Category — Population Health
Last week, Phytel participated in a pre-conference workshop at the HIMSS conference in Orlando. The workshop was called, Transforming Healthcare Delivery: The Patient-Centered Medical Neighborhood. The day-long workshop’s speakers included experts from each of our partners involved in the CMMI grant, TransforMed, VHA and Cobalt-Talon, plus one of the CMMI grantees, Greater Baltimore Medical Center.
The 30 participants who attended the workshop represented a variety of organizations, but the common interest was how to deploy effective Health IT to support population health strategies. Speakers presented on analytics, culture change, care team transformation and patient engagement, specifically on how sources and uses of data are being applied to enhance and mature the PCMH and PCMN.
Dr. Robin Motter of Greater Baltimore Medical Center (GBMC) stressed the importance of executive and clinical leadership to drive change. GBMC practices are recognized as patient-centered medical homes, which is an essential building block. To further assist their PCMH teams, Dr. Motter showed examples of how Phytel tools are assisting their care teams with identifying and engaging cohorts of patients with diabetes. Dr. Motter shared that having real-time information about their patients—and the ability to drill down and take action with at-risk patients is a game-changer:
I was asked to speak on Building the IT Infrastructure for Population Health and Care Management. We had a very lively “unplugged” discussion about the progress and challenges of moving from Volume to Value-Based payment models, all while acknowledging the critical importance of technology, intelligently applied, to empower care teams, the front line of patient-centered care.
Click here to see my presentation and let us know if you want to learn more.
March 4, 2014 No Comments
In a new blog series, Jerry Green PhD, Vice President of Quality for Phytel, will be sharing his six keys to Lean-Six Sigma. You can read the previous entries here.
If I only remember six things about Lean-Six Sigma, it would be:
- Always think horizontally
- Addressing the constraint is more important than addressing the Non-Value Add
- You cannot make the turtle go faster
- Sometimes it’s better to NOT be busy
- Don’t forget the other two
- Professor John P. Kotter had it right all along
In many cases, healthcare technology can change, but the process around the new technology is forgotten and staff isn’t educated on using the new tool. This type of change is referred to as an installment. With an installment, care teams have no choice but to accept the change, adapt, and move on.
During my career as an improvement practitioner I have seen many project leaders follow the same installment approach to process improvement – forgetting that technology, processes, and people are interrelated [see Figure 1.0], and that making a change to one of the three impacts the other two, resulting in lower process efficiency and effectiveness than before the change.
The Three Problems:
1. Problem forgetting Technology: This scenario is the most prevalent for Lean-Six Sigma practitioners, who may follow a process improvement methodology to the book by identifying a practical problem, building a statistical model of the problem, designing a statistical solution on paper, and then launching the process improvement based on the model. However on day one, care teams refer to their new work instruction, log in, and realize that the system or tool that they use will not allow the new workflow.
For example, I have seen non-value added process steps such as hierarchical approvals, which had previously been removed from the workflow, being required entries in the system before a page can be saved. Care Coordinators trying to work at the top of their license cannot because the system requires physician intervention; process flows are halted by required system batching.
2. Problem forgetting People: This scenario is seldom forgotten by Lean-Six Sigma practitioners, but often purposefully ignored. Formal education takes time and therefore increases the timeline for any improvement, and could result in having to address care teams’ challenges to the change. However, ignoring formal education is the quickest way to ensure that any process improvement will fail. Care teams may naturally keep following the old process that they were previously educated on, while the project leader moves on to the next non-value added process improvement.
3. Problem forgetting Processes: This scenario is rarely due to the efforts of a Lean-Six Sigma practitioner – systems change, yet current process flows do not follow the same workflow as the system now requires. Keep in mind, most system changes are for the good, but the efficiency expected may be lost due to a lack of standardization fraught with many versions of tribal knowledge. Productivity suffers as care teams attempt to figure out what to do and how to do it. Processes will change, because there is no choice, but often the changed processes are not optimized and can become a quagmire.
The Solutions to the Three Problems
First, anytime a process or technology improvement is considered, include the other two as part of the project scope in the charter from the get go.
