As the purchasers and payers—both public and private—of U.S. healthcare continue to push providers forward to deliver value for the monies spent on providing care to patients (the employees and enrollees of said purchasers and payers), provider leaders are increasingly drilling down towards the core of patient care delivery to improve the clinical and financial outcomes demanded. In that, they inevitably are coming to recognize the need for clinical transformation—the reworking of care delivery and clinical practice—to make those deeper changes.
Clinical transformation was cited by the editors of Healthcare Informatics as one of the Top Ten Tech Trends the magazine named in its March issue, which will be published in print in the coming days. And this week, the Trends are being presented online, including the clinical transformation Trend. It was in that context that Editor-in-Chief Mark Hagland interviewed Brian Patty, M.D., CMIO at Rush University Medical Center in Chicago, in February; Dr. Patty was one of several clinician and industry leaders interviewed for the Trend. Below are excerpts from their interview.
What does clinical transformation look like to you right now, out in the field?
I think one of the coolest models I’ve seen is at Ochsner Health, with their digital medicine model. They’ve formed a unit called their digital medicine unit. They asked, what are the two biggest barriers to home monitoring? Because we really feel we can drastically improve outcomes among our high-risk patients through home monitoring. And the two biggest barriers they found were that primary care doctors didn’t know what to do with the home monitoring-based data, and patients didn’t know how to set it up. So they created the Ochsner bar, the O bar, modeled after the Apple genius bars in the Apple stores. And basically, patients can go there. They have all the equipment available, like weight scale, blood glucose monitor, fitness tracker, etc., and they set it up to connect with the patient’s phone, the Epic MySite, and they set up the patients. Then they set up this group to monitor these key patients and do virtual coaching of these patients in between their primary care visits. So the PCPs write an order to refer patients to a virtual medical group they’ve set up. And the virtual medical group fills out a form. And then they monitor the patients. And they started out with hypertensives who have never been in blood pressure control and who are seen several times a year. They had 400 patients referred to them, and within three months, they had 76 percent of those patients under control.
And how do you interpret what they’ve done, in the context of clinical transformation?
It’s a great example, because here, you’ve taken a difficult patient population that has not improved through traditional medical care delivery, and you’ve applied a new way of managing those patients—patients who had been chronically out of control for years. As a result, the patients are going to live longer and better, and will cost less.
And you had mentioned a virtual medical group aspect to this?
Yes, they’ set up an integrated practice unit—physicians, physical therapists, pharmacists, dieticians, nurses, social workers, etc. And this group of people said, what are the needs of these patients? What kind of team do we need? So this team manages these patients in between their physical visits with primary care docs, and they make recommendations, including for referrals to social workers, etc.
Is that where we have to go to achieve clinical transformation?
Yes, absolutely. And the side effect of this is that the patients become more engaged in their care.
In hospital organizations where it’s happening, what are the key elements?
The organizations where I’ve seen clinical transformation efforts work well are using Lean methodologies. And where we come in, it has to work in and through the EHR [electronic health record]. And if we can make a care delivery process work through the EHR, we can hardwire it. At HealthEast, we focused on that, on hardwiring processes through proper setup in the EHR, so that the easiest way is the right way. And whether you’re using care pathways or workflow navigators, or all the tools in your EHR, you have to understand those tools.
So now, you can support the organization by designing the workflow and care steps in the EHR, to make it flow, and to make it the natural workflow of someone who wasn’t initially involved in the design of this workflow, but as they walk through their workflow, it’s natural to the way they do it.
One thing that many leaders talk about is the continuous “blessed cycle” of gathering data, analyzing that data, sharing it with clinicians and using it to inform and guide the reworking of care delivery processes, and then beginning the cycle again through gathering data on the reworked processes.
