At Texas Health Physicians Group (THPG), the physician organization integrated into the Arlington, Texas-based, 21-hospital Texas Health Resources, Shawn Parsley, D.O., president of THPG, and Barbara Adams, vice president, innovative technology solutions, for THPG, and Texas Health Resources, are deeply involved in forward-focused efforts around accountable care organization (ACO) development and population health management work.
Texas Health Physicians Group encompasses 829 providers, including physicians, physician assistants, and nurse practitioners. THPG is participating both in the Medicare Shared Savings Program for ACOs (MSSP program), in concert with the UT-Southwestern Medical School in Dallas, in which it is covering 64,000 lives altogether (46,000 from THPG and 19,000 from UT), and in several commercial shared-savings ACO contracts with commercial health insurers—Aetna, Cigna, and Blue Cross Blue Shield of Texas, covering an additional 60,000 lives.
Dr. Parsley and Barbara Adams were among the healthcare leaders interviewed by Healthcare Informatics Editor-in-Chief Mark Hagland for the magazine’s September-October cover story. Below are excerpts from the interview they gave to HCI this summer in the preparation of that cover story.
Tell me about the issues and opportunities around leveraging data analytics to support your ACO and population health work at THPG.
Shawn Parsley, D.O.: Clearly, having analytics makes up a major portion of your ability to actively do anything with these contracts. There’s a period of time where we’re standing with a proverbial foot in the boat and foot in the dock, in terms of the fee-for-service world and the fee-for-value world. What we took on first was a quality incentive program for the docs that was really payer-agnostic, and designed to represent the entire panel a physician had, with incentives. We really want our physicians to think about how they take care of all their patients. So the first step was to develop a quality analytics dashboard that would have the capacity to look into the EMR data, without regard to which EMR is involved, and extract the information and compile it in a centralized database.
Shawn Parsley, D.O.
When did you go live with that architecture?
Barbara Adams: We went live at the beginning of 2014. It was there in 2014, but we were still validating and testing the data, so that by January 1, 2015, the measures would show directly in the dashboard So the physicians have a performance incentive in 2015, and one of the gates is simply using the dashboard.
What are some of the core data elements involved?
Parsley: Among them are tobacco cessation counseling, colorectal cancer screening, breast cancer screening, hemoglobin a1c management, and hypertension management. For the hemoglobin a1c management measure, we use the National Quality Foundation measure on having a hemoglobin a1c test within the last 12 months.
What kinds of data are you providing, and are physicians looking at?
Parsley: What we do is that we attribute a patient to a provider based on which provider has seen the patient the most often. And let’s say that our target for hemoglobin a1c management is that 70 percent of patients need to be compliant with a1c management; we’re giving the dashboard that shows the doctor where their patients are. If for example, 65 percent of the doctor’s panel of patients are compliant, they can drill down in the dashboard and find out who’s not compliant, and their care manager will call them and intervene telephonically or in person. And that provides a discrete list of patients with gaps in care.
What results have you seen so far?
Parsley: We can’t really say what our results are in the MSSP yet; but one of the things we have noted very clearly is that the physicians who access the dashboard, and we can tell when they log in—the more often they access the dashboard, the higher the probably that they will be meeting the measures, and conversely, those who access the dashboard least frequently tend to be lower; so in other words, they’re starting to act on the measures. About 50 percent of the physicians are accessing the dashboard pretty regularly. The other 50 percent aren’t doing so regularly yet; but this is the first year where we have payment tied to this, and the payments go out in December.
What development and governance processes have been involved?
We have a group called the Key Council. It’s mostly tied to our Medicare Advantage program, with a mentor/mentee program, with each mentor having three to five mentees.
And who are the mentors in that program?
They’re doctors who have performed really well. Right now, that’s in the Medicare Advantage program, but we’re going to roll out that same structure with the MSSP program and ACO programs.
Barbara, what have been the main challenges from the IT leadership standpoint?
Adams: Guess how many places a doctor can document tobacco cessation in the EMR? About five different places, but there’s only place in the EMR where it will give them credit, because it’s mapped to the dashboard. And it’s not the doctors’ fault. You get into a groove with your EMR. And we can’t map five different places. But with regard to the technical challenges, the biggest practical challenge is variation in EMR documentation, which leads to a complicated mapping process.
How many EMRs are involved in this?
