There is a major movement toward not only alignment, but real integration between hospitals and physicians nationwide. Unfortunately, the transition to an employed physician model is not always a smooth conversion. Or a risk-free one.
Many physicians and healthcare organizations are still unsure about physician employment and can't forget the failure of employment models in the '80s and '90s. Others believe closer alignment and integration is the key to providing patients with better healthcare; improving quality, outcomes, and efficiency; and reducing healthcare costs.
Not gatekeepers anymore
The good news is physician employment is no longer based on the gatekeeper model, which is what the '80s and '90s under capitation and HMOs were supposed to be, says Brett Hickman, a Chicago-based national leader of the health industries strategy and planning practice at PricewaterhouseCoopers. Once patients had to leave the primary care environment for specialty care, there were no controls. It was a fee-for-service environment.
"We really didn't have true alignment across the whole spectrum," Hickman says, adding that the three biggest lessons healthcare organizations learned from that experience was that they overpaid for the value of a practice, didn't incentivize physicians to remain productive, and didn't realign incentives toward institutional goals.
The driving forces today are different. With the passage of the Patient Protection and Affordable Care Act of 2010, there is pressure from the government to build accountable care organizations. The belief is that entities such as hospitals, physician practices, and long-term care will deliver better care if it is coordinated and if financial rewards go to those organizations producing better outcomes.
In addition, physician practices that have been dependent on ancillary revenues to support physician compensation are being negatively impacted by reimbursement changes, says Hickman. These practices, such as cardiology and oncology groups, are looking at how they can realign with healthcare systems.
"We need to reorganize ourselves in a way to really tackle community health from a quality, cost, and efficiency perspective," says Stephen Moore, MD, senior vice president and chief medical officer (CMO) at Catholic Health Initiatives (CHI).
To that end, CHI, a nonprofit health system with 73 hospitals and 40 long-term care, assisted- and residential-living facilities, announced in March the appointment of T. Clifford Deveny, MD, to the newly created position of senior vice president of physician practice management. The Englewood, CO-based organization's goal is to significantly expand the number of employed physicians from approximately 1,500 to more than 3,000 in the next two to three years.
"We need to have a secure base of physicians from an employment perspective as well as a cadre of community doctors through other contractual arrangements in order for us to align all the incentives from a regulatory to legal and compliance standpoint," Moore says.
The health system plans on having 65% of its net patient service revenue come from outside the acute care hospital and be able to fully manage the risk of community populations-with the help of data analysis tools-by 2020.
Small physician practice gives up the reins
Endocrinologist Karl David McCowen, MD, founded Tacoma, WA-based Endocrine Consultants Northwest in 1980 and became part of Franciscan Medical Group (FMG) nearly 30 years later in 2009. There was a perfect storm of conditions that led the practice, which included three endocrinologists and one nurse practitioner, to seek employment, McCowen says-namely, the diabetes epidemic, difficulty recruiting, and pressure to adopt EMRs.
"Some of our staff was getting a bit older, and if we wanted to decrease the practice load, it was not financially sustainable," says McCowen. "We thought about the options. One was to close the doors and walk away, but I have single mothers working for me and we love our employees, and the impact to the community and our patients would have been profound because we are the largest group locally."
So McCowen made some inquiries at Tacoma, WA-based Franciscan Health System along with another local health system that was ruled out early on because of cultural fit.
"It was a difficult decision after 30 years, but if we were going to survive to continue to serve the community and our patients, we had to do something," he says.
First, FMG, which is part of Franciscan Health, presented a compensation model based on national standards, McCowen says, explaining that there is no point in going through the process if the compensation model doesn't work. McCowen's practice also wanted to know the fair market value of its hard assets and whether its employees would have jobs.
In the end, any employee who wanted a job received a position, the practice received fair market value for hard assets, and the doctors were fairly compensated for the workload, says McCowen, who now has a role in the leadership and governance of FMG.
One of the major benefits of an employment model is zero administrative stress. "I have a lot of confidence in my level as an endocrinologist, but the [business] landscape has changed and it is a tough place," says McCowen.
And now that he is no longer burdened with administrative issues, McCowen says he has a new lease on what it means to be a doctor. "I love the practice of medicine, and it has allowed me the chance to rejuvenate my practice."
Medical group focuses on improving patient care
The driving factors behind Integrated Healthcare Associate's (IHA) decision to merge with Saint Joseph Mercy Health System, part of Novi, MI-based Trinity Health, differ substantially from many other physician practices that are choosing employment based on financial concerns.
