. It would have a capitated payment model. The benefit design would be a hybrid of Medicare Advantage—integrated, capitated; but it would be like original Medicare in that enrollees would still have freedom of choice; but the catch is if you went out of network, you’d pay more. It’s very much like a point-of-service model. So it drives patients in network. We think we’ll see a model that bears some resemblance to this model, coming out of CMMI. That will be a red-letter day for us.”

Importantly, Crane said, “We see a model like this as offering the antidote to single-payer proposals,” including proposals that governor-elect Gavin Newsom indicated interest in, during the gubernatorial campaign that he won on Tuesday. “We’ve been dialoguing with Gavin Newsom,” he reported, “and we’ve said, look, look, if you were to take the capitated, integrated model and spread it across all of California, the savings would be more than the savings needed to generated universal coverage. All we would need would be subsidies and other support.”

In response to a question from the audience about physicians’ reactions to practicing under capitation, Crane said, “The overarching reaction has been extremely good. Physician burnout nationwide is driven by the fee-for-service model. The fee-for-service physician is a hamster on a wheel, continuing to try to see more and more patients, as Medicare payments go down. Contrast that to where you can focus on the patients with highest needs. Take WellMed in Texas,” Crane said, referring to one APG member group, WellMed Medical Group, based in the Dallas area. “Their PCPs are seeing 15 patients a day, and they want to drive that down to 13, using a multidisciplinary team of clinicians and others to drive down the levels of work” to allied health professionals, in order to relieve some of the burdens physicians are facing in their work lives. “And so one of the byproducts is higher levels of physician satisfaction. So just as this model produces results around the Triple Aim, a byproduct is improved physician satisfaction.”

Finally, in closing his address, Crane addressed the healthcare IT leadership audience directly, saying, “You guys are so central to the management of a population. Informatics has been important in the FFS world to a certain extent. But to a physician group being paid through capitated, needs to know who’s’ diabetic, who’s being admitted to hospitals, who will become sicker in the next year, all of that depends on informatics. So I see our fates as inextricably linked.”

 

 


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The Key to Clinical and Financial Success? Atrius Health President Gives Out His Recipe

November 8, 2018
by Rajiv Leventhal, Managing Editor
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“We have a different history, based on our DNA,” says the organization’s president and CEO

Atrius Health, the Newton, Mass.-based health system that has long been a pioneer in the value-based care movement, recently reported a strong financial performance for 2017, as it finished the year with a $24.4 million operating surplus—representing a turnaround of approximately $56 million from 2016.

Officials noted that a critical success factor for the health system, inclusive of more than 30 clinical locations in the state, was innovating in an array of different ways, including: increasing the use of predictive analytics to support population health management, moving care to lower acuity sites (ambulatory, home, and virtual), and working to improve access to care for high-risk behavioral health patients.

The patient care organization’s president and CEO, Steven Strongwater, M.D., recently discussed with Healthcare Informatics some of these initiatives, as well as other factors that have led to Atrius Health’s strong clinical and financial performances of late. Below are excerpts from that interview.

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Looking at the revenue success Atrius has been able to achieve recently, what are some of the primary factors you would give credit to?

We have managed our expenses pretty aggressively, and there are three [sub]-areas within that: in the first category we have managed our operational costs aggressively; in the second bucket, we have managed our medical expense trends aggressively; and then targeted growth is the third bucket. And the underpinning of managing our expenses has been in the analytics space.

For example, we historically might review every one of our patients [via] a case manager. We [now] can develop analytical algorithms that would mainly identify our sickest patients, so rather than have to review everyone, we could review the top 1 percent, or 5 percent, of our sickest patients. And then we have interventions and plans, which helps us with medical expense management. We could then re-engineer the case management department, because we wouldn’t need as many nurse case managers since we would be doing less work. So the management of the medical expenses and our operating costs have to a large extent been built on the back of using analytics. 

The transition to value-based care has been difficult for all health systems, but Atrius has certainly been at the forefront of some key initiatives, such as your ACO (accountable care organization) models. What have been the core experiences and takeaways for you, in this shift to value?

We have a little bit of a different history [than most], based on our DNA. We started as a staff model HMO, so we have been doing population health before it was described as population health. We have organized all of our care and systems around individual patients, and then populations of patients, meaning we have developed disease registries, and identified those people who sit in the high-risk categories—either the top 1 percent, 5 percent, or the rising risk categories. Then have planned tailored interventions, including trying to manage and prevent [disease] for the general population. We have built most of this work around our Epic EHR [electronic health record], so there are a series of tools—be it order sets or reminders—that complements the analytics. And we have built the analytics into the EHR so it’s now analytics that are much more actionable.

