In the wake of the American Hospital Association's workforcereport released in November, HealthLeaders spoke with NAHQ Executive Director and CEO Stephanie Mercado, CPHQ, about how that quality component is the linchpin to building and keeping a strong workforce. This interview has been edited for brevity and clarity.
HealthLeaders: A takeaway that leapt out on the video summary of the report on your website was that hammers don't build houses, but people do.
Stephanie Mercado: That's right.
HL: Your report is all about the fact that we have all these marvelous information tools now, but we have a workforce that seems at times unable to use or optimize the use of those tools to really make the kind of difference we need to see in healthcare. That includes bending the cost curve, employee retention and all the things we write about over and over again. What was the origin of the report? How did you decide at this time that you needed to do this kind of survey or fact finding? And how did you go about gathering the evidence that you present?
Mercado: Let me rewind the tape a little bit further. I joined the organization about eight and a half years ago. And at that point in time, there were a handful of healthcare quality leaders. CQO [chief quality officer] roles were almost nonexistent. There were a few VPs you'd hear about, but most of the time it was directors and managers and coordinators of quality.
One of the things that occurred to me was how different the educational pathways are for people working in healthcare quality. I had previously come from the American Orthopedic Association and American Academy of Physical Medicine and Rehabilitation, where there are well-worn academic pathways for training – medical school, residency, fellowship, board certification, licensure, the whole thing. But the same is not true for people working in healthcare quality.
Stephanie Mercado, CPHQ, executive director and chief executive officer of the National Association for Healthcare Quality. Photo courtesy NAHQ.
People working in healthcare quality generally are more like-minded than they are like type. And they're usually put into the role because they were really good at something else. I saw a chief quality officer position description the other day sent to me by a recruiter, and it said "MD required and quality experience preferred." And I thought, how could this even be right?
The whole reason why NAQH exists, and of course the impetus for the report, was to say we've got a lot of people and a lot of investments have been made over the years advancing quality, safety, and value. And yet, we do not have any standards for how we educate and train these individuals. That's the reason why we do all of our work.
We started by developing the Healthcare Quality Competency Framework, that has the eight dimensions, 29 competencies, and then, unpublished, 486 skills, stratified against foundational, proficient, and advanced levels. With the framework in hand, we know what work is supposed to be getting done out there in healthcare quality. Creating the standard and validating that standard twice in the market was the first step.
Once we had the standard validated, we were then able to start assessing both individual contributors and contributors within teams. That is really what you see in the workforce report. The first few data tables that you notice are from our aggregated national dataset. And the ones in the appendix are actually from healthcare organizations that we work with, to come in and help them understand how to leverage their workforce, through a solution we offer called Workforce Accelerator. At the end of the day, there's no technology implementation or consultant that will replace a coordinated competent workforce. And so that needs to be the focus of for sustainable systems.
HL: The report includes a data analytics data point, which was that 57% of respondents indicate analytics as part of the responsibility, but most work at lower levels of competency.
Mercado: Well, that is big. All of these competencies must be present in a high-performing organization. And I'm just pulling up health data analytics in particular. So 57% say that they work in that domain, and only 20% are performing at advanced ends of the competency spectrum.
HL: So why the gap here? They're not being trained properly?
Mercado: Oh, so many things. But yeah, there is not a well-worn academic pathway or even training solution that gets people ready to do this work. We have been saying what needs to change in healthcare for more than six decades – what needs to be measured, what we need to be doing, what technology needs implemented, all of these things, but we haven't said how. The whole how part of the equation has been left largely addressed.
The how gets back to hammers don't build houses, people do. A lot of times healthcare leaders, with very good intentions, will deploy technical solutions and then suffer from challenges with operator error because the people don't know how to use the tool. Safety event reporting software is the thing that helps identify risks and events in a hospital. It's a way to engage the workforce. And they will report things like, if there was actually an incident, like a slip and fall or anything like that, that goes into there.
And then there's also things like they put in near-misses or good catches, like, hey, there's water on the floor. And they enter it into the system to say it needs to be cleaned up, or we almost gave a patient the wrong medicine. They implement that into the event reporting. But guess what they don't do: Most organizations do not train their workforce on how to identify those risks and events. So now you have a whole software solution, which is very well-intended and necessary in healthcare, but the competencies required to identify those risks and events have not been part of the solution.
HL: One of the AHA report's recommendations is to foster professional development, expertise, and leadership skills by offering interdisciplinary training across organizations, departments, and sites of care. That would seem to intersect quite nicely with what you're urging.
Mercado: We are 100% on the same page with investing in continued professional development. We would expand upon that to say what we need in order to do that well is create some more of the standard operating procedures of how teams work together.
We have been working with a variety of healthcare organizations, first in pilot, most recently in beta, and are now moving past beta to actually go into healthcare organizations and implement this model.
For example, we are working with the Veterans Health Administration. The VHA implemented NAHQ's implementation model for this, which we call the Workforce Accelerator. VHA did that in beta with us with three of their VISNs [VHA regions]. They just expanded with us, and the VHA now has all 18 VISNs working on the workforce accelerator program with us. So the entire VHA infrastructure is now aligned to this effort. And it also represents the first time that the VHA has ever centralized quality.
This is really big news, that the largest health system in the country is working with NAHQ to deploy this solution with success. Not only are they having organizational success, but individuals are feeling more engaged and more supported at their organization. They're creating succession plans for staffing and things like that. It's been a real success story at the Veterans Health Administration. And we have others -- Bon Secours Mercy Health, Valley Medical Center -- and many other organizations are working with us on this and it is working. We're really excited about that.
HL: How does this effort increase the likelihood that population health efforts are going to be successful at healthcare organizations?
Mercado: Let me tell you a story to answer that.
One of NAHQ's board members works at ChristianaCare. And for a long time, she led the department of quality. And she was so good at it and so effective as a leader, when they got involved in population health, many years ago, they asked Patty, who's my board member, Patty [Patricia] Resnik, to go lead the population health initiative. When she arrived in the population health department and was stitching together her team and getting everything situated and organized, what she realized was that the people who were there didn't have skills in quality and the skills that you need to have an effective population health program. You need to understand data, and you need to be able to do performance and process improvement. You need to be able to understand the different payment models and how you can support populations and measure those outcomes. How you can improve things like vaccination schedules and annual mammograms and all those things? Those are quality skills.
