As the pace of change across healthcare—both in the United States and everywhere, but particularly in the U.S.—accelerates, things really are changing quickly now on multiple fronts, from the policy and regulatory arena, through reimbursement change, and into the business and operational, clinical, and technological spheres. There’s no segment of the healthcare industry that is not significantly changing. But more importantly, the signposts seem to be getting clearer and more closely spaced apart these days—and that is significant.
Sure, there are plenty of “Debbie Downers” and “Negative Nancys” out there (and my apologies to anyone named Debbie or Nancy). There may even be more Debbie Downers and Negative Nancys than in recent years; after all, the pace of change is putting increasing pressure on everyone in healthcare; and the pace of change is accelerating precisely because the costs and challenges of healthcare, particularly in the U.S., are forcing change. As we reported this summer, actuaries at the Centers for Medicare and Medicaid Services (CMS) announced in mid-July that total U.S. healthcare expenditures would grow from 17.5 percent in 2014 to 20.1 percent in 2025, with total spending rising from $3.3013 trillion in 2014 to $5.631 trillion in 2025. And as I’ve stated in several blogs since then, that anticipated 70-percent increase in total U.S. healthcare costs is concentrating everyone’s attention, as the reality that we in the United States are going over a healthcare cost curve, is becoming more and more apparent.
But while hospitals, physician groups, and all types of healthcare providers are under pressure as never before to curb costs and improve outcomes and experiences, some of that very pressure is stimulating tremendously creative responses. As the hoary adage notes, necessity is the mother of invention; and in the case of the U.S. healthcare system, necessity is a very large and high-pressured mom indeed.
But things really are moving forward in many areas. And below are a small number of examples from across the constellation of our coverage this year at Healthcare Informatics, as well as a few other sources, that paint a portrait of a healthcare industry replete with pioneers who really, genuinely, are moving the needle on healthcare system transformation.
Pioneering physician groups: stepping up to risk and population health management
Yes, we all know of physicians and medical groups who are either panicking at all the changes taking place in policy, regulations, reimbursement, and the business of healthcare these days, but there are also lots of physician leaders who are taking the reins of the merging new healthcare, and doing it with confidence. Probably one of the most self-confident of physician group leaders I talked to this year was Jeffrey LeBenger, M.D., a head and neck surgeon who is chairman and CEO of the 650-provider Summit Medical Group, based in Berkeley Heights, and serving patients across a swath of northeastern New Jersey, via 36 different clinic sites. I interviewed Dr. LeBenger for our September cover story on physicians and risk, and he had absolutely no lack of confidence about his group’s ability to manage financial going forward. “We spent millions developing our care management program, with hospitalists and with extensivists. And now we have four high-acuity urgent care centers. That’s the model. With chest pain, belly pain, our patients go there. And our admission rate is only 2-3 percent from our urgent care centers, whereas at the average hospital, they’re admitting over 20 percent of those patients.”
Importantly, LeBenger and his fellow executives at Summit Medical Group are compensating their physician colleagues based on quality metrics, with the result that they’ve achieved success in patient outcomes, on a per-member per-month average cost of $60, “whereas the benchmark in New Jersey is over $110,” as he told me. And if you read that cover story, you’ll see that physician leaders like Dr. LeBenger and his colleagues at Summit, are indeed “cracking the code” on how to engage their physician colleagues forward to truly manage care as well as costs, in the medical group setting—a critical success factor for accountable care and population health going forward.
Innovators push the envelope on multiple fronts
Speaking of innovation, our annual Healthcare Informatics Innovator Awards program netted four amazing winning teams of innovators, and eight wonderful semi-finalist teams. To those who complain that the leaders of U.S. patient care organizations simply aren’t moving fast enough to keep up with the demands facing them, we offer the stories of these twelve teams as proof that there are plenty of pioneers pushing the proverbial envelope across every area of endeavor open to patient care organizations.
Take for example our first-place-winning team, from the University of Texas Southwestern Medical Center health system in Dallas. The folks at UT Southwestern are showing the industry what clinical transformation means. There, clinician, clinical informatics, IT, analytics, and administrative leaders have come together to create an Ambulatory Quality Outcomes (AQO) Project that is improving processes and outcomes across 40 medical specialties, and using rapid-cycle improvement processes to improve care delivery and care management, physician collaboration, and the capability to participate in meaningful quality outcomes benchmarking. All of this is being supported by intensive development work on the part of IT and analytics leaders at the organization.
