The DuPage Medical Group, a multispecialty medical group with 425 physicians and 60 locations, with 3,200 employees and about $490 million in annual revenues, is based in the western Chicago suburb of Downers Grove. It serves patients in both DuPage County, and also beyond it, in Kane, Will, and Cook counties. The organization’s doctors admit to several local hospitals, and the medical group has formal affiliations with Advocate Good Samaritan Hospital, Central DuPage Hospital, Edward Hospital, and Elmhurst Hospital (Edward and Elmhurst recently came together in a merger). The medical group’s closest affiliation is with Edward-Elmhurst; indeed, DuPage Medical Group shares the same instance of the Epic electronic health record (EHR) solution with Edward-Elmhurst. DMG has had Epic’s practice management system since 1997 and its EHR since 2006. The organization has also become intensively involved in accountable care organization (ACO) development, both through the Medicare Shared Savings Program and in the private insurance sector, as well as in value-based purchasing development.
Recently, Krishna Ramachandran sat down with HCI Editor-in-Chief Mark Hagland in DMG’s administrative offices in Downers Grove, and talked about a wide range of initiatives and advances taking place at the medical group. Ramachandran joined the organization in June 2010, and in May 2012, was promoted to his current position of chief information and transformation officer. Below are excerpts from that interview.
You’ve been involved in clinical transformation along a number of dimensions. Tell me a bit about the most recent developments taking place at DuPage Medical Group.
Certainly. In 2011, we formed a joint venture with Edward Hospital called Illinois Health Partners—a joint contracting partnership, encompassing ACO and other contracts. It was mostly a capitated patient contracting entity, while consolidating some management and billing services. So Epic, Edward, and DMG are all partnered together in that. And the contract that Epic had with Edward was extended. We had Epic first. They started their Epic conversion with their medical group. And the Edward medical group started with our DMG workflows, and made tweaks. The three-way contract was done end of January 2012, and they were live by May. So that really gave them speed. And there were about 150 Edward doctors going live.
And they were using our training, and it was a shared system; so it was a huge joint effort. That was the summer 2013; and in April 2013, the hospital went live. That has been a joint effort for us. And if something goes wrong, it will impact all of the groups. So my team was sitting side by side with them in the command center, so it was a true partnership. And Bobbie is great. And last week, the Elmhurst Clinic and Affiliated Doctors went live; they’re affiliated with Elmhurst Hospital. About 130 doctors. And they’re now live on Epic also. So every year, we’ve had some massive go-lives. But it’s all gone well.
How big is your IT team?
We’ve got 50 FTEs.
You’re also pushing ahead full-bore into accountable care, correct?
Yes. We’ve been a core founding organization, along with Edward Hospital, of Illinois Health Partners, which started out as a joint contracting entity, and which in January of this year, became an ACO under the Medicare Shared Savings Program. In addition, as of July, we’ve become an ACO in a private arrangement with Illinois Blue Cross Blue Shield. It started off as an HMO. But through the same business entity, we also provide billing services, as Midwest Physician Advisory Services (MPAS). MPAS, as a wholly owned subsidiary of DuPage Medical Group, provides managed care services and billing services for the Edward doctors, the Elmhurst doctors, and of course the DuPage doctors as well, via a staff of 250.
With all this progress and activity, what are the biggest challenges and opportunities you and your IT team face these days?
Two things. One is, most EHRs, as they’ve started, have been expensive ways from moving paper to electronic; they’re been data repositories, and have done a good job with electronic data collection. In terms of initiatives like ACOs and quality initiatives we’re doing, they’ve really challenged us to make data actionable. We have tons of data; but how do we make that data actionable to our physicians?
One example is our creation of dashboards. We first introduced them back in 2010; and we provide the doctors with unblended data down the individual doctor level, how they’re performing, including in terms of their clinical outcomes. The PCP ones speak to diabetic care, asthma management, blood pressure scores. And everyone can see how everyone else is doing. I was really nervous about the level of transparency; but honestly, the doctors would rather embrace something like this themselves, rather than waiting for the government to do it. And that’s a mark of how forward-looking they are. So converting data into actionable stuff. And we’ve used the dashboards for many other things—meaningful use, payer quality projects—for example, asthma, diabetes, genetic utilization.
The physicians really have embraced and internalized dashboard use in the past four years?
Yes, for sure. And dashboard use is part of physician bonus structures and other phenomena.