HL: To what degree are the analytics tools a part of the problem? Hammers are hammers. We all know how they work: they pound nails. In the case of technology deployed in the healthcare space, they're not simple. They're tough to evaluate and compare. We often hear this drumbeat of well, you're just using the wrong tool. If you just use this other tool, things are going to be better. And now it's gone beyond use this other tool – it's use this other AI with this other data set and you'll be successful. To what degree has the industry have allowed itself to be distracted by this endless discussion of what's the right tool? Are any of them good enough if you train people adequately on how to use them?
Mercado: They might be. Technology's job is to enable people to do their best work. Technology does not replace, in and of itself, people doing the work.
HL: It's critical thinking skills, too. It's not just their sheer competency with using the tool. It's how critically do they think – how they're able to make connections between things they might not otherwise connect.
Mercado: Absolutely. One of our competencies is in data, health data analytics, collecting data from disparate sources, being able to understand the relationship between it and then moving on to make that information useful and actionable. There's not a technology solution that does that without a human driving the thinking behind that.
HL: We're in an industry that's more and more hammered by spiraling costs, reduction in payments from Medicare and others. In such an environment, how do you persuade organizations to answer the call to action? Can you tell them with any certainty, based on your early work with VA and others, this is going to pay such dividends, that you'll wonder why you never did it earlier. Is it that straightforward? What's the cost involved? And what's the return on investment involved in making this workforce investment?
Mercado: We're researching right now the best way to quantify the value of activating these ideas. What we do know is people and organizations that are working with NAHQ to advance a coordinated, competent workforce, they are continuing to work and they're expanding their work. And they are not only seeing a difference in their quality infrastructure and having a more positive effect, but they are hearing from the workforce that the workforce feels supported, valued, recognized, to do their best work.
HL: You mentioned 486 skills, as yet unpublished. Are you going to publish those?
Mercado: We haven't published them for a couple of reasons.
Number one, we believe that the high degree of variability in healthcare delivery is very much related to the high degree of variability in healthcare quality competencies, so we're not going to solve for the end state problem without moving upstream and getting these competencies figured out. We have also observed that when we do push information into the market, because it is needed, it is needed very badly.
Since we released the report, a handful of weeks ago, I believe we're up to about 4,000 downloads of that report, and lots of sharing. No one person needs a list of 486 things to do. An organization needs it all, because they deploy that holistically. So we only get back to organizations that work directly with us.
HL: Academia has played a role in training the workforce. Should they be also playing a role in this? And how?
Mercado: From an academic, higher-ed perspective, in clinical disciplines we have done a good job at training our clinicians on clinical competencies for quality, how to clinically do their job well. But there is a high degree of variability in non-clinical competencies, in the training there. Even within nursing, they do it, [but] they're working on getting a more standardized way.
So it would not be fair to say they don't have it, but we have a long way to go in terms of standardizing the non-clinical competencies – performance and process improvement, health data analytics, population health, care transitions – the non-clinical competencies. NAHQ works with a handful of nursing programs right now to hardwire our non-clinical competency-based training into nursing curriculums.
It's actually listed in this document which groups we're working with – George Washington, Georgetown, University of North Texas, Western Governors, etc. There are such things as quality and safety Master's Degree programs, but we are not graduating very many people through those programs. So we need a bigger commitment to Master's level training in the discipline of quality and safety as well.
In a lengthy interview with HealthLeaders, ONC Chief Micky Tripathi says simplified data exchange will benefit providers, patients, and even public health.
Federal rules state that certified EHRs must support the standard FHIR application programming interfaces (APIs) by the end of this year. It's one more step toward transforming patient information access in a years-long process dating back to the birth of the EHR, and will touch the day-to-day information sharing of providers, patients, and even public health agencies.
HealthLeaders recently spoke with Micky Tripathi, PhD, MPP, director of the Department of Health and Human Services' Office of the National Coordinator for Health Information Technology, about the standardized FHIR API rule and how it will impact health systems and patients in 2023. This interview has been lightly edited for brevity and clarity.
HealthLeaders: What can healthcare IT professionals expect as API standardization is implemented at the end of 2022, as the legislation directs?
Micky Tripathi: They should have available to them the standard FHIR API in their EHR. If they don't already have that available to them, they should be asking their vendor where it is.
That will take time for that to get incorporated into workflows. ONC doesn't have the authority to tell a provider they're required to implement it. As you probably know, providers will often not purchase the latest and greatest software upgrade, so it may be that they lag a little bit. CMS rules do require that providers who participate in payment rules, by the third quarter of 2023, have it in their system as a part of certified electronic health record technology. This policy was finalized in the 2021 Physician Fee Schedule based on the updates to certified health IT finalized in the ONC 21st Century Cures Act final rule.
The other thing I think that they can expect is that they'll have the availability of more apps that are connected to their systems. Some may be apps for patients to be able to access their information. Some may be apps that are for provider-to-provider exchange, or other kinds of use cases. The idea of the standard FHIR API is to make EHRs a little bit more like open platforms that spur a lot of innovation for providers and patients to be able to have better use of data that's in EHR systems.
Right now, because you don't have a standard API across all these EHR systems, an app developer has to build one version for Epic, one version for Cerner, one version for eClinicalWorks, one version for Athenahealth [and so on]. And that undercuts the economics of it. It makes it really hard to scale. The opportunity here is to say that standard FHIR API ought to create more innovation that makes the economics better for truly scalable types of apps in the same way that we've seen in other industries.
We published a blog in August where we were tracking how many vendors were actually certified already. We noted at the time that only 5% of vendors had actually certified their system for the standard FHIR API, but those vendors were large vendors, so they actually covered, like, 60% or 65% of hospitals and 75% of ambulatory providers.
HL: Concerns have been raised about the fact that consumers could use these APIs to share their health data with non-covered entities. Such entities may or may not be adequate data stewards of this highly sensitive personal data. Is there a need for ONC to perform ongoing oversight of these entities to assure patient privacy, or is additional legislation or regulation necessary?
