Many physician group practices around the country are facing multiple challenges when it comes to collecting and reporting out quality measures in the various accountable care organization (ACO) and other value-based programs in which they participate.
Part of the ACO experience when it comes to participating in any of the Medicare-sponsored programs includes submitting quality measures at the end of each performance year. In January, all ACOs receive a reporting inventory for their attributed beneficiaries on whom they must submit quality measures. Through this reporting process, the Centers for Medicare and Medicaid Services (CMS) determines each ACO’s quality score, an aggregate score across four domains of care. While several of these measures are claims-based and can be measured by CMS on behalf of the ACO, many measures require clinical information and are to be submitted through the group practice reporting option (GPRO) web interface.
GPRO reporting has traditionally been a time-consuming task for ACOs. They must collect data for 15 measures (with a minimum of 248 patients per measure) across multiple provider groups, not to mention, the data used for submission is contained in several different electronic health record (EHR) systems. Without a way to automatically pull clinical data from the EHR systems, KCN staff would have to manually extract and review the patient data and then consolidate it into the GPRO web interface for submission.
Facing that set of challenges, the leaders of Kootenai Care Network (KCN) of Coeur d’Alene, Idaho, who joined the Medicare Shared Savings Program (MSSP) in 2017, have been moving forward in that area, using technology from the Irving, Texas-based Lightbeam Health Solutions, to significantly reduce the burden of quality reporting – combining clinical data from 25 disparate EHR vendor systems and saving hundreds of hours of clinician labor. As an added perk, the process automatically closed 57 percent of the quality gaps uncovered—improving the ACO’s quality scores and preventing costly reductions in the ACO’s shared savings rate.
To manually complete required GPRO measures for 248 patients, it takes nearly 46.5 business days of labor, estimating this process will take five minutes per patient per measure. Kootenai Care Network’s CMS registry file contained 3,164 ACO beneficiaries. Once the organization’s managers had loaded the registry file into Lightbeam’s GPRO module, the platform automatically completed 57 percent of the gaps, eliminating the need for manual abstraction while reducing their total workdays from 46.5 to 20.
Recently, Shelley Janke, R.N., director of quality and care management at Kootenai Care Network, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the current initiative and what’s been learned along the way. Below are excerpts from that interview.
Tell me a bit about Kootenai Care Network and its founding, and its connection with Kootenai Accountable Care?
We were a clinically integrated network, formed in 2016, and we formed an ACO in 2017, with our first year enrolled in the MSSP in 2018. Last year was our first measurement year. Kootenai Care Network is the clinically integrated network; Kootenai Accountable Care is the ACO. Our participating hospital is Kootenai Health, a 330-bed community hospital. And then we have 540-plus providers in the network. And then upwards of 300 providers in that group are in the ACO. Not all network providers are in the ACO, but all ACO providers are in the network. Two-thirds of the 540 are independent providers in the community, and one-third are employed by Kootenai Health. One-third are primary care and two-thirds are specialists. Not all employed physicians are primary care.
Tell me a bit about the challenges around the group practice reporting option?
The 2018 results are still embargoed, so I’m not able to share results for 2018. But we’re very optimistic about what we’re seeing. When it’s unembargoed, you’ll have access to that. But we have had a lot of success with the network in the ACO. All ACOs can look a little bit different. And we have a really strong combination of two-thirds independent providers. And we have 31 different EHRs. And how do you move the needle in terms of improving care quality, in terms of risk-stratifying the patients, etc.? You have to have something that brings all the relevant data together.
So one of our most successful endeavors has been, number one, to achieve significant engagement with providers, and to improve care. And Lightbeam has been integral in gathering data. A condition of participation is that you’ll share certain data elements to improve quality and decrease costs. And sharing that data in a way that doesn’t involve heavy manual data distraction or leaning heavily on practice leaders—you have to have a population health management solution/tool to do that.
So, an example, we picked focused quality measures that we thought provided a significant quality opportunity, and that gave a manageable bucket of work to physicians and practice leaders. We identified four or five measures, and used Lightbeam to identify data elements like who needs breast cancer screenings, colorectal. Between 2017 and 2018, the number of women assigned to our ACO and network needing breast cancer screening, we improved that by 15 percent. We increased the rate of colorectal screenings by 10 percent. Combined, network and ACO manage more than 30,000 lives. We improved our control of hemoglobin a1c; we’ve improved that by 14 percent. 14 percent more diabetics are under glucose control. And then annual wellness visits: so much is foundational to patients coming in for their annual wellness visits. And within one year, that improved by nearly 20 percent. Some reports have found that the national wellness visit average can be 18-25 percent. We’re over 50 percent, and our target is to be over 70 percent; that’s where the high-performing ACOs are. We went from 35 percent to close to 50 percent within one year. That was a pretty big deal.
What have been the biggest data analytics or IT management challenges in all of this?
The different EHR systems are all variable in their composition. When you use an application like Lightbeam, it relies on interfaces with the different systems, and some systems can more robustly interface. We’re heading in the right direction. One of the challenges is that if you look at it from the perspective of an independent provider, an EMR is expensive. And if you’re an independent practice that’s smaller in size, it can be expensive to buy a really robust EMR that can easily interface.
So that’s one issue. And also, the EMR is heavily dependent on standardized workflow. And Lightbeam has helped us, when we report on quality for a provider and the provider says, that doesn’t jibe with my actual practice, sometimes it turns out they’re not reporting accurately in the correct fields. So that can be a challenge. EMRs are designed for standardized practice. And as a clinician, you have to adhere to standards of use of EMRs.
Can you speak to some of the challenges and opportunities involved in the physician culture element of all of this?
We’ll always hear from them, don’t make me do one more click, don’t take me away from my patients. And we hold that value, we’re always advocating for not creating more clicks. And because they know we’re committed to that, they’ve been more engaged. And we’ve asked them to be more mindful of coding. And we’ve asked them to be mindful of identifying the patients who might need to be engaged. When you’re part of an ACO and part of a network, and you really express the heart of wanting to move care in the right direction, they’re engaged. On the other side, we understand that we need to maximize their time with patients and relationships with patients, and not detract from those.
What have been the biggest lessons learned so far?
Putting real-time information in the hands of people doing this work, is incredibly important. And figuring out ways to do that efficiently, and making sure that data is accurate, are both important. If I tell a provider, you haven’t done this patient’s annual wellness visit, and they have, I lose credibility. There are a lot of lessons involved in interfacing 31 EMRs.
I’ve actually never operated without a population health tool in my career, and when I’m around anyone who’s doing population health manually—that’s noteworthy. This has decreased our reporting burden, so we can focus on things that matter, conversations, and clinical pathways, and reducing readmissions. It all really fits together when you’re doing things like chronic care management. You need the automation to get away from the tedium: it really is about working smarter, not harder. This has been a journey in working smarter, not harder. I think that was the intent of the MSSP ACO in the first place.
We have a Kootenai Care website. And our care management, we’ve had great success with chronic care management. In our first year, we actually enrolled, with five care managers, 800-plus patients; but we also have care managers in the community who work with patients. We looked at their data prior to and after enrollment, and the ER visits went down 11 percent, acute admits went down 19 percent, and readmissions 30 percent. We looked at an average of 14 months’ worth of data before enrollment, and 9 months after they enrolled—so, across a span of 23 months. Mathematica Policy Research has a whitepaper on the impact of chronic care management. And we’ve had really great engagement from both providers and patients. And there are three videos about chronic care management on our website.