What’s the key to flipping the doctors culturally on the use of dashboards? Do you talk to those lagging behind in their performance?
Yes, we have a process, involving discussions, and department chairs and so on. In terms of meaningful use, in Q1 2011, none of the doctors met the goals; but for the last three years, over 99.2 percent of our physicians have successful attested to meaningful use. And we’ve been able to prove and show time and time again, that it works. To your earlier question, there’s a few things we did to approach it culturally. One is to say, we have to do this before somebody else does it. We’ve shown that we’ve led the way in many ways, let’s do that here, too. Two, we can’t let the perfect be the enemy of the good; let’s start somewhere in terms of the data. There’s always a garbage-in-garbage-out aspect to it; but we’re all ears, tell us how we can better refine these things.
And in terms of meaningful use, we did three things. One is we basically carted a 20-ish-page document that said, what is the measure, what is the government asking us to do, and what is the goal? And here’s how you can influence the measure in the EHR in terms of smoking cessation or BMI management, for example. And we did the same thing with our staff, because many times, these things can be influenced by staff participation. And then we went out to every site. We probably logged thousands of miles doing this. And our first meaningful use dashboards, we hand-delivered, to individual physicians, and said, this is important. And from then onwards, the organization wanted to do this, and we activated peer pressure and competition, and also, people saw that we were providing ways to help them succeed. Read the book Switch, by the Heath brothers, about the culture of change; and for change to happen, you have to appeal both to the emotional and the logical side. We said, MU will help us recoup our investment in our EMR, but we also encouraged them in terms of how it would help them in their practice.
And in terms of making data actionable, in January 2013, we opened something called the Breakthrough Care Center. This is a joint partnership with Humana. They’re a 50/50 owner. What it really is, is a high-risk care model. The team and I worked on it for a year, and we went live at two sites, in January 2013. And basically, we had two of our most experienced internists leave their practices and join this center, to provide high-touch care for really high-risk people. When you read the statistics about the highest-risk patients—we’re trying to provide a very high-touch environment for them, including a physician, nurse practitioner, dieticians, and others, all on-site.
And we’ve created predictive models that mine data from our Epic system, to do risk stratification. And we work with the PCPs of these patients, to refer them to the Breakthrough Care Center; right now, there are about 800 patients enrolled. It’s a moving story, in that they do so many things to help really sick patients lead healthier lives outside the ED and the hospital.
So it’s a very personal approach, right?
Absolutely. And what’s clear is that in managing the care and the health of these patients, you need an approach that involves some combination of high-tech and high-touch care. Our goal is to prevent an ED visit, an emergency ambulance run, etc. We’re helping our patients to lead better lives, and also obviously saving money in the process, being good stewards of the healthcare dollar.
We’re also moving ahead on telemedicine. We went live in June for e-visits for certain conditions, for all of our capitated patients—60,000 patients, about 15 percent of our patients. That lets patients fill out an online form for certain conditions, and they get to communicate back and forth electronically with their personal physicians in those areas. And we’re just starting Skype-based e-visits.
Based on all these experiences, what do you think CIOs and other IT leaders at large medical groups should be doing now?
Part of it speaks to my point about converting data into actionable results. The other is making sense of all the payer requirements, and then implementing that in the context of the EHR, without interfering with patient care. So for example, Blue Cross has quality projects; Blue Cross has quality measures; CMS has quality measure, and meaningful use has quality measures. So how do we effectively communicate things?
Of course, the broader context of all this is that we as a healthcare industry are all very much in the “tweener” phase of quality measurement, as the healthcare system gradually evolves forward from being volume-based to being value-based. For CIOs, gaining an understanding of value-based healthcare delivery and payment, of accountable care, of care management, is very important.
And that speaks to the broader advice that I would offer. What I am seeing is that the world of the CIO and the role of the CIO are changing and evolving. Before, we were really in charge of keeping the lights on; and we provided the plumbing and the infrastructure piece. But it’s becoming, how are we adding value to the executive team? How am I helping my colleagues to succeed, to use tools, systems, processes, and change management, to make things happen? Whether it’s helping our partners get up on the EMR, or helping our clinicians analyze care management, or creating dashboards, ultimately, it’s the human change aspect of this, getting our doctors accustomed to working with data, improving outcomes—none of this happens automatically. So the more we can become close partners with our operational counterparts and clinical counterparts in helping to move the organization forward, and the more we can help solve business problems, the better. That’s what I would say.