Drilling Down to the Data, Engaging the Doctors

April 10, 2013
Mercy Health Partners’ Amy Frankowski, M.D., talks about the opportunities and challenges involved in sharing clinical performance data with physicians—and moving forward collectively in an accountable care context

A lot of innovation has been taking place recently within Catholic Health Partners, a Cincinnati-based integrated health system that encompasses 29 hospitals, making it the largest health system in the state of Ohio. As part of a broader strategy aimed at optimizing resource use and improving clinical outcomes, leaders at Mercy Health Partners have been working with the Cleveland-based Explorys, a big data-focused analytics vendor. And as at other Catholic Health Partners health systems, the Mercy Health Partners folks are making progress in improving outcomes across entire physician groups.

In January, Healthcare Informatics Editor-in-Chief Mark Hagland interviewed Kenneth Bertka, M.D., president of physician clinical integration for both the seven-hospital Mercy Health Partners, based in Toledo, a division of Catholic Health Partners, and of the entire health system, about the organization’s overall innovation work, as well as its partnership with the Cleveland-based Explorys, a big data-focused analytics vendor. Following that interview, Hagland spoke with his colleague Amy Frankowski, M.D., the senior medical director of clinical integration at Mercy Health Physicians, the physician organization within Mercy Health Partners. Mercy Health Physicians encompasses 300 physicians, evenly divided between primary care physicians and specialists, as well as about 1,000 staff members in 80 locations across the greater Cincinnati area.

Dr. Frankowski has been helping to lead the ongoing development of Mercy Health Select,, a Medicare Shared Savings Program (MSSP) accountable care organization (ACO) chartered in July 2012. Mercy Health Select encompasses, Mercy Health Physicians, as well as local Mercy hospitals. Below are excerpts from that interview.

With regard to your title, senior medical of clinical integration—is that more of a “CMO-ish” title or a “CMIO-ish” role?

It’s more “CMO-ish.” But because of the need for a common data platform and all the need for information technology, I’m intimately involved with all of our IT.

Amy Frankowski, M.D.

Do you have a staff reporting to you?

We have a team within Mercy Health Systems, so there is a director under me who is a doctor, with an IT background. But I don’t personally have a staff under me; we run a lean ship. The roles are evolving. I report to Dr. Dan Roth, the President of MHP. He had previously been CMIO of Catholic Health Partners.

How long have you been in your current position?

I’ve just been in this position since May 2012; before that, I was the medical director of clinical transformation; my role has expanded, because of the development of our clinically integrated network and our ACO. I still practice as an internist; I see patients about 20 percent of the time now.

MHP itself has been a rapidly growing group. There have been a lot of changes; our market had a lot of independent physicians, but the consolidation of physician practices into large groups has really taken off in the past three years, and especially in the past year. So we’ve been bringing in a lot of physicians who hadn’t previously been involved in collaborative efforts like measuring quality.

That’s always a cultural challenge, correct?

Yes, I would say the cultural change is the biggest challenge, followed by the IT challenge. Many of the doctors were independent business owners who by choice or because of economic factors became employed physicians, and for many of them, it was the first time they were on an EHR; and all of our ambulatory doctors are live on Epic. And we have about 400 affiliated doctors, and we’re trying to bring up most of the primary care doctors on Epic in the next year; most specialists are on something. Our goal is to get them all live within the next year. And we require all physicians to move towards being on an IT platform.

Have you attested to Stage 1 of meaningful use for your employed physicians?

Yes, in spring 2012. But we did decide that any new primary care doctors need to get onto Epic [the core electronic health record system from the Verona, Wis-based Epic Systems].

What core elements are you measuring right now?

One of our core elements is patient satisfaction; we’re also measuring our employed physicians on quality incentives, on the outpatient side. On the inpatient side, we’re tracking all the traditional HEDIS [Health Effectiveness Data and Information Set] measures [from the National Committee for Quality Assurance, or NCQA] as well as Joint Commission factors, the readmission rate, etc. For the outpatient group, we initially decided to track patient satisfaction and quality measures.

Which quality outcomes are you measuring right now on the ambulatory side?

We started here in southwestern Ohio looking at preventive measures, diabetic measures, and coronary disease. On the preventive side, the same elements that Dr. Bertka mentioned. And in our region, we started a couple of years ago with those. And then in our region, Aligning Forces for Quality is a National Quality Forum initiative—funded by RWJF [the Robert Wood Johnson Foundation]—and we publicly collect and report what are called the D5 measures. So we publicly report the D5 and the C4 measures—coronary measures, and colonoscopy rates.

Now the problem is, we were doing fairly well in being able to give reports to our providers on a quarterly basis, out of Epic. But to make any kind of real-time or active changes for our changes, we were experiencing a big lag. By the time a provider would get the information and share it, some time would have passed. So we need to collect the information, make sure it was accurate, and be able to identify our best practices and make changes. So at the end of 2011, we became engaged with Explorys.

