Using Automation to Reach Patients

Provider organizations can use an automated process to generate health risk assessment data. Patients receive an e-mail inviting them to complete an HRA. When they click on a link, it takes them to the HRA on a website. After they answer the questions, the application automatically calculates scores for their risk factors and their willingness to change their health behavior.

Care managers can use this data in a variety of ways. For example, they can identify all patients with high-risk scores. They can also stratify the population as high, medium or low risk, with the assistance of registry reports, and use that classification as the basis for appropriate interventions.

Engaging Patients to Change Behavior

Care managers may also factor in each patient’s willingness to change. For example, if a patient has high blood pressure, is overweight and is an active smoker, but is not ready to change, the care manager might consider that patient for an online education program or might send a message inviting him or her to attend a motivational program offered by the healthcare system.

Learn More

Listen to a webinar about engaging patients using care automation within an ACO environment.

Methods of Evaluating Educational Outcomes in Diabetes Care

The study will compare four methods of evaluating educational outcomes in diabetes care:

1. Physician self-reports
2. Competency assessments based on case studies
3. Examination of a sample of patient charts
4. Data drawn from Phytel clients’ electronic registries, which cover all of a practice’s patients with diabetes

“Phytel’s expertise in population health management and its comprehensive database will enable Joslin to make valid comparisons among different methods of assessing performance and patient level outcomes relative to educational and non-educational interventions.”

– Julie Brown, CCMEP, director, Joslin Diabetes Center

Quality Initiatives Focus on Physician-Led Population Health Improvement

This is just one of many Phytel quality initiatives that are focused on physician-led population health improvement.

Other recent 2012 announcements include:

• NCQA Approved Use of Phytel Solutions to Meet Medical Home Criteria. Physician practices can receive automatic credits toward NCQA recognition if they deploy Phytel’s patient outreach and care management services.
• Phytel was announced to be on the advisory committee of the AMGA’s Chronic Care Challenge around Hypertension. The American Medical Group Foundation (AMGF) is launching a national multiyear campaign to reduce the burden of hypertension and related chronic conditions.
• Dr. Richard Hodach, Phytel’s Chief Medical Officer authored a peer-review article within HMFA entitled Automation is Key to Managing a Population’s Health. The article discussed requirements for success with population health management include a high degree of clinical data integration across the healthcare organization’s care enterprise and automated tools for engaging patients in their own care.

Whether our clients are pursuing PCMH, ACO or P4P quality initiatives, our solution and services can leverage existing EMR data to help automate and engage patients for population health management across dozens of conditions and measures – all while demonstrating financial performance! In fact, hundreds of physician groups and healthcare systems that collectively care for more than 20 million patients use Phytel’s patient outreach, care management, patient engagement, transitions of care and analytics solutions in population health management.

And Phytel, because of our focus around quality and health outcomes – is invited to become engaged in more and more projects like Joslin Diabetes.

Read our white paper Improving Compliance to Diabetes and Hypertension Protocols Using Coordinated, Proactive Outreach.

Traditional Quality Programs Aim to Improve Existing Products

Traditional quality programs, such as Lean and Six Sigma, focus efforts on improving existing products and services. For instance, the established process improvement approach for Six Sigma is called DMAIC (Define, Measure, Analyze, Improve and Control). After project sponsors define an improvement opportunity, a project improvement team measures the current state, analyzes for root cause, improves the existing process by eliminating the root cause and then controls the improvement by ensuring old ways do not creep back into the improved process, product or service.

Since the late 1980s, when Motorola developed the methodology, this traditional approach has been successful for many companies. The same can be said for Lean after Toyota developed the Toyota Production System.

However, even with the plethora of success stories, traditional quality programs can sometimes come at a devastating price, because improving an existing product or service assumes the status quo will continue. As a result, although it is in a “new and improved” state, it is still the same product or service. What happens when the market shifts and no longer desires that particular product or service?

Improve or Innovate Your Healthcare Product or Service?

Investing resources on improving a product or service that is at the end of its life is akin to improving mechanical typewriters when the market was demanding word processors. This mindset can be even more damaging because it  draws attention away from an imminent external paradigm shift and focuses on an internal self-fulfilling optimism for the dying product, which results in missed opportunities and eventual demise.

In the healthcare industry, where the speed of change is equal to, if not greater than many technology hypergrowth markets, organizations must constantly review their products and services before spending time or resources on improvement.

There are certain situations in which continuous improvement can further enhance customer satisfaction and loyalty, resulting in even higher demand. But for most organizations, a different approach is needed; one that is geared toward innovation.

Phytel’s Approach to Innovation

Fortunately, an approach to innovation does exist, referred to as Design for Six Sigma. There are several different Six Sigma designs a company could use, but the method depends on the type of product of service provided. Here at Phytel we use an innovative methodology termed DMADV, an approach especially useful for innovating software and service processes.

5 Steps to Innovate Healthcare Products and Services

Define and Measure

After the need for innovation is identified (Define), the project team begins collecting the Voice of the Customer (Measure). During this phase, several concepts are deployed, including industry-standard tool called a QFD (Quality Functional Deployment), which prioritizes and maps our customers desires to delivery options.

These customer desires are referred to as CTQs (Critical-to-Quality features or services). CTQs in the healthcare industry could come from clients, patients, quality organizations (such as the NCQA) or regulatory agencies. In the QFD, the relationship between each CTQ and how to deliver is measured, allowing subject matter experts to determine which features to develop in the new product or service.

Analyze

Once the CTQs and the approach to deliver them are defined, the project team outlines, at a very high level, alternative solutions (Analyze). Additional tools, such as a Pugh Matrix are used to compare the various alternative designs, often resulting in what is referred to as a Frankenstein model. The Frankenstein model takes the best of all the alternative solutions and combines them into one best approach.

Design

The design with the highest score, typically the Frankenstein design, would then transition into the detailed design phase (Design). During this stage, the high-level design is analyzed and broken down into a task-level structure than can be performed at an individual contributor level.

At this point, the design on paper is then translated into what is referred to as a Transfer Function. This is a mathematical representation of the design so that the performance of the design can be measured against the CTQs. Usually tweaks to the design occur to improve the likelihood of achieving the desired results. Once the design is structured, the team then determines what type of changes is needed to support the new product or service. Many times, technology changes, process changes and training are required to prepare the organization.

Verify

Finally, the product or service is piloted on a small scale in a beta environment to check for final tweaks and to gather measurement data on the results (Verify). During this final phase, the project team collects data from the pilot and ensures that the process to produce the new product or services is stabilized. Control Charts are often used to determine process stability, followed by a capability analysis to determine the probability of delivering against each CTQ. The new product or service is monitored throughout its lifecycle for continuous improvement. That is, until it is no longer in demand.

Conclusion

When should a company operating in the healthcare industry innovate rather than spend time and resources on improving existing products and services? Well, the answer to that question depends on the life stage of each product or service offered.

