Hospitalist physician groups often find it challenging to isolate the data elements from hospital data systems to study their own impact for performance improvement. Rohit Uppal, M.D., chief clinical officer of the hospitalist group of TeamHealth, a large physician outsourcing company, is working with vendor IllumiCare to measure the quality and cost of care provided by hospitalists and how one hospitalist group compares to another.
In a recent interview, Uppal said Knoxville, Tenn.-based TeamHealth is starting to deploy IllumiCare’s Smart Ribbon product, which offers a ribbon of information that appears within or momentarily hovers over a hospital’s EHR to display real-time cost, risk and other data. The goal is to empower clinicians to practice more clinically efficient medicine, while also being better stewards of resources.
TeamHealth has more than 200 hospitalist practices, and Uppal’s role is accountability over their performance, both clinically and operationally. Local teams look at data with hospital systems “and I receive all of that data, too,” Uppal said. “We put that data in a data lake, and we're able to do some analytics to understand where our opportunities are, where our blind spots are, and then deploy resources appropriately.”
I asked Uppal if there are some challenges involved in in comparing groups of hospitalists or in getting access to the right kind of data that you want out of the systems of their health system partners.
“You wouldn't believe the challenges we face,” he said. “We are a very data-driven organization, very metric-focused, Our clinicians are really dedicated and motivated by the data available to us within the hospital. But attribution is a huge issue.”
With most of the data they get from the hospital, it is not clear if they can trust the attribution at the individual level. “There are a lot of flaws in attribution and the accuracy of data,” Uppal said. “The timeliness of the data is another issue. Usually there is a six-week lag at the minimum between performance and when you see the data. You're getting data that represents two months ago, and then you're trying to act on that data, already knowing that the environment or the situation has changed.”
TeamHealth has a robust quality improvement structure, Uppal said. “We bring together leaders who have a passion on a certain issue such as readmissions. We ask what we can do to improve the care we deliver to our patients. What are our common areas of opportunity? We develop programs so we can have a standard approach to readmissions.”
They work on training and monitoring the communication skills of their hospitalists. “We know one of the biggest drivers of readmissions is either miscommunication, with patients not understanding what to do or they understand but they don't really have a trusting relationship with our clinician,” he explained. “We also have to make sure that we are working with other specialists to develop a cohesive plan for the patient. If the patient is going from the hospital to a nursing home, we have to make sure we are getting the right information to the most acute providers, so they know exactly what they need to do. Or it might include setting up the right resources for physical therapy at home. It involves a lot of teamwork and collaboration.”
As a recent report from Illumicare notes, there are myriad challenges to measuring the impact of hospitalists. “First, not all providers who practice hospital internal medicine are labeled as a ‘hospitalist’ in the data. Second, a hospitalist is hardly ever the only provider involved in the care of an inpatient. Third, any one patient may be cared for by multiple hospitalists or other advanced practitioners who are aligned with that hospitalist group (and, in some patients, there is overlap in the groups). Fourth, patient populations are heterogenous.”
With the data it has access to, Illumicare said it is able to derive key metrics on physician efficiency and cost behavior by assigning the wholesale cost (not charge) to every medication, laboratory, and radiology order. “We are able to risk-adjust inpatient acuity, assign orders to a respective hospitalist group, understand the propensity to consult specialists and compare the quality and cost of various hospitalist groups operating in the same health system,” the company’s report said.
TeamHealth was one of three groups the study looked at. While their patients’ average length of stay exceeded the expected Geometric Mean Length of Stay (GMLOS), among the three provider groups studied, theirs was the closest to the GMLOS. (The GMLOS is the national mean length of stay for each diagnostic related grouper (DRG) as determined and published by CMS.) “Despite performing the best on length of stay, it also had the lowest readmission rate. “These are signs of clinical quality and efficiency,” the report said.
“The report from Illumicare was very validating for us,” Uppal said. “I mentioned before how hard it is to get data that we can trust that's highly reliable data. We design these processes and create a culture around performance improvement. Without good data, you don't always know the impact of that work in a way that you know it's attributed to your team. This is so motivating for me. But imagine being the team that makes all of the effort to make those improvements. Being able to see that there's actually something tangible resulting from that is very powerful.”
Uppal discussed why the Illumicare’s Smart Ribbon approach, which provides clinicians with cost data as well as quality data at the point of care, is attractive. “When you think about hospitalist medicine, it really developed for two big reasons. One was the recognition that quality and safety in the hospital was suboptimal. But we also recognize that there are a lot of resources in the hospital, and with the cost of healthcare being such a big issue for our communities, it's really important for us to be good stewards. Having the ability to have that cost transparency, not only to know how you're performing, but to take it a step further and even nudge you at the point of care, to say, hey, you're about to make a decision that based on evidence-based medicine may not be the most cost-effective decision, and may not be the best decision in terms of the quality of care.”
I asked Uppal if there were some lessons learned from the pandemic that will inform his work going forward. “What's interesting is that the things that we need for us to be successful are the same even during the pandemic — making sure that you have good teamwork and collegiality within our team and making sure that we have good integration between our team and emergency medicine and critical care — that we're all working very effectively together.” There is also an increasing emphasis on clinician well-being, he added. “We can’t do any of this in isolation. It’s really got to be a partnership with the hospital and their staff working on these issues to improve together.”
