Category — Population Health
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 No 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
Recently, Dr. Sean Rogers, medical director and compliance officer at Bend Memorial Clinic (BMC) shared BMC’s journey in leveraging health information technology for accountable care and population health management, and I found it to be an exceptional example of matching the right technology to the right care principles to improve health outcomes. Below are some of the key points of the presentation, including next steps and lessons learned.
The overarching theme of Dr. Rogers’ presentation was the integration of information technology and people, all in the service of delivering better patient care. To transition from our current healthcare environment to a true population health management style, we will now be responsible for guiding the health of an entire patient population – a hefty goal.
For Bend Memorial Clinic, the patient-centered medical home (PCMH) was the prime model to achieve this goal.
A Journey in PCMH
BMC, a physician-owned multispecialty group in Central Oregon, embarked on its PCMH journey in 2009. When the group realized this model would enable providers to deliver the kind of care it hoped for its patients, as well as help BMC be financially sustainable, it partnered with a local Medicare advantage plan and built a model around their joint PCMH principles.
For BMC, the key principle of PCMH has been the ability to deliver the “right care, to the right patient, at the right time, in the right location.” Dr. Rogers shared a fascinating story to demonstrate the power of the PCMH model for his organization: A 55 year-old man came to see Dr. Rogers and had been very healthy throughout his life, and hadn’t been to the doctor in over a decade. The staff members at BMC are encouraged to ask patients about preventative screenings and order tests if they are lacking, even before the patients see the doctor. A medical assistant inquired whether the man had undergone a colonoscopy and ordered the test when it was revealed he hadn’t. Through this preventative screening test, BMC discovered the man had Stage 3 colon cancer and renal cell carcinoma. A simple process change and a focus on team-based care saved this man’s life – twice.
How Technology Makes it Possible
Central to Dr. Rogers’ presentation was the idea that technology is profoundly important in the population health model. Below is the list of healthcare technology that BMC employs for population health – Dr. Rogers gave a great overview of why each is important in his presentation:
- Electronic health record
- Patient portal
- Electronic disease registry
- Patient outreach
- Quality metrics reporting
- Referral tracking
- Transition of care coordination
- PHI access for external providers
- Clinical decision support
- Health information exchange
- Predictive modeling
Specifically, BMC’s patient outreach solution from Phytel has driven meaningful outcomes for the organization. Over 1 year, 95% of BMC’s patients with a gap in care were successfully contacted, and 87% responded to confirm a visit. Dr. Rogers shared that he was initially skeptical about patients’ willingness to respond to calls, but the ability to efficiently and accurately reach out to patients who have gaps in care has been profoundly impactful for BMC.
Lessons Learned in Population Health Management
Dr. Rogers shared lessons that BMC has learned along the way of its population health journey. First, communication is incredibly important between all stakeholders. In addition, the importance of buy-in from senior management as well as the support of physician champions should not be underrated – these are key to driving change. Dr. Rogers also pressed the importance of adequate resource allocation, in regards to both money and people that can devote time to making your project a success; for example, whenever you are reporting quality metrics to physicians, you should always have dedicated resources validating the data to ensure it is sound. Lastly, don’t lose momentum once you get your project off the ground. Change is hard, so focus on proving the benefit of your efforts.
For BMC, the use of technology to improve communications, improve the identification of needed healthcare services, improve population health, and reduce cost are big goals, but ultimately achievable with the right tools and a focused commitment to succeed.
To learn more about BMC’s journey, watch the full webinar here.
July 23, 2013 No Comments
Each day, many providers apply the right combination of clinical expertise, attention to detail, and interpersonal skills that enable them to diagnose and treat a complex case based solely on a health history gleaned from patient and a detailed physical exam.
As healthcare shifts from volume to value, providers are now asked to demonstrate accountability for identifying, interpreting, and mitigating all health risks and condition-related symptoms experienced by a few thousand patients over a period of years. Obviously, an entirely different tool set is necessary to meet this challenge. Proactive identification of the health needs of a group requires data aggregation and interpretation based on each patient’s risks against treatment guidelines.
Historically, the infrastructure necessary to deliver services that support the health and well-being of large populations has existed in an end-to-end fashion only in HMOs and throughout health plans. Today, numerous innovations projects are exploring alternative ways to achieve the data, process, and service integration required in the absence of a single organizational affiliation. The Federal Trade Commission and Department of Justice recently defined criteria by which independent provider groups can identify themselves as a Clinically Integrated Network (CIN) to negotiate contracts with one or more health plans.
Below is an excerpt of a new whitepaper that looks at the importance of clinical integration of providers, reviewing the background and definition of Clinically Integrated Networks.