But keep in mind that this is the “tip of the iceberg”. As was learned by the disease management industry and emphasized in a recent publication by Ian Duncan, this could be a mistake. Below the waterline, so to speak are other cohorts of individuals with varying degrees of health risk and cost that will be the next individuals in the top 5-10%.

Beyond High-Risk Patients

So while PHM focuses partly on the high-risk patients who generate the majority of health costs, it has to systematically address the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbate their illnesses.

According to the Healthcare Risk Adjustment and Predictive Modeling by Ian Duncan, the implication of the analysis for predictive modeling may be seen in the transition of members between cost groups.

The first point to note is that the overall cost distribution remains relatively stable. Healthy members count for 69.5 percent of all members in the baseline year and almost 67.6 percent in the subsequent year. Within the Low cost category (67.6 percent), however, 85 percent of members (57.4 percent of the total 67.6 percent) were previously healthy, and 15 percent regressed from Chronic or Catastrophic categories to Healthy. Conversely, Catastrophic cost members were 1.8 percent of the population in the baseline year and 2.2 percent in the subsequent year. Fewer than one-third of these members (0.6percent of the total 2.2 percent) were previously catastrophic.

Importance of Intervention for All Risk Levels

This and other research has demonstrated that there is considerable movement between cohorts. Understanding that and being able to effectively and efficiently intervene is crucial. Or said another way, managing, outreaching and providing care and education to what is beneath the waterline is critical to success.

Leveraging Technology and Automation

Such an approach requires the use of automation. Not only are there not enough providers and care managers to manage every patient continuously, but PHM also involves a large number of routine tasks that do not have to be performed by human beings. Bringing modern information technology to bear on these tasks saves time and money and makes PHM economically feasible. Automation also allows organizations to better assess population needs and stratify populations based on geography, health status and utilization, and demographics.

So in the end:

• You have to accept that there is a roll for managing the complex patients with the highest costs at the top but if you don’t manage the patients across the population, you will fail in managing cost across the whole population.
• Being able to stratify the population by health risk and clinical care gaps is critical to be able to mange with limited resources.
• You need both a high-performance team as well as technology automated wherever possible to achieve the goals of population health management.

Download Phytel’s white paper on Population Health Management.

Overall, this was a great article with comprehensive points detailing the challenges that physicians and practice administrators need to consider for an ACO model. However, I had some concerns over the prominence the article gave to using an EHR to mine population data. Specifically in point #2, the author briefly mentioned “Additional Responsibilities,” stating that staff needs to take on extra responsibilities for outreach to manage a population etc.

ACOs Will Benefit from Automation

While it’s true that EHR systems have the data, they are specifically designed to assist physicians to care for individual patients, not for managing a population or large patient panels, as ACOs will require. It is crucial that physicians and administrators understand the drastically different workflows and capabilities needed beyond the raw data, and that without proper automation, these “additional responsibilities” cannot be scaled to effectively impact the population and have the potential to break a practice’s back.

For ACOs to be effective, practices will need to closely track a patient’s care history to identify and meet their care needs. This includes monitoring a patient’s status between episodes of care so the practice can intervene proactively, give patients appropriate support, and engage them in their own care. More and more physician groups are using electronic registries and patient outreach programs to assist them in these efforts. By using the registry data from EHRs, these programs can send automated phone, e-mail or text messages to patients, telling them to make an appointment with their physician. Such tools enable physicians to practice at the top of their license and relieve their care teams from being overwhelmed with the responsibilities care management of large populations entail.

Engaging Patients, Managing Care

In effective ACOs, automation will be key to engaging the patient and managing their care, allowing practices to:

• Use registries to track the health status and care gaps of all patients
• Use proactive outreach to notify patients when they need care
• Manage more patients at different levels of risk
• Automate case management and transitions of care workflows
• Implement educational and operational improvement processes

The transition to ACOs and other emerging models of care is certainly top of mind for physicians right now so the more education and communication we can have on these issues, the quicker we’ll reap the rewards of better population health.

Patient-Centered Medical Home Improves Care Coordination

The PCMH is already generating tremendous enthusiasm among providers and payers. In 2012, it will join the mainstream of healthcare delivery as organizations recognize that it is the best vehicle for attaining the objectives of accountable care.

Without the ability to leverage digitized clinical data, it is impossible to achieve the medical home’s primary goal of improving care coordination in a scalable way. Fortunately, the federal government’s HITECH incentive program is driving the rapidly increasing adoption and meaningful use of EHRs. As structured electronic data becomes the norm, many more providers will be able to tap clinical databases for real-time identification of care gaps, automated outreach to patients who need preventive and chronic care, care coordination, predictive modeling and risk stratification of the population. These tools will help providers build successful medical homes and ACOs.

Automation Technology Supports Patient Engagement

Meanwhile, efforts to promote patients’ engagement in their own care will benefit from the accelerating use of automation technology to replace outmoded, inefficient manual processes. In addition to automated patient outreach methods, online educational tools and health-risk assessments will become commonplace. Mobile health applications will proliferate. Most important, physicians and care teams will have the tools they need to maintain continuous contact with patients between office visits or episodes of care.

Population Health Management and Automation

Finally, care management will benefit from the new automation approaches. Healthcare systems are placing care coordinators within physician practices, and those professionals are beginning to leverage digitized health data to help them manage patient populations. We will see much more of this kind of activity in 2012.

As a veteran of the disease management industry, and most recently, spending several years assisting provider organizations to manage their patient populations, I fully appreciate the problems inherent in traditional employer-based and health plan-sponsored disease management programs.

However, like Al Lewis, I also disagree with the statement that disease management is dead. Although some models have failed in the past, disease management models continue to evolve and are being transformed and incorporated into new physician-led population health models such as the Patient-Centered Medical Home.

Further, as health systems assume more financial risk and move towards Accountable Care Organizations, they will take on responsibility for managing entire populations and will be using population health tools and services that evolved from the original disease management principles and fundamentals.

I would like to emphasize several points that strongly indicate that disease management is alive and well.

Provider-Led Population Health

Today, there are a number of marketplace drivers such as Meaningful Use, Pay-for-Performance, PCMH and ACO and, not coincidentally, that share an underlying objective of provider-led population health. Population health means responsibility for everyone in the population: both those who are active health seekers and those who are not.

Achieving the IHI Triple Aim will require providers to provide patient-centered, personal, coordinated care across their populations. Provider-led population health will demand new tools and automation to be successful and will resemble those introduced and pioneered in employer and health plan-sponsored disease management programs (e.g., define population, identify care opportunities, stratify by risk, engage patients in care, proactively manage care, and continuously measure and monitor outcomes).

NCQA and Disease Management

I see no evidence that NCQA was in any way responsible for the demise of disease management. NCQA should be praised for their pioneering work on population health, quality reporting, disease management programs and HEDIS measures. They are now on the leading edge in the development of Patient-Centered Medical Home (PCMH) and the Accountable Care Organization (ACO) standards. Again, disease management principles and population health management are embraced in the new standards that NCQA has developed. The PCMH is widely endorsed and adopted. There are now 3302 NCQA-endorsed practices across the country and the number continues to grow.