Second, cutting over a process or technology change without a pilot is the primary reason the other two are not addressed adequately. A small scale pilot will highlight technology, process, and education issues in the plan very quickly, which are much easier to address in a pilot then after a full-scale launch.
Third, remember that education is seldom the total solution, but rather part of a technology or process solution. Employees come and go, so develop robust processes and systems so that continual education for existing employees is not necessary. A robust process would include automation, most activities would meet the value add criteria, and the process would flow logically.
Remember that any change should include a change in process, technology, and how people work. Spending time up front and addressing all three will increase the likelihood that the change will stick and that efficiency and effectiveness are realized sooner:
- Include all three in the project charter
- Pilot the change on a small scale
- Build robust processes that do not require continual education for existing staff
Learn more about Lean-Six Sigma in additional blog posts, including why it’s important to “always think horizontally,” why “addressing the constraint is more important than addressing the non-value add,” and “you cannot make the turtle go faster.”
February 27, 2014 No Comments
To manage population health, healthcare systems and group practices must build the requisite infrastructure, including software tools designed for data analysis and workflow automation. The front end of this IT infrastructure is a type of analytic solution known variously as predictive analytics, predictive modeling, or health forecasting. In a population heath management context, these algorithmic tools predict which people are likely to get sick or sicker in the near term.
This is crucially important information to provider organizations and health plans that take financial responsibility for care. Ten percent of patients generate roughly 70% of health costs; five percent account for half of health outlays. By identifying which people are high risk or likely to become high risk, risk-bearing entities can intervene with them to improve their outcomes and lower health costs. Most health plans offer case management, disease management, and health coaching programs to these members. Some healthcare organizations seek to ensure that high-risk patients receive necessary services and day-to-day support from care managers. To improve outcomes and lower costs, these organizations must connect predictive analytics with workflow automation tools that enable care teams to intervene with the right patients at the right time in the right way.
At a high level, here are five ways to leverage predictive modeling for population health management:
- Risk stratification. Classify patients as low, medium or high risk. Use that information to allocate resources at a population-wide level, identify high- risk patients, alert providers and care managers about those patients, and design interventions to prevent other people from becoming high risk.
- Workflow automation. Couple predictive modeling with automation tools that enable providers to reach out to patients with care gaps and allow care managers to touch more patients in various ways, ranging from high-touch case management to web-based education and coaching.
- Readmission prevention. Use preventive modeling to identify which patients are most likely to be readmitted. Intervene with these patients so they receive the support they need to avoid readmission.
- Provider attribution and risk adjustment. Apply risk adjustment to evaluate the performance of individual providers, sites, and your whole organization in comparison to others. Use risk adjustment to measure variations in care, improve quality, and show payers how your organization ranks in utilization and quality.
- Financial risk calculations. Employ predictive modeling to calculate how much care delivery will likely cost for your population in the coming year. Use these figures to determine whether the organization will lose or make money under proposed risk contracts.
To learn more about making the insights of predictive modeling actionable for population health management, read the full whitepaper, “Predictive Modeling and Population Health Management.”
February 4, 2014 No Comments
Achieving Value-Based Healthcare Quality from the Bottom Up: Applying Lean Six Sigma to Achieve Population Health Management Goals
Phytel presented at the 15th annual PEX Conference this month, sharing insights on “Achieving Value-Based Healthcare Quality from the Bottom Up: Applying Lean Six Sigma to Achieve Population Health Management Goals.” The PEX Conference brings together process professionals, business leaders and executives who want to improve their business through process and operational excellence.
In a time when we are all trying to do more with less, I find the concept of applying Lean Six Sigma to population health management goals to be incredibly relevant to our clients, and wanted to share an overview of our presentation:
Dr. Richard Hodach, MD, PhD, MPH, Chief Medical Officer at Phytel, began the presentation by explaining how population health is undergoing a transformation from volume to value. Healthcare spending is out of control and far exceeds how fast our national economy and average wages are growing – this is the problem that has set into motion a series of initiatives aimed at transforming the healthcare system. Just focusing on the sickest patients will not bend the trend in moving toward a value based system. The sickest only represent about 2-3% of the iceberg, as shown above the waterline in Figure 1.0. In addition, 67% of the patients with a catastrophic event were not catastrophic the year before. In other words, of those who are the sickest, 67% were considered well the year before.
