As the leading patient care organizations in the U.S. get deeper into population health management, priorities are becoming far more patient-centered than ever before, according to a panel of speakers at the iHT2 (a sister organization to Healthcare Informatics) New York Health IT Summit on Sept. 29.
More than half of healthcare managers surveyed expect to recoup their investments in population health management programs within three to four years, according to a recent survey by KPMG LLP in New York. The growth in the number of accountable care models, value-based contracts, and other reimbursement models is driving much of the emphasis toward population health. As such, the panel discussion at iHT2 New York centered around how organizations are measuring the impact of population health management on the patient, population, and health of the organization delivering care.
On the panel were: Michael Udwin, M.D., executive director, physician engagement at McKesson Corporation; Luis Tavares, senior vice president and CIO at the West Orange, N.J.-based Barnabas Health; Paul Wilder, CIO at the New York eHealth Collaborative (NYeC); and Mark Hagland, Editor-in-Chief at Healthcare Informatics. Moderating the session was Judy Hanover, research director, IDC Health Insights. Below are key experts from that panel discussion.
Hanover: What were best practices for getting started with population health and how did you make decisions on technology to support those strategies?
Tavares: We have ACOs in north and central New Jersey. For our central ACO, we are one of the few in the country where we had an organization who wasn't part of our [network] as part of the ACO. That was an interesting twist. We started with the Medicare Shared Savings Program (MSSP) three years ago. The marketplace is different in the north and central part of the state. There a lot of different physicians. When we started looking three years ago, there was no solution that met our needs, so HealthEC co-developed with us a solution for our needs, and they have since sold to other organizations across the U.S. Our [population] has gone from 30,000 to well over 200,000, so we have to decide if we need something bigger for us.
How has the technology landscape as well as priorities changed as we get deeper into population health management?
Udwin: Most folks are focusing on the quality element, in terms of readmissions, and identifying the highest risk patients. The next step is to look back one level and see if we are identifying the patients who aren't the sickest, but could be at risk in the future. Utilization is the next step after that, and then pharmacy, radiology, and imaging issues.
Wilder: Well one thing that has changed in the last few years is meaningful use. We all were doing it for years, and now the dialogue is waning a bit, so we are accepting the pain that brings with it. We do think it's worth it in the end. Standards and the ability to move data around has improved, though it's not perfect. The idea is to build a larger tent with broader constituents, and you can't do that for a population that is not directly at risk for us. New York has one of highest Medicaid percentages in the country, so it's a different kind of risk and a different model. There are different health systems and different data. There is a real challenge in dealing with non-standard clinical data. Behavioral and mental health data from a security standpoint has been tough. That's a big part in improving the population, and there is a lot we could learn from the Veterans Administration (VA) if we integrated with them and better understood some things that they do. Less people are resistant to sharing data now though; they know if they don't share it, they don't get it back.
Hagland: I just interviewed someone from a health system in Delaware, and I learned that putting all of the pieces together is really fascinating. You have risk assessment analytics, you have to stratify and figure out who you have. Organizations are realizing that the rising risk enrollees are the key people you have to figure out. Highest risk patients are obvious to providers as they see them often. The care management tied to analytics and all processes being linked is key, though. That requires process integration and operational integration, and doing HIE, but doing all those things at once is challenging.
Tavares: We wanted to make sure that we put together an operating plan for the year. Patient stratification was the first thing—4 percent of our patient population in our ACOs represent 26 percent of our costs. From a cost perspective, how do you manage that? That is risk category 1. Our focus was on risk category 2 patients, and trying to move them down to a lower category, while also keeping them from getting to category 1. So for us, management was often in that middle layer.
Hagland: Organizations are finding that you have to catch those people earlier. Claims and clinical data need to be married— you have to connect Mrs. Smith who is pre-diabetic with a care coordinator and manager in a way that makes sense. This requires patient engagement too, since those people are not realizing the risk they are at.