Importantly, UT Southwestern’s leaders made two key decisions that have helped to shape everything that has happened since then. First, the decision was made to engage the physician leaders from as many outpatient specialties (referred to as clinics) as possible, meaning, ultimately, 40 different specialties, rather than simply start with one or a few and slowly roll out processes. And second, related to the first, the decision was made to force process standardization, by creating a standardized data architecture for the clinical decision support mechanism to be leveraged within the EHR, across all specialties, for the initiative’s analytics purpose. Meanwhile, those leaders also achieved their specific goal of creating robust patient registries in all the specific medical specialties. To date, the leaders of the initiative have built 58 specialty-specific patient registries, created 134 process and outcome measures covering 77 primary and 44 additional medical conditions, created 111 new clinical decision support tools within the EHR, and created 97 new workflows across 40 specialties. Very importantly, 58 patient registries have been created, with over 16,000 patients documented to date, in those registries.
Getting predictive around health risk
One area that is becoming brighter with hope is in leveraging big data through analytics, in order to not only identify patients and health plan members who are already at high risk for hospitalization and other forms of medical care, but also those individuals whose risk is rising. As Managing Editor Rajiv Leventhal reported in his special report on analytics in the November/December issue, Independence Blue Cross Blue Shield in southeastern Pennsylvania, serving two million members in five counties in and around Philadelphia, uses a predictive tool that calculates an individual’s likely future health state based on associated clinical conditions or diagnoses. The risk matrix, from San Mateo, Calif.-based healthcare analytics company Lumiata, helps the payer identify where members might be at risk for or might have certain conditions, and then helps alert their providers, as Michael Vennera, senior vice president and CIO at Independence Blue Cross Blue Shield, told Leventhal.
A key element? With the analytics tool, the payer can go to providers in its market and say that there is a chance patient X has a certain condition, even though it’s not diagnosed on his or her claims. All different types of data go into that risk engine, says Vennera—medical claims data, prescription drug claims, lab results, and also basic demographics such as age, gender, and location. “Then what we get out of it is a prediction around diseases with different confidence levels for different members. And then you can use that to follow up,” he says.
ACO leaders begin to put the puzzle pieces together
Collaborative work is also enhancing the drive towards population health and accountable care on a trans-organizational level as well. As Managing Editor Rajiv Leventhal noted in an article in October, a study of 19 ACOs published by Premier Inc., with support from the Robert Wood Johnson Foundation, found that the leaders of ACOs are starting to figure out how to put together all the different elements that will lead to success under risk-based contracts. As Leventhal noted, “According to the researchers, review of the qualitative findings yielded a number of overarching themes that capture opportunities, challenges and outcomes as organizations develop and implement ACOs. For instance, while nearly every ACO studied is working with community social service organizations, 84 percent cited increased support from their community partners as an opportunity for improvement that is very different from the work that hospital-based organizations have traditionally considered. This includes moving to serve as the central hub to enable community organizations to be more effective in meeting the needs of mentally ill and chemically addicted residents, as well as teaming with employers and local gyms to offer exercise and nutrition-based counseling to address preventative health needs, the report stated.”
That October report’s findings were further buttressed just this month, in a report that consultant Rebecca Tyrell authored for The Advisory Board Company. In “Building the Business Case for Community Leadership: Lessons from the BUILD Health Challenge,” Tyrell wrote that, based on some of the learnings being aggregated by providers participating in the BUILD Health Challenge (a collaborative supporting population health work by hospital-based health systems), provider leaders are learning that they must: engage leadership by building a compelling business case for population health; prioritize their initial focus; leverage the unique strengths of community-based organizations to “extend care team reach”; and design “seamless screening and referral protocols.”
Hospitals move to get all the dollars due them
With the reimbursement landscape shifting dramatically these days, there’s simply no question that the leaders of U.S. patient care organizations are having to scramble when it comes to retaining appropriate reimbursement from federal, state, and private payers. Not surprisingly, the mother of invention that is necessity, is driving innovation forward in the revenue cycle arena as well. As we reported in July, executives at the eight-facility Florida Hospital in Orlando have been engaged in intensive data analytics to uncover gaps in clinical documentation that can negatively impact case mix index (CMI) and thus decrease reimbursement. Jeff Hurst, Florida Hospital’s senior vice president and senior finance officer shared with me the story of how, leveraging a clinical documentation solution from the Burlington, Mass.-based Nuance Corporation, he and his colleagues have been able to achieve a 29 basis point increase in CMI that equates to a $72.5 million increase in appropriate revenue over two years. Such efforts are inevitably going to become far more common going forward, as the leaders of patient care organizations will find that they increasingly lack any luxury to let any appropriate reimbursement go unreimbursed.
HIEs create and test a “Patient-Centered Data Home”
And even the health information exchange arena, which has been plagued with a number of challenges in the past few years, innovative leaders are pushing ahead to create pioneering change. As Assistant Editor Heather Landi reported just this month, “Three health information exchanges (HIEs) that are part of a larger pilot to develop and test a ‘Patient Centered Data Home,’ announced a major milestone this week and are now successfully exchanging patient health data among their systems and across state lines. The Indiana Health Information Exchange (IHIE), Michiana Health Information Network (MHIN), and East Tennessee Health Information Network (etHIN) reached an agreement to enable data-sharing among their HIEs, ensuring that a patient’s healthcare record follows them wherever they seek care. The Patient Centered Data Home (PCDH) Heartland initiative is the third and largest pilot for the Strategic Health Information Exchange Collaborative (SHIEC), a national trade association for HIEs that is acting as the project lead. The other pilots are already in production.” As John Kansky, president and CEO of IHIE, said upon the unveiling of this initiative, “This is an exciting first step toward a much larger goal. At the completion of this pilot, we’ll be exchanging health information among seven HIEs and across five states.”