In a volume based system, healthcare providers must become proactive and go below the waterline and provide care to patients before they become catastrophic and high cost.
Karen Handmaker, MPP, VP of Population Health Strategies at Phytel, followed up Dr. Hodach’s introduction by highlighting that although many healthcare providers have jumped on board with population health in terms of their goals in going from value to volume, the infrastructure to actually manage populations is still emerging. In order to manage the infrastructure, healthcare providers must rely on best practices for managing population, referred to as the “front line” or the foundation for the “bottom up” approach to quality improvement. Karen proposed four problem areas in need of transformation in order to facilitate providers going from volume to value:
1. Pre-visit process encounter is not optimized
2. Primary care providers often to not know their patient was admitted
3. Patients at risk of acute event are not identified proactively
4. Care teams are not working at the top of their license
During my portion of the presentation, I broke the class down into groups of 5-6 to discuss how Lean Six Sigma approaches could be used to address each area:
1. Redesign Pre-Visit Process to Optimize Encounter
- Traditional DMAIC (Define, Measure, Analyze, Improve Control)
- As Is (Current state) and To Be (Desired state) mapping
- SIPOC mapping (Supplier, Input, Process, Output, Customer)
- Pareto Charts (the 20% causing 80% of the problem)
- Value added flow analysis and constraint management via automation
2. Create a New Process to Alert PCP of Admissions
- Design for Six Sigma (DMADV) (Define, Measure, Analyze, Design, Verify)
- Collect the CTQs (Critical to customer Quality)
- Use an FMEA (Failure Mode and Effects Analysis) to identify what to design out
- Quality Functional Deployment to help identify measures to focus on (A Tool useful for identifying and prioritizing how to measure the CTQs)
- Use a To Be map to identify the perfect process that would care for the items identified in the CTQs and FMEA.
3. Identify Patients at Risk of Acute Event
- Collect data (Attribute and Continuous)
- Use hypothesis testing tools to identify the relationships between input variables and outcome variables (use a prediction model when feasible)
4. Enable Care Teams to work at the top of their License
- Use principles from John P Kotter for change
- Create a sense of urgency
- Form a guiding coalition
- Create a vision of the future
- Communicate the vision
- Empower action
- Create short term wins
- Don’t let up
- Make change stick
What ideas do you have for applying Lean Six Sigma to population health management goals?
To learn more about Lean Six Sigma, read my blog series, “6 Keys to Lean Six Sigma.”
January 24, 2014 No Comments
Last month we did a webinar that really struck a chord with our nearly 200 participants who stayed on to ask a lot of questions. Why? Now that the term “population health management” is part of the common healthcare vernacular and organizations are in the midst of value-based contracts, people are finally starting to understand what “population health management” requires on the front line in primary care.
“Are you ready for population health?” is a very important question. The reality is that most organizations have not yet reached the tipping point between the dominant FFS payment and new value-based models that pay for quality and savings rather than volume. Most organizations are straddling FFS and value-based incentives for different cohorts of patients and payers while still rolling out PCMH and population health management (PHM) tools and processes.
We work with many organizations that are in this transition from volume to value. Claims-based analytics systems and EMRs are in place, PCMH initiatives are underway and care managers have been hired, but the ability to run effective PHM is still evolving.
Many of the quality measures common to most value-based contracts cannot be improved without encouraging specific patient behaviors across thousands of patients. Whether the desired behavior is getting a mammogram or changing eating habits and medication compliance to reduce HbA1c rates, organizations first have to know who to target. Delivering the right information in the right way to designated team members is, therefore, a fundamental competency for PHM. These are not manual tasks.
Ultimately, successful PHM must follow a “bottom up” approach to achieve quality and savings goals. Each layer of this model is dependent on effective deployment of health information technology (HIT) applications. Clean, real-time data forms the foundation upon which care team members can take action to engage patients and improve outcomes.
Click here to review the webinar slides. You can also learn more about how HIT can power your population health strategies in the recent PCPCC report, “Managing Populations, Maximizing Technology”, that is cited in the webinar. Of course, we welcome your comments to this blog post and we will reply.
