It’s all about accountability and transparency, correct?
Yes, and we’re trying to do those kinds of things. I don’t pretend that we’re as far along as some, but we’re moving forward. And one thing to note is that 40 to 50 percent of the patients in California are a part of Kaiser. And I’ve always maintained a close relationship with my patients who go into and out of Kaiser, as their employers change contracts. But Kaiser has made reimbursement lower, frankly, in Northern California, while the cost of doing business is higher here than in other parts of the country. So we’ve already got certain elements in our landscape now.
What kinds of things are needed, IT-wise, to make ACO organizations successful?
I’m not a super-fan of EMRs in terms of the improvement in the quality of records in the EMR; but you do know when a patient was seen, what they were seen for, and so on; and that is finally now being done in a way that the EMR can be usable and of benefit. And let’s face it: the big dollars are spent in the hospital. The amount of money spent on outpatient care is relatively tiny. And so the quality of inpatient care is going to have to continue to be improved.
All patient care organizations and clinicians will also have to be working forward in terms of systemically averting unnecessary readmissions as well, correct?
Correct. And I think the way to avert readmissions is to be able to know what happened before they were admitted in the first place. And the second thing is that you have to avert emergency room visits. And the easiest thing for the emergency room doc, no matter how well qualified, is to admit a patient to the hospital.
What have your lessons learned been so far?
One thing is that we thought some of the oldest physicians who we thought would be the most recalcitrant, have been some of the most embracing of chronic care management and of clinical IT, both because they think they will both help them practice longer, and will bring younger physicians more readily into their practice. A second lesson learned is that every physician practice is different, and EMR rollout is not easily made “cookie-cutter-able.” In terms of the physicians being willing to stick with it, it has to be easy, and it if takes 14 clicks and they get lost in the system, they won’t stick with it.
One of the things that makes us lucky is that we have IT infrastructure and an IT team. The MSO [medical services organization] that supports us—Pacific Partner Medical Systems, Incorporated, or PPSI—has a team of 90 employees, and about 15 of them are IT employees.
While the federal Centers for Medicare & Medicaid Services (CMS) unveiled the proposed rule for accountable care organizations (ACOs) on March 31, numerous patient care organizations have already been developing ACO-type arrangements in the commercial health insurance sphere. The steps being taken to begin coordinated care initiatives range across a spectrum from very preliminary work to some more advanced models (while some medical groups have already done work with CMS through its earlier ACO demonstration project).One medical group executive who has had some preliminary experience with working to coordinate care, and with leveraging clinical IT in that effort, is Kersten Kraft, CEO of the Santa Clara County Independent Practice Association (SSCIPA), which is comprised of over 800 physicians (just under 300 of them primary care physicians), and is based in San Jose, Calif., while serving the entirety of Santa Clara County. SSCIPA is an affiliate of Stanford Hospital & Clinics in Palo Alto.Under Kraft’s leadership, SSCIPA has moved forward into a variety of contracting initiatives; and in tandem with those efforts, his organization has moved forward in the clinical IT sphere as well. Kraft—who in addition to leading his organization as its CEO, continues in practice as a urologist—spoke with HCI Editor-in-Chief Mark Hagland earlier this spring, shortly before the proposed rule on ACOs was released. Below are excerpts from that interview.Tell us about your organization’s experience in leveraging clinical information systems to support care coordination.Like many IPAs, as our organization grew and had more contracts, and with the need for care data, we ended up developing our own software, which we call Access Express. It was an in-house-developed software that became popular enough internally that we decided it could be used by others; so Hill Physicians in Northern California, and NAMM (North American Medical Management) in Southern California, and Monarch, have all used it. It was not a medical record; it was basically for authorizations.So when it came time to implement an EMR, we looked around, and found a software program in the U.K. that was built on the same platform as our software, and could be integrated. It started out as clinical information-gathering by an anesthesiologist who had trouble getting pre-op information on his patients, and went on to be a chronic care product in the U.K. They had no need for the patient coordination part, because they have a single-payer system. So a little over a year-and-a-half ago, we met with them and agreed we would use their software, and integrate it into a complete package and distribute it in the U.S. The integrated package we call Access Express 5.0; their software is called Exelicare, and the company is called AxSys Technology, Ltd., and the company is based in Glasgow, Scotland. Their only real venture outside the U.K. is as the provider for a chronic care software in Ontario.