"We started out whole-as a strong financial performer with a strong drive to grow, the ability to recruit providers, and great quality scores," says Mary Barton Durfee, MD, IHA's executive vice president and CMO. "The driver was improved patient care. We thought we could do an even better job by having partners."
IHA, an Ann Arbor, MI-based multispecialty practice with more than 200 providers, including physicians, nurse practitioners, and physician assistants, was approached by Trinity Health about developing something different than a referring relationship.
"We were flattered by the approach and request, but initially decided that we'd pass," says Cindy Elliott, MHA, IHA's executive vice president and COO.
But after further review by the board, IHA determined that it was in the best interest of the group and its patients to enter into the strategic partnership with Trinity, which was completed in December 2010. "We had been very focused on the quality outcomes of our patients, but so many of those outcomes are systemwide," says Durfee. "To get better outcomes and care coordination and keep people from being readmitted in the hospital, we felt that a partnership was in the best interest of our patients."
The whole process took about nine months, with IHA becoming a wholly owned subsidiary of Saint Joseph's, says Elliott. "Our physicians are still employed by IHA, and our name, brand, and the way we present to the public is still IHA."
Key to the partnership's success is that IHA's CEO and CMO now have seats on Saint Joseph's board, and vice versa. It is important to be able to evaluate all the opportunities that come up on a daily basis, says Elliott. "It is really helpful having those folks around the table who can listen to those discussions and be helpful in directing the next steps."
Tips for a seamless transition to an employment model
Transitioning to an employment model is not without its hazards. Take this advice from executives and physicians:
Don't lose yourself in the transition. Know what is important to you and stay close to your mission and values.
Be meticulous. Keeping patients first and preserving the culture were top priorities, says Mary Barton Durfee, MD, executive vice president and CMO of IHA. "Everything we did reinforced that approach. It was thoughtful and we spent a huge amount of time on the details. It was well worth the time invested."
Determine cultural fit. It is important to understand the organization's corporate mission and culture. "Make it a point to talk with current and past provider employees with permission of the system," says endocrinologist Karl David McCowen, MD. "If the system doesn't give permission, then get up and walk away."
Know the expectations. Read the organization's provider handbook.
Realize that you are no longer the boss. You will now have to comply with corporate policies and HR standards.
Review separation and termination policies. Joining a group is a lot like getting married-easy to do, but tough to undo.
Understand the value of your practice in today's market. There is no true goodwill anymore associated with practices because if that doctor is not there, there is no income stream or profit stream to assign to goodwill, explains Brett Hickman, a Chicago-based national leader of the health industries strategy and planning practice at PricewaterhouseCoopers.
Making physician employment work
These elements are key to successful physician employment:
Restructure governance. Give physicians a voice and role in the organization. "Nine times out of 10 when these things fail, leadership at institutions say, ‘We got the financial deal done and took care of them, and they are still unhappy,' " says Brett Hickman. But those organizations didn't have an effective way of engaging physicians in the leadership of the institution, he says.
Realign financial incentives. Physicians should actively participate in the success of the institution and legally be accountable for quality, efficiency, and access, says Hickman. For example, Catholic Health Initiatives (CHI) plans to change its payment model to focus more on quality, population management, and reduced hospitalizations rather than office visits and procedures. Before physicians come on board, they need to understand how the current compensation model differs from theirs and where CHI is ultimately going, says Stephen Moore, senior vice president and CMO.
Engage physicians. The physicians-primary care included-have to be involved in establishing the care delivery process or the institutions are going to be at risk, Hickman says. "You have to make sure the physicians are engaged in [managing patient care] or they won't change their behavior to deliver care in a more cost-effective way."
For the past two years, Southeast Texas Medical Associates (SETMA) has been on a journey to be recognized as a patient-centered medical home (PCMH)—although, in truth, the journey began more than a decade ago.
The Beaumont, TX–based multispecialty practice began aggressively working with managed care in 1997, says CEO James L. Holly, MD. “This was an effective way to address many of the needs of our patients, especially the cost, quality, and access to care by our medically most vulnerable friends and neighbors.”
SETMA then became involved in Medicare Advantage, which enabled the practice to extend care to many patients who previously could not afford or obtain it.
In 1998, SETMA adopted electronic health records, but soon realized that they were too expensive and difficult to manage if the only benefit was an electronic method of documenting a patient encounter. So the following year, SETMA redirected its efforts to electronic patient management and began developing disease and data management tools.
