Annamalai Ramanathan is one of those healthcare executives who can truly say that he’s seen things from both the healthcare IT side and from the non-IT side, as both a healthcare IT executive and now as a non-IT executive in medical administration. For a few years, he had worked at the Medical College of Georgia, in Augusta, Ga., as senior transformation leader, tasked to help evaluate the next generation of innovation in technology around care management, and to bring that innovation back to the Medical College of Georgia. Then he transitioned to a position as director of clinical transformation, in charge of process change for clinical transformation.
Then, in mid-January of this year, Ramanathan was asked to transition again. Now, he is director of administration in the Department of Family Medicine at the Medical College of Georgia. He spoke recently with HCI Editor-in-Chief Mark Hagland on the varying perspectives of IT and non-IT leaders in healthcare administration, and what he’s learned from working on both sides of the divide. Below are excerpts from that recent interview.
When you think about how different things look from how they looked when you were on the IT side of care delivery administration, what strikes you most?
I live in a world in which there’s an interesting intersection between volume and value. We’re still very volume-driven, but we have our eyes on value. In my day-to-day operations, I have targets to meet with regard to quality, volume, and work RVUs in terms of physicians’ production. Now, increasingly, I’m being asked to look at value, meaning quality in relation to volume. So I’m looking at what the potential upside and downside of the transition value will be. So the IT tools are essential, and some of these population health tools are becoming more important.
What kinds of population health tools are you looking for?
We’re in the early stages of understanding what’s out there. There are various tools in the marketplace, and I’m always open to new things. Now, the natural lead-in is to tools embedded in core EHR [electronic health record] products. But there’s a gap in those tools with regard to predictive modeling, as offered by vendors like SAS. So I’m looking at companies like Jbion, which does care learning using machine language processing. We haven’t signed any deals yet; we’re in the early part of the journey around these tools, and are keeping our view wide.
But the off-the-shelf embedded tools don’t seem so great, correct?
What do you and your colleagues to do in the next year or so, as an organization, in this context?
We need to create a governance team with both clinical and operational leadership, so they understand how these practical requests are funneled and prioritized, and so that there’s a clear accountability in the use of these tools. So we are staging it by creating a foundational governance structure.
And where you in that process?
We’re starting to have conversations. We’re looking at Carolinas Health, Memorial Hermann, and a health system in Florida, talking to them, and trying to learn what we can learn about an IT governance structure. The challenge is not to create the rigor, but rather to ensure that there is real clinician participation. I’m seeing the same stakeholders involved in multiple meetings and engagements. And what happens is that there’s a level of fatigue when you go to them for prioritization.
How do you convince the physician leaders in your organization, or any organization, to be willing to invest their time and effort and mindshare into this?
That’s a great question. You need to bring in your physician champions to own it. I’m also seeing CMIOs becoming exhausted. The CMIOs are stretched; certainly, my CMIO is stretched. So CMIOs cannot be expected to be the main leaders. At the same time, CMIOs are great with statistics and numbers. And also, you need to give people quick wins, and say, this is how your department is performing, and in order to get to the next level, here are the several key steps you need to take to get there.
In other words, you need to break it down into clear process steps?
Exactly. And we in healthcare tend to fall into a conversational interaction about this. I always think that it’s because healthcare comes from a non-profit culture. Meanwhile, in technology, where I was before healthcare, things were much more action-oriented. So if you can make it more action-oriented, with clear points of accountability, you can make it more successful. And so my hope for the population health governance committee meeting, is for us to make it more action-oriented.
There are population health pioneer organizations right now breaking new ground, but there is no established template for this right now. How do you get around that?
Learn from other industries, is a strategy I often follow, and one I think we’ll need to pursue in healthcare. Because population health management is about risk assessment and risk management. So what can we learn from other industries? I would look at the payers, like AIG and similar companies. What do they do, based on understanding risk? So, I run a primary care-based organization. And we’ve just started documenting who our payers are and who are patient panels are, in a concrete way; historically, we knew this in a tribal way, but now it’s becoming more concrete. So we’re looking at HEDIS measures, and taking small steps based on known publications and known protocols, and then evaluating what works and what does not.
So it’s a journey. And in a teaching environment like ours, we have a lot of senior practitioners who have been here 25, 30 years, and they can add a lot of value.
Once they’ve been given a conceptual and practical framework for understanding the risk involved, they can do so, right?
Yes. And so, this is what diabetes looks like; and so we have a young woman physician who is helping us break this down in terms of how we could manage diabetics under population health management strategies. And I’m a business guys. And the thing is, your old rules didn’t get where you needed to get to. So, understanding processes and breaking them down, and thinking about alternate therapies, too, for example. We’ve integrated acupuncture and chiropractic into our primary care delivery for several years, and that has helped. We have one doctor of osteopathy; she does both; she’s trained as an acupuncturist. And she has a relationship with a leading institution in China. And we’re integrating that interaction over time.
As you move forward, what would you like your CIO and CMIO to be doing?
That’s a very interesting question for me as a former CIO. They’re largely doing what I’ve wanted, but also, it will be great for them to be involved in our operational strategy. When I’m moving from a volume-based to a value-based environment, I’d like for them to collaborate with me and work on innovation with me. I have operational needs, such as I need to reduce no-shows among new patients for doctor visits. So we need them to help me vet potential technologies and then of course to implement them along with me.
In today’s environment, they’re very, very busy from an operational point of view. And innovation has not been top of mind; but I need for it to be; if not, it can be grinding for all of us.
When you look at reimbursement right now, will be preparing to create an ACO [accountable care organization], or will you focus on managing transition to MIPS?
Probably MIPS [the Merit-based Incentive Performance System], based on where we are right now. It’s a safer option to start with. Now, we are a patient-centered medical home department. And that gives us an edge in the CIA composite part of the MACRA. And as we become more PMCH-competent, I like to think that we will become more oriented to an ACO type of environment. But at the onset, it will be MIPS, just to understand the landscape.
Even MIPS will be challenging. Do you think it will be hard for physicians and physician groups? Or will it go well for them?
I think it will be somewhere in between. But it’s important to remember that providers aren’t really motivated yet by payment models; they’re motivated by outcomes. So I think if we can show that the outcomes can be better in a MIPS type of environment, the acceptance will be much higher, and the outcomes will be better. So it’s up to us in operational leadership to show what the outcomes can look like.
On a scale of 1 to 10, where are you, around the prospects for the next year or two, in terms of this shift in the reimbursement and policy environment, in terms of optimism/pessimism?
I’m probably at about a 5 or 6! CMS [the federal Centers for Medicare and Medicaid Services] is not giving us the time to make the shift. Compared to MU, for MACRA, tit seems to be like it’s going to be a go-cold-turkey situation. I think a runway would have been very helpful; even though [CMS Acting Administrator] Andy Slavitt may be giving us a bit of a delay. My team may think it’s about a 4, but I think it’s about a 5.
What should CIOs and CMIOs look out for in the next year or so, in the context of all of this?
Three things, in my humble opinion. One is, help us optimize the care workflow, based on physician burnout and documentation challenges for physicians and nurses. So, please understand the workflow and work with us. Second, partner with us to understand what the next-generation technology might look like, to prepare for the next-generation operational needs. Act as a good filter for us. And last but not least, be with us in the clinic, and understand what’s not safe in our current workflow that can be identified and leveraged by technology. IT leaders seem to be very busy operationally, and can’t seem to pull themselves away to help us look at next-generation needs for us right now.
Is there anything else you’d like to add?
I think it’s good for CIOs and other IT leaders to get an operational view on a regular basis, of where the needs are; I see that as a gap.