Clinically Integrated Networks
Until recently, except in group-model HMOs such as Kaiser Permanente and Group Health Cooperative, clinical integration was viewed primarily as a legal concept that allowed unrelated fee-for-service providers to negotiate joint contracts with payers. These providers often came together through vehicles such as physician-hospital organizations (PHOs) and independent practice associations (IPAs).
The Federal Trade Commission (FTC) and the Department of Justice (DoJ) initially regarded efforts by providers to negotiate together as per se violations of antitrust law that would lead to price fixing. But about 15 years ago, the agencies began to issue statements and rulings that carved out a legal space for clinically integrated networks to bargain with payers if their stated purpose was to improve quality and reduce costs. These opinions have continued to grow in scope over the years.
In February 2013, for example, the FTC issued an advisory opinion permitting the operations of the Norman (Okla.) Physician Hospital Organization, a partnership between the Norman Regional Health System and the Norman Physicians Assn. Although this clinically integrated network (CIN) plans to negotiate prices with payers, the FTC said that was unlikely to lead to a restraint of trade since the independent physicians are free to contract with health plans on their own.
The FTC and DoJ define a permissible CIN as “an active, ongoing program to evaluate and modify the clinical practice patterns of physician participants to create a high degree of interdependence and collaboration among the physicians to control costs and ensure quality.” Among the criteria for such a program, the agencies state, are the selection of high quality providers, ownership and commitment by providers, physician investment in the program, appropriate use of health IT, collaboration in the care of patients, quality and cost-improvement initiatives, data collection and dissemination, and accountability.
As healthcare organizations prepare for accountable care, these requirements have taken on a new importance. That is because few organizations encompass all of the providers they need to deliver comprehensive, integrated care to a population across all care settings. Even if healthcare systems employ physicians, they usually need help from private practice doctors and other unrelated providers in the community. That means that their clinically integrated networks must cross business boundaries and that unrelated providers will be bargaining with health plans on shared savings and bundled payment arrangements. To do that legally, they must abide by the federal rules.
One current definition of a CIN is a jointly governed group of providers, including independent physicians, physician groups, employed physicians and hospitals or health systems, that work together to:
- Develop mechanisms to monitor and improve the utilization, cost and quality of health care services provided
- Develop and implement protocols and best practices
- Furnish higher quality, more efficient care than could be achieved by working independently
- Pool infrastructure and human and financial resources
- Jointly contract with commercial and government payers and employers on a shared savings or financial risk basis.
This approach is especially important to healthcare systems because their employed physician groups often do not include enough primary care physicians for a successful ACO. The CIN approach allows them to integrate outside PCPs with their employed doctors to create the proper balance of specialties. For example, Orlando Health in Orlando, Fla., employs 500 physicians, the bulk of them non- primary-care specialists. To align community PCPs with its goals, Orlando Health has created a 400-doctor CIN that includes both employed and independent physicians and has partnered with the largest primary care group in central Florida.
According to the Premier ACO collaborative study, having more employed physicians was not associated with a more successful ACO strategy. “In fact, some of the highest performers had the lowest proportion of employed physicians.” So a clinical integration approach can be the best way to gear up for accountable care or value- based reimbursement.
Review the full whitepaper, including basic requirements, leveraging automation tools, the importance of risk stratification, applying care management and patient outreach, and real client examples from Jackson Health Network and Orlando Health.
June 10, 2013 No Comments
We announced earlier this year that Phytel has achieved prevalidation status from the National Committee for Quality Assurance (NCQA) for autocredit toward 2011 patient-centered medical home (PCMH) criteria. Let’s take a deeper look at what this means for providers.
Why Prevalidation Matters: NCQA and Phytel
NCQA’s PCMH 2011 Prevalidation program is designed to help physician practices identify products that simplify certain aspects of meeting PCMH 2011 requirements. NCQA evaluates advanced registries, population health management tools, EHR systems, and other related technology solutions that provide functionality that meet standard requirements. Following a successful evaluation, a product is awarded autocredit that can be transferred to practices utilizing the prevalidated product, eliminating the need to provide documentation for the associated factors within their PCMH 2011 survey.
For Phytel customers, this means that by simply using Phytel solutions – Phytel Outreach™, Phytel Insight™, and Phytel Coordinate™ – you can automatically pre-qualify for PCMH recognition credit from NCQA for specific factors, earning important points that relate to “Must Pass” elements and save valuable staff time searching for data, running reports, and contacting patients.