Yes, that’s all very important. And in that context, there are two things we look at from a Lean standpoint. You go through two different cycles. One is an SDCA cycle—“standardize, do, check, act”; and the other is a PDCA cycle—“plan, do, check, act.” The SDCA cycle involves looking at where there is variation within a cycle, and how to minimize that variation. The oscilloscope is going up and down a lot, and we want it to be a flat line, where everyone’s working to a standard. And then when you’ve got everybody working to a standard, then you see where your performance gaps are, and you figure out how to close those gaps, and make a big leap to get to a new standard. And you go back over and over again through SCDA and PDCA cycles. That is at the core of the work.
Do you see organizations transforming their clinical cultures now, as a part of the broader clinical transformation effort?
Well, you have to transform culture to get there. The way we do business hasn’t gotten us to the right place. We have to look at ourselves as organizations and figure out how we get to the next place. The buy-in comes from leadership, but then how we get there comes from front-line staff. And Lean works both top-down and bottom-up. Leadership defines the gaps, and front-line staff figure out what needs to be changed to get to that place. So leadership transforms the culture of the organization, and front-line staff gets us there. So the strategy is from leadership, and tactics from staff. Gemba: Lean term where the value is added, where the organization interfaces with the customer. Where the physician meets the patient is where the value is added.
Do you think that the majority of physicians now see where the puck is headed?
I think so. I think it’s a big shift to get from a fee-for-service, volume-based model, to a value-based, PMPM [per member per month] model. How that changes, how you approach care, involves a lot of complexity and change. In a value-based model, I’m taking a more holistic approach. You’re looking at keeping people healthy, whereas in a fee-for-service world, you’re treating people when they’re sick. It’s a different mindset. Primary care’s gotten that all along; we’re really moving to more of a primary care-focused world, which is appropriate. We need to be holistically managing the patient.
What can and should CMIOs be doing in all this, to help lead change and to help lead clinical transformation?
In order to make any significant change in healthcare today, you need people, process and technology—all three elements. So if you create three circles in a Venn diagram, with those three elements, you’ll find that they intersect in the CMIO: I understand the technology, I understand the people and process, and I understand how they will use the technology. So I see myself as being in the center of that Venn diagram, connecting the people to the processes to the technology.
Where will we go in the next few years on this journey into clinical transformation? Well, the initial impetus towards value-based care came from CMS [the federal Centers for Medicare and Medicaid Services]; they were pushing it. But when I look at where I’m moving towards value-based care, it’s primarily from private payers. They’ve really taken the ball and run with it. So no matter what happens with the new administration and Congress, the private payers will be pushing VBC, and probably the only way they’ll engage with you is if you’re willing to take on some risk with them. So it’s going to happen. And if you look at the major next wave from CMS, it’s MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] and MIPS [the Merit-based Incentive Payment Program within the MACRA law] and APMs [alternative payment models, also within the MACRA law]. And [MACRA] had bipartisan support; it passed in the Senate with 98 percent or something. So no matter what they do with the ACA [Affordable Care Act]—and they’ll probably make some adjustments, and everything needs adjustment—MACRA’s not part of that. And MACRA is really how we’re getting paid, and CMS is saying, I’m going to incent you to move to a value-based payment model with MACRA, and that’s how it’s going to be. So MACRA will move forward. And ultimately, you’ll see CMS incenting you to move towards a value-based payment model via APMs, as well as with the quality measures under MIPS. This year, 60 percent of your payment comes out of the quality piece, but eventually, the percentage of your payment coming out of cost, will increase over time.
Are you optimistic about the path forward and about the rate of progress being made in patient care organizations right now?
The organizations that succeed by skating ahead of the puck are going to be the ones that survive this phase of change. If you say, I’m going to stay stuck in the fee-for-service world, you’re not going to survive, because private payers are moving in that direction, too, and the better you get at [at-risk-based care delivery], the more likely you’ll survive. Because that’s where this is headed, and the only ones that will survive will be those that move in that direction. And as we move forward, we have to engage in new ways to engage patients. For years, medicine has taken a paternalistic approach—these are the pills you need to take and how you need to take them. It’s becoming a partnership. So the strategies we can use to engage patients in their care—whether telemedicine or home monitoring or patient education—the more successful we’ll be.