Demonstration Projects

The demonstration projects from 2006 showing equivocal outcomes and financial results for disease management programs are dated and not a part of the newer provider-led delivery models. More recent demonstrations around PCMH, multi-payer pilots, and ACOs have shown successful health outcomes. Key components from the disease management industry and programs were incorporated into these new demonstrations.

• PCMH Demonstrations showed positive results which were attributed to dedicated care managers and data-driven analytics, principles used in disease management programs. (Fields, Leshen, and Patel) (Takach).
• Payers publishing positive results around ACOs are using all of the principles established in the disease management programs but in a new environment, featuring collaboration between payer and physician. (Higgins et all).

Implementation

One of the biggest issues in the early disease management programs was that the physicians and care teams were not involved in their implementation. Many of these programs were designed very well but were focused predominantly on patient education and behavior change. Doctors became very disappointed and distrustful and cited many reasons to not accept these programs as valid.

• Patients were getting enrolled into programs without their provider’s permission. Patients were getting information or education that was coming from the employer or health plan, rather than their physician.
• Results were coming back to physicians based on paid claims and were not timely or comprehensive, raising questions of accuracy. These reports used data that was old and not as rich as could be found in their offices, such as lab results and other biometric indicators.
• Doctors were frustrated by the multitude of payers offering DM programs to segments of their patient population and expecting doctors to follow different rules or incentives for different patients.

Doctor Involvement

Doctor involvement, not disease management, was one of the principle issues that needed to be changed. New legislation, payment reform/quality incentives, movement toward value-based accountability emphasizing the other marketplace drivers mentioned above will continue to embrace providers around improving quality and value. Provider organizations are being given the responsibility to manage their entire patient panel. To do so, providers will use the tools built and pioneered by the principles within disease management programs:

• Patients will be engaged proactively by their physicians and care teams, providing them with self-management tools and behavior change support to prevent disease and complications, and coordinating their care when other services are needed.
• Reports will use data from EMR systems, which are more timely and accurate. More importantly, physicians recognize that data in these reports are related to them and their patients, and they accept the information as opportunities to improve.
• Physicians and physician leaders are now beginning to think in terms of “my population”, which may include multiple payers, but one set of evidence-based standards and financial goals.

Conclusion

So, in the end, disease management is becoming transformed and deployed into new models, refining some aspects and putting the provider in the leadership role to achieve new thresholds of success.

References

• Fields, D., E. Leshen, K. Patel. 2010. Driving Quality Gains and Cost Savings Through Adoption of Medical Homes. Health Affairs. 29(5):819–26.
• Health Affairs, 30, no.7 (2011):1325-1334; Medical Homes Show Promising Results Reinventing Medicaid: State Innovations To Qualify And Pay For Patient-Centered Mary Takach
• Health Affairs, 30, no.9 (2011):1718-1727; Between Health Plans And Providers: Early Lessons From Accountable Care Models In The Private Sector: Partnerships; Aparna Higgins, Kristin Stewart, Kirstin Dawson and Carmella Bocchino

How Many Value Streams Does Your Organization Have?

Many entities can flow through an organization, but only one entity can flow through a single Value Stream. For instance, a patient would represent the primary entity that flows through a medical practice’s or hospital’s core Value Stream, while a staff member, who also represents an entity flowing through a healthcare organization, flows through an entirely separate Value Stream.

Experience has shown that most organizations have between five and eight Value Streams that either directly or indirectly touch their constituents.

What Makes a Value Stream Map Effective?

For a Value Stream map to be effective, it is critical to determine the beginning and ending points of the end-to-end horizontal process. Identifying the beginning and ending of a Value Stream can easily become an area of great debate.

For example, many may feel that the patient Value Stream begins when a person enters the practice or hospital, whereas others may feel that the Value Stream begins through a healthcare branding campaign. Both are correct, but all must agree on which beginning point to use for the Value Stream. The same goes for the ending point. It is generally best to start the process at the very first point in which the entity is touched and then end at very last point.

Identifying Process Steps

Once the beginning and ending process steps are established, individual process steps must be identified in order of flow. These steps represent a noun and a verb combined to articulate a high level action that is necessary to deliver the entity through the process.

After the high level process steps are determined and aligned into the proper flow, the sub-process steps need to be identified for each high level process step. Again, it is critical that each sub-process step be aligned into its logical flow.  It is recommended that during the mapping exercise, the departmental groups performing each sub-process are named. This allows for a cross-functional visualization for the end-to-end Value Stream.

Defining Core Metrics

After the process is mapped, the core metrics for each Value Stream must be identified and measured. This will facilitate continuous improvement by monitoring and measuring the Value Stream against a patient-stated requirement.

Benefits

Some of the benefits in visualizing the path of an entity as it flows through an organization are:

• Staff members can see how their process directly or indirectly touches a patient.
• The effects upstream processes have on downstream processes become evident.
• When changes are made to an upstream process, it is much easier to model the expected downstream effect.
• When quality and process metrics fail to meet requirements, it is easier to determine the point at which the root cause occurred.
• Hand-offs between processes can be better managed. In many cases, the transition between handoffs is where both defects and delays occur.
• Each process step can be measured in terms of its impact on overall cycle-time.
• It can aid in identifying areas for quick improvement.

Conclusion

Horizontally Value Stream mapping how an entity moves end-to-end though an organization can offer many benefits beyond the traditional vertical way of thinking. This method encourages organizations to take a patient-centered focus in how it manages processes and measures success.

Causes of Readmissions

The immediate cause of a readmission is usually a rapid deterioration in the patient’s condition, related to the patient’s primary diagnosis and/or comorbidities. But in a broader sense, it can be attributed to systemic failures that often begin in the hospital and continue in the fragmented healthcare settings that patients move through after discharge.

The literature on care transition problems shows there are five main areas that contribute to preventable readmissions:

• Poor preparation for discharge
• Patients’ low health literacy and comprehension
• Failure or inability of patients to see physicians for follow-up after discharge
• Lack of hospital follow-up
• Lack of communication between inpatient and outpatient providers

Readmissions occur, by definition, after a patient has left the hospital. Yet the foundation for post-acute care is laid during the hospital stay—and that preparation is often inadequate.

The Role of Medication Reconciliation

A prime safety issue cited by many experts is missing or inadequate medication reconciliation at the time of discharge. The medications that patients received in the hospital are often discontinued at discharge, while the drugs they were taking before they were admitted may or may not be resumed. Dosages may also change.

The Joint Commission has identified medication reconciliation as a key requirement for ensuring patient safety. The Institute for Healthcare Improvement also cites medication reconciliation as an opportunity to reduce readmissions. This is clearly an area in which improved follow-up and communication between a hospital and a patient’s post-discharge providers could significantly contribute to lower rehospitalization rates.

Improving Patient Health and Safety

By preventing readmissions, healthcare organizations could improve patient health and safety while responding to new government incentives and penalties. A patient-centered, automated approach is the most efficient and cost-effective way to reach out to all discharged patients not just once, but repeatedly over the critical 30- to 60-day period post discharge.  Such a model, judiciously combined with high-touch care management for high-risk patients, is the most efficient and cost-effective way to make sure that all patients who have been discharged are contacted and their healthcare needs are properly addressed.

