High costs and inconsistent quality have plagued healthcare for too long. Three trends – systemic, economic and transformative – are influencing the industry’s move toward more proactive community based, coordinated population health management.
Healthcare is an ever-changing industry, and a new reality is emerging. It requires providers to become more proactive to achieve better clinical and financial outcomes and to become more efficient in driving down costs. Organizations will need a strategic approach and an operational focus for population health management to address three trends shaping our collective future:
Systemic – More chronic conditions and complex care
A recent RAND study estimates that three out of five Americans have a chronic condition; two out of five Americans have multiple chronic conditions. These high-risk, high-cost patients frequently see multiple providers. Unfortunately, these patients do not often get the coordinated response they need from a fragmented continuum of care.
Economic – More value-based reimbursement models
The United States spent $3.2 trillion on healthcare in 2015, and it is the single largest expense of the federal budget. Efforts to curb these rising costs include introducing value-based, at-risk financial models to replace fee-for-service payments.
For example, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) went into effect Jan. 1, 2017, and reforms payments for healthcare services for 55 million Medicare patients. The associated Quality Payment Program (QPP) is the regulation that will shift the reimbursement model from volume-based payments to a more comprehensive value-based framework.
Transformative – More alternative care settings
For better clinical and financial results, patients need the right care in the right place at the right time. New outpatient care settings – such as day surgery clinics, urgent care centers and even patients’ homes – may offer better options than traditional acute care facilities.
These trends represent a significant cultural and organizational shift. Providers must create focus on the consumer, and deliver more individually coordinated, community based patient care. These concepts are not new, and neither is the solution: a proactive and coordinated community population health management strategy.
Focusing on high-risk and rising-risk patient populations
Providers need to create care teams to manage patients with chronic disease across the continuum. The highest risk patients comprise only 5% of the population and almost half of the nation’s healthcare costs. It seems logical to focus care management efforts here first.
But Advisory Board researchers predict that focusing on only high-risk patients will net the organization a negative 3-4% margin in five years. Costs for this group decrease, but the unmanaged rising-risk patients will get worse and threaten financial stability.
Advisory Board researchers also modeled an approach where the health system managed care for rising-risk patients, which comprise 20% of the population. Without intervention, these people will become high-risk patients.
Focusing care management strategies here can reduce the number of people converting from rising-risk to high-risk from 18% to 12%. This significantly improves the financial picture, netting the organization a positive 3-4% margin in five years.
Now is the time to act
Uncertainty around national health policy has caused some providers to hesitate. Unfortunately, waiting to move forward with a population health platform and strategy could increase financial and competitive risks. For example, even with all of the political debate and disagreement over healthcare’s future, it is clear the government will continue its march toward value-based care payment reforms.
Consumers have shown an increasing appetite for quality and control over their own healthcare. This explosion of data must come together in a single, united view of the patient. It requires a strong foundation of integrated IT solutions that enable an open, connected community of health.
A new white paper explores four core capabilities that population health solutions must have to deliver excellent value to healthcare organizations. To learn more, download Enabling Proactive Health Management.
The healthcare industry is more focused on the consumer than ever, triggering a call for true interoperability and open health data exchange through Application Programming Interfaces (APIs). Government regulation, consumer demand and innovative developers will make 2018 the Year of the API.
Application Programming Interfaces (APIs), or sets of tools and specifications that enable software to interact, are not a new concept. Other industries have opened up their APIs to enable innovative data exchange. Think about how any car dealer can pull up your financial information, or how your airline ticket can appear on your mobile phone – open APIs make these capabilities possible.
Open APIs are not as common in healthcare, which is part of the reason our industry lags others in being able to offer these consumer-centric information exchange capabilities. Allscripts is the only company that recognized early on how important it was – for innovation and interoperability – to create an ecosystem that makes it easy for applications to take root and deliver what clients need to be successful.
The demand for interoperability in healthcare is bringing APIs into the spotlight, and it’s more important than ever that APIs are open and available to connect disparate technologies to one another.
Interoperability beyond the EHR
For many years, the conversation around healthcare interoperability was narrow in scope: doctor-to-doctor information exchange. But as healthcare organizations successfully adopt electronic health records (EHRs), a variety of interoperability use cases highlight countless opportunities that exist above the EHR.
We hosted National Coordinator for Health IT Don Rucker, M.D., at our company’s annual health conference in August. It was heartening to hear that expanding interoperability is a top priority. Here’s what we heard from Dr. Rucker:
1)There must be a steadfast focus on the consumer. Moving past the focus on patient access, healthcare consumers must have command of their information. Data must be as mobile as they are.