One example is something we have built for an adult population, a model called CRISPI, our clinical risk predictor, which is based on about 60 variables [to predict a patient’s risk of hospitalization]. If you are a CRISPI patient and you call in, there is a purple flag across the top of the record, and anyone who sees the purple flag is told to [tell the patient to come right in], or if you are over 65-years-old, we send someone to your home if you feel that you can’t come in.

That action has helped us reduce our ED utilization to the lowest in the state. We have built a comparable CRISPI model for pediatrics, called “CRISPI Junior,” and that has allowed us to deploy a pediatric care facilitator to help us manage down our costs and improve patient outcomes.

The lessons learned are that you need: an EHR; a data repository that you can use to do analytics on; and the algorithms to layer in that will then feather back into the workflow, so at the point of care you can manage patients, and/or you can triage the work to case managers, population health managers, and healthcare facilitators.

We also have a large visiting nurse association, called VNA Care, and we coordinate with them. We register our sickest patients, our CRISPI patients, in something called the Care in Place program—a nursing outreach program, so in the event someone gets sick, we deploy a nurse or nurse practitioner to his or her home. That has helped tremendously in reducing ED visits. So we identify those CRISPI patients, get them registered in these programs, and then try to manage down total medical expenses by changing the way we provide care and also the location of care.

We have set up a hospitalization-at-home program as well, called Medically Home, in which we have essentially set up a hospital by virtue of putting a patch on a patient capable of doing the biometrics, and then [installing] an iPad and a phone with direct access to mission control. The idea here is to basically manage patients in their homes, with our VNA Care [providers] caring for these patients.

From an innovation standpoint, what other health IT products or services have been most important and beneficial for your organization?

Working with Johns Hopkins, we have identified indicators of frailty from free-text clinical notes. So this is for people at risk for falls, isolation, and things of that sort. We have also been using NLP [natural language processing] to find and then close care gaps, so if you have an underlying clinical condition such as heart failure, it is best practice to do a certain number of things and be on certain medications. We have used NLP to identify patients who are not getting those medications or treatments, and then we can intervene.

We have also been working with IBM Watson to develop a new product, which allows for reduced foraging in the medical record. It works by compiling a lot of clinical content for a given condition into a single screen, and then it allows you to compare to a similar cohort of patients, like your patient, to then enable you to pick the best treatment option—principally, which medications work best and the like.

NLP is exceedingly important and will be going forward. We have been using NLP to try to reduce unnecessary messages in the inbox, as we are looking to reduce physician burnout. A lot of burnout is due to piling on work through the EHR, so we have focused on the inbox in particular to reduce those unnecessary messages.

Another thing in pilot mode is that we are working with healthfinch to do automated medication refills. To a large extent, that will use a bot inside the EHR to do the things that would otherwise be done manually—checking for labs, for drug interactions, for the occurrence of your last visits, and making sure your dosages are correct, for example—and then making it possible in one review to click “refill” once the patient gives you the pharmacy to send it to. And that will reduce inbox messages by about 15 percent when we are at scale.

Reducing physician burnout is a major theme in healthcare these days. How can addressing this issue help change the organizational culture?

Reducing burnout, or what we call returning meaning and joy to the practice of medicine, is one of our top strategic priorities. And it’s a top priority because unless you have a happy and activated workforce, your patient care suffers. There is a reasonable amount of literature that suggests if your doctors are burnt out, the quality of care suffers and the risk of an adverse event goes up. There is a cost to burnout, in early retirements and turnover, which is quite significant.

We have created a whole department to focus on this; we have a three-part plan, following the framework of the Stanford University professional fulfillment model, which addresses the practice’s efficiency, the organization’s commitment to wellness, and then personal resilience. We have a body of work going on in all those buckets, with the biggest emphasis on improving practice efficiency.

There has been a re-training of our staff to have them work at the top of their license so the physician doesn’t have to do everything. The EHR has changed the workflow, so everything goes directly to the doctor now, as opposed to it going to many team members, which it did historically. We are trying to get back to team-based care and have the record triage messages so that only the work that needs to get to the physician gets there.  