New CMS Regulations Begin October 2012

Front and center are the Centers for Medicare and Medicaid’s (CMS’) new regulations on preventable readmissions. Starting Oct. 1, 2012, hospitals with “excessive” readmissions—situations in which that number of patients readmitted to a hospital is significantly higher than expected—will lose a percentage of their Medicare reimbursement across the board. In FY 2013, the decrease can be up to one percent of reimbursement, rising to two percent in 2014 and three percent in 2015.

In the first year of this program, CMS will examine 30-day readmission rates for patients with heart failure, acute myocardial infarction, and pneumonia—three of the leading conditions for which patients are readmitted. Beginning in FY 2015, CMS may also scrutinize chronic obstructive pulmonary disorder and several cardiac and vascular surgical procedures.

Lowering Readmissions through Partnership for Patients

CMS has also launched other programs that might contribute to lower readmission rates. To begin with, the agency plans to spend $500 million—or half of the $1 billion earmarked in the Affordable Care Act for improving patient safety—to help hospitals and their community partners decrease readmissions over a five-year period ending in 2016. Through the government-sponsored Partnership for Patients, CMS will pay these “community-based organizations” a set amount per discharge for managing Medicare beneficiaries at high risk for readmission.

Other Incentives: Payment Bundling and ACOs

Two other CMS initiatives authorized by the health reform law are worth considering: payment bundling and accountable care organizations ACOs). Under CMS’ recently announced plan for its bundling demonstration, providers may choose among four different options. One option includes all care provided from admission to the hospital to 30 or 90 days after discharge. Another would cover only post-acute care for up to 30 days.

In both scenarios, providers would be paid on a fee-for-service basis, adjusted retrospectively for variance from a budgeted amount. While neither option penalizes providers for readmissions, both encourage improvements in the quality of post-acute care, which should reduce the number of readmissions.

Shared-Savings Program for ACOs

Finally, next year CMS will launch its shared-savings program for ACOs, which are groups of hospitals and doctors that are committed to raising the quality and lowering the cost of care. To receive financial rewards from CMS, these organizations will have to save money, which will give them a strong incentive to cut readmissions.

Nevertheless, it will be difficult for healthcare organizations to decrease readmissions significantly in our fragmented, uncoordinated healthcare system. While most of the levers of improvement are known, reengineering inpatient processes and engaging patients and outpatient providers remains challenging.

Leveraging Technology to Auomate the Post-Acute-Care Process

Fortunately, new applications of health information technology now offer inexpensive ways to automate post-acute-care processes. These solutions can raise the effectiveness of care managers, improve the communications between inpatient and outpatient providers, and make it easier for patients and caregivers to absorb and apply the knowledge required for self-management of complex conditions.

Medicare’s PGP Demonstration

Let’s look at the Medicare PGP program for example. The experiences of the 10 groups that participated in Medicare’s five-year physician group practice (PGP) demonstration show exciting examples of how these healthcare leaders took on the challenge of care coordination inside their practices and between sites of care to meet their goals.

Incentives for Innovation

The PGP pilot turned out to be a dry run for Medicare’s shared savings program for accountable care organizations (ACOs). Similar to what’s been proposed for the Medicare ACO program, the PGPs were eligible to split savings with Medicare if they met certain quality benchmarks and the savings exceeded 2 percent of expected costs.

In the demonstration project, participants could keep up to 80 percent of the savings they generated, depending on how well they did in meeting 32 quality goals, which is a powerful incentive for finding innovative and effective ways to better manage patient care.

Quality Improvements

According to the Centers for Medicare and Medicaid Services (CMS) report released in July 2011, in the fifth year of the five-year demonstration:

• All 10 groups achieved benchmark performance on at least 30 of the 32 measures.
• 7 groups achieved benchmark performance on all 32 performance measures.
• All 10 groups achieved benchmark performance on the 10 heart failure, 7 coronary artery disease measures and 2 preventive care measures.

Also for Year 5, four of the PGPs earned incentive payments based on the estimated savings in Medicare expenditures for the patient population they serve. The groups received performance payments totaling $29.4 million as their share of the $36.2 million of savings generated for the Medicare Trust Funds in performance Year 5.

Reasons for the Savings

The PGPs attributed their savings to a number of factors:

• Organizational structure
• Investments in care management and care redesign
• More intensive diagnostic coding
• Changes in market conditions

Each PGP that achieved savings used different care management strategies that may spark ideas for other primary care groups moving towards ACO models and similar population health models.

• The Dartmouth-Hitchcock Clinic in Lebanon, NH, focused on evidence-based care initiatives, including better use of care alerts, changing workflow for support staff, and using nurse case managers to work with high-risk patients.
• St. John’s Clinic in Springfield, MO, used a comprehensive patient registry, care alerts at the point of care, a case manager in the emergency department to plan transitions of care, and a care team dedicated to patients with congestive heart failure.

Conclusions

RTI International, the company that analyzed the PGP pilot for the CMS, drew these lessons from the test, many tied to the use of technology-based solutions:

• Medicare patients often have several comorbidities that need to be treated simultaneously. Therefore, group practices must address the need for complex care management that goes beyond traditional disease management for single conditions.
• Complex care management could be enhanced by combining disease-specific patient registries, or by using registries that encompass all patients.
• Planned visits can be facilitated through the use of data systems (e.g., registries and electronic health records) that analyze data and provide physicians and other clinicians with pertinent information about the patient prior to a visit. A visit planner report may, for example, provide a list of overdue tests for a patient that could be performed prior to a visit.
• Key change opportunities include increasing patient engagement, expanding care management, improving care transitions, and expanding the role of nonphysician providers.

The groups that were part of the PDP pilot demonstrated that technology, such as patient registries, plays a major role when adopting a proactive approach to care management.

What’s Next

In future blog posts, we will build on these takeaways, and talk about how the combination of technology and automation can foster even greater strides in population health.

• Create incentives for physician groups to coordinate the overall care delivered to Medicare patient
• Reward them for improving the quality and cost efficiency of health care services
• Create a framework to collaborate with providers to the advantage of Medicare beneficiaries.

The successes of two PGPs that participated in the demonstration — the Marshfield Clinic and the Geisinger Clinic —depended largely on their well-executed coordinated care approaches and their effective use of technology.

Marshfield Clinic

The Marshfield Clinic, a 730-doctor clinic in Marshfield, WI, generated about half of the total savings in the demonstration that included 10 PGPs. The group has been using an electronic health record since 1985 and has long-running quality improvement programs.

For the demonstration project Marshfield:

• Focused on reducing hospital admissions, partly by expanding its telephonic case management program for patients who had heart failure and hypertension complications
• Expanded its anticoagulation drug therapy management program, designed to reduce costly complications of warfarin therapy
• Introduced partial open access scheduling and redesigned care processes for chronic disease patients to ensure they received all recommended care

Electronic tools are essential to population health management at Marshfield. The clinic’s EHR automatically generates an intervention list for each physician that identifies high-risk patients with multiple chronic conditions. Marshfield also uses electronic prescribing, a data warehouse for analytics, patient registries and care management software.