Tripathi: The first thing that patients need to know is that using these apps can provide great benefit to them. But when they use these apps, if it's not an app that's provided to them by their provider, then they are taking the protection of the data into their own hands, meaning they're responsible at that point for what happens. So they're responsible for doing the diligence on the app, or making sure that the app has the privacy and security protections that they want, and that the app is sharing information in ways that they deem appropriate.
That's a source of a lot of confusion for individuals in the country, and that's a real problem for us as a country. HIPAA has been called something like the most misunderstood, most important law in the country because people think that HIPAA protects medical record data wherever it lives. And it doesn't. It only protects medical record data when it's in the hands of certain entities, like a hospital, a doctor, or a health insurer. So that's the first thing: Patients absolutely need to know that they are the ones who are responsible, once they've downloaded the information and brought it into apps that they control that weren't provided to them by their provider. It's something that HIPAA didn't really contemplate back in 1996.
Right now, the protections that exist for entities that live outside of HIPAA, and data that flows outside of HIPAA, is FTC Section Five, a consumer protection kind of provision that affords some protection, but not nearly as much as a patient probably thinks it affords. Basically, FTC Section Five says that an organization needs to abide by its published privacy policies. You can have an app that lives outside of HIPAA, and has a privacy policy that literally says we're going to take your data and sell it to whoever we want, whenever we want. And of course, you just click through. That technically wouldn't be a violation because they told you, right? It was in the fine print, but they told you.
The data that that lives outside of the healthcare delivery system itself has a ton of what we would consider medical record information. It's just not in a medical record. Think about the information that is part of what we call the data exhaust, the data that I just leave behind when I'm using my phone. So I get a backache. And I start to search 'backaches.' And then I use Google Maps to go to my doctor. And then I use Google Maps to go to CVS or Walgreens. And then I get the prescription, then I look up the drug on Google, and then I, and then I have fitful sleep for two weeks and every night in the middle of night, I'm picking up my phone and looking at my phone. All of that information is information that one could put together and create what people call an inferred medical record, that I would argue is probably at least as good for that particular encounter as the medical record that my doctor actually has. Because it's a day-to-day track of how I'm doing.
The conversation about privacy is really a much bigger conversation. It's not just HIPAA. It's not just medical records. It's about privacy in general, and just the recognition that we have information that's out there that people can use to infer things about our healthcare that we may not appreciate.
HL: Another issue that comes up with this patient-directed data is provenance. Patients might want to carry their digital X-rays to their next provider. But today, the system seems more suited to asking the next provider to request the X-rays from the previous provider. And that's where lots of complication ensues -- how difficult it is to do that? And we're starting to get into the info blocking issue. Does this new API standardization in any way address the issue of provenance?
Tripathi: It does.
You just described two different patterns for exchange of information. One would be provider-provider, whereas we think of the B2B, and the other would be B2C2B. I get my records from one provider, and then I myself am the broker, or the custodian, of that data, and then I provide it to the next provider.
What we want is to support both, because we think both are really valid, and that provides resiliency and assuredness in the system. In an ideal world, it would actually be automated, so that the provider's scheduling system would see that you are coming in tomorrow, and I should blast out queries to find all the records on you that I can find, so that those are available to the provider when they're doing a review of your chart before you come in the next day. That's how a number of nationwide networks work today. They do look at the schedule one to three days in advance, and they go off and query the information. But we also want to enable, through these FHIR APIs, the ability for you to do just as you said, that you want to be in control of it for whatever reason. So it supports both. TEFCA [the Trusted Exchange Framework and Common Agreement], which we haven't talked about, would support that provider-provider exchange, and the FHIR API kind of capability would support that kind of focused exchange.
HL: Patients also want something that can be auditable. Do the API regulations themselves provide for that?
Tripathi: I totally agree with that. That's one of the ways in which that backbone infrastructure, TEFCA, provides that kind of high-volume, high-reliability capability in the back end that's traceable and auditable. It's a part of the technology and the technical specification. And it's also a requirement from a HIPAA perspective, if you're a provider organization, you're required to keep track of the disclosures that are made of that patient's information to you or to other parties. Now, again, a non-HIPAA entity, they don't have those requirements. So that's the thing to be cautious of.
HL: Will the new APIs help in any way with compliance with the information blocking regulations? Or are they two separate issues?
Tripathi: They are separate issues, but they are related.
The way in which they are separate issues is that information blocking is agnostic to technology, completely. Information blocking is focused on the data that says that there is a corpus of data called electronic health information, which is the electronic portion of the HIPAA-designated record set. And that information is what is required to be made available to patients or other authorized parties, by any actor under information blocking, which is providers, technology developers like EHR vendors, and health information networks. So that's agnostic to FHIR, to CCDAs, it's even agnostic to EHRs.
The data doesn't have to be in an EHR. It's really just about the data. It defines, there is this data and you as an actor are required to make that available if it's available to you electronically. The way in which it's related, and there's an overlap, is that FHIR APIs give a provider or technology developer or health information network another way of making that information available in an easy manner.
HL: It's been some months now since the implementation of information blocking. What is the data telling you from what people are reporting on the information blocking portal?
Tripathi: There's over 500 complaints now. I think it's running at probably something like one every day or two every three days. As you can see on the portal, where we, every month, summarize the data and break it out by category of the complaint, the complainant, and then category of who the complaint is against. The majority of the complaints are coming from patients, or their authorized representatives, I think over 80%, and those complaints are mostly against providers.
500, on one hand, seems like a lot. On the other hand, if we compare it to HIPAA complaints, which are in the tens of thousands per year, it's kind of a drop in the bucket. But we're just getting started here. So those proportions could change just because of small sample and all of that. But we're encouraged, actually, that a large number of the complaints are from patients.
I don't want there to be any information blocking. But to the extent that if you think about these regulations are somewhat arcane, and certainly providers are aware of them, but even a lot of small providers don't sort of fully understand the scope of it right now. And we're doing a lot to try to educate and provide outreach. Vendors understand that because they're actors, and they could get penalized if they don't comply with it. But it was surprising to me that it was bubbling all the way down to patients. So the patients actually knew there is this thing called information blocking, and they actually have recourse. They can actually come to the ONC web site.