2) Data should be put to work. Clinical data will require analysis by providers and others with a stake in our collective shift to value-based care. Interoperability challenges sometimes limit the industry’s ability to draw insights from ever-increasing amounts of information. Now that we have the data, let’s make it work for us.
3) Open Application Programming Interfaces (APIs) will soon be the norm. API toolkits help to make data more mobile, and they do so in a simple, cost-effective way. In fact, APIs will play a big role in achieving the first two priorities described above, if vendors embrace them and providers adopt them. Momentum of APIs is tremendous.
To move forward on these priorities, Dr. Rucker indicated that ONC will be engaging stakeholders while they undertake key definitional work: What does interoperability really mean? What level of data fluidity is necessary to affect both quality and cost? How do we measure information exchange?
As we collectively answer those questions, we will work toward increased access for stakeholders and a framework that improves patients’ access to their own medical records. Every step toward greater clarity and consensus enables us to invest confidently in new interoperability technologies and standards, such as Fast Healthcare Interoperability Resources (FHIR), and helps the industry abandon habits that have been keeping information locked away.
Evidence that open APIs are the key to unlocking interoperability
Ten years ago, Apple introduced its first iPhone, introducing a new era of user-centered technology. This technology made it easy for apps and created a brand-new ecosystem. It’s just what healthcare needs.
More than ten years ago, Allscripts was the first in the healthcare industry to embrace an open platform because we recognize this is the only way to achieve the promise of interoperability. Allscripts APIs are open and fully supported, which means that we encourage third-party applications to work with our solutions.
Through our developer network, we’ve helped healthcare applications exchange data nearly 3 billion times in just four years, and that rate continues to climb. In August 2017 Allscripts hit a new milestone by facilitating the exchange of more than 100 million data shares within a single month.
Now, more than 1,000 third-party developers work with Allscripts to deploy innovative solutions using FHIR and proprietary APIs. These relationships are in addition to the 170+ existing Allscripts developer partners, all currently available through the company’s application store (https://store.allscripts.com).
Health IT is always about the patient. By giving innovators access to our APIs, we’re helping clients integrate the innovations that matter most to their patients. The EHR was always a means to the end goal. I am optimistic that ONC’s work on the priorities outlined above, coupled with innovation in the private sector, will be the catalyst needed for true healthcare interoperability.
While interoperability has been in the spotlight for years, we’re not where we want to be yet. But Tennessee-based Holston Medical Group has made real progress connecting physician groups for better patient care.
At every industry gathering I attend, we see evidence that health IT is not fully interoperable yet, even after years of dedicated effort, regulation and expense. For hospitals and physician offices that are grappling with this complex issue while managing waiting rooms full of patients, there is frustration. But there is also hope.
Hopeful signs for interoperability at Holston Medical Group
We can take inspiration from medical groups that have made real progress toward interoperability. Holston Medical Group, based in Kingsport, Tennessee, is one of these success stories.
Holston Medical Group helped form a physician-led Accountable Care Organization (ACO), Qualuable Medical Professionals, and a healthcare transformation company, OnePartner, which offers a private health information exchange (HIE). Together, these organizations are connecting independent physician groups for better patient care and improving the overall health of their communities.
When Holston Medical Group helped establish the ACO in 2013, one of the top priorities was finding a way to help medical groups with different systems to work together. It needed to normalize all of that data from disparate electronic health records (EHRs) to give clinicians access to complete patient information.
That’s where OnePartner comes in. It’s another collaborative effort, this one providing The OnePartner HIE Community Record, powered by the dbMotion™ health information exchange platform. It enables secure, safe and actionable access to information across the continuum within each provider’s native workflow.
To participate in the ACO, physicians contractually agree to also participate in the HIE and share their data with the community of providers. Regional participation in the HIE has brought together 750,000 patient records and enables the exchange of 200,000 clinical and financial messages every day.
The effects of data-driven decisions and connected care
With more community-based, comprehensive, accurate patient data available at the point of care, providers can create better care plans. Holston Medical Group is using patient data to succeed in several areas, including these examples:
Stratifying patients with chronic conditions – Holston Medical Group physicians use data to identify and address various conditions, including the top four disease states in the population: hypertension, diabetes, depression and asthma. Care teams analyze where they can have the greatest impact to improve outcomes for better patient care.
Extensivist Clinic provides inpatient care in an outpatient setting – To more effectively manage patients with complex conditions, Holston Medical Group created a care setting in which patients could receive specialized interventions and avoid hospitalization. Access to the HIE is especially important here, providing real-time updates on information such as medication changes, ancillary services and referrals.