In 2000, SETMA determined that to provide excellent care, it needed to track the quality of care, audit the care given to populations of patients, and statistically analyze its outcomes. “We began tracking and auditing various quality metrics, including diabetes, hypertension, care transitions, congestive heart failure [CHF], and chronic stable angina—most of which were published by Physician Consortium for Performance Improvement. In time, we expanded that to include other nationally recognized metrics,” says Holly.
Finally in 2009, SETMA embarked on its journey to be recognized as a PCMH.
Recently, Holly discussed with HealthLeaders his views on SETMA’s care model, healthcare reform, and the lessons learned along the way:
HealthLeaders: What were driving forces behind your decision to adopt a PCMH model of care?
Holly: The features of medical home which intrigued, attracted, and challenged us were:
The process of coordination of care and the outcome of coordinated care.
The further development of our team approach to healthcare, including a truly collegial relationship between nurses, medical assistants, administration, information technology, nurse practitioners, and physicians.
The realization that the “patient-centered” element of medical home was the ultimate reality of the principle we have stated to our patients for the past fifteen years.
We have long given our patients report cards telling them what they should expect from their healthcare provider. Now, we have added outcomes transparency to those expectations with our decision to publicly report process and outcomes metrics.
Our COGNOS Project (using business intelligence software to build a data mart and auditing tools) enables us to do real-time auditing on our care processes and outcomes.
Believing the key to 21st century healthcare is thinking about our patients when they’re not in our presence and using technology to fulfill the requirements of excellent care.
This process led us to seek medical home recognition from the National Committee for Quality Assurance [NCQA] and accreditation from the Accreditation Association for Ambulatory Healthcare [AAAHC], the two bodies offering evaluation of medical groups as medical homes.
HL: How does your model of care work?
Holly: At the core of SETMA’s practice is that one or two quality metrics will have little impact upon the outcomes of healthcare delivery. SETMA employs two definitions: A “cluster” is seven or more quality metrics for a single condition (i.e., diabetes or hypertension), and a “galaxy” is multiple clusters for the same patient (i.e., diabetes, hypertension, lipids, and CHF). SETMA believes that fulfilling clusters and galaxies of metrics at the point of care will change outcomes. The following are the key elements of our model of care:
The tracking by each provider on each patient of their performance on preventive, screening, and quality standards for acute and chronic care. Tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the provider, nurse, and clerk.
The auditing of performance on the same standards either of the entire practice, each individual clinic, and each provider on a population or panel of patients.
The statistical analyzing of the above audit performance to measure improvement by practice, by clinic, or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, socioeconomic groupings, education, and frequency of visit.
The public reporting of performance on hundreds of quality measures by provider. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool plans and medical home coordination document summarizes a patient’s state of care and encourages them to ask their provider for any preventive care that has not been provided. We believe this is the best way to overcome provider and patient treatment inertia.
The design of Quality Assessment and Permanence Improvementinitiatives. This year, SETMA’s initiatives involve the elimination of all ethnic diversities of care in diabetes, hypertension, and dyslipidemia. Also, we have designed a program for reducing preventable readmissions to the hospital.
HL: How easy was it to transition to this model of care?
Holly: It is one of the most difficult things we have done. I use the word “is” because I believe that all of us who already have medical home recognition or accreditation or both are still in the process of transforming the practice of medicine by the principles, ideals, and goals of medical home. The formal process took SETMA from February 16, 2009, to the date we first submitted our NCQA application on April 12, 2010.
The transition is a true transformation rather than a reformation. Reformation comes from pressure from the outside, while transformation comes from an essential change of motivation and dynamic from the inside. Anything can be reformed if enough pressure is brought to bear. Unfortunately, reshaping under pressure can permanently alter the structural integrity of that which is being reformed. Also, once the external pressure is eliminated, the object often returns to its previous shape as nothing has fundamentally changed in its nature. Transformation is not dependent upon external pressure, but is sustained by an internal drive, which is energized by the evolving nature of the organization.
The currently proposed reformation of the healthcare system does nothing to address the fact that the structure of our healthcare system is built upon a patient coming to a healthcare provider who is expected to do something for the patient. There is little personal responsibility on the part of the patient for their own healthcare, whether as to content, cost, or appropriateness.
Transformation of healthcare would result in a radical change in the patient-provider relationship. The patient would no longer be a passive recipient of care. The collaboration between the patient and the provider would be based on the rational accessing of care based on need, not desire.