HL: How do you process those reports? Do you reach out to the providers who have been named? Do you reach out to vendors who have been named? What does ONC do with that other than collect that information?
Tripathi: The law was fairly specific about the way this has to work, and it's pretty complicated. ONC is responsible for the policy, which is to say, to define what is information blocking, and to define what would be allowable exceptions to sharing of information. That's what we put into effect on April 5, 2021. We said, here's the policy, here's the regulation. You are from this point forward required to comply with this regulation.
But what the law specified was that the Office of Inspector General in HHS is responsible for investigation and enforcement. ONC is not a law enforcement organization. It isn't as if we have investigators who can go out to the field and determine whether someone is complying with that. OIG is responsible for enforcement. They haven't yet published their final rule on how they're going to do enforcement. So right now, in theory, you know, OIG isn't doing enforcement, because they don't have the final rule out.
Now someone can complain directly to OIG if they want, but we were the ones who were stated in the law to set up a portal and allow complaints to come into that portal. What happens with ONC is, we get a complaint, we'll do a high-level screen of it to determine certain things. Is this information blocking, at least on the face of it? Or could it be information blocking without investigation? Payers, by law, were not named, so ONC doesn't have the authority to say, this applies to payers. So we're not going to pass that forward to OIG.
To anyone who submits a complaint, we say that within 48 hours, we'll let you know what's happened to it. And so that means there are two things. One is we'll say if this does not appear to be information blocking, if you'd like to resubmit, please resubmit. But this does not appear to be information blocking. Or we say we have passed your complaint to OIG. And that's all we can do at that point.
HL: What's on your priority list for 2023?
Tripathi: TEFCA is a big one – nationwide network interoperability. To date, our nonprofit partner, the Sequoia Project, has gotten 12 letters of intent from different organizations who are stating that they intend to become [TEFCA] networks. We're anticipating that in early 2023, we'll be able to announce the first set of potential candidate Qualified Health Information Networks who have made it through the first big step, which is that their eligibility has been approved, meaning their application has been accepted and approved, and they are signing the common agreement.
HL: And when this goes live, that will mean a much greater velocity to the sharing of health records?
Tripathi: Yes, it should mean greater velocity. It should also mean a broader aperture to the type of information that can be shared. Now, that won't happen overnight. But we're working very hard to have public health be a part of these networks. For example, right now, you've got nationwide networks like Carequality and Commonwell that do great work, but public health agencies aren't connected, for a whole variety of reasons.
But now with ONC, and the CDC, and other parts of the US government involved, you're helping to provide that overall governance framework, and we're now working with public health agencies to say how can we get them directly connected to these networks, so they can get the information directly from providers in you know, in low-cost ways, that's a better deal for taxpayers. So we're not paying for all these complicated interfaces in every jurisdiction. And it also means higher performance and a better public health system overall.
Closing gaps in care requires knowing just when a technology-powered nudge will help, rather than cause more stress.
At Ardent Health Services, physician burnout is a constant concern, and an issue that technology can address. The challenge for the Nashville-based healthcare organization, formerly known as the Behavioral Healthcare Corporation, is to find the right technology and not make things worse.
To thread that delicate needle, they're using a technology, developed in part by physicians, that identifies gaps in care and cost considerations.
Ardent deployed the IllumiCare Smart Ribbon in June and has found immediate benefits in a metric that often puts "lots of pressure" on its hospitalists, says chief medical officer FJ Campbell.
"The classic metric is discharges before 11 a.m.," Campbell says. "If you're moving your med/surg patients out by 11 a.m., then you're able to transfer your patients from your ICU to your med/surg units. We deployed IllumiCare, and discharges by 11 a.m. went up over 175%."
But reaching this level of improvement involves much more than just plopping the latest technology in front of hospitalists, Campbell says.
FJ Campbell, chief medical officer of Ardent Health Services. Photo courtesy Ardent Health Services.
Ever since he attended medical school, Campbell has been intrigued by the inefficiencies evident in the hospital setting.
"When you're a surgery resident, and you're in the hospital 100 to 110 hours a week, you take inefficiency personally," he says.
After passing his boards, Campbell pursued an MBA and entered hospital administration, initially as director of medical operations at Virtua Health. A stint at Centennial Medical Center, a flagship hospital of HCA, reinforced a notion to bring clinicians into operational decisions, one that ultimately informed his interest in tools such as Smart Ribbon.
"People who understand workflow make better products," he says. "And good workflows lead to good clinical outcomes, which lead to good financial outcomes."
Since then, Campbell says he has sought out technology defined in part by clinicians themselves, since they're the ones who ultimately have to live with that technology.
After HCA, Campbell became an equity partner and chief medical officer at an urgent care company called CareSpot. He also served as vice president of clinical services at Community Health Systems before moving to Ardent.
At Ardent Health Services, Campbell is responsible for all clinical service lines and initiatives, including hitting the health system's CMS metrics and Leapfrog scores. Nursing and case management services also report to him.
"The case management activity has been concentrating on moving patients through the continuum of care," he says. "The nursing activity has been around how do we leverage technology to overcome the staffing challenges that we have?"
Campbell also helps identify opportunities to start delivering care more effectively outside of the hospitals' four walls. That focus on workflow was intensified by the pandemic.
"We had to be conscious and cognizant of workflow," he says. "Like, how are we going to separate respiratory illness from non-respiratory illness? How are we going to turn a med/surg unit into a step-down unit? How are we going to make negative pressure rooms widely distributed now?"
Pandemic time highlighted the number of clinicians who didn't have a clear enough understanding of operations and their challenges, Campbell says.
"You had many operators with no clinical background, who had to understand clinical medicine a lot more to really appreciate how they could problem solve," he says. "COVID created a nexus and a need for it between operators and clinicians. We're going to have to be doing more to leverage technology to achieve our clinical and operational outcomes."
Clinicians want to be well-informed, but any hints or nudges from technology must be delivered in a manner that is not disruptive to their workflow, Campbell says.