Thinking futuristically about data and about enhancing the health of really big populations
There’s so much going on across all spheres of activity in U.S. healthcare that it’s understandable that U.S. healthcare leaders sometimes feel they lack the conceptual and temporal bandwidth to follow developments outside the U.S. Yet the benefits of doing so are many, including discovering how Europeans, Asians, Latin Americans, and others are innovating in their national healthcare systems. While those healthcare systems may appear superficially extremely different from the U.S. system, many of the underlying challenges—aging populations, explosions in chronic disease—are actually very similar across many countries. That’s why it was particularly fascinating to participate in the World of Health IT (WoHIT) Conference in Barcelona in November, sponsored by the Berlin-based HIMSS Europe, a division of the Chicago-based HIMSS (Healthcare Information and Management Systems Society). Not that anyone should derive satisfaction from the fact, but it was strangely heartening to learn that virtually all of the western European societies are struggling with the same core problems facing us in the United States.
I met and interacted with many healthcare leaders from across Europe and beyond, and heard terrific presentations and discussions at WoHIT. One particularly excellent encounter I had was with Jaana Sinipuro, whose title is leading specialist in the Digital Health Hub at SITRA, the Finnish Innovation Fund, a Finnish public organization sponsored by the Finnish parliament that sponsors innovative work in social welfare services, education, and technological development. Sinipuro is helping to lead the architecting of what is known as “Isaacus—the Digital Health Hub.” The Isaacus initiative is preparing to collect health status and health data from across all relevant databases in Finland—not only those from the provider sector of Finnish healthcare, but also from social welfare agencies and other sources—in order to improve the capabilities of researchers to uncover social welfare and health status patterns across Finnish society, and therefore support the development of new policies and programs to address issues such as chronic disease and the social determinants of health in that country. As Sinipuri told me on Nov. 26, the Isaacus initiative is creating a national data protocol (another version of this already exists in neighboring Estonia), which will collect data of all types, from all sources, on the Finnish population, in order to proactive engage in analytics that can help improve the healthcare—and health—of all Finns.
Essentially, as she explained it to me, Sinipuro is one of the national healthcare leaders helping to create a nationwide database of all Finns, one into which data from all sources will be poured, including personal health data and social-determinants data, and out of which healthcare leaders will derive data and analytics to identify Finns at greater risk for the need for medical intervention. The use of a data-lake concept, and the broad collaboration across the public and private sectors around this initiative (happily typical in the Nordic sphere), make this initiative terribly exciting to learn about. And though the policy and operational landscape is different in the U.S. there are broad elements of the Isaacus initiative that could be replicated with real success here.
Yes, it is happening
I could go on and on, really, as we editors at Healthcare Informatics have had the privilege to talk to so many leaders in healthcare, both based in the U.S. and outside it, leaders who are transforming healthcare for patients, families, communities, and societies. There is absolutely no question about the fact that patient care leaders in the U.S. in particular are facing a more rigorous future going forward, as reimbursement and other changes reflect the fundamental challenges of having to shift away from a fee-for-service-driven system and into a value-based one. And things are going to be messy—in some cases, very messy.
But every single pioneer I’ve spoken to this past year has expressed to me their sense of optimism that the transformation of U.S. healthcare is now and truly underway—and that, yes, it can be done. Will it be hard? Oh, yes, very hard. Will it take time? Absolutely: it really will take at least a decade in order to shift some of the core foundations of our U.S. healthcare system into the future state that they need to exist in. Will there be uncertainty? Yes, definitely. But the fundamental reality—that we must change our healthcare system dramatically, in the face of inexorable societal changes that are making the present system unsustainable—is one that we can all bank on. So as my fellow editors and I at Healthcare Informatics look back at this year, and forward towards the next year, we see a healthcare system in great ferment—and one with the genius—and the will—on the part of the pioneers of the system, to make the needed changes. We’ll continue to bring to you, our readers, the news, features, analysis, and commentary that you need, as you participate in this great task ahead of us. And we’ll keep our focus on the great opportunities and potentialities embedded in the need for change going forward. We’ll be doing the same, too, as we host 12 new Health IT Summits next year, in cities across North America, with industry leaders convening to share learnings and perspectives with you and to sit together to help map out healthcare’s future. I truly wish every reader of our publication, and every attendee at any of our summits, a wonderful year-end holiday season, and tremendous success and happiness in the new year!