January 20, 2014 No Comments
For traditional health systems and physician groups, embracing the Accountable Care Organization (ACO) model is no easy matter, as value-based care has turned the tables on traditional fee-for-service reimbursement. To help, Phytel has outlined a recommended roadmap to successful population health management. Physician practices that follow this five-step roadmap will be well positioned to achieve quality outcomes and financial success in the changing healthcare environment.
1. Commit to Patient-Centered Medical Home (PCMH) Delivery Model
This first step requires an organization-wide commitment to patient-focused efforts such as reduced waste, improved effectiveness, and proactive initiatives to increase patient compliance with care plans. To meet these goals, invest in refining clinical practice through implementing new technologies and care management processes.
2. Secure Payer Involvement and Alignment
Securing payer involvement is an important step in establishing a financial mechanism to sustain and scale the PCMH initiative. Although involving payers from the outset is ideal, often a practice must invest upfront in population health processes and technology to demonstrate results before payers will sign value-based contracts. Having the technology infrastructure in place and the ability to show you can identify and intervene with at-risk populations and individual patients is key to gaining payer involvement.
3. Leverage Care Management Resources
The third step in the roadmap is putting the appropriate care management personnel and processes in place to support practices as they manage their patient populations. Phytel suggests creating high-performance care teams led by physicians, which encourages each care team member to work at the top of their.
4. Implement Technology to Identify and Address Gaps in Care
A critical complement to organizing the care team is implementing health information technology that empowers the team to efficiently manage population health and scale their system for value-based care. Phytel recommends implementing protocol-driven registries that automatically identify care gaps and trigger messages to patients for recommended care; applications that stratify patient populations according to identified health risks and create personalized, automated interventions; automated communications that follow a patient’s hospital or ER discharges to help prevent unnecessary readmissions; and sophisticated analytics that measure an organization’s effectiveness in its quality improvement initiatives.
5. Measure Quality-improvement Effectiveness with Analytics
The fifth step in the roadmap to successful population health management is to implement sophisticated analytics that measure an organization’s effectiveness in quality improvement initiatives. This functionality for analytics and insight on both the clinical and administrative level will help ensure you are meeting the Triple Aim – lowering costs while improving quality and the patient experience.
Learn more about how one organization transitioned to value-based care using these steps in this case study on Bon Secours Virginia Medical Group.
January 16, 2014 1 Comment
In a new blog series, Jerry Green, Vice President of Quality for Phytel, will be sharing his six keys to Lean-Six Sigma. You can read the first entry here, explaining why it’s important to “always think horizontally,” as well as the second entry here, on why “addressing the constraint is more important than addressing the non-value add.”
If I only remember six things about Lean-Six Sigma, it would be:
- Always think horizontally
- Addressing the constraint is more important than addressing the Non-Value Add
- You cannot make the turtle go faster
- Sometimes it is better to NOT be busy
- Don’t forget the other two
- Professor John P. Kotter had it right all along
In my second blog I discussed the importance of addressing the constraint before addressing the Non-Value Add. Identifying the #1 constraint in a value stream must always come before addressing non-value added activities. The constraint can be either value add or non-value add, and even value added activities often contain non-value added sub-activities.
- Every process will always have a #1 constraint
- Sometimes the #1 constraint cannot be sped up, therefore, it is known as a turtle
Before accepting the fact that the #1 constraint cannot go faster, consider standardization, a new design, new technology, automation, and simplification. Once all has been done, then the organization must build in a buffer and manage to the turtle.
One way to standardize is to implement a 5S process as developed by Hiroyuki Hirano. Implementing 5S will help reduce the non-value added time of searching, sorting, walking, and extra motion. Just 5 minutes of added capacity per exam could be enough to see one or two more patients per day, increasing the total daily revenue.
Example of 5S for the patient exam:
- Sort: Remove any unnecessary clutter from the exam room keeping only essential items needed for the exam. Ensure that any expired materials are removed as well. Prioritize what is used the most during an exam.
- Straighten: Arrange the exam room so that the most-used items are the easiest and quickest to access. Label all storage areas, such as cabinets and drawers, with the names of the items stored within. Place a “restock” note card approximately two-thirds of the way down each stack of items to remind that it is time to restock. This will ensure that the provider does not have to leave the exam to find needed items. Remember to put items that are used the most closest to the area in which the exam will take place.