HL: How is the patient experience different today under this model?
Holly: The patient experience has dramatically changed. For instance, the patient’s care is evaluated on the basis of more than 200 quality metrics; the patient receives a summary of these quality metrics with a recommendation to contact his or her healthcare provider to request that any metrics not completed be done and care transition points are attended to; and a “plan of care” and “treatment plan” baton is handed off to the patient so that they can participate effectively as the head of their healthcare team.
Because of SETMA’s department of care coordination, every patient who leaves the hospital receives a follow-up call the day after discharge. This is not a 15-second administrative call to fulfill a metric, but it is a 12–30 minute call, which has substance. Selected patients seen in the clinic receive follow-up calls at any interval determined by the healthcare provider related to vulnerabilities or complexities of their care.
In addition, both during the visit and in the treatment plan, a section is included which is entitled, “What If?” This section shows the patient how his or her risk will change if a number of individual elements or a combination of multiple elements used to calculate the risk is changed.
HL: What steps did you take to ensure your providers and support staff were on board?
Holly: The first step we took in transforming our practice was an in-depth evaluation of our practice by the medical home standards published by CMS and NCQA. All of our executive management staff and providers were involved in this evaluation, which resulted in a 400-page review of our practice. The evaluation allowed all of our providers to see where we were, where we needed to go, and be part of the transformative process.
We looked at the requirements for medical home and designed tools that made it easier to fulfill the requirements than not to fulfill them. We were able to transform our disease management tool follow-up documents into plans of care and treatment plans.
We close the clinic one-half day each month and have a seminar to discuss the ideal of medical home and how we are performing or not performing. We have illustrations of where we are doing it well, and we share that by e-mail daily; and when we do not do it well, we share that as well.
We welcome and seek ideas from all members of our team to improve our processes and outcomes. We post on our website by provider name performance on more than 200 quality metrics.
HL: What advice do you have for practices seeking to undergo a similar transition?
Holly: Look into your own organization for the creativity and energy to change. There are many consultants and agencies who would like to charge you hundreds of thousands of dollars to transform you. At best that will be reformation. Transformation can only come from within, and it can only be sustained by your own passion, resolve, and relentless pursuit of excellence. Get counsel from those who have succeeded, evaluate their ideas, and modify them to your situation. Often the best help is free. Excellence and expensive are not synonyms.
HL: For practices seeking recognition as a medical home, what should they know about the application process?
Holly: It is tedious and complex, particularly NCQA. But that may just reflect my prejudice about forms; others may find them simple and straightforward. Currently, less than 1% of medical practices have any form of medical home recognition, so the process is in its infancy. It is SETMA’s judgment that an ideal process would be a combination of AAAHC and NCQA.
HL: What lessons have you learned along this journey?
Holly: It is worth the process, the price, and the pain. This is the future of healthcare, and it is possible to be part of that future now. It is not easy, but it is not impossible. Measure your success by your own advancement and not by whether someone else is ahead or behind you. In the same way, share your success with others. The following steps will help:
Determine where you are and where you want to be.
Select the template or model you will follow.
Outline the steps you will take.
Develop a timeline for completing each task.
Be innovative. Emulate the best of others, but expand upon their work and make it yours.
Be patient but eager.
Enjoy what you are doing and celebrate where you are.
Authors of the book, The Hospital Executive's Guide to Emergency Department Management, Kirk Jensen, MD, MBA and Daniel Kirkpatrick from BestPractices, an emergency medicine leadership and staffing practice in Fairfax, Va., offer advice on how hospitals can ensure they are equipped to handle seasonal fluctuations in ED patient arrivals.
Petitti is a strong proponent that the healthcare industry needs to constantly reevaluate its practices and treatments in light of new evidence. But changing the status quo is often easier said than done, she has learned firsthand.[Read more]
Diane E. Meier, MD, Director, Center to Advance Palliative Care, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, explains her role during the past 10 years as running a political campaign to convey the value of palliative care to various audiences, including C-suite executives, physicians, nurses, patients, families, policy makers, and philanthropists.
Michael Dowling, CEO of North Shore-Long Island Jewish Health System, has set a 10-year goal for his organization to be in the top metric in terms of quality, patient safety, patient satisfaction, and care coordination. "You want to be in a situation that when people come to North Shore they get the full complement of services, easily coordinated, with total transparency and communication. Where people leave at the end of the day and say, 'That was a great experience,'" he says. Here, he talks about how the organization is putting patient care at the center of everything they do. [Sponsored by Medseek]
"The one-size-fits-all approach is not a very good direction for not only preventive medicine but medicine in general."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Diana Petitti's story.