During its first year of participating in the demonstration, Marshfield reduced hospitalizations of patient in the anticoagulation management program by 29 percent. Satisfaction among patients enrolled in care management programs exceeded 85 percent.

Geisinger Clinic

Geisinger Clinic based in Danville, PA, is part of a health system that includes the Geisinger Medical Center and two other hospitals. The Clinic employs about 640 physicians in 41 practice sites.

Geisinger had disease management programs in place when it joined the PGP demonstration. The group wanted to extend those programs to Medicare patients. Additionally, Geisinger introduced a case management program for high-risk, complex patients.

In the pilot, Geisinger sought to reduce hospital admissions and readmissions through disease and case management, enhanced use of its EHR and an advanced medical home model. Geisinger emphasized patient-centered, team-based care across the continuum, transitions of care coordination, readmission risk screening and telephonic care management and/or device-based remote monitoring for CHF patients. It also redesigned its systems of care to reflect evidence-based guidelines.

Geisinger’s EHR can provides best practice alerts to providers at the point of care. Physicians can view a summary of the patient’s care, and they receive reminders about needed tests and other interventions. Equally important, they’re in close touch with the care managers who are handling their most difficult cases.

Coordinated Care Lessons Learned

Registries, care management software, and automated patient outreach—all used in conjunction with EHRs—are among the tools that these groups deployed successfully to manage their populations.

Defining Care Coordination

The Agency for Healthcare Research and Quality (AHRQ), after consulting many sources, came up with this definition:

“Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

“Deliberate organization of patient care” or, in simpler terms planned care … whatever its specific application, coordinated care is planned care. And “planned” means something that goes beyond a doctor’s orders or treatment plan. Planned care requires an entire care team comprised of multiple providers and team members dedicated to the delivery of quality health care to their patient population.

Components of Care Coordination

The components of care coordination, according to AHRQ, include:

• Essential care tasks and responsibilities
• Assessment of a patient’s care coordination needs
• Development of a coordinated care plan
• Identification of team members responsible for coordination
• Information exchange across care interfaces
• Interventions that support care coordination
• Monitoring and adjustment of care
• Evaluation of outcomes, including identification of care coordination issues

Coordinating All Aspects of Patient Care

As healthcare organizations form ACOs and medical homes, they will be required to effectively coordinate all aspects of care across populations and care settings.

A March 2011 Commonwealth Fund consensus report on combining these approaches to health care reform observes that care coordination will be the linchpin of this transformation:

“The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.”

The Role of Health IT

The consensus report also emphasizes the role of health IT in care coordination, while asserting that much of today’s existing information technology is inadequate to the purpose:

“Anchoring the electronic health record (EHR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises. Health IT requires new functional capabilities, such as multiple team member access and permissions, care management workflow support, integrated personal health records, registry functionalities, clinical decision support, measurement of quality and efficiency, and robust reporting.”

The bulk of the technologies required to achieve these goals are already available. Among the reasons they’re not being properly deployed in most cases are these:

• Electronic health records are often not designed to fully support population health management initiatives or care coordination workflows.
• Registries tend to be focused on patients with particular conditions, rather than entire populations.
• Care management workflow support is still a relatively new concept and not widespread, but one that more and more groups are embracing.
• Some provider organizations lack the infrastructure to consume new technologies and transition to new processes.

Conclusion

Technology tools are being used to improve communications across care settings, especially during transitions of care. These range from traditional point-to-point interfaces to physician and patient web portals to secure electronic messaging. Even computer faxing has its place as the industry moves from paper to electronic documentation of care. The automated stratification of patients into different risk categories is also important to groups seeking to do population health management.

The effective coordination of a patient’s health care services is a key component of high-quality, efficient care. It provides value to patients, professionals and the health care system by improving the quality, appropriateness, timeliness and efficiency of decision-making and care activities, thereby affecting the experience, quality and cost of health care.

“Anchoring the electronic health record (EHR) in the traditional visit-based care delivery model limits the potential of the medical home to generate paradigm-shifting care delivery transformation and the positive outcomes it promises…Health IT requires new functional capabilities, such as multiple team member access and permissions, care management workflow support, integrated personal health records, registry functionalities, clinical decision support, measurement of quality and efficiency, and robust reporting.”

The bulk of the technologies required to achieve these goals are already available. Among the reasons they’re not being properly deployed in most cases are these:

• Electronic health records are not designed to do population health management or care coordination.
• Registries tend to be focused on patients with particular conditions, rather than entire populations.
• Care management workflow support is still a relatively new concept, but one that more and more groups are embracing.

Group practices that are trying to transform themselves also have to manage a variety of other issues, including cultural barriers to change, potential infrastructure issues, and limited reimbursement for non-visit and non-physician care.

Key Building Blocks

Technology tools are also being used to improve communications across care settings, especially during transitions of care. These range from traditional point-to-point interfaces to physician and patient web portals to secure electronic messaging. Even computer faxing has its place as the industry moves from paper to electronic documentation of care.

The automated stratification of patients into different risk categories is also important to groups seeking to do population health management. For example, UNC Healthcare uses a health risk assessment (HRA) survey to find out how sick each of its patients with diabetes is. Then it uses an advanced patient registry and evidence-based algorithms to drive team-based care for each of those patients, depending on the severity of his or her condition.

Many practices use electronic registries to supplement their EHRs. These registries compile lists of subpopulations that need particular kinds of preventive and chronic care, such as annual mammograms for women over 40 or HbA1c tests at particular intervals for diabetic patients. The continuously updated data in the registries comes from EHRs, practice management systems, or a combination of the two. Evidence-based clinical protocols, which can be customized by physician practices, trigger alerts in the registries. When a registry is linked to an outbound messaging system, patients are notified by automated telephone, e-mail or text messages to contact their physician for an appointment. Some registries can also send actionable data to care teams prior to patient visits.

Care Coordination Leverages IT

The overall lesson to be drawn from the efforts to improve care coordination will require the use of information technology. The identification of patients with particular conditions, health risk assessments, the ability to send care gap alerts to providers, the care management of chronically ill patients, tailored patient education, and persistent reminders to patients to get the care they need—all of these interventions require some degree of automation to be performed in a timely, consistent, cost-effective manner.

The recent advances in health IT and further developments in this vital field will continue to support and enhance care coordination as it expands across the spectrum of care. Assuming that payment methods support coordinated care, we can look forward to a proliferation of new IT tools that will help turn the dream of affordable, high-quality healthcare for all into a reality.

While many organizations are initiating Lean as a way to increase process efficiency through waste elimination, others are pursuing ISO certification as a way to ensure their services consistently meet and exceed their patient’s requirements.

Where Lean is embodied through employee empowerment, ISO appears to be embodied through command and control. As Lean seeks to eliminate nonvalue-added activities, ISO seems to add bureaucracy through increased documentation control.