"It really starts getting back to [technology] made by end-users for end-users," he says. Best practice advisories from EHR vendors such as Epic must be accurate, and IllumiCare, by populating the Epic App Orchard with its own apps, adds more important ways to inform clinicians without being intrusive.
"If you're going to give them something that is going to take their attention away from the next lab to track down or the next X-ray value to assess, your clinical decision support content had better be spot on, easy to access, easy to understand, and therefore easy to execute on," Campbell says. "Otherwise, forget it; you will be blown off in a New York minute."
Executives should focus even more on workflow as the successful path to technology adoption, he says.
"I'm going to bring you a tool that's going to make it easier for you to execute on your job," he says. "You're either going to see that very quickly, or if you won't, you're going to help position me to make modifications with the other clinical partners that we have."
Cherry Health is using EHR technology to launch new services and view and share data with other providers as it transitions away from fee-for-service care.
Federally Qualified Health Centers (FQHCs) are a breed apart. Incorporating multispecialty practices with primary care, behavioral health, and even dental care, these 1,400 providers across the US see some 30 million Americans a year, many insured by Medicare and Medicaid.
One such FQHC, Cherry Health, covering western Michigan and headquartered in Grand Rapids, serves more than 65,000 patients annually via a network of more than 80 providers and 800 healthcare professionals. The patient population is 55% Medicaid, about 15% Medicare, perhaps 20% uninsured, and a very small percentage of commercial payer coverage.
Like many other FQHCs, Cherry Health has partnered with NextGen Healthcare for its electronic health record platform. NextGen is now leveraging the cloud to allow providers to share performance metrics and learn from each other.
This should help Cherry Health as the nation's FQHC network, supported by funding from the Health Resources and Services Administration (HRSA), continues to get squeezed, and value-based payment models are just around the corner.
"The reason that we stayed with NextGen was due to the flexibility in our different specialties," says Glenda Williams, chief information officer at Cherry Health. "We can have one integrated health record, that we don't have all these separate systems that all of our staff need to look up to be able to care for the patient."
Glenda Williams, chief information officer at Cherry Health. Photo courtesy Cherry Health.
The technology also helps with another critical issue affecting healthcare: Stress and burnout.
"Our strategy has been to talk to our providers to identify what additional technologies we can put in place to help them so that they're feeling less burned out," Williams says. "Whether or not that is from a technology standpoint, from my side, or whether or not it's from a staffing side from our CMO side, maybe they need extra help. Maybe they need a different workflow. It's really about identifying what needs they have and coming up with a solution."
Cherry Health is transitioning from fee-for-service to value-based care, says Cynthia Duncanson, the organization's chief financial officer.
"We do get paid on a fee-per-service basis, and our incentives are relatively low compared to what our program income is from the Medicaid fee-for-service payments," Duncanson says. "But we are getting ready to transition within the next year or two to an alternative payment methodology for our primary care medical population, where it will be per member per month, completely crosswalked between that fee-for-service with a little bit of incentive, all the way over to mostly incentive. Medicare's also crosswalking us in that same direction as well."
In 2022, in anticipation of this change, Cherry Health implemented NextGen's population health tool, Williams says.
"My strategy is having access to data and using the data to make our decisions," she says.
NextGen has added an extra tool in this regard, by establishing a national collaborative of FQHCs using its EHR several months ago, according to Srinivas Velamoor, executive vice president and chief growth and strategy officer at NextGen Healthcare. More than 60 have signed up so far, and NextGen expects that number to grow beyond 100.
"They all have common issues in terms of having visibility to metrics, like no-shows, and making sure they're looking at the same quality measures," Velamoor says. "They are very eager to understand how they're doing relative to others in the country that look like them, and not just focus on their own performance."
Williams says the collaborative will allow FQHCs to be more innovative in solving the clinical problems they face.
"Why reinvent the wheel if someone else has already has a solution in place?" she says.
For example, in addressing no-shows, the FQHC can separate patient populations out into groups, identifying those who don’t have e-mail addresses, or those who prefer phone calls or text messages, so as to better target its messaging and marketing campaigns.
"We're the first FQHC to have that dual designation," she says.
This will allow Cherry Health's providers, including physicians, nurses, physician assistants, and community health workers, to move from station to station within clinics while the patients remain in one place, instead of traditionally being shown into room after room, Duncanson says.
The challenge of making all these changes requires close communication between Williams, Duncanson, and the rest of the leadership team.
"We're constantly collaborating," Duncanson says.
"We're just two doors down from each other, and we've got a standing meeting to go over any issues that we may have, and we produce monthly reports that we share," Williams says.
The GIThrive platform combines gut bacteria analysis and trigger food identification with app-based personalized action plans, food diaries, educational materials, and 24/7 personal support from registered dietitians and health coaches, backed by a multidisciplinary team of gastroenterologists, microbiome scientists and other clinical professionals.
"When you look at different chronic conditions where digital health has really tried to make an impact, you've seen a lot of organizations and solutions focus on people suffering from diabetes or behavioral health issues," says Bill Snyder, chief executive officer at Vivante Health. "There's been a big gap in the solutions that that work with patients who suffer from chronic digestive issues."
Vivante Health clinicians are licensed in all 50 states with type II NPI (National Provider Identification) numbers, Snyder says.
Bill Snyder, chief executive officer of Vivante Health. Photo courtesy Vivante Health.
"We're very focused on supporting the existing care ecosystem," he says. "We're not looking to replace gastroenterologists, because there's great work that they do. What we're doing is front-end work. We're evaluating acuity. In many cases, we're finding high-acuity patients and telling them, you really need to get in to see a provider in a brick-and-mortar clinic, or see a gastroenterologist, because you're presenting with some pretty high-risk potential condition attributes."
The organization partners with health plans and self-insured employers to make its program available to members and employees.
"58% of our membership today does not have a formal diagnosis, but they've come to us with an average of 3.9 symptoms," Snyder says. "That can be for different reasons. From some, they don't have access to the care they need. For others, maybe they've seen providers, but haven't been able to get a diagnosis, and haven't been able to get any symptom reduction. Or for others, maybe they haven't seen a provider, and they really should."
The GIThrive app acts as a point of intake. Users are asked questions about their symptoms and condition, if they are taking medication, and if they're working with a provider. Vivante then assesses the user's acuity and builds an evidence-based clinical protocol based on that information.