Also, currently, with Cincinnati, we’re the leader in developing the patient-centered medical home. We were very proud to report that 18 sites out of 45 primary care sites were certified by the NCQA as patient-centered medical homes, at level three; and we’re working to get them all certified. Cincinnati was a leader in developing pilots for medical homes. But NCQA updated the guidelines in 2011 and made the requirements more stringent, so that you had to be live on an EHR to achieve certain criteria; and the other main requirement was that you had to be doing continuous quality improvement and producing outcomes reports. And we’ve been especially focused on diabetic care.

Tell me a bit about how the mechanics of working with the Explorys solution work.

As of this past fall, our primary care providers can log into the system as often as they want to, to this information, with real-time feedback, to see how they’re doing on all the measures on our scorecard, and they can compare themselves to their own site, and to all the doctors in their region, and then the whole system.

How many measures are there altogether?

Explorys offers a very broad menu; but we went with our scorecard, and then also the diabetes measures, so altogether, it’s about 14 measures.

Have you seen any changes in results since the fall?

We have had improvements across all of our measures throughout the course of the year. And we have different docs in different places. And one of the challenges of working with Explorys—it’s helped our doctors see their scores, but one of the first things the doctors ask is, is the data real? Because everybody has the sickest patients, the greatest challenges, the most exceptions, right? But the ease of use makes all the difference here. It’s a Google-like capability. It’s easy to find out if your mammography rates have improved.

The purchasers and payers of healthcare are demanding that providers become more accountable and transparent, and this is how you start, right, providing the doctors will usable information in real time?

Yes, absolutely. And we did a crosswalk, looking at our different insurers and their different P4P [pay-for-payment] measures—Humana, Cigna, Aetna, etc.; and then we looked at the required quality measures for medical home certification, and we looked at what the 33 quality measures required for participation in our Medicare ACO; and we’re going to have to begin reporting on those in February. So we’re using Explorys for that. And so we took a crosswalk between the P4P measures, medical home measures, and ACO measures, and said, what are the most common elements? Because we can’t ask doctors to look at their behavior and change their behavior on 56 different things. So we started small, picked the elements with the most commonality; and they were all measurable things. Because many of the things the federal government and private payers are asking us to measure are things we previously might not even have been measuring. Initially, we did the work by hand through chart-pulls. With 30 doctors, it’s a challenge that takes weeks to do; with 300 doctors and expanded measures, it couldn’t be done by hand.

So we initially wanted to get our doctors’ attention by focusing on the most common measures; because the primary care physicians in particular are being asked for more and more, in a shorter and shorter period of time. So that’s how we picked the measures we started with. Explorys offers a very large menu, but they were also willing to work with us on what we wanted.

Can you share a few examples of your progress?

Certainly. Our pneumococcal vaccine rate rose from 52 percent in 2011 to 60 percent at the end of 2012; our colonoscopy rate went from 34 percent to 40 percent during that time. And our tobacco cessation counseling rate rose from 56 percent to 77 percent. Those are some examples. And because we had new doctors, that can sometimes dilute the scores, but by keeping this small, the things they’re looking at… it’s allowed our docs to move forward. And also, with Explorys, we’ve been able to give them peer-to-peer comparisons in real time. That’s very powerful and motivating.

The thing is, if you’ve got a physician who’s starting at a 20-percent rate on a measure where the national average is 80 to 90 percent, that doctor will ask, how can I possible get there? But if doctors can compare themselves to one of their peers who’s maybe in a worse socioeconomic environment in town and has half the staff they have, then maybe that will really make a difference. And within our medical homes, each site is able to do some testing for change: how can we improve mammography rates, for example? Do we do a reminder with all our reminder calls? Or twice a year, use the Epic patient portal to shoot out a reminder? And Explorys also allows us to drill down, so that if I pull up my Explorys information, I can see for myself or my practice site which patients haven’t gotten mammograms this year, and I can do an outreach to them. As part of our population health management initiative, we’re going to target certain specific measures and then repeat, such as colonoscopy rates. And we can intervene on multiple preventive issues at the same time, with reminders.

What have the lessons learned been so far around effectively leveraging IT to do this kind of work?

IT is very important; data accuracy is very important; transparency is very important. But we have to keep in mind that we’re all human, too, and we have to take into account the human factor, and you have to be able to reach the physicians where they’re at. As part of our development of our ACO and clinically integrated network, we’ve visited a number of sites around the country. And we’ve found out that there’s no perfect information system that can do all things for all people. And that actually was reassuring, knowing we were taking good steps. And being able to reach the doctors where they are today is so important. So is being able to verify this data, and being able to see which patients are and are not compliant; that has been very validating. And each doc who comes up on the system may find something that’s more unique and interesting, and that makes it that much better and cleaner for each next doctor.

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