Consequently then, how can a healthcare organization pursue both approaches when the two seem to be in such conflict with each other? As difficult as this may sound, the solution is actually very simple. Apply Lean thinking to the ISO deployment, and ISO thinking for Lean standardization and continual improvement.

Lean Core Concept

The core concept of Lean is to eliminate nonvalue-added activities in the core value streams. Any process step can be tested for value by asking three questions:

1.    Would patients in our community be willing to pay for it

AND

2.    It changes the service or offering

AND

3.    It is completed correctly the first time (quality, access and reliability)

ISO Core Concept

Whereas the core concept of ISO is to ensure the organization consistently delivers a quality service to the patients. Therefore, the two approaches work well together when employees and care teams are empowered to not initiate ISO with process steps that do not meet the Lean criteria, but rather remove them, and only control and continually improve the process steps that result in high patient experience of care.

Combining the Two Approaches

Through this approach, organizations can empower your staff to improve process efficiency while standardizing and controlling the most critical process activities within your value streams.

Jerry Green is Director of Quality Management at Phytel.

Applying Lean to Healthcare

This book is important for any organization that is wondering how Lean applies to healthcare (after all, the origins of Lean are in the Toyota Production System). Even if your organization is already in the process of implementing Lean or a similar total quality management (TQM) methodology, it is a very engaging read. It is written in narrative form — no “how–to” or value stream maps — and it really brings the Lean principles to life.

Incorporating Population Health Management

One chapter clearly stands out for me: ”Ambulatory Care Breakthrough” was compelling because I could connect what was in the book to what I observed when I visited NSPG’s flagship clinic in Danvers, MA to start collaborating with NSPG to incorporate our care management and population health solutions into their Lean workflows.

VMMC assembled a precursor to Phytel’s Outreach and population health solutions, starting with paper medical records, computerized billing systems and new roles for medical assistants and care managers as they work with patients who schedule appointments — but it has taken almost 10 years to develop.

Care Management Using Lean

We can use their example to help clients like NSPG implement care management in a manner consistent with Lean principles. However, by leveraging technology and adopting a total population perspective, our products go even beyond what VMMC describes they have done for primary care by engaging more patients more persistently to achieve true population health management.

A recent Gallup survey showed that more than 85% of adults over 65 years old express confidence in their doctor’s advice. But it’s not just seniors that feel this way. Despite online access to a wealth of medical information and widespread questioning of common medical practices in the media, trust in our providers is high across the country. For example, more than 70% of Americans do not seek a second opinion because they are confident in the accuracy of their doctor’s advice.

So there’s a lot of trust – and for the aging, a lot of visits. The average Medicare beneficiary makes 6 physician visits each year and 90% see a physician at least once a year.

Recommended Care Visits Lacking

Yet, a recent CDC report finds they don’t get what they should:

• In some states, 28% of women over 65 have not received a mammogram in the previous 2 years even though almost 50% of all new breast cancers occur in this age group.
• More than 65% of new colon cancers occur in patients over 65 but more than 30% have not received a colorectal cancer screening.
• Less “invasive” prevention measures don’t fare much better. More than 30% of older adults do not receive an influenza vaccine, have never had a pneumococcal vaccine or have not been screened for diabetes (if they don’t already have the condition).

Keeping Patients Healthy

New models of care such as the Patient Centered Medical Home are at the forefront of prevention over treatment, bringing clinics a population health framework and a focus on keeping patients healthy. Medicare is also removing some financial barriers by providing preventive services at no cost to patients.

Medicare’s Annual Wellness Visits

But that’s not enough. Eliminating cost alone is unlikely to result in widespread use of these services. Providers can initiate discussions with their patients about prevention. Older adults, especially, rely on their physicians’ advice. Medicare’s new Annual Wellness Visit and the development of a personalized prevention plan are a perfect opportunity.

Many patients are just waiting to hear about it from their doctors.

The current visit-centric model works when providers only have to keep track of and manage the patients who schedule a visit; however, when new payment models, such as pay-for-performance and capitation require providers to keep track of and manage every patient in their panel — their patient population — provider organizations need new sources of expertise and ways to scale their services beyond the visit encounter. Many provider organizations are rightly looking for population health expertise from prestigious and successful health maintenance organizations such as Kaiser and Geisinger. Other sources for population health expertise that provider groups may not have thought of right away are self-insured employers.

As I described in the first blog in this series, self-insured employers and provider groups that seek to be accountable care organizations (ACOs) share the goals of population management — and employers have been at this for about 20 years and have figured out the best practices that the most successful employers consistently apply.

The lessons learned from employers that have implemented successful population health programs are readily applicable to physician organizations preparing to transform themselves into patient-centered medical home (PCMH) models on the road to becoming effective ACOs.  The following table maps the employer best practices to the practice-based population health (PBPH) environment to illustrate the important parallels and common strategies.

Each of these “Employer Best Practices” deserves a dedicated discussion and blog entry to explain further how leading employers have created the infrastructure they need to identify, manage and engage employees to improve their health. In fact, if your organization has already become a certified PCMH or is in the process of doing so, these employer best practices may look familiar — and that’s because the PCMH (and the ACO, by extension) is based on population health principles.

In a population management culture, providers will let their patients know they will be identifying opportunities and resources to help them to be healthier all year long, not just when they come into the office or have an acute event. And, providers will create efficient and proactive care teams to support greater numbers of patients than they can today with manual processes, disparate sources of data, and limited staff.

Now, progressive employers are increasingly looking to partner with providers who adopt the same best practices and leverage the physician-patient relationship to achieve even better results than employers could on their own.  So, provider organizations with their eyes on ACOs, should take a closer look at what employers have demonstrated thus far.

Karen Handmaker is Director of Population Health Management at Phytel.

What if you were asked to take on the role of a primary care physician? Your objective would be to ensure that ALL of the patients you are responsible for receive the quality care they need at the right time and in a cost-effective manner. After all, isn’t that what you and I want as a patient? Let’s just walk through what that would be like. You would:

1. Identify who your patients are (the average primary care physician has about 2,500).
2. Research each patient and evaluate them against all the guidelines for their applicable conditions and risk factors.
3. Ensure they receive the recommended care needed during each visit, and if they are not active in their care, reach out and engage each patient.
4. Track and measure the quality of care you provide ensuring every patient gets consistent and high quality care, and since you are probably participating in multiple different quality initiatives (P4P, Meaningful Use, PQRS, etc,) capture the information to meet all the requirements of each initiative.

As reported by David Margolius and Thomas Bodenheimer in a 2010 Health Affairs article, “Transforming Primary Care: From Past Practice To The Practice Of The Future,” providers and care teams are increasingly challenged to keep up with all the activities surrounding patient care.

Many physician organizations have begun to solve the problem through a significant increase in the use of midlevel practitioners, care managers, care coordinators and health educators. Recently, I attended a conference at which a large medical group presented on how they were going to hire 50 data coordinators to help their care teams deliver higher quality of care.

