Transforming care delivery in a value-based environment

Scottsdale Health Partners (SHP), a physician-led clinical integration network (CIN), was founded with a mission of transforming healthcare delivery in the greater Scottsdale, AZ, community.

SHP is a joint venture between the HonorHealth health system and the Scottsdale Physician Organization, representing a broad spectrum of medical specialties with a pluralistic model, allowing providers to remain independent and entrepreneurial. Its focus is on achieving the Triple Aim of healthcare: improving the health of the patient population, improving the patient experience, and reducing costs.

Today SHP has contracts with seven major insurance companies and covers more than 40,000 patients. In January 2014, SHP was awarded accountable care organization (ACO) status in the Medicare Shared Savings Program. During that first year, SHP successfully achieved cost savings of nearly $3.7 million by engaging physicians, evolving and integrating care delivery, and launching an open, flexible, clinician-friendly technology solution to manage the health of its population groups.

Challenge

Moving closer to the goal of achieving the Triple Aim hinged on the following:

• Building a system of engagement to support the physicians that joined and bought into the SHP model. SHP needed to identify the most effective way to share a maximum of actionable information with providers and bring transparency to its CIN participants. Achieving SHP’s goals meant partnering closely with both primary care and specialty practices. SHP needed to facilitate data sharing, identify patients most at risk, help clinicians close gaps in care, and simplify reporting on quality measures.
• Identifying an open, easy-to-use IT platform with flexibility to run multiple contracts and adapt to emerging models of care. During the two-year planning that preceded SHP’s 2012 launch, the executive team determined that it needed an open health information exchange (HIE) platform that would make complete, accurate patient data from 40+ different EMR systems available to all 700+ participating physicians.

This meant the IT infrastructure would need to integrate with various health information systems with a robust underlying HIE technology. The IT platform also would need to be flexible enough to meet evolving regulatory requirements.

Finally, preparing for the future was a paramount concern. SHP was seeking a standards-based platform with an open application programming interface (API) to support a wide range of population health management applications, with a very modern, scalable database and analytics at the heart of the system.

Solution

SHP knew that solving this challenge would require:

• A strong physician engagement strategy;
• A care management program with two distinct yet highly integrated services: transitional care management and comprehensive care coordination programs; and
• An innovative technology platform to support the engagement and collaboration among 700+ physicians at more than 230 practices with more than 40 EMRs.

SHP required an open-standard, open-access approach to its technology architecture. The platform needed to be clinician friendly and easy to use, to encourage adoption, and improve communication and coordination.

The CIN/ACO also needed to ensure that its physicians, who are spread out in disparate practices, would be able to use the EMRs they were already comfortable with – while also having the ability to share health information and coordinate care. Achieving this goal would be no easy feat.

After a thorough review of available options, SHP partnered with Orion Health, a precision medicine-focused company with advanced population health technologies and deep knowledge of what it takes to make HIEs work. Orion Health’s flexible open platform technology provides a common interface to facilitate the seamless exchange of crucial health information for SHP’s clinicians.

Within the platform provided by Orion Health, there are multiple ways to view a patient record, including a timeline view. A notification hub feeds SHP’s secure messaging solution, TigerText.

Traditional hospital-based technologies fail to support the critical needs of ambulatory care management. They are focused on inpatient processes, not ambulatory processes. SHP found innovative ways to leverage the power of an open-architecture platform to build applications that effectively support care management in the community.

Connected care results inbetter outcomes, improved ACO performance

This transition has resulted in significant improvements in care quality and cost savings.

More than anything else, the resulting improvements in transition of care and care coordination have correlated to positive outcomes for patients and efficient operations for the ACO.

SHP custom built census reporting and real-time alerting for care transitions and care coordinators into its technology offering, demonstrating the flexibility of development with Orion Health’s open platform. SHP is now working with its partner on designing and testing an expanded care management solution. SHP care coordinators are able to build custom assessments, communicate with the patient’s care team, record and track patient goals, create care team tasks, and document efficiently, all within a single platform that integrates all the patient data.

SHP’s challenge – to find a robust population health management platform that allows clinicians using dozens of different EMR systems to exchange health information in real time – was a lofty one. Partnering with Orion Health to leverage its open-platform technology was the ideal solution, as evidenced by the dramatic improvements in SHP’s metrics that matter in today’s value-based care environment.