In a small farming community in south-central Illinois, Daniel Wujek, M.D., of Litchfield Family Practice, a 19-person, family physician group, is leading his organization down a tough road, one that has required patience and a steady investment of both time and resources.
Considering this is Litchfield, which formed as a 19th century railroad community and later became a famous stop-over town on Old Route 66, it's only appropriate that Dr. Wujek would have to take a metaphorical journey. Transit is entrenched in the city's history.
What's more, as a rural healthcare provider that's trying to achieve advanced population health management, a definite rarity, Litchfield Family Practice has had to take this journey without a "GPS" guiding the way. After all, how many independent physician groups in rural areas, that take on every kind of patient, from prenatal to geriatric, and care for a large Medicaid population (approximate 40 percent of its patients; 6-8 percent are without insurance completely), have done this kind of thing before?
Despite this, Litchfield has already achieved level 3 patient-centered medical home (PCHM) certification from the National Committee for Quality Assurance (NCQA) and is aiming to go even farther in its population health scope. As Wujek tells it, the mere concept of becoming a PCMH didn't even seem all that far-fetched to Litchfield Family Practice in the first place.
"We had always kind of seen ourselves as the practice that coordinates care for its patients and takes ownership of its conditions. We saw [PCMH] as a way of advancing what we had already been doing," Wujek says. "The majority of our diabetic patients, our hypertension patients, don't have easy access to consultants. So we take management of their problems. We coordinate referrals."
Thus, when Hospital Sisters Health System (HSHS), a Springfield, Ill.-based health system with hospitals spread across in Illinois and Wisconsin including in Litchfield, asked Litchfield Family Practice to be in a medical home pilot project back in 2009, it unsurpisingly accepted.
Using the EHR for Coordination and Reporting
From the time Litchfield decided to go down the path of becoming a PCMH to when it submitted its application was approximately one year, says Wujek. Already, the organization was using its electronic health record (EHR) from the Chicago-based software vendor, Allscripts to collect data for the purpose of patient follow-ups and clinical reporting.
Throughout this process, using the EHR and other resources, Litchfield was able to enhance its care coordination and quality reporting capabilities, making it more in line with an NCQA certified PCMH. In terms of quality reporting, Wujek says the EHR created several layers of data for Litchfield physicians to use.
"One of biggest areas of focus was in diabetes. Every six months we aggregate the data for all of our diabetic patients, and we present it as a group, each physician gives their own data and how they're doing on each measure. We look at how the practice is doing as a whole, and try to come up with some strategies for improvement on some of the measures we’re failing on," Wujek says, adding that Litchfield provides the physicians with more simplistic monthly reports, as well.
For care coordination, the EHR can develop certain clinical decision support (CDS) prompts that will remind the physicians when a patient needs, for instance, to get screened for colon, prostate, or cervical cancer. If someone is due for some kind of health service, such as a mammogram, Litchfield can recognize this in the EHR and Litchfield's team of providers will track down the patient. In one instance, Wujek says this process allowed the organization to follow-up with someone who ultimately was diagnosed with thyroid cancer.
"It could have gone on longer, if there wasn't a follow-up," Wujek says. Thanks to this kind of coordination, he has seen multiple examples when some disease was caught before it was too late.
Facing the Challenges
In the process of becoming a PCMH, Wujek says, one of the biggest struggles it has faced is dealing with patient information that comes from outside its office. In the area, he says there isn't even that much connectivity between Litchfield Family and the hospital that is literally 100 yards from its office, never mind one that is 45 minutes away and does its lab results on paper.
"It would make our lives so much easier if we had a way to electronically get information from outside sources. We spend a lot of time tracking and tracing down information," Wujek says. Currently, its working with a number of other local area providers to fix this problem. "We see ourselves as the person who makes sure we have a broad overview of the care of that patient. If they're seeing someone else, even if we trust that person, we want to know what's going on."
Another ongoing challenge is Litchfield's attempt to implement a patient portal. Ideally, Wujek says, this portal will allow providers to interact with patients over the web and increase efficiencies for its staff. However, it's been a struggle to get patients to use the portal, which went live in June of this year. Lack of broadband access, he says, is one of the major reasons why.
Little Bites at a Time
Even as someone who works in an organization that was well prepared to become PCMH certified, Wujek advises others who plan on going down this path to recognize it will take a while. Writing the policies alone took significant time, he says. Patience is a virtue in this case and small steps work wonders.
"Take it little bites at a time, don’t get too overwhelmed looking at all the measures at one time. Start off with some you feel you’re close to, start working on those, and slowly start taking a bite out of it at a time. Make those changes incrementally," Wujek says. "Pick a certain measure, create the workflows that are needed to get that in place, and then figure out what the next one is going to be."
Physician buy-in is another critical element, Wujek says. Without it, even if you force those physicians to move forward with these changes, it won't have the same effect.
Next up for Litchfield on the road ahead is PCMH recertification, value-based contracts with third-party payers, and an accountable care organization (ACO) like clinical integration network with HSHS and other area providers. Wujek says the network would be similar to what is being done by Advocate Health Care in Chicago, and would open it up to value-based purchasing opportunities as well as better information sharing. He points to the work being done at the University of Pittsburgh Medical Center (UPMC) with dbMotion (a company which Allscripts acquired earlier this year) as example of what he'd like to do with data interoperability.
"We want to be on the leading edge of this," Wujek says.