Unfortunately, hiring your way to a patient centered medical home isn’t realistic. Most of these organizations see the future and are preparing to become an Accountable Care Organization (ACO). In an ACO, the cost of delivering care will be controlled and hiring large numbers of resources to manage the patient demand won’t be an option.

The Care Management Role

I am a firm believer in the critical role that a care manager will play in this new world of healthcare that is upon us. The care manager is responsible for making sure patients are having effective visits, providing one-on-one care for the highest risk patients and making sure at-risk patients stay healthy when they aren’t in the office.

In my experience, one thing is clear, the care management processes being implemented today tend to be very manual and touch only segments of the patient population, and often only those patients that have an office appointment.

How many patients can an individual care manager attend to using only manual processes?

Data suggests that the average physician has about 900 adults with chronic conditions.  Thirty percent of those, or 270 patients, are high-risk or complex and should be assigned to a care manager.

By extrapolation using this simple scenario, every physician with this size panel would require 1.35 care managers; 10 physicians would require 13.5 care managers and 100 physicians would require 135 care managers.

And still, only the highest risk patients would receive support from the care management team.

The Importance of Technology

Technology has become a ubiquitous part of almost every aspect of our lives:  online shopping with suggestions about what I would like to read, a text message telling me my flight changed gates, emails reminding me my car is due for a 60,000 mile checkup. Unfortunately in many areas, healthcare delivery can appear behind the curve.

The only way care management fulfills the design of its creation is leveraging the power, repeatability and scalability of technology.

What would the world look like if you combined the power of modern technology with the power of a care manager?

• ALL patients would receive personalized, systematic, and just-in-time reminders about an overdue test, a reminder for a cancer screening or the need for an office visit. The reminder would be in the patient’s preferred mode of communication.
• The care manager would receive a stratified and prioritized list of high-risk patients that will always need the personal touch of a care manager.

By applying technology to population health strategies that continually identify, assess and stratify provider panels, physician groups can use automation to augment the role of care teams, manage the patient population more effectively and efficiently, drive better outcomes and decrease overall cost as demanded by new delivery model payment incentives.

It’s an enticing notion: focus resources on the sickest patients if you want to drive savings in health care, the 20% of the patients that drive 80% of the costs (or the 5% that drive 43% of Medicare‘s costs).

As I write, smart people are getting caught in the appeal of the notion. We can solve a big chunk of our health care crisis if we just take advantage of the 80-20 rule! There are health system administrators busy instructing data analysts to mine their data for high-cost patients. Those same analysts will be instructed to pass the information along to case managers who will then be told to bring order to the spiraling costs. When the administrators review their efforts, it may even look like they worked: the patients who were “case managed” showed lower costs in the period after they started getting managed. The problem is that there really wasn’t any other outcome possible.

I’ve been involved in health care analytics in one form or another for the past 15 years. The most common analytic error by far involves concluding that the inevitable was instead caused by intervention. One example is showing savings on a disease management program for heart failure patients in which the patients were enrolled right after they’ve had a hospital stay for a heart attack. The statistical problem with such an analysis is called “regression to the mean.” In practical terms, it means that most patients don’t stay acutely ill all the time. If you measure future outcomes versus the time a population was sickest, odds are that at least some of the population will improve and the outcomes will look better.

Back when I ran the analytics department at a disease management company, we did research in which we found that even for the rare diseases we worked with (diseases such as multiple sclerosis, cystic fibrosis and systemic lupus) the highest cost patients in one year were not always the highest cost patients the next. Generally, there was more than a 50% turnover of the top 10% of patients from year to year. That means that if you took the 1,000 highest costs patients in 2009, 500 or less would still be high cost patients in 2010. Usually, it was because they had some kind of an acute crisis from which they recovered. Whether we did nothing or provided intensive case management to the costliest patients, about 50% were going to get better and their costs were going down (which is why we didn’t just focus on the sickest of the sick).

One of the standard quality metrics followed by groups that track health care quality is the percentage of diabetic patients with an HbA1c value of greater than 9%. (The Wisconsin Collaborative for Health Care Quality does a good job of creating visibility around this metric.) Programs are currently being designed to target the 9%ers, to bring their scores back in line. The challenge with focusing only on the 9%ers is the same as with the high cost patients. Here at Phytel, we’ve done research on the turnover rate of the 9% patients. We’re finding that like any other outlier, they change from year to year – at a rate of over 60%. That is, for every 1,000 patients with an HbA1c score of 9% or more in 2008, only 400 of them continued to have a score of over 9% in 2009. Despite the turnover of the 9%ers, the overall percentage of patients with 9%+ HbA1c scores has remained relatively stable from year to year (at least in the data we’ve analyzed). In other words, as soon as one 9%er drops to a lower level, another is waiting to take his or her place.

I grew up in the North East where we had frozen ponds most of the winter. That meant a lot of pond hockey. The best players were always the ones that skated to where the puck was going to be rather than to where it was at any point in time. The same approach is critical when it comes to affecting the small pool of patients that drive the bulk of health care costs. You need to find them early, before they’re a high cost patient.

Why is this issue important? I wrote in the second paragraph that some health system administrators are busy creating case management programs designed to target their sickest patients. One of the reasons is to prepare their organization to take on global payments, with the goal of becoming an accountable care organization. The reasoning is that if they can just remove unnecessary costs for the sickest patients, they’ll save enough money to make those global payments profitable. But their efforts are akin to Sisyphus rolling his rock up the hill only to have it fall once he gets to the top. No sooner will a high cost patient start improving in this scenario than another will be waiting to take his or her place. If the “manage sickest 5, 10 or 20%” approach is employed on a grand scale, we won’t move any closer to bending the health care cost trend curve.

The trick is finding sick patients before a crisis event, before they’re really sick. The availability of lab results data from electronic medical records is critical in that regard. And once you find them, affecting those patients requires a skill set that our health system (which includes more than only the providers themselves) is just beginning to develop – that of reaching out to patients and motivating them to actually modify their behavior. One just has to reference the massive efforts (both public and private) that have gone into reducing the number of smokers to understand how significant this challenge truly is.

Ted Courtemanche is the Vice President of Analytics and Outcomes at Phytel.

As we all know, the meaningful use requirements of the HITECH Act are designed to facilitate quality improvement, better care coordination and population health management.

However, it may not be widely known that physicians will typically need to use supplemental information technologies along with their EHRs to show meaningful use consistently over the next five years.

While EHRs are good at point-of-care interactions and decision support, physician practices and hospitals will need to acquire certain additional technologies to address quality improvement and manage population health. These may include electronic registries, multiple outreach and communications methods, software that can calculate the metrics required for quality reporting, and solutions that extend the reach of the provider and care team to help keep patients engaged in their care.

While the stage 2 and 3 requirements have yet to be drawn up, the final rule for stage 1 already shows that HHS remains on course to deploy meaningful use as a lever to get physicians to use EHRs for quality improvement and population health management.