It’s a complicated manner and it has to do with staff training, technology, and workflow. Getting to “joy perfection” is a long road. We have been on this path for three years, and I think we have done more than most, but we have not solved the problem. We have probably reduced 60 million clicks, but it’s still not enough. There is too much of an administrative need currently, and we are trying to work with regulators to reduce that demand, but it’s a heavy lift.

What are a few core pieces of advice you can offer CIOs, CMIOs and other clinical informatics leaders as they continue to forge ahead into this new world?

You need to have a great data repository, and you may need to assess the skillset of the people working in the organization. Data scientists become important and helpful. You need to be able to create disease registries and identify people, so you can plan interventions to improve outcomes and lower costs. It cannot be a “hint-and-hope” strategy; it has to be a structured approach.

A lot of this is built on an important data foundation, so you need to have the infrastructure that is the data repository, the tools to extract the data, and the mechanism to push it out to a group of people who can take action on it.

 


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Precision Medicine Alliance Brings Democratization of Precision Medicine

October 5, 2018
by Damon Hostin and Robert Weil, M.D., Industry Voices
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The goal is for every patient to have access to the best treatment possible, when and where they need it.

Hospitals are built on data. Most often, medical data for research pile up in silos instead of being appropriately shared to develop more innovative ways to treat patients.

At Catholic Health Initiatives and Dignity Health, we have started to think differently about the possibilities that surround the data and expertise our clinicians bring to solving our patients’ care needs.  It’s why we joined forces to create the nation’s largest precision medicine partnership.

Because of that spirit of innovation, investment and the information-sharing agreements we established under the Precision Medicine Alliance, LLC, about 12 million patients in 16 states will have access to more promising treatments based on a genetic understanding of their disease.

The alliance currently is focused on advanced diagnostic tumor profiling. However, we are preparing ourselves to provide more specific diagnostic and personalized therapies for a number of genetic and acquired conditions, including cardiovascular medicine, neonatology and pharmacogenetics.

Before the alliance was formed, access to precision medicine-based care was inconsistent to all populations, making it available primarily to the well-insured and those with the personal wealth needed to pay for the specialized tests.

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In a sense, the alliance represents the democratization of precision medicine. That’s because, for the first time, we have created a cost-efficient program that allows community-based hospitals, both large and small, to become partners with the alliance and introduce these vital programs locally.

The alliance highly complements national oncological programs at CHI and Dignity Health, which together serve more than 100,000 patients annually. Starting this fall, each oncology patient at active sites will be matched to all biomarker-appropriate therapeutics and will be screened for eligibility to enroll in a clinical trial. This makes Englewood, Colo.-based CHI and Dignity Health, which is headquartered in San Francisco, the first health systems in the nation with their own precision medicine program with reach across a national footprint. Together, the two systems have 139 hospitals and hundreds of other care sites.

The alliance couldn’t have happened soon enough amid the rapid pace of advancement in cancer treatments. Identifying new genetic markers and their effects on cancer occurrence, prognosis, and treatment options occurs at a staggering pace. Even the best-informed physicians may struggle to keep up with new treatment regimens for the most common cancers, let alone rarer forms. 

The alliance is working to accelerate change. It is switching how we view and treat oncology patients throughout our network as well as working on wellness and prevention among our higher risk populations.

By actively screening patients and learning more about how genetic makeup and some environmental factors may influence health and care, we are far better positioned to identify and intervene earlier.

We already have hundreds of thousands of patients under management in the system today—a mega-community of actionable medical information. That community is enabling CHI and Dignity Health caregivers to share—in real time—their insights and outcomes on patients with cancer.

At CHI and Dignity Health, we see our early work as a catalyst for furthering this emerging science, using next generation strategies, technologies and a strong partnership.  Our precision medicine alliance is not centered on discovering the next major genetic marker.  We view our purpose as creating a model that disseminates the benefits of precision medicine to more patients and more caregivers.  Access is equity and it is dictated by our mission.

Through the alliance, CHI and Dignity Health caregivers can more effectively identify the best drug therapies and possible clinical trials for their patients. Besides changing the way we treat some of our patients, we are also creating a repository of data to drive better clinical decision-making and treatment discoveries for generations to come.

We believe our early commitment to precision medicine through the alliance has helped set the stage for even greater and wider use of this promising methodology. With that, every patient can have access to the best treatment possible, when and where they need it.

Damon Hostin is the CEO of the Precision Medicine Alliance of Catholic Health Initiatives and Dignity Health.  Robert Weil, M.D., is senior vice president and chief medical officer of Catholic Health Initiatives and a board member of the Precision Medicine Alliance.


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