Based on that protocol, Vivante Health's remote care team of health coaches and registered dietitians support patients as they work on alleviating their symptoms or seeking in-person care.
Vivante Health also offers an optional microbiome analysis and, beginning in 2023, will incorporate more third-party tests, such as full lab panels.
Snyder says Vivante Health has helped thousands of patients since its launch two years ago.
A large proportion of Vivante Health's patients do not need to be referred into a brick-and-mortar facility, Snyder says. Instead, Vivante Health's team works with these patients to identify trigger foods and provide services such as medical nutritional therapy and cognitive behavioral coaching.
The benefit to employers is reduced emergency room visits and improved medication adherence, he says.
"From a patient outcomes perspective, they're coming back and saying, 'I feel better, my symptoms are reduced, I have a much better idea of how to improve my digestive health, and my overall health and well-being is improved as well,'" he says.
Vivante Health is also attracting attention from traditional health plans and is looking forward to moving ahead with some of those relationships in 2023, Snyder says.
Another tool in Vivante Health's toolbox is GI Mate, a handheld breath hydrogen monitor. The device, which measures hydrogen concentration in a user's breath, can help identify lactose intolerance and several other digestive disorders.
Prior to joining Vivante Health, Snyder spent nearly 12 years at Humana, ultimately heading up the insurer's Chicago office. After Humana, he headed sales at Virta Health, which treats type 2 diabetes through a physician-led remote care team, including individualized nutrition therapy.
"I've always being doing entrepreneurial things," he says.
Snyder left Virta to join Vivante because "there's a huge opportunity here to impact a lot of lives in an untapped space." A family member who suffered from digestive symptoms and conditions impressed upon him the toll that can take on a life day to day, he says.
One challenge to growing a digestive health-oriented provider is the stigma attached to the condition.
"We hear it time and again that people were nervous about accessing care, nervous about talking about it," Snyder says. "It's unfortunate that it still occurs."
One of Vivante Health's investors is Intermountain Ventures, an arm of the integrated health system based in Salt Lake City.
"Just having the opportunity to talk about Vivante Health with Intermountain's gastroenterology team, and some of their other practitioners, so they could understand what we're building, was phenomenal," Snyder says.
The biggest challenge of his job is keeping the patient first, he says.
"It's heavy lifting, and it's a lot of work," he says. "The great part is, it is definitely a great mission that people get behind and are excited to be pushing forward."
Southern California Kidney Consultants is collaborating with Strive Health to improve outcomes and chronic care management for Medicare patients living with kidney disease.
Higher quality, cost-effective kidney care is the goal of a joint entity formed between the largest nephrology group in Orange County, California, and a Denver-based technology company.
The joint venture between Southern California Kidney Consultants (SCKC) and Strive Health is targeted at Medicare beneficiaries in Southern California, whereby each partner shares in the financial benefits, management, and governance of risk contracts with Medicare and Medicare Advantage plans and Independent Physician Associations (IPAs), aimed at improving outcomes and reducing costs.
The partnership includes 21 providers, based mostly in Orange County, who serve 5,000 patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Leveraging Strive's platform, SCKC aims to prevent the progression of kidney disease.
Centers for Disease Control and Prevention (CDC) estimates show that kidney disease impacts 37 million adults, or 15% of the US adult population, including more than 38% of those over 65 years old. Kidney disease is responsible for $410 billion of unmanaged annual medical spend, demonstrating the need for payment models that are based on outcomes.
"We know that our dedication to value-based models will make our practice a leader in the community," says nephrologist Nirav Gandhi MD, one of SCKC's partner/owners. "We evaluated several partners to help us on our journey and are confident that Strive offers the strongest vision, capabilities and team in value-based kidney care.”
The new SCKC/Strive entity contracts with Medicare, Medicare Advantage plans, and IPAs to take risk on the outcomes and costs of their kidney patient populations. Strive will supply SCKC with access to data and technology resources, administrative support, management expertise, and an interdisciplinary clinical care team including nurse practitioners, dietitians, pharmacists, care coordinators, and licensed clinical social workers. These team members act as an extension of the nephrologist’s office and help manage comorbidities, such as diabetes, that can impact a patient’s overall health.
"For so long, the investments in this space have been really focused on treating people with kidney failure once their kidneys fail," says Ben Kuhn, senior vice president of partnerships and growth at Strive Health. "A big focus of Strive and this partnership is on getting upstream, intervening with patients who have chronic kidney disease, helping to prevent and delay the progression of their kidney disease to avoid kidney failure. That's obviously in the interest of the patients, the providers, and also in the interest of the payers."
For SCKC, the partnership is intended to break a vicious cycle of patients failing to follow-up with their care providers or keep in touch in a timely fashion, which can lead to adverse health outcomes and even death.
"We get referrals of patients who have anywhere from mild to moderate to severe kidney disease that are sent to us in the office," Gandhi says. "What happens is sometimes these patients, whether it's insurance-related or they get lost to follow-up, or they just have a hard time for socioeconomic reasons, or various other reasons, they are not able to follow up or necessarily adhere to the treatments and everything that's necessary to try to delay progression of their kidney disease. They may end up suddenly crashing into the hospital ER, where they present and they're in advanced kidney failure."
In deliberating whether to partner with Strive, SCKC's partner/owners did due diligence, Gandhi says.
"Anytime you have a bunch of doctors who have a little bit of intelligence and ego, we're all going to have some opinions," he says. "We've been working on something like this for over 18 months and Strive is not the only company we spoke to. We had presentations with other companies. We even spoke to some of the large dialysis organizations, to figure out who we think would partner best with us to do what we wanted to do."
Competitive approaches varied from technology companies trying to do healthcare to healthcare companies trying to do analytics.
"We thought Strive was kind of both," Gandhi says.
SCKC will use Strive’s technology platform, which gathers data from hundreds of sources, to gain a holistic view of the patient’s experience. That information can help paint a picture about the risk of hospitalization or progression of disease, helping nephrologists better tailor care to a patient's specific needs.