How Phytel Supports Compliance with NCQA PCMH 2011
The Phytel platform is designed to help build a high performance PCMH based on population health management principles and leveraging technology to achieve best practices across your enterprise. In fact, a number of functions directly support specific elements of the PCMH 2011 standards set forth by NCQA.
The three Phytel products that received autocredit toward PCMH 2011 scoring are Outreach, which automates patient identification and reminders to reduce gaps in care; Insight, which provides actionable performance reporting by practice and provider; and Coordinate, which automates care management workflows. For example, autocredit applies to the following factors, among others:
- Element 2D, Factors 1-3, Use Data for Population Management (and meets the Must Pass threshold)
- Element 3A, Factors 1-3, Implement Evidence-Based Guidelines
- Element 6A, Factors 1-2, Measure Performance
Beyond autocredit, many other Phytel-enabled functions support compliance with additional factors required to meet standards related to the management and coordination of care, fostering self-management capabilities, and demonstrating ongoing quality improvement.
So How Do You Get Started?
Current Phytel customers can contact their Phytel Client Manager for instructions and a letter certifying they have been using Phytel products for the NCQA-required minimum of three months to upload in the NCQA PCMH survey tool.
For new Phytel customers, or customers expanding their use of Phytel products, our implementation process effectively prepares clients planning to apply for NCQA PCMH recognition by recommending relevant Outreach protocols and Insight conditions and measures, focusing on provider attribution and data integrity, and configuring sample Insight and Coordinate care management and quality improvement workflows for your care teams that tie to specific standards and elements. All in all, Phytel’s focus on automating essential functions makes building and sustaining your medical home much easier!
Visit the Phytel PCMH website to download a free PCMH toolkit.
May 8, 2013 No Comments
I recently listened to a great webinar, in which Jennifer Endicott, VP of Clinical Integration at Orlando Health, shared how the organization is embracing healthcare IT to drive effective clinical integration. Her story included several best practices and a fantastic overview of key industry topics, so I thought it would be important to share a summary if you haven’t seen it…
Orlando Health, a community-based, not-for-profit health system, serves a population of 2 million residents in Central Florida – not to mention the 50+ million visitors that the area sees annually. The health system needed a way to keep track of the patients that were coming in for care, as well as those that were slipping through the cracks. Orlando Health also has a strong focus on creating a “Patient-First clinically integrated model of care” that represents who it wants to be as a system in the future: an outcomes-driven, value-focused provider that offers the highest quality, lowest cost care in the market.
Tackling a New Model of Care
In the new model of care, we know healthcare systems must shift their strategies from a traditional, reactive care environment to an ACO strategy across clinically integrated networks. For Orlando Health, it had too many process running across various registries to handle the load of tracking multiple chronic conditions and measures simultaneously. The health system just didn’t have enough time or budget to hire staff to scale this model and needed to automate these processes.
Phytel brought enterprise care management to Orlando Health, enabling the health system to manage all of its patients, not just those coming in, using real-time data. Care coordinators are now able to use the system to obtain any given set of measures and identify gaps of care, as well as assess patient compliance for chronic conditions.
In addition, Orlando Health was able to engage disparate providers through a robust clinical integration plan, leveraging mechanisms to monitor utilization, control costs, and assure quality of care in their population health management efforts across the care continuum. To achieve clinical integration, Orlando Health focused on three key areas: scaling the ACO infrastructure, enabling care management, and patient-first population engagement.
Phytel helped the healthcare system by analyzing its workflow requirements to ensure it captured the data points needed for reporting. Specifically within the context of ACO 33 measures, Orlando Health found that it was critically important to collaborate with a vendor that helped them understand the workflow processes to be able to do that.
Realizing New Opportunities
Automated outreach represented a bigger opportunity than Orlando Health originally saw, enabling the health system to take population health management to the next level through managing transitions of care. By offloading burdens of the care management process to automated processes, it resulted in less money spent on internal resources, and more time freed up for care teams.
Outreach efforts also improved patient engagement. In one example, primary care physicians reported difficulty in getting patients to bring their medications to their visits. A scripted medication reminder was then added in an automated communication to patients, and physicians saw a remarkable increase in the number of patients who brought in their medications. Through automated outreaches, Orlando Health is now able to get messages out in real-time to help patients improve the level of care that’s delivered to them.
Watch the full webinar presentation here.
What are you doing out there to embrace healthcare IT? Share your thoughts in the comments below.
April 24, 2013 No Comments
In December, more than 100 healthcare professionals gathered together to discuss leveraging digital data and technology to manage population health cost effectively. A key takeaway was that new care delivery models require new workflows, and new electronic tools are needed to automate those workflows – including a focus on improving patient engagement.
