In Texas, the evolution toward value-based care is one full of roadblocks, but throughout the state—the largest in the continental U.S. with the highest uninsured rate in the country—levels of progression vary. In bigger markets like Dallas-Fort Worth and Houston, for instance, patient care organizations are taking on far more risk than in smaller, rural areas.
In Tyler, Texas, a rural Eastern Texas town about 100 miles from Dallas, with a poverty rate of 21 percent, Paula Anthony is the vice president and CIO of East Texas Medical Center (ETMC) Regional Healthcare System, a 10-hospital patient care organization that she has been with for more than 20 years. Last week at the CHIME 2017 Fall CIO Forum, Anthony sat down with Healthcare Informatics Managing Editor Rajiv Leventhal to discuss some of ETMC’s biggest challenges right now as it relates to healthcare IT and value-based care, as well as other trends and innovation going on in the region. Below are excerpts of that interview.
How far along is your organization in moving toward value-based care? And how advanced is the broader Texas area in this evolution, as well?
The answer is pretty divergent—where ETMC is headquartered and where its hospitals are in East Texas is a much smaller population area than in Dallas-Fort Worth (DFW), and that has major implications in terms of taking on risk and being in accountable care organizations (ACOs). The DFW market is much more advanced than us in this; there is not much risk-based work going on in East Texas. The total population of members wouldn’t get big enough to make it viable here at this moment, but I do think the shift [toward value] will come here, eventually. Right now, our market is resilient to all kinds of risk-oriented managed care programs, largely due to the numbers. But clearly, Dallas is different with a much different set of players in that market.
ETMC is in an interesting position, because for other reasons we have taken on bigger population health initiatives. We’re a rural [health] delivery system, and our patients move around our hospitals and clinics over a wide geography. East Texas is known for terrible health habits and poor eating, with a lot of patients who have congestive heart failure, diabetes, and obesity. Those are the reasons we do population health. We also happen to run a third-party administration company, so we manage health plans on behalf of large self-funded groups. So that’s the other reason we have been focused on population health—to help our large self-insured health plans do a better job of managing their own employees and driving down their own health spend. So it has been more in that space rather than taking on downside risk directly. There is very little ACO activity in this market. We do have a lot of the infrastructure to support it but we have not done it.
How is your IT infrastructure? Are you leveraging analytics at a high level?
I would say we’re on the curve, but not that we are leveraging analytics at a high level. But we aspire to, and we are beginning to capture that data in ways that are queryable and actionable. Are we doing much with that data yet, though? No.
What’s the state of HIE (health information exchange) in the region?
I sit on the THSA (Texas Health Services Authority) board, and their whole mission is to advance the exchange of clinical data across disparate organizations. Yet still, there is nowhere near any kind of real critical mass in this state. And there are a few reasons for that: there is no state mandate that says you must be [connected]; and there is no way to commonly identify patients in the state—those efforts have stalled. At ETMC, we deliver data to 3,000 to 4,000 allied providers in our region. But those states that were able to pull off statewide exchange did it because they had to. Governance also has been a big issue. We have had all kinds of trouble getting competing hospitals to participate. Also, figuring out funding is always a problem. And frankly, the technology is still weak.
We can deliver data because we’re using a portal-based product and a web-based service. We can capture data from our EHRs (electronic health records) and then push it out. We do take data in but we have fewer parties sending us data than vice versa. However, taking hospitals out of it, most of our data exchange partners are physicians and home health agencies, and they don’t have a lot of IT resources. Overall in Texas, we are behind other states on HIE. So many states have pushed this agenda for years and achieved some remarkable things. I think we’re on our own way.
What innovation is ripe in your region right now?
Once we got past reimbursement and some other hurdles around telehealth, it’s been great. And it’s gotten way better in recent years. We have a number of telehealth initiatives, including using it for urgent care, and we also have small hospitals that don’t have hospitalists on staff full-time, so they can do remote consults. And we’re starting to use it with mental health services, too. We started our telehealth initiatives by showing folks that it has worked with people who physically couldn’t get to the bigger health systems, but now we are selling millennials on the convenience factor, as well.
Maybe this is more aspirational than reality, but I think we are all rapidly moving towards doing things faster and getting patients to collect more data so that it’s not such a big burden on physicians and also so that patients are more engaged in the process. We’re working on figuring out how to collect data from patients directly, suck that into our EHRs, and evolve care patterns, care practices, or workflows to support that. Now, we are not there yet, but that has been one of our biggest interest areas—it appeals to patients and our doctors also like it.
As far as the big stuff you see in the bigger academic centers, like AI (artificial intelligence), we’re not moving there right now. It’s just not on the top of our list. We are still moving into optimizing our EHRs. They are great to automate the movement of transactions, and yes, they have some clinical benefit because they create standards and speed up some processes, but we have not yet figured out how they could really help us do things like limit the number of variations in our treatment patterns, for example. We have not taken advantage of these millions of data points we have. EHRs are still mostly about collecting data to optimize reimbursement, and it’s time that we collect all this data to improve how we treat patients, and make that more repeatable. That will impact costs.
How are you coping with MACRA/MIPS?
You can’t be in healthcare without having to constantly look at what’s coming from a regulatory perspective. It’s irritating, but it is what it is. It is low on my things to worry about; we’ll adapt as we need to.
Where is cybersecurity on that list of things to worry about?
Getting the funding needed to put those services in place has been easy [due to the many public breaches]. It’s a risk management effort—how much money and effort do you put in to mitigate risk, and where is that tipping point? I am proud of what we have done [at ETMC]—we have a small team who works really hard and our biggest problems, like many others, are medical devices and patch management, with those “FDA-approved” devices that can’t be touched. What’s unfortunate about cybersecurity, to me, is that we have to do it but it’s not about strategy or advancing the delivery of healthcare. Rather, it draws us down a path that’s transactional. It’s hard to say that it’s relevant to the evolving business model.