As part of Healthcare Informatics’ Dallas Market Report, released earlier this month, senior leaders from Texas Health Resources (THR), the 29-hospital health system based in Arlington, Texas, were asked how the Dallas-Fort Worth region is progressing in its value-based care initiatives, in its ongoing health information exchange (HIE) evolution, and how organizations such as THR are working to reduce physician burnout.
Luis Saldaña, M.D., chief medical informatics officer (CMIO) at THR, who has been in a leadership role at the health system for over a decade, had plenty to say about all of these issues and more. As such, beyond what was included in the Market Report, the expanded interview with Saldaña can be read below.
How are THR, and the Dallas region more broadly, progressing in areas such as risk-based contracting and population health? What is it that your C-suite leaders, board, and others are asking you to do in these areas as the healthcare landscape continues to shift?
The trends here in the Dallas-Fort Worth market are similar to other markets. You do see some regions lag behind when it comes to fee-for-service versus value-based care. The Southern/Texas market runs a bit behind the North and the Northeast in terms of the penetration of value-based care. From leadership, we are certainly shifting our mindset to that value-based world. We are strengthening our alignments with physicians, and you’re seeing this in general, and also we’re partnering with independent doctors, as well as some key local partners for various different arrangements that would facilitate delivering population health. So how can we ensure that we serve the needs of the Dallas-Fort Worth market? It’s one of fastest growing markets in U.S; we just have continued growth. The first thing is a need for a foundational growth in IT infrastructure to support the growing market. So we are being asked to deliver that.
We are also seeing new growth in terms of partnerships and alignments. We created a partnership with University of Texas Southwestern Medical Center here in Dallas to form Southwestern Health Resources. We will develop a clinically integrated network with them that we think can help serve the population a little better, in terms of delivering to their needs. A lot of the resources are now there, and we’re looking externally as well for how to develop an IT infrastructure. So there is now data from UT Southwestern physicians who are also interfacing with THR systems. We now have to look outside [our organization] to see where information flows happen and be sure that we facilitate that to support the work we’re doing to improve the health of this market.
Another thing to point out is that we have also created a joint venture with Aetna, called Texas Health Aetna. So it’s getting into the work of a health plan [the partnership was the first of its kind in North Texas to fully align the incentives and capabilities of a national insurer and major health system, according to officials at the time], and this will be really focused on value and quality. We starting that work on that, and the question becomes how can we better support this?
Luis Saldaña, M.D.
Why have there been struggles in this region as it relates to value-based care progress?
You probably have to talk to some folks in the C-suite about the strategic side, but if you think logically, the payer-provider collaboration part makes sense. We’re getting the initiative that we have to focus on value and that we have to deliver the best product we can here at THR for our patients; that’s our mission. Ultimately, the goal is to improve the quality. There are cultural differences and political differences; we have the highest uninsured rate in Texas in the country, so you always have unique things that lead to these “micro-climates” of payer mixes and things.
How do you see the broader health information exchange landscape in the Dallas region? How are things progressing at THR?
It is a bit of a unique market, but we’re an Epic shop and many of big players here in town are also Epic shops. The positive thing with that is that we use [Epic’s] Care Everywhere [interoperability platform] pretty robustly. We have seen incredible growth in the number of exchanges by leveraging Care Everywhere in the last three to four years.
We have to work collaboratively to reduce barriers to information flows, and we have done that here. Are we putting barriers in the way of data exchange and making it harder than it needs to be? We have done some work on that and we have seen great growth in our [volume] of exchange. Our doctors love [Care Everywhere]. It’s one of the best things they say about the EHR [electronic health record]. They see all of the information, they have a glimpse of everywhere the patients have been, and everything that’s going on with the patient. They get that comprehensive view.
We do have our own HIE that we started sometime back, but the challenge has been embedding it into the EHR workflow. It has to be there in that workflow for doctors to use it effectively. They can’t go outside that EHR workflow; they won’t do it. And we do feed into the state HIE as well, but we have found that using Care Everywhere and the work Epic has done with [Carequality] to tie in all of the data has been [efficient] for us. It’s easier to work on this platform with local partners than it is to bring in national Veterans Affairs (VA) data [for instance].
Physician burnout is a hot topic of late. As a physician and also an IT leader, what can you say about your role in reducing the burden that technology puts on doctors?
We see all of the conversations around burnout; we cannot ignore them. This forces us to be proactive in evaluating if our technology is serving our physicians or is it enslaving them? We are now focused to look at that, and that involves a lot of conversations with physicians, so engaging them more. You have to keep an ear to the ground. We can easily go from doing really well to doing really poorly, so you have to include the physician’s voice in all of this, and that’s a big part of what I do. And you have to keep each other honest—is there another way to solve this [problem] beyond another pop-up? That forces us to be innovative and solve problems.
Much of innovation is how to solve a problem without defaulting to everyone who wants a hard stop somewhere. You have to put yourself in their shoes as well. Ultimately, we have to look at continued EHR optimization, and that involves our work with our informatics teams, our vendors, and us partnering with them to provide feedback. In which ways does the EHR work for them and in which ways does it not work?
So we have to provide feedback to vendors, too. What vendors thought they were doing in terms of usability might have decreased satisfaction. And physicians can do better in terms of how they use the EHR. Who uses it efficiently, who doesn’t, and who is struggling and working after hours to keep up with documentation burdens? We can identify opportunities for improvement if we can do that.
To this point, how is THR approaching regulations such as MACRA/MIPS?
This goes back to when meaningful use first came out, and we are seeing the same uncertainty at times and wondering if it will go away. But in general, it circles back to the changing landscaping with an increasing focus on value and quality. So you need to build the capabilities to support that focus, which will include robust quality analytics. And then you’re most of your way to supporting MACRA/MIPS.
We have Texas Health Physicians group and we will leverage the APM [alternative payment model] path for them since we work more closely with them. We also have our physician partners, externally, that are on staff but not employed, and are independent physicians. But we want to facilitate them being able to get data, too. So for them, it will separate into being a hospital doctor or a non-hospital doctor. We support the hospital doctors. I think that lens helps us to stratify things a bit so we know where to focus our work. So I’m not sure if anyone is truly “ready,” but we are comfortable from previous experiences that we’re doing the right things to be prepared.