To meet stage 1 meaningful use requirements for population health management, supplemental technologies may be required. For example, the patient reminders in stage 1 require condition identification first and then gaps for the condition which is performed by the EMR technology. Hundreds and sometimes thousands of patients may need to be contacted. This can consume many hours of staff time, calling or mailing these individuals. Technology can take this same list and automatically generate phone call, email messages, and text messages, analyze the response rate and resend the message. This activity is continuously being performed in the background rather than a one-time action taken on a condition list and can provide reports to the team on a regular basis to track effectiveness.

To meet meaningful use requirements during all stages, healthcare organizations and providers will be seeking the ability to generate lists of patients with specific chronic conditions or preventive-care needs, collect and report quality data, and generate condition-specific educational materials for patients. To do this manually would be a burden on care organizations. The solution lies in finding a way to automatically identify, engage, and track patients who need preventive and chronic care services.

What all of these methodologies have in common is that they automate the work of monitoring, educating and maintaining contact with the patient population that meaningful use will require. Especially at a time when primary-care providers are in short supply and stretched thin, it is essential to provide this level of automation so that the routine, repetitive work can be done in the background, rather than taking up the valuable time of doctors and nurses.

Information on the care gaps of specific patients should be automatically generated and provided to care coordinators and care managers within practices. These clinical staffers can then use this information to prepare doctors and nurses for patient visits. Between visits, they can use the population health improvement technology to make sure that patients get their needs addressed and come back for follow-ups. The technology solution does the heavy lifting, increasing care managers’ productivity and allowing practices to do more with fewer personnel.

To attest that a physician has gathered data on at least six of the 38 quality measures, practices will have to identify the numerator and the denominator on each metric. For example, if smoking cessation advice is the measure, an organization must be able to identify the number of smokers in the practice and what percentage of those patients received physician counseling.

By combining EHRs with these automated approaches, physicians can show meaningful use, qualify for medical home certification, obtain pay for performance incentives, and prepare themselves for the value-based reimbursement systems that are down the road. At the same time, these adjunctive technologies enable physicians to gather the quality data they will need to report to Medicare and private payers in an automated manner. And by giving care teams real-time data on the services that patients need when they’re in the office, these methods empower physicians and other clinicians to improve quality and engage in productive conversations with patients about how they can maintain or restore their health.

It’s clear that the meaningful use requirements of the HITECH Act can be met using EHR and supplemental technologies to keep patients engaged and coordinated in their care.

Dr. Richard Hodach is Chief Medical Officer at Phytel.

A crucial component of healthcare reform is to transform our care delivery system to improve quality and control costs. To do that, the government is working with the private sector to test and promote new structures such as the patient-centered medical home (PCMH) and the accountable care organization (ACO). Both of these innovations, which will gain momentum in 2011, require providers to make sure that everyone in their patient population is receiving appropriate preventive and chronic-disease care.

Today, many physician practices and hospitals still operate in the traditional fee-for-service model.  To build a successful medical home or ACO, however, providers will have to coordinate care and work with patients to improve their health between as well as during office visits. They will also have to track and monitor their patients’ health status, and reach out to those patients who are noncompliant or have fallen out of touch with their physicians.  In essence, they will be required to adopt a population health management approach and strategy.   And more importantly, they will need automated capabilities in order to support these initiatives.

Even with financial support from payers, physician practices cannot do this type of population health management without the aid of health information technology. Beyond electronic health records, they will need registries, multi-channel patient messaging technologies, and web-based tools for health risk assessments and patient self-management education.  Using registry-generated data to identify care gaps, physicians will be better able to deliver necessary services to patients when they visit, matching care team skill sets to patient-specific needs.  Similarly, care managers will use advanced population-based reporting and stratification to identify patients who need personalized interventions, and deliver automated methods to empower patients to become active participants in their own health.

In the next year, we’ll see the spread of these automation and care coordination tools as alternative care delivery models take root and grow. While experts say it will take some time before population health management becomes the norm, many healthcare leaders are already jumping on the bandwagon to take advantage of the incentives that Medicare and private insurers are offering.

Steve Schelhammer is CEO at Phytel.

As group practices grapple with the paradigm shift to population health and ACOs, they would do well to heed the lessons learned by large employers that have been practicing a form of population health management for years. For a self-insured corporation with thousands of employees, the patient population consists of all those employees and their dependents. To the extent that companies can prevent these people from getting sick or help them control their conditions, they can lower their healthcare spending and improve their workers’ productivity.

Interestingly, ACOs have the same motivations to embrace population health as employers do:

1. Financial Accountability. Employers, as self-insured plans are responsible for the healthcare costs of their employees and dependents; ACOs will be financially accountable for their patients through contractual arrangements with payers.
2. Risk Management. Employers and ACOs both understand that today’s unmanaged health risks can become the high cost cases of tomorrow without effective health programs in place today.
3. Member Engagement. Employers invest heavily in engagement strategies to increase employee loyalty and retention, making participation in health management programs more successful.  ACOs will adopt similar tactics to build “stickiness” with all of their assigned patients.

Many employers started down the path to total population health management with programs targeted towards employees who are already sick.  Employers have implemented these “disease management” programs over the past decade to minimize costs and improve compliance with evidence-based care standards among individuals already diagnosed with common chronic conditions such as diabetes, heart failure and asthma.  According to the National Business Group on Health (NBGH), 72 percent of big employers are investing in this $2.5 billion-a-year industry, up from 67 percent in 2008. Although the programs have been broadened to include a wider range of conditions, disease management programs still touch only those who have been diagnosed, and the most intense interventions are focused on the “sickest of the sick.” Employers have recognized that disease management programs alone do not equate to a population health approach, because these programs do nothing to prevent or mitigate the causes of chronic conditions in the first place.

Now, in addition to disease management, many companies are increasingly emphasizing wellness and health promotion, which promise to deal with what they see as the number one driver of health spending: poor health behavior by their employees and dependents. Once a relative rarity, wellness programs are now embraced by most large employers and round out total population health strategies that address health needs across the continuum of care. Nearly half of employers purchase specialty programs to alter lifestyles and health behavior, and the majority of companies offer smoking cessation and weight management programs, according to a 2010 survey by the NBGH. Thirty-nine percent of employers consider wellness programs to be their first or second most effective strategy for controlling health costs.

Companies with effective and comprehensive population management strategies have demonstrated lower health costs, higher productivity, and higher profitability.  Companies that achieve the best results use a combination of tactics to drive participation in health management programs, including financial incentives, creative marketing and automated communications, onsite health clinics and coaches, as well as online education and self-management tools.  ACOs preparing to achieve their twin goals of cost savings and high quality outcomes will be able to apply many employer strategies to their delivery model.

One advantage that ACOs may have, however, over employers is the ability to leverage the patient-physician relationship to encourage participation and positive behavior change.   Despite employers’ longstanding experience with population health, they have failed to integrate effectively with the patient’s most trusted health advisor, his or her personal physician.  In fact, progressive employers are looking to ACOs to take population health to the next level by bringing the physician to the center of the equation.

Karen Handmaker is the Director of Population Health Management at Phytel.