"We’re giving leading nephrology groups the ability to intervene earlier based on data, which enhances the patient experience and makes expensive treatments less necessary," Kuhn says. "SCKC has leaned into these innovations, and the group and their patients are well-positioned to succeed in the future of kidney care."
The SCKC/Strive partnership also fits in with the Comprehensive Kidney Care Contracting Program launched in 2021 by the Centers for Medicare & Medicare Services' (CMS) Innovation Center, whereby nephrologists can take on value-based care incentives for Medicare patients they are already seeing.
"We were not going to join somebody where we're not heavily involved in decision-making, because we still think we know what we're doing better than anybody else when it comes to taking care of these patients," Gandhi says.
Strive manages more than 56,000 patients with CKD and ESKD through partnerships with nephrologists and other care arrangements with payers and providers. Earlier in 2022, the company signed a nephrologist-led partnership with the nation’s largest nephrology group, Nephrology Associates of Northern Illinois and Indiana (NANI).
Voice-enabled technology supports residents' independence and connects them with caregivers.
A senior care facility owned by one of the largest health systems in the country is deploying voice-activated "digital concierges" to bring together residents, their care teams, and loved ones to improve their quality of life and health.
The Gardens at St. Elizabeth, a Denver, Colorado-based CHI Living Community and division of CommonSpirit Health, is using Serenity, a network platform based in part on Amazon Echo Show devices, to reduce the burden on staff and empower residents to receive timelier updates on their health and living situation.
Overseeing this effort is Jane Woloson, executive director of The Gardens at St. Elizabeth.
"Serenity is an essential part of our communication by helping support independence for our residents, connecting our internal and extended care teams, and giving families more peace of mind that their loved ones are receiving the excellent care we are known for," she says. "Each day, we see the powerful impact this solution has on our residents and our community."
With her professional roots in the hospitality industry, Woloson sees similarities between running hotels and senior living communities. Since 2008, these communities have been more focused on the clinical aspects of the business, she notes.
Jane Woloson, executive director of The Gardens at St. Elizabeth, part of the CommonSpirit Health network. Photo courtesy The Gardens at St. Elizabeth.
The Gardens at St. Elizabeth features 132 independent living apartments and 57 assisted living apartments, with another 12 assisted living apartments and 36 memory care apartments opening within a month. The building has a long history, containing a 125-year-old chapel, and serving originally as a tuberculosis sanitorium and, later, an orphanage. It became an assisted living facility 40 years ago.
"One of my personal philosophies is to support independence," Woloson says. "If we can set residents up or give them the tools to be as independent as possible, I think we're moving in a successful direction."
Each participating room is equipped with an Alexa smart device. Residents can ask and receive voice-enabled answers to common questions, such as the day's lunch menu, or activities, and they can summon staff. Front desk personnel can communicate via the device to let residents know when a package is waiting for them. Residents will also be able to sign up for activities such as beauty appointments and transportation.
On the clinical side, Woloson says, these devices can help implement care plans for residents. Rounding physicians, hospice, home care, pharmacy, home health, and other providers are able to participate on the platform with patients.
"It saves a lot of phone calls to the front desk," she says. "Patients are not relying on someone else. Maybe they have failing eyesight, and they can't see the daily menu themselves."
The Serenity Connect platform and accompanying app, and its secure messaging, are HIPAA compliant, and also allow authorized family members to keep tabs on the resident's communications via the Alexa devices. These family members also have a direct line to key staff at the facility.
"Our nursing staff are getting instantaneous information," Woloson says. "Nurses can look at the app and have a great pulse on exactly what's happening with each individual resident's care."
A corporate leadership group at The Gardens at St. Elizabeth worked with corporate attorneys and the IT department to select and deploy the technology, initially as a pilot project. If residents ask the Alexa device something that would go against HIPAA guidelines, the device responds that it cannot answer that question, Woloson says.
"There's a false perception that senior citizens have no interest or bandwidth to work with such devices," she says. "That's not the case. The feedback from residents has been extremely positive. The data says they're using it, on average, four times a day. I think that's fantastic."
A study performed by Serenity and The Gardens at St. Elizabeth found that the platform saves five to 10 hours per week per key staff member at the facility. In addition, the platform reduces resident isolation and loneliness.
The Gardens at St. Elizabeth deployed the platform during the pandemic.
"It was a great time to do it, because of the importance of communication," Woloson says.
The platform has also become a selling point for the facility, as prospective residents and their families shop around for assisted living. So far, the platform has led to three new waitlist sign-ups and two new move-ins, she says.
Prospective residents who may be on a waitlist will soon be able to begin participating in the Serenity platform before moving in, providing a new kind of onboarding, Woloson says.
"At the time that Serenity Connect was introduced to us, I jumped all over it as something I wanted to participate in," she says.
The Indiana-based health system's new program supports recovering patients at home through personalized engagement and remote patient monitoring.
Parkview Health, a not-for-profit, Indiana-based network of 10 hospitals and more than 100 clinics, will be offering virtual care programs designed to support patient recovery and self-management at home.
The program, featuring patient engagement, device-based monitoring, and telehealth tools to manage patients who are at risk of readmission, is being deployed in partnership with Veta Health, a provider of remote patient monitoring services.
"A strong virtual care offering is essential to how we best serve our post-acute and chronically-ill patients who are most at risk," Maximilian Maile, senior vice president of digital health at Parkview, said in a press release.
Parkview selected Veta Health to replace its existing telehealth platform, with plans to support more services soon. The multi-year partnership, which encompasses integration with the Epic EHR, will enable the health system to move patients more seamlessly through its care settings and reinforce the clinician-patient relationship.
Once they are enrolled, patients receive biometric monitoring devices to record their vital signs and a digitized care plan to report their symptoms, with communication via cellular data networks to Veta and Parkview. Patients can also view educational content and communicate with their care team via video conferencing. Digital care plans are uniquely tailored to each patient.
The RPM platform is designed to alert care teams about risk factors and disease exacerbation, permitting proactive, early intervention. By leveraging remote monitoring devices and telehealth capabilities to support the care journey, the program will offer connected layers of interaction and support from care teams to optimize recovery and outcomes.
Parkview Health is a not-for-profit, community-based health system, which serves northeast Indiana and northwest Ohio, covering a population of more than 850,000 people.