Early in her career, Diana Petitti, MD, MPH, realized that she was more interested in taking care of populations of patients rather than individual patients. She was attracted to epidemiology and public health, which led to a position as an epidemic intelligence service officer for the Centers for Disease Control and Prevention after she completed one year of clinical training. "My career started as a risk factor epidemiologist and evolved into a career focused more on the delivery of healthcare, quality of care, and evidence-based medicine," Petitti says.
Historically, preventive medicine was a specialty in a field that very few people thought of going into, and that the public really wasn't aware of, says Petitti, who is professor of biomedical informatics at Arizona State University and professor of basic medical sciences at the University of Arizona College of Medicine.
But today, there is a new vitality to preventive medicine. "People are realizing that it is much better to keep people from getting sick in the first place than to try to make them better once they are sick," Petitti says.
She credits much of this awareness to the massive problem of obesity and hypertension that this country is grappling with. "People realize that we could have started earlier and prevented a massive amount of what is going to be morbidity," she says. "The obesity epidemic has focused both the public and medical profession on the potential of prevention and helping them realize that we don't need to let that happen again."
Follow the evidence
Petitti is also a strong proponent that the healthcare industry needs to constantly reevaluate its practices and treatments in light of new evidence. "It fits directly with not just preventive and evidenced-based medicine, but a broad attempt to apply the principles of evidence and more tailored care across the spectrum, from prevention all the way through treatment," she says.
But changing the status quo is often easier said than done, as Petitti learned firsthand in November 2009 after the U.S. Preventive Services Task Force released new mammography guidelines. Petitti, who was vice-chairwoman of task force, ended up spending much of her Thanksgiving holiday that year preparing for a Congressional hearing prompted by the fallout the revised recommendations created.
"Certainly it was recognized that they were going to be controversial and it was going to be difficult to make changes to something that was a set of practices that were so widely embraced by advocacy organizations. But the response and reaction was way beyond anything that I anticipated," she says. "I was surprised at the degree of media attention and concern—almost hysteria—about these guidelines."
The original mammography recommendations were fairly vague, says Petitti. The guidelines were to do a mammogram in women age 40 years or older every one to two years.
The new recommendation was much more specific. It said to screen women age 50 to 74 every other year, and for women age 40 to 50 the decision to screen should be based on a discussion with their physician taking into account individual preferences," Petitti explains. In addition, the guidelines said specifically that "we really don't have evidence to make a firm recommendation about screening women over the age of 75," she says.
The backlash to the revised guidelines was immediate. Headlines included "Breast-Screening Advice is Upended," "Breast Exam Guidelines Raise Furor," and "Political Fallout From the Mammogram Maelstrom."
The concern was that the new guidelines, which reversed a longstanding recommendation that women in their 40s automatically undergo an annual or biannual mammogram, would result in increased breast-cancer deaths among women in their 40s who forgo screening. In addition, there was a fear that insurance companies would immediately deny coverage for mammography for women age 40 to 49 who opt to have the test done.
The guidelines generated controversy because of the emotional nature of mammography, Petitti says. "Many people know someone who has had breast cancer or had breast cancer diagnosed with mammogram and who believes or feels that the mammogram saved the life of that person," she says. The release of the recommendations also came out at a time when there was a lot of political debate about healthcare reform. "People that were opposed to the healthcare reform bill really seized on it, inappropriately in my opinion, as an example of the government not letting you do what you wanted it to do," she says. "It would have been controversial no matter what but definitely became fodder in the cannon in the battle for healthcare reform."
Still, Petitti says that mammography is just one example of how the healthcare industry can ensure that it doesn't fall into the trap of, This is how we did it before, so we should continue doing it that way forever. In general, there is a desire to be much more specific and tailor recommendations more directly to a person's individual risk, she says. "If we look at personalized medicine, in reality the mammogram guidelines were an attempt to make more personalized recommendations about when to have mammography. The one-size-fits-all approach is not a very good direction for not only preventive medicine but medicine in general."