- Shine: Clean all equipment and keep it clean. For an exam room this step is required and therefore nothing new. Yet for other organizations, this step is often neglected. During the exam, ensure that everything is always restored to its proper location so that it is ready for the next exam.
- Standardize: Set up every exam room in exactly the same way. This will facilitate interchangeability so that finding needed items becomes second nature and eliminate the need to search and locate.
- Sustain: Within the schedule, allocate time to restock items, to sort out expired items, to shine, label, etc. Discipline is key, and this is the step in 5S that is often neglected, resulting in backsliding to original disarray.
A New Design
Are there activities that could be done in parallel, or can the sequence of activities be changed to eliminate waiting and batching within the #1 constraint? One way to help answer these questions is to visualize the process using a spaghetti diagram.
A spaghetti diagram is a drawing of the physical path taken by an entity as it travels through the steps of a process. As shown in Figure 1, a spaghetti diagram can help visualize the transportation within any process. Using this approach with those involved in the activity can help identify where the work flow could be optimized by moving equipment closer, reordering the activities for better flow where feasible, as well as identifying activities that could be done in parallel by another individual.
Never undervalue the idea that a new technology can replace an existing process or procedure, allowing providers to spend more value added time with the patient. Thirty years ago a mercury thermometer was commonplace. The time to get a patient’s temperature would range from two to three minutes. Today, a provider can take a patient’s temperature, and with much better accuracy, in seconds using an electronic instrument. During the time mercury thermometers were used, the thought of taking a temperature in seconds would have seemed inconceivable.
In addition, providers can use information technology as a way to reduce non-value added time for themselves and their staff, while at the same time increasing patient engagement. For instance, using automated interventions that work seamlessly in the background, providers can engage patients in their care by efficiently reaching those who need services and education in self-care, without increasing non-value added time. This can allow practitioners to repurpose their own time to the #1 constraint. One example that comes to mind is Phytel’s suite of products.
Phytel’s product suite:
- Helps providers and practices manage their patients more efficiently by automating busy work
- Increases patient compliance resulting in maximized revenues and patient loyalty
- Allows practitioners to manage chronic disease patients through automation
And, these products do this all without providers and practices wasting time mulling through records and files. Not only can improvements in information technology help reduce non-value added time for providers and practices, thus increasing the capacity of the turtle, it can also improve the quality of care by allowing providers the ability to act quicker using timely and comprehensive information.
Automation is an area of concern that must be addressed and fully understood. Many organizations fall into the trap of manumation. This term refers to manual process that are automated, but the automation requires more human effort than the manual process itself. In addition to manumation, this author has seen many organizations automate workflows in one organization that require a downstream organization to engage in additional manual activity.
Automation must either reduce the overall total cycle time of a value stream or increase the capacity of the #1 constraint. Here at Phytel, in an effort to better automate QA testing in its software development value stream, a controlled dataset concept was introduced. During the initial gathering of critical to quality elements it became apparent that one solution would merely move the manual effort to another department. Because the concept of manumation was known, the improvement team quickly redesigned the concept in a way that not only automated the QA testing environment, it ensured that no extra downstream work was necessary.
Healthcare providers must be aware of this trap as well. Moving a constraint to another part of the value stream will result in no improvement from the effort. It is essential to visualize any automation concept within the entire value stream or suffer the cost of manumation.
The process of simplification is generally the easiest and quickest way to increase the capacity of a constraint but often the hardest to see. Visualizing the trees rather than the forest can result in an inability to find the easiest way to perform an activity.
A few examples include but aren’t limited to:
- Reduce handoffs that can occur in the constraint: Determine where handoffs can be eliminated, allowing an employee to complete an activity without handing off responsibility to another. For example, empowering Care Coordinators to work at the top of their license without physician approvals, where appropriate, can simplify the value stream as well as increasing time for the turtle.
- Identify where redundancy in the value stream can be eliminated: Removing redundant reports, projects, and activities can allow an organization to repurpose resources to the #1 constraint. For example, eliminating reports synthesized by a Care Coordinator that at one time were useful but today no one reads could allow the Care Coordinator to repurpose time and assist in the #1 constraint, thus increasing its capacity.