CHIME will distribute information collected by Health-ISAC, including newsletters, lists of vulnerabilities, threat bulletins, and other actionable and relevant information. This may include indicators of compromise, tactics, techniques, and procedures (TTPs) of threat actors, advice and best practices, mitigation strategies, and other related material.
Members will also have access to the Health-ISAC annual report, focused security research prepared by or in collaboration with the Health-ISAC, white papers, and other relevant non-technical material to healthcare CIOs.
“We are very excited to have this opportunity to share with the members of CHIME and AEHIS,” Denise Anderson, president and chief executive officer of Health-ISAC, said in a press release. “We see it as our mission to strengthen the resilience of the health sector through the sharing of actionable situational awareness, threat indicators, vulnerabilities and best practices among other intelligence vital to the security of health organizations. In addition, through this partnership we offer an opportunity to join our trusted community and the valuable information, connections and services we provide.”
CHIME is an executive organization serving chief information officers, chief medical information officers, chief nursing information officers, chief innovation officers, chief digital officers, and other senior digital health leaders. CHIME serves more than 5,000 members in 56 countries and two US territories, and partners with more than 160 healthcare IT businesses and professional services firms.
Health-ISAC is a global, non-profit, member-driven organization offering healthcare stakeholders a trusted community and forum for coordinating, collaborating, and sharing vital physical and cyber threat intelligence and best practices.
Health information exchange technology helps reduce wait times for follow-up care after ED visits.
A certified community behavioral health clinic in Richmond, Virginia, is benefitting from a real-time statewide health information network that lets clinicians track their patients' emergency room visits.
Powering this data feed is Virginia Health Information (VHI), a private 501(c)3 organization in existence since 1993, which recently implemented a layer of technology to speed the flow of patient admission, discharge, and transfer information between different healthcare organizations around the state.
This enables allows care teams at Richmond Behavioral Health Authority (RBHA) to identify their patients presenting at other points of care, enabling rapid response for behavioral health crises and other urgent matters and connecting them to RBHA's case management services for longer-term support, tailored to their unique needs.
VHI Chief Executive Officer Kyle Russell is basically the second leader of the organization, starting as a data analyst working on an all-payer claims database in 2013. Back then, received claims information lagged could be six or nine months behind, but since its primary use was in research and setting health policy, that kind of lag was acceptable.
In 2019, by an act of the legislature, VHI became the health information exchange for the commonwealth of Virginia. Real-time reporting, such as vaccinations, became imperative.
Now, "the biggest program by far within the health information exchange is the Emergency Department Care Coordination Program (EDCC)," Russell says.
VHI became the vehicle through which clinicians could determine whether a patient had been in any of 10 different clinics or emergency rooms in the past six months, for instance.
RBHA's BeWell, part of its certified community behavior health clinic, began eight years ago with funding from the state and the Substance Abuse and Mental Health Services Administration (SAMHSA), a program of the US Health and Human Services Department, and has served more than 3,000 people since then. RBHA serves a population of uninsured Medicaid patients, providing case management, psychiatry, primary care, group counseling, all over one roof, according to Sara Hilleary, program manager for RBHA's integrated care clinic.
By August 2020, RBHA, which also serves as the community services board for the city of Richmond and surrounding areas, was poised to begin using the new, more real-time information. Rates of domestic violence and suicidal ideation had spiked as the COVID-19 pandemic raged. RBHA received additional SAMHSA funding to connect its systems to VHI's and begin tracking its patients as they presented to clinics and emergency departments in Virginia.
Part of what powers the actionable health information exchanged is when emergency clinicians enter specific ICD-10 codes into each patient's record. Specific ones, such as a code indicating the patient has engaged in self-harm, alerts programs such as RBHA to initiate follow-up outreach to patients. Additional data points, such as missed appointments, can be correlated to ED visits and the ICD-10 codes to paint a more complete picture of patients at risk.
EDCC is also able to generate reports to track ED utilization by various time periods such as one week, a month, or six months, Hilleary says.
Although state and federal grants help maintain the operation of VHI, the information exchange also must rely upon support of health systems who participate in its network.
EDCC was brought into being by mandate of the Virginia state assembly in 2018. Although every health system in the state must connect to EDCC, "we have to operate like a business that either has to provide value to the state of or value to a private entity to make it all work," Russell says. "For most entities, it doesn't cost them anything."
RBHA did not sign on right away, but was an early adopter of EDCC, Russell says.
The care coordination software powering the EDCC is provided by PointClickCare.
"We get e-mail alerts, and then we are able to reach out to hospitals, if individuals are still there, or we are able to reach out to the individuals themselves and see if they need either to get reconnected with services or collaborate with them or their current care providers if there are any other needs," says Jillian Olson, an RBHA care coordinator.
The sudden statewide activation of EDCC posed its own challenges to VHI.
"You have this mass avalanche of connectivity that comes in with the mandate," Russell says. "You're going from zero to like a really big system in six months, but then after that, it's a trickle, because it's voluntary," with variation in what the attached providers do with the exchanged information. RBHA excels at doing a lot with it, he adds.
The pandemic complicated this next growth phase of EDCC, Russell says.
"With COVID, [ER] utilization went down," he says. "So how do you know how it's really doing?"
But over time, EDCC data shows that by implementing a care coordination program such as that in place at RBHA, ED utilization consistently drops 20% to 40%, Russell says.
And the care coordination platform also decreases wait times for patients requiring post-ED follow-up care at RBHA, Hilleary says.
As for other health systems that haven't yet tapped the potential of EDCC, Russell says many eyes are on the state to see how various players are participating.
"The health plans notice," he says. "RBHA is like this rock star contributor. If someone [else] is connected and doesn't do anything with it, what does it take to also get them to become strong, active users? That's where the real value-add change happens."
Part of that is being driven by informal regional collaboratives, such as one in the Tidewater region of Virginia, sharing best HIPAA-compliant data sharing practices among hospitals, health plans, freestanding and ambulatory practices.
"We don't have to push that," Russell says. "They're taking ownership of it themselves. We're looking at doing something like it in the Piedmont area" of Virginia as well.