Looking back over the past year, Petitti says there have been some positive outcomes from the controversy the recommendations generated. For example, there has been a call for a broader effort to systematize the approaches for recommendations based on evidence, she says. It also shined a light on the issue of groups that have a vested financial interest in a certain kind of recommendation. "A lot of positive things came out of this even though it definitely ruined my Thanksgiving," Petitti says. "Anytime you are changing something there is going to be a backlash, but it still needs to happen."
"The demands of the future are going to require much more holistic services. So we have to be able to be prepared to do this."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Michael Dowling's story.
Michael Dowling wants to ensure North Shore-Long Island Jewish Health System is viewed as an innovator in the industry, an organization that is at the cutting edge and sets the standard by which other healthcare organizations are judged. Dowling has been the president and CEO of North Shore-LIJ since 2002, and his 10-year goal for the organization is for it to be in the top metric in terms of quality, patient satisfaction, and care coordination and recognized as an organization that puts quality and patient safety at the center of everything. "You want to be in a situation that when people come to North Shore they get the full complement of services, easily coordinated, with total transparency and communication. Where people leave at the end of the day and say, 'That was a great experience,'" he says.
To that end, Dowling is taking steps that place North Shore-LIJ at the forefront of many health reform initiatives, such as the push for electronic health records and the development of accountable care organizations.
Technology is a core component of North Shore-LIJ's strategic plan, Dowling says."There is going to be increasing focus, properly so, on measuring quality and making sure that we provide the ultimate in safety. There is going to be more focus on care coordination, which is managing the care of the patient not just when they are in the hospital for three days, but managing the continuum when the patient is in different locations. There is going to be a lot more focus on transparency, and it is almost impossible to be able to handle any of this without a strong infrastructure and whole continuum of services, as well as a very robust electronic health system and IT system."
So North Shore-LIJ, which has 14 owned hospitals and a workforce of more than 42,000, announced in September 2009 that is investing $400 million to integrate EHRs in the practices of employed and community-based physicians, and other facility physicians. The health system is offering to subsidize up to 85% of the software and operating costs of an EHR system for roughly 7,000 affiliated physicians through two different subsidy options. Doctors who choose the connected model will receive a 50% subsidy (as permitted by law) for all of the costs associated with buying, operating, and using the EHR for five years.
The integrated model provides an 85% subsidy that includes all of the above, plus physicians would agree to collaborate on the development of and follow clinical care guides that are built into the system and based on nationally recognized standards of care for certain disease states like diabetes and congestive heart failure. Under this model, the community doctors would also agree to report their performance data related to those parameters back to North Shore-LIJ on a monthly basis so that the health system can aggregate that data to determine the impact the program is having on the community.
The health system began rolling out this program earlier this year, and it is being well received among physicians, Dowling says. More than 500 physicians committed to implementing the EHR before November 2010. "I've always looked upon this as a multi-year effort," says Dowling. There is a lot of education to be done, he explains. "When you stand up and say that we want to enhance our IT system and put in EHRs, everyone will say yes. But then when you sit down and explain what all that means it gets more difficult, because it is not just about technology. You have to change work processes." "Everybody knows that we have to manage the coordination of care better than we have done before, so the IT issue is very central to our overall strategy," says Dowling.
Dowling is also positioning the organization to be able to provide all services throughout the continuum. They are expanding their outpatient, long-term care, sub-acute care, and rehab programs. The health system also has established programs for home care, hospice, and palliative care, as well as a transportation network. "Patients don't fit into neat boxes," says Dowling. "We tend to put people in little silos and deal with parts of the individual instead of the totality of the individual. The demands of the future are going to require much more holistic services. So we have to be able to be prepared to do this."
Dowling views ACOs as having the ability to manage care and take responsibility for cost and care of the patient over the continuum. Or to take responsibility for a cohort of patients—like all patients with diabetes or a heart failure. "We'll be paid more based on quality outcomes—not what we do, but based on how well we do it," he says. Fundamentally, ACOs will be able to track patients across the continuum, be able to monitor outcomes, be able to share information, be able to transfer information from one location to another, be able to measure quality, and reduce the annoyance that patients currently suffer by having to repeat things over and over again, Dowling explains.
As a result, there will be more of an emphasis on the concept of interdisciplinary teamwork. This is going to be a challenge for the education systems because the health industry has to educate people for interdisciplinary action rather than educating people in silos, says Dowling. "We are very good at educating people in silos and then telling them after they graduate that they have to work in teams."
