Now, with the healthy and relatively healthy patients at the bottom of the pyramid, there’s an IT architecture that’s critical to make them “sticky” to us. Two or three years ago, if you’d asked me where a patient portal fits into this, I would have said it’s a phase-three kind of thing. But now, I’ve come to realize that a patient portal is incredibly important early on. If you look at Group Health, pretty much half of certain primary care interactions are online already. Can I schedule a visit online, can I check my lab results and see my meds? And ultimately, you get to full-on e-visits or simple chronic disease management online, etc. This allows us to better manage people who aren’t super-sick, and therefore, scale or doctor and nurse time, and also, it helps us with patient retention as well. For example, on a personal level, I go to a practice with a great patient portal. And so now if my doctor left, I would still stay with that group practice.
And you get a lot of pushback on where the relationship actually lies, from doctors. Would my patient ever go to Wal-Mart or Walgreens? I think that any generation is totally more open for a more convenient solution. And particularly, patients under the age of 50, the Generation Y and Generation Me people—unless you have a significant illness, your relationship with a doctor is completely subsumed by my getting what I want when I want it. And if you can’t build connections with patients outside 9 AM to 5 PM, you are going to lose.
How do you shift the thinking of physicians in practice around all this, and with what tools do you engage them and help them to optimize medical practice?
Getting physicians oriented to all these details, well, I say, you have to go through anger, denial, and fear before you get to acceptance around change—it’s like the Kubler-Ross model! So you have to say these things more than once. And the patient portal concept is a great example of starting this discussion going even in the mostly-fee-for-service space. If you can offline a patient from a visit around simple things like med check-ins to the portal, you could add another 500 patients to your panel; so it does help your practice to become more efficient. And when it comes to actual population health, you have to start look at stratifying patients. And there’s a fee-for-service imperative with this as well; if I start building a medical home with diabetics, you can offset the investment in things into things like a disease registry and a personal health nurse coach, you can add in more patients. So that’s the kind of thing you can start to do even before your risk level starts to flip.
And per IT and analytics, I think we don’t pay nearly enough attention to workflow in any of this stuff. And in particular in the care management space, it’s 10 percent strategy, 20 percent getting the right tools and data, and the rest is the tough work around changing workflow or adjusting tools to the workflow. At one point do I need the data? At what point do I need the tools? All of this stuff has to be really, really thoughtful. And when I look at the true pioneers, I look at Montefiore in the Bronx, and they’ve been able to standardize their approach to possible interventions. And this gets back to an IT need that a lot of systems will have in the next few years, is that they needed a care management information system. The nurse in the clinic or doctor doesn’t need to be arranging Meals on Wheels, but it needs to be a seamless process, and you need a system that can cue up and order all of these things.
What would your advice to CIOs and CMIOs, with regard to everything we’ve been discussing here?
There are certain things we need to do system-wide, such as implementing electronic health records [EHRs]; and when you’re making these big platform choices, I’ve become wary of big ambulatory EHR vendors that say ‘We can modify our system to meet any workflow,’ because then you’re hardwiring crappy workflow. So you have to have a vendor partner that can hold your hand and work with you on workflow design together. And don’t always think that something that is super-customizable to your environment is the best thing; because most of us have crappy workflow.
So the discussion around workflow with clinicians is going to have to be nuanced, then?
Definitely. Doctors are extremely smart people, and they’re problem-solvers. But they’re already busy 10-12 hours a day in their practice. So you’ll have to compensate doctors for doing this work, but also draw on the resources of the practice leadership and care team, to own part of this. I mean, do you have an awesome practice manager to spearhead this stuff? We have to make the team owners of a lot of this stuff. And having a lot of EHR platforms—even in employed physician groups, even in the most financially integrated groups, people a few years ago would say, we have to be on the same EMR platform; now it’s about getting the information you need, and they’re turning to HIE. So something I’ve been advising larger medical groups and health systems, if you want to bring that 100-doc medical group into your system, and they’re on athenahealth, maybe you don’t need to bring them into Epic or Allscripts. It’s all about meeting the doctors’ needs at the level at which they’re practicing.