We’ve got two primary EMRs, Epic and Allscripts Professional. But our providers on Allscripts have individual servers, so they’re not on one single database, which means that we still have to do customization per server and train the doctors. So that’s a technical challenge; and data validation is a challenge. And how to measure—how to calculate the numerator and denominator—that is also a challenge. For example, if a patient is partially immunized, and if you just put in the year, not day and month, it won’t get credit in the dashboard. So it becomes a circular problem, as you try to create places in the EMR, trying to map it, and trying to get physicians credit for their documenting what they’re doing.
Parsley: That’s been one of our single biggest challenges, getting everyone educated and trained.
How do you overcome resistance? For many physicians, participating in this work ends up translating into their saying, “Don’t tell me to do another thing today!”
Parsley: I agree. Even before I became president, my predecessors were starting to build this message, and that is that medicine is changing. And if we’re going to be successful, we have to start building now. Using the boat and dock analogy, when the boat leaves the dock, if you’re not ready to jump in, you’re in trouble. So we’ve had pretty good receptivity to that message. There seems to be a general understanding that we’re doing this in preparation for the future. And Barbara’s group and the quality team have been very, very careful in building these things to try to create as little disruption as possible, and recognizing that workflows in place for a long time are violated by these dashboards.
That said, when you create performance incentives… some docs have done it one way for a long time and believe they should achieve their quality metrics because they’re doing the work regardless of how they’ve done it. And it’s created some dissatisfaction among providers, but we’ve had to stand firm, because at the end of the day, we have to be able to document this correctly. The data showing that the physicians most engaged have performed much better, has been very powerful. Doctors love data.
With regard to IT development, strategically speaking, what do you need to do in the next year or two?
Adams: The Holy Grail for an IT-techie person like me—patient attribution remains one of the number-one challenges. People underestimate how hard it is to attribute patients to physicians. I think the Holy Grail is combining EMR and claims data. Because right now, we’re still in the world of, here are your gaps in care, but it’s in the EMR. So I may already have had a colonoscopy and Dr. Parsley if he’s my physician wouldn’t know it. So it’s combining outside claims data with EMR data, to provide a true picture of things. And claims data is 30-45 days behind. And in the next two to three years, it’s going to be real-time notification. We don’t have all those things in place yet. So for the next year, we’ve got to get better at patient attribution and risk stratification, and then be able to combine EMR and claims data.
Parsley: I agree: if there’s a report in an old file somewhere that shows the patient did get their colonoscopy in the timeframe needed, and if we had the payer data in a timely way.
What have you all learned about prioritization?
Parsley: I’ll take the issue of culture. The culture of the organization is critical, and I think you have got to start by getting your physicians engaged in the culture that believes that medicine is changing. Because I the doctors in your group don’t believe medicine is changing, you won’t be successful. The nuance is to admit that what we’re about to embark upon is a process of change, and it won’t be perfect when we roll it out. Because if we waited until something was absolutely perfect before we rolled it out, we’d never get it off the ground. And my predecessor did a nice job getting the ball rolling.
And in the two years I’ve been involved, working with Barbara and with our quality team, we’ve really been successful moving forward. So that’s the first thing. The second priority, getting the technology rolled out well enough so that you don’t look incompetent. It still has to be pretty good before it gets out there, in order to get them to do it. I would argue that when we created this stuff internally and we and IT and quality really worked it all through together, and got it down to where it was 90-95 percent there, that was really a big step.
How does that understanding of strategy translate into project management?
Adams: I would say the priorities I’m seeing are changing the focus of my team. They’re not just IT/EMR builders anymore. They’re turning into workflow experts. They know where a diabetic foot exam should be in the patient visit. It’s not just, document it there but understanding why it works in that workflow. So the priorities are changing from being strictly technical, and it’s really turning into a clinical advisory, problem-solving, collaborative kind of activity.
Parsley: That’s why the culture piece is so important; you’ve got to have that collaboration part.
What would your advice be for CIOs, CMIOs, and other healthcare IT leaders?
Adams: Whatever kind of ACO you’re in, identify which measures you’re going to report on and where it’s going to be in the EMR by collaborating with your physicians and clinicians, and standardize on that, including on education and training, because that documentation will be where you’re going to be successful with your payer.
Parsley: Yes, that’s the critical element of getting everyone to do it.