To fill in this educational gap, North Shore-LIJ has developed programs and partnered with others. "We have tens of thousands of people who go through training in our organization every year," says Dowling. North Shore-LIJ also works very closely with medical schools by creating its own programs, and it has partnered with Hofstra University to establish the Hofstra North Shore-LIJ School of Medicine, which will open in 2011. "At the end of the day it is the people who make the difference and who understand that they are not working in individual silos," says Dowling. This often appears as one of the soft issues and not that serious, he says. "But, quite frankly, you can have the best technology, but if you don't have the right people, it just won't work."
The opportunity for improvement is extraordinary and leadership is essential to making it happen, says Dowling. Senior healthcare executives and health systems have to be accountable for outcomes and the continuum of care, he says.
"Leadership is about believing there can be a better future and making sure you move your organization in that direction," says Dowling. "If we do that, I think we'll have the opportunity to change how care is delivered and people will believe that they are getting true value for their healthcare in terms of quality."
When Riverside Health System implemented its EMR in 1996, the idea was that it would be able to use the data to help drive improvements in care.
"We thought we'd have all of the data fields in our notes," says Charles Frazier, MD, vice president of innovation. "Everybody thinks we'll get all this data and be able to do all of this stuff with it, but it is a difficult thing."
After 10 years, the VA-based health system—which consists of four acute care hospitals, rehabilitation and long-term care facilities, and the Riverside Medical Group, a 350-member multispecialty physician practice—was still working on problem lists, lab values, medications, and elements such as gender and age. Today, the health system is still continually trying to improve how it puts information into the EMR, Frazier says.
Riverside developed a patient portal in 2003 to improve communication with patients and provide guidance on preventive care. But after several years, only 20,000 of the health system's some 350,000 active patients were using the portal.
"When you have such a small percentage connected on the Web, you have to think of something else, and most everybody has telephones," says Frazier.
So Riverside implemented Dallas-based software vendor Phytel, Inc.'s proactive patient outreach solution to help it follow up with patients—especially those who are out of compliance and in need of recommended care.
The technology captures data from practice management, scheduling, billing, and/or clinical information systems such as EMRs. It then creates physician-specific registries and screens patients based on a couple hundred nationally recognized disease management and preventive health protocols.
The software searches for gaps in care, such as a diabetic patient who has not seen his or her physician in more than a year. It then sends an automated message—voice messaging, text, or e-mail—that is from the physician or medical group asking the patient to contact his or her doctor. Physicians pay a monthly subscription fee for the service, which is based on the number of physicians rather than patient volumes.
The technology looks for things that the physician has ordered that have not been done or for services that are recommended, says Steve Schelhammer, Phytel's CEO. "We find the patients that are out of compliance and [have] fallen off the radar screen, and we motivate those patients to get back into the healthcare system so that they can get the appropriate care."
Riverside, which began using the technology roughly 10 months ago, focused its efforts on patients with chronic conditions such as diabetes and hypertension. Currently, the software is only pulling data from Riverside's financial system, but the health system hopes to have data from its EMR and clinical systems included by the end of this year.
Until then, Riverside is extracting data from its clinical system for Phytel to use. For example, Riverside shared mammography data that it pulls on a monthly basis for its physicians. The technology screened the data and sent automated messages to all the female patients aged 40—69 who had no record of a mammogram during the previous two years.
Riverside set up a specific telephone number for the women to call so it could track how well the initiative was working. "We had more than 250 mammograms scheduled through that process," says Frazier, adding that they also identified patients whose EMR was incorrect and corrected the information.
Riverside is now working with the vendor to better communicate with its patients who have signed up for the health system's patient portal either electronically or via text message rather than by phone.
Similarly, The Iowa Clinic in Des Moines wanted to ensure that its patients were receiving appropriate follow-up care and screening services. "Even though we were putting an EMR in place, it didn't really have the right components to make sure we were reaching out and following up on certain aspects as it relates to the delivery of care," says CEO Ed Brown. "Phytel appeared to be at the time one of the solutions to that," he says, adding that some colleagues were having positive experiences using the technology.
The Clinic, which is an independent, physician-owned, multispecialty practice with 135 physicians serving more than 400,000 patients annually, started using the system with its internal medicine, cardiology, and OB patients. For internal medicine, the group focused on congestive heart failure, diabetes, hypertension, physical exam, and mammogram, says Julie Sanders, director of quality. "For cardiology it was very similar protocols as far as disease states, and we look at heart failure, hypertension, and coronary artery disease. For OB, we reached out to those [patients] who have not had the HPV vaccine, [those with] abnormal pap smears, and those who needed a wellness screening.