Udwin: Now, what's the best model to deal with those patients? Is it a hybrid or central approach? Do you want to do it a practice level, overarching level, or some sort of hybrid of both? Regardless, you have to make sure it works with physicians' workflows and doesn't impede anything, and you have to identify all of the gaps in care. I would suggest using that centralized system for traditional preventative medicine, then a targeted approach for the high acuity patients.
Tavares: Yes, gaps in care are a major question. You have to figure out a way that every clinician who touches a patient knows those gaps. Your formula [for doing so] could be different, but it's the only way to catch all of them. Until you get to every person that opens the patient's record, you wont see all the gaps in care.
Hagland: This ties into the leap from the old disease management model to true population health management. There are so many patients with many chronic diseases. Now as we are going into this new world, that old model works less well.
Tavares: We are changing so fast, in every facet of the organization. We are managing populations, and a major requirement of that is doing a great job in care coordination. We have four or five different parts of the hospital calling patients after they are discharged, and they could be getting different information.
At times, patients could get confused by multiple portals and a lack of centralized information. What are some best practices for doing a better job on focusing on the patient?
Hagland: It's getting to be a lot about socioeconomic factors. Many issues are not medical; people are homeless, so how do you have patient engagement without homes where you can reach them at? You are responsible for the outcomes of a population, so you have to do non-medical things to do be truly effective. You also see more care moving into the home where data can be integrated in a more automated way with devices set up in the home.
Tavares: We are getting there, but honestly we aren't doing a great job yet. Vendors have to think and change the paradigm in which they develop solutions. Develop from the patient in, and thats the opposite of what many are doing. We have three different portals we use for patients, but we can't keep doing that. I think we could let the marketing and communications team driving the portal strategies.
Hagland: One of our epic fails has been around the concept of the personal health record (PHR). No one has ever communicated with me about my PHR, but I know I have one. It should be a point of great engagement, but it's not.
Wilder: I have given speeches about being a patient first and a provider second. Health 3.0 is really hyperlinks on steroids in that it links you to every piece of information that you could ever want. That sounds good, but the progression is that as we are revealing more in information, the patient becomes more active. Healthcare needs to let go of some data. Portals are a digest—if we continue to hold that complex data, we don't give the consumer a chance to work with it. Finance started to do that in terms of managing my portfolio for me. Patients need that data to figure it out and they need an advisor to help them [along the way].
Hagland: Three words--the OpenNotes movement. Leading-edge health systems are plunging right into it and they are getting great patient engagement from that. Patients aren't calling their doctors every day, contrary to people's fears. The level of trust also improves with that. For patients to be first, and be a part of the care team, some version of Open Notes will help with that. Also, you need to clean up your physician documentation protocols and get rid of note bloats. It needs to be a more disciplined process.
Tavares: It can't be a question about who owns patient record. It belongs to the patient. How do you make it available to him or her in a consumable way? Most patients, as constructed currently, might not figure out these notes. If you know your patient will be reading it, write it in a way so they can understand it. That's different from clinician-to-clinician notes..
How do you keep patients in the network and avoid leakage? Sometimes it seems as they are being treated as inanimate objects.
Tavares: We need to measure value from the patient's perspective. They get attributed to us and they have no say in that. We need to get out of that model and treat them as people who need our help by doing things such as looking into their families.
Hagland: You have to prove the specialist in your network is the better option. You have to show them theres a reason that benefits them for doing this. You have to up your game in terms of awareness and care, and being patient-centered.
Tavares: For us, if they come to our cardiologist, and not someone we don' recommend, it costs a whole lot less. That could drive behavior.
Wilder: I fully agree [on patients not being objects]. I also believe the transparency of quality data is ridiculously poor. Cost is one thing, and yes I do have access to care when I want it, but I will also pay for something that I think is higher quality. I do that with cars and other things too. I wont go to a mom-and-pop place for car problems—I'll go to my dealer/manufacturer since I want to keep the history there. Telling me that i shouldn't go to an urgent care facility because it's not as good as the primary care physician, where I would have to wait a day, is insulting. Urgent care is out-of-network, but it also provides comfort and convenience. So it's not always about cost—accessibility matters too.