Changing patient health behavior—a must-do for organizations involved in population health management—can be challenging for a number of reasons. For some patients, the day-to-day lifestyle behaviors that compromise their health have become ingrained habits that will require more than good intentions to change. For others asked to take on new self-care behaviors, the recommendations may compete with other responsibilities or require skills, resources, or motivation that they don’t have.
Needless to say, although physician recommendations continue to hold significant weight with patients, professional advice is rarely all that is needed to help a patient change behavior. More commonly, it will take incremental plans made over a period of time and an understanding of a patient’s priorities, personal strengths, and obstacles to change.
Shifting the Focus to the Patient
A shift to patient-centered planning is just one of many implicated by new expectations around the longitudinal management of an assigned patient population. Many of the transactional, symptom-related encounters with patients will be replaced by a sequence of consultations that need to result in achieving a steady-state of optimal health. This makes it possible and helpful for care teams to develop therapeutic partnerships with the patients who need their support most. Incorporating both behavioral science and customer relationship management techniques into routine communication strategies and care planning efforts will increase their ability to activate patients to care for their health.
Bidirectional communication must become the norm, and information must be made personalized and actionable. Whereas the predominant voice in patient counseling conversations of the past was that of a provider or care manager, the most productive sessions going forward will draw out the patient. Care team members must become more comfortable listening. It is only through learning a patient’s concerns, priorities, preferred strategy, and perceived needs that the most relevant information and support can be provided. Focus will shift from didactics to action planning exercises that prepare the patient for successful execution of incremental changes that become the foundation for new habits. Ongoing monitoring and feedback from the care team will strengthen patients’ engagement in managing their health.
Automated Tools to Enable Patient Engagement
Monitoring progress and adjusting the frequency of evaluation and/or communication will be important to helping patients sustain efforts to achieve their health goals. Fortunately, automated tools now exist to enable providers to do this on a population-wide basis. A patient-centered medical home or accountable care organization must have visibility across their patient population to those with gaps in routinely recommended screenings, diagnostics, or treatment, as well as those who are not responding optimally to their current treatment. This information must guide population-based outreach for evaluation, revised treatment, and coordination of care as needed. It is this type of reporting and communication strategy that will result in health care delivery that is consistent with current practice guidelines and that results in the improved health status of patients over time.
Download a white paper, Provider-Based Patient Engagement: An Essential Strategy for Population Health.
April 4, 2013 No Comments
In December, more than 100 healthcare professionals gathered together to discuss leveraging digital data and technology to manage population health cost effectively. A key takeaway was that new care delivery models require new workflows, and new electronic tools are needed to automate those workflows – as seen in this example of managing 8,000 diabetic patients in a multispecialty group.
Imagine you’re the CMO of a multispecialty group with 50 providers, half of them primary care doctors. Your network has 250,000 patients and a business that’s 70% commercial insurance. The group received NCQA recognition in 2011 for its patient-centered medical homes (PCMHs), and it’s considering some risk-based contracts.
A health plan with 100,000 patients wants the group to sign a quality-based contract to manage patients with diabetes. The main goal is to decrease the number of patients who have high A1C values. If the network can do that, it will get a bonus.
The group first needs a high-level overview of the diabetic patients who are insured by this health plan. Based on the prevalence of diabetes in the population, there are about 8,000 patients in that category. Currently, only 38% of them are in full compliance with their care plans. To reach the goal, the group will need to reduce the percentage of diabetic patients with an A1C > 9.0 from the current 28% of the diabetic population to less than 15%.
The group has an application sitting on top of its EHR that can identify the patients with diabetes and attribute them to their primary providers. It also extracts the baseline A1C values for this population. You can also see how individual providers are doing and how they could improve.
Using this data, you can sit down with the providers, explain what the contract is about, and give them data on their performance. Next, you can share your findings with the group’s quality committee, which sets goals, such as see all diabetics twice yearly and decrease their average A1C by one percent within a year.
To meet these goals, the group can use automation tools to:
- Risk stratify the population
- Segment the population by condition, insurance, etc.
- Identify care gaps
- Alert patients who have care gaps that they need to make appointments
- Help care managers identify high-risk patients who they need to focus on
- Enable care managers to initiate a variety of micro-campaigns for all patients with diabetes
- Help providers do pre-visit preparation
- Survey patients to improve post-discharge care and ensure that the patients get their questions answered
- Generate performance reports for physician feedback, showing doctors how they compare with their peers and national benchmarks
Automation tools like these can facilitate most aspects of population health management. In addition, providers that use Phytel solutions can get auto-credit toward NCQA recognition of their PCMHs.
March 27, 2013 No Comments