Online health risk assessments (HRAs) can be used to help make patients aware of their health problems and to help care managers stratify their patient populations by health risk. This approach complements the primary risk stratification strategy, which relies on registry reports to classify patients based on clinical data.

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.

On April 12, 2012, Joslin Diabetes (the world’s largest diabetes research and clinical care organization) and Phytel announced a collaboration on a landmark research initiative to compare the accuracy and predictive value of current assessment methodologies in diabetes care.

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.

Recently, Physicians Practice published an article, “Top 4 ACO Considerations for Physicians.” It posed this question to readers: “Confused about how ‘accountable care’ will affect your practice? We’re here to help.”

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.

A Value Stream is an end-to-end process that flows horizontally through an organization in order to provide value to a client, patient or customer. Many organizations map processes vertically rather than horizontally focusing on a department over the entity that flows through the entire organization. In a horizontal process design, however, because the entity is what is mapped and not a facility or department, handoffs can be visualized and downstream affects identified.

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.

Readmissions are a major problem in U.S. healthcare. Nearly one in five Medicare patients discharged from the hospital returns there within 30 days, and between 50 percent and 75 percent of those readmissions are considered preventable. Medicare pays about $17 billion annually for 2.5 million rehospitalizations of its beneficiaries, and other payers spend roughly the same amount every year for all readmissions of non-Medicare patients.

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.

A growing number of primary group practices are taking a proactive approach to care management because they know coordinated care will be a linchpin driving impending changes in the care delivery system. Larger organizations especially are building the infrastructure they will need under new delivery and payment systems that are emerging for Medicare, Medicaid and commercial programs.

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.

In 2005, the Centers for Medicare & Medicaid Services (CMS) launched a physician group practice (PGP) demonstration designed to:

• 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.

In the book, “Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the Perfect Patient Experience,” Virginia Mason Medical Center (VMMC) describes its Lean journey over the course of the last decade. One of Phytel’s clients, North Shore Physicians Group (NSPG), which is part of Partners HealthCare in Boston, has engaged the services of the Virginia Mason Institute to help apply the same Lean methodology (aka the Virginia Mason Production System) at NSPG’s primary care practices.

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.