- Poka Yoke: This is a Japanese term meaning “mistake proofing”. Mistake proofing an activity will reduce the amount of time in rework and the cumulative negative effect of error. Two examples that many organizations use are drop down menus on electronic forms and auto-population of data. Both methods can reduce non-value added time, rework, and checking. Another type of poka yoke method is to color code male and female items so that only blue goes with blue, green with green, and so forth. This method will reduce the time in finding what is needed and reduce the likelihood of error.
- Co-locate and sequence tasks and items: This process should be done in the 5S exercise, but revisiting while simplifying may help process improvement teams come up with new ideas. For example, move copy machines and supplies closer to the area that use them the most, use tablet devices that can easily be carried for data retrieval and input, and flow the area so that patients, or the entity, have to go shorter distances. A spaghetti diagram will work great for co-locating items.
- Reduce approvals: Approvals are often necessary, especially in the medical arena. However, be careful that approvals do not become bureaucratic. For example, allow nurses and staff to work at the top of their license, empowering them to approve what they can without a physicians signature. When approvals are essential, develop the workflow so that only the final approver is necessary and remove lower hierarchical approvers from the flow.
- Reduce motion: Not to be confused with transportation, motion refers to movement while in a stationary process. Twisting, turning, and reaching are all examples of motion. Although a spaghetti diagram can help identify where transportation is a quagmire, it will not help with bringing insight into motion; only through direct observation can motion be reduced. Observing where motion adds time to a constraint can bring additional insight into where co-locating and sequencing tasks could reduce significant time in the process, as well as reduce fatigue for those performing the activity.
Build in a buffer for the turtle
Although waiting and inventory are non-value add, sometimes it is necessary to ensure that the turtle is not wanting, waiting, or delayed.
- Inventories should be checked often to ensure that those working in the constrained process do not have to leave the area to retrieve items.
- The primary entity flowing through the process, such as the patient, must be ready when the constraint is ready to pull (see part 2 of the blog series for more information).
- Information that is needed during the exam must be readily available without the practitioners having to ask for it or find it. For example, obtaining necessary information about the patient upstream can facilitate a quicker diagnosis and ensure that waiting on information is reduced. In addition, having information technology available at the point of contact with the patient can also reduce motion, transportation, and waiting.
Before accepting the #1 constraint is a turtle and cannot go faster, consider standardization, a new design, new technology, automation, and simplification. Once the #1 constraint has been accepted as not able to go faster and all has been done, the value stream must then be designed around the turtle. As discussed in part 2 of the blog series, the #1 constraint can never be waiting or delayed. Therefore, it becomes necessary to build a buffer for the constraint. All proceeding activities must support the time buffer with lead time management such as Little’s Law, inventory control, and reduction of information retrieval.
Stay tuned for my next post, Part 4: Sometimes it is better to NOT be busy.
October 10, 2013 2 Comments
But there are many forms of technology and many ways that automation can impact workflows. And, frankly, the effort can seem daunting. How can organizations determine which strategies are the most important and most effective so they can start now?
We have recently written an article for Becker’s Hospital Review in which we identify 4 key technology strategies required for population health management success. These include:
1. Fish smart; don’t boil the ocean
While there is a great demand for “big data” warehouses and complex analytics, there is much that can be done with data that resides right in the practice with the right “technology assist.” For example, applying evidence-based algorithms to patient-centric registries can readily identify those who need attention to close important care gaps.
2. Produce “actionable” data, not reports
Lists of patients in need of attention still need to be acted upon—with intelligent automation, personalized and targeted messages can be sent to patients without any or little manual effort.
3. Make sure actions fit within care team members’ workflows
Population health is not going to succeed if it’s perceived as extra work for already stretched teams—automated tools, properly applied, can help care teams transform and integrate population health functions into efficient workflows.
4. Enable scale
Population management implies scale—standardized workflows across providers, practices and the enterprise are essential to achieving population health goals—and automated technology is the enabler.
For more detail and examples, please read the full article here and share your comments below.
September 24, 2013 No Comments