Launching precision medicine solution – At the end of 2016, Holston Medical Group announced it would use 2bPrecise – an EHR-agnostic, clinical-genomic solution – to help physicians find, select, order and receive genomic tests for patients. It plans to use the solution to improve quality of mental and behavioral healthcare and treat patients more individually with a new level of diagnostic precision.
These examples demonstrate what dedicated clinicians can accomplish with open and interoperable technologies. And while the industry is not satisfied with its current level of interoperability, signs of progress should give us hope and keep us moving forward.
Generating value with interoperability
The shift from fee-for-service to value-based financial models raises the stakes for interoperability. Providers can earn more if they solve the technical challenges that obstruct collaboration and coordination and participate in clinically integrated networks.
Holston Medical Group’s efforts to enable physician groups to come together and learn from each other’s strengths are helping those practices to maintain independence and generate value. Qualuable is one of the top-rated ACOs in the country. It has generated more than $40 million in shared savings over three performance years.
When will healthcare be interoperable? In some corners of the world, such as Holston Medical Group’s home base in Tennessee, we see hopeful signs of progress. When healthcare as an industry embraces open and interoperable technologies, only then will we experience truly connected care.
Good care coordination strategies can help healthcare organizations survive the shift to value-based care. Learn how one hospital successfully overhauled care management and how open and interoperable systems help deliver truly connected care.
Closed IT systems lock data into “silos.” These systems make it difficult to share patient data with one another, and they hinder care teams that need complete, real-time information about patients at their fingertips.
More than ever before, payment and delivery system reform is requiring tighter collaboration across fragmented settings. As risk-based financial models become more common, the industry is focused on breaking down data silos and creating more open, connected communities of health.
The real world has changed for the good; there are many more acute, ambulatory and community-based organizations that are digitized today than there were at the beginning of this decade. There is not a single geography nor country where all caregivers and patients communicate and transact on a single integrated patient record.
Organizations that can effectively manage patients across care settings – and among different healthcare systems – will survive the industry’s shift to value-based care. A good, comprehensive care coordination strategy is the foundation for increased access, appropriate cost and higher quality of care across the continuum in today’s environment.
How one hospital successfully overhauled care management
Like many healthcare organizations, Massachusetts-based Holyoke Medical Center participates in Centers for Medicare & Medicaid (CMS) value-based programs, including Medicare Shared Savings Program (MSSP) and Model 2 Bundled Payments for Care Improvement (BPCI) Program. Holyoke Medical Center recognized the need for a new approach to successfully participate in these programs and redesigned its entire care management function.
“One of the challenges we had was that our outpatient and inpatient case management efforts were disconnected. Departments couldn’t see what the others were doing, so we risk loss of continuity of care,” Director of Transitional Care Management Michael Ipekdjian RN, BSN, PHRN said in a recent case study. “To accomplish quality care across the continuum, you can’t have these siloes.”
Unfortunately, disconnected systems contribute to gaps in communication, which can lead to gaps in care. Beyond potential risk for the patient, it can cause organizations to lose out on shared savings and bundled payments, too.
Holyoke Medical Center set goals for its effort to revamp care management: 1) provide superior transitional care management services, 2) improve clinical outcomes, 3) sustain reduced readmission rates and 4) improve utilization of appropriate services.
Its new structure includes an inpatient Case Management department, outpatient Community Navigation department and a Patient Call Center to engage patients post-discharge. Once all teams reported into the same leadership, Holyoke deployed a platform to encompass discharge planning, utilization management and evidence-based care plans.
Holyoke Medical Center operationalized a significant amount of technology in just six months.With a more unified structure – and technology that supports this approach – it provides smoother transitions for patients and closes gaps for better patient care.
As a result, Holyoke achieved its goals. For example, superior transitional care management services boosted its Press Ganey care transition score from 54.4% to 60.4% and reduced its readmission rate from .9 to .8 in just six months.
Vision for the future: Open, interoperable and connected
Until patients can go anywhere, anytime and know the provider is up to date, our job is not done. Technology must have two key attributes to achieve this; it must be open and interoperable. The result of the open-plus-interoperable equation is a connected community.
An open platform enables a world of possibilities and potential for healthcare. Core systems that are open help providers to extend and scale functionality – so they can meet the specific needs of their community. They can easily integrate proprietary software or plug in new applications from the industry’s most creative innovators.
When we add true vendor-agnostic interoperability, we enable providers to exchange data with any system – accessible in the provider’s home system. Of course, it’s important to also limit the “firehose” effect by organizing the information and making it actionable for clinicians.
Until we reach the post-silo era, clinicians lack the full picture for optimal decision-making and patients will suffer from this lack of access. But innovators, such as Holyoke Medical Center, show us that an integrated, unified approach to care management is possible – that open and interoperable systems lead us beyond data silos to a truly connected community of health.