"We have definitely had patients come in who have been delinquent for care," says Sanders, who was somewhat skeptical at first regarding how many patients were really out of compliance and in need of this type of outreach.
Riverside chose 50 primary care doctors to test the technology, based on physician capacity, says Frazier. The health system didn't want to reach out to a patient for follow-up care with a physician who was extremely busy and would be unavailable for three to six months, he explains.
There was the initial data mapping work with Phytel, so that it knew where the data were coming out of the finance system. Riverside's quality committee then evaluated the vendor's protocols and made adjustments based on the data in the financial system. It eliminated some of the protocols and modified others altering age intervals or changing the protocol from six months to one year, for example. The last piece was training practice staff on what to do when patients called in.
The Clinic followed a similar process--data mapping and reviewing protocols. Aside from the standard glitches associated with deploying new technology, "it was a very easy rollout," says Beth McGinnis, director of administrative services, billing, and information technology.
"When we turned the protocols on, we did some tweaking--patients were being called who we didn't want to be called," says McGinnis. The technology does have an opt-out capability, so you can remove those patients from the system or note when calls should resume.
Closing the care loop
The technology also funnels the data back to the care team so when a patient calls in the clinicians are prepared.
Initially, the patient would call saying, "I got this call saying that I need to come back in for some reason," says Frazier. The clinical staff would go right to Phytel's website to determine why the patient was called, ask some questions, and make an appointment when appropriate. Now, however, when an outreach call goes out, there is a document that is sent to Riverside's EMR system explaining why a patient was called.
"Now our staff doesn't have to go to a different application or website, and they can stay in their primary application, which is the EMR," Frazier says.
Riverside is also working on more scripting for its staff. When a patient calls, the clinician will now say, "You were called because we believe you need follow-up for diabetes. Does Dr. Frazier see you for diabetes?" That may seem like an odd question, Frazier says, but say that patient sees an endocrinologist who is not in the Riverside family. But "our financial system says that they have diabetes and haven't been in to see me for six months," he explains. "So the staff member can catch that and say, 'We'll make sure not to call you for diabetes anymore,' and update the system."
Brown and Frazier agree that the benefits of the system and positive responses far outweigh the handful of patients who were called when they shouldn't have been.
Based on data from December to July, Riverside booked more than 13,400 appointments, and of those appointments, about 9,100 would not have been made without the intervention. In addition, those visits generated roughly $675,000.
Likewise, The Iowa Clinic, which went live with the system about nine months ago, successfully contacted more than 16,600 patients with gaps in care, and of those, roughly 8,500 appointments were made within 60 days. "We have also increased compliance with standards of performance that have been laid out for us by some of our payers for performance improvement," says Brown.
"It has a positive impact on the bottom line, but it is not disproportionately out of line with what it would have been before because those openings would have been filled by other services," says Brown. "But we are making sure that patients are getting more appropriate care for their needs."
Managing patient populations
Providers are still determining what accountable care organizations (ACO) are exactly and how they will be structured. But one thing is certain?technology will play a key role in helping organizations better manage populations of patients.
Today, when a physician tells a patient, "I want to see you back in so many months for follow-up labs," the responsibility rests with the patient, says Ed Brown, CEO of The Iowa Clinic.
But with so much emphasis being placed on patient-centered medical homes, P4P, meaningful use, and ACOs, "the bar is being raised so that there is responsibility on the provider to maximize the outcome of that patient's health," Brown says.
"That is the transition from a fee-for-service-based payment system to a global payment system," says Steve Schelhammer, CEO of Phytel, Inc. "To be successful, providers have to have capabilities to help them manage the entire population, not just the population that is actively seeking healthcare."
The idea of ACOs and complying with protocols that are set internally or externally will be enhanced by technology, agrees Brown. "As we establish protocols for various disease processes, we'll have within our demographics in our EMR the patient population that qualifies for the protocols," he says. Those patients need to be tracked closely, and "technology will enhance our ability to perform up to a high level of care based on the protocols that have been established."
In the future, Charles Frazier, MD, vice president of innovation at Riverside Health System, envisions technology solutions like Phytel enabling nurses to coordinate patient care more effectively. Rather than having patients call their physician practice, they can call a central number where nurses looking at the EMR can say, "Yes, I see where you do need follow-up for diabetes, and by the way, can I go ahead and make your eye appointment and order lab work that Dr. Frazier will need when you come in?"