Laying the IT Foundations for Population Health
HAVE WE REACHED AN INFLECTION POINT ON STRATEGY AND IT DEVELOPMENT, AS THE INDUSTRY EVOLVES FORWARD TOWARDS THE NEW HEALTHCARE? RY MARK HAGLAND
With greater policy certainty assured by the Supreme Court's affirmation of the constitutionality of healthcare reform this summer, industry pioneers are beginning to shape the new healthcare, and moving forward on a broad range of population health-based concepts. The strategic challenges- and opportunities- for healthcare IT leaders can't be overstated.
Perhaps nothing encapsulates more succinctly how rapidly the perceptual landscape of healthcare is changing these days than what has happened with regard to the name of a recently established school of public health. As David Nash, M.D., dean of the Jefferson School of Population Health, explains it, "When we established this school, we took a big risk in 2008, calling it a 'school of population health.' But," he says, "I got the name from the 2001 book Crossing the Quality Chasm [published by the federal Institute of Medicine], where they use the term." What's more, he adds, "When we did an informational search four years ago, we found only one other school with 'population health' in its name, and that one was in Adelaide, Australia. Now," says Nash, whose school, affiliated with Thomas Jefferson University in Philadelphia, has 320 students currently enrolled, pursuing any of four different graduate degrees in public health, healthcare policy, health economics, and healthcare quality, "we've seen a lot of organizations moving into this realm in the past year, with Hofstra Medical School, affiliated with the Long IslandJewish Health System, having just started a department of population health, and the NYU Medical School doing the same."
It's not surprising that Nash, a one-man healthcare policy think tank and publishing industry, would be on the leading edge in an area like this; for decades, he has seen the future, from clinical guidelines and practice protocols to outcomes measurement to comparative effectiveness to clinical care performance improvement, and has been trying to help cajole the industry forward in all those areas, and more. But these days, Nash is far from alone, and while it was indeed prescient for him and his colleagues to designate their new school a school of population health back in 2008, we seem to be reaching an inflection point now in 2012 in terms of the awareness of population health as a key concept for industry change.
Consider the following:
* At Presbyterian Health Services, an integrated delivery system in Albuquerque, N.M., clinician and operational leaders have created a groundbreaking program called "Hospital at Home," which sends out teams of doctors and nurses to care for patients in their homes rather than admitting them as inpatients. Those patients are very carefully screened, using rigorous criteria, and fall into certain well-defined care categories. The concept, which the Presbyterian folks adapted after studying a white paper by Bruce Leff, M.D., a professor of Medicine at the Johns Hopkins University School of Medicine, who conceived of the idea and coined the phrase, is aimed at improving outcomes for certain frail elderly patients, while at the same time reducing care costs and optimizing care management practices. Using this model, the Presbyterian organization has been able to reduce costs per episode by about 20 percent on average, while improving outcomes and patient satisfaction.
* This summer, leaders at Intermountain Healthcare in Salt Lake City, Utah, announced that they had been awarded a $9.7 million federal contract by the Centers for Medicare & Medicaid Services (CMS), as part of that agency's Health Care Innovation Awards initiative. The award, according to Lucy Savitz, Ph.D., director of research and education at Intermountain Healthcare'sInstitute for Health Care Delivery Research, will "greatly accelerate our ability to put into practice new ways for patients to partner with clinical teams in making decisions that will reduce potential health risks; take a populationbased view of care delivery design and decision-making and align financial incentives to insure sustained excellence in the care we are able to provide to our community."
* At the four-hospital, SpringfieldMass.-based Baystate Health, Evan Benjamin, M.D., the health system's senior vice president and chief quality officer, reports that Baystate has established a bundled payments contract with its affiliated health plan, Health New England, in order to find ways to improve outcomes and reduce costs in a variety of areas, beginning with total hip replacements in 2011, and total knee replacements and other surgical procedures this year. The planning for this pilot project, Benjamin notes, "took about six to seven months of planning... and that's pretty typical, as we looked at the amount of work [involved] in terms of changing the model of care, setting up gainsharing models, looking at the patient population, setting up quality measurements." The results so far? Using a gainsharing model of 45 percent of revenues going to physicians, 45 percent to the systems hospitals, and 10 percent to its visiting nurse association, the Baystate folks have been saving about $800 per case (based on an average cost per case of $25,000), while reducing average length of stay for these procedures from 3.5 inpatient days to 2.75 days and maintaining consistent quality outcomes.
MORE CERTAINTY IS FOLLOWING THE SUPREME COURT ACA RULING
All of these initiatives have been bolstered by the June 28Supreme Court ruling on the Affordable Care Act (ACA), which affirmed the constitutionality of the healthcare reform legislation passed by Congress and signed by President Barack Obama in March 2010. That development was important, because, along with health insurance access changes and reforms, one entire area of the ACA was a set of programs that, legislators hoped, would leverage the purchasing power of the Medicare program to revolutionize payment incentives across the healthcare industry.
Indeed, several programs either directly or indirectly related to the population health concept, and all focused on realigning financial incentives to physicians and hospitals, were created as elements in the ACA with the requirements for these programs set to be fully articulated under the aegis of the Medicare program. Among them were three mandatory programs: value-based purchasing, avoidable readmissions reduction, and healthcare-acquired conditions reduction. Among the voluntary programs sanctioned under the ACA are the accountable care organization (ACO) shared savings program and the bundled payments shared savings program. In addition, the patient-centered medical home (PCMH) concept continues to receive strong support from both the federal government and the National Committee for Quality Assurance (NCQA), which monitors and certifies aspects of managed care-based healthcare delivery.
Now, with the constitutionality of the ACA upheld (with the exception of an aspect of the law that allowed the federal government to sanction state governments that refused to expand their Medicaid programs), all those interviewed for this article agree that they are working in a landscape of greater policy certainty.
And that greater policy certainty, says Jefferson's Nash, means that, following the June 28Supreme Court ruling, "We're at a tipping point. After all," he says, "when you think about it, what is healthcare reform? It's practicing population health-based medicine. And," he says, soon, "you'll be able to look beyond the Kaisers, the Geisingers, the Ochsners"- integrated health systems already well-known for their innovative approaches to care delivery and management. And what's the common thread there? Physician leadership with employed physicians. Now, that's not the national model. But I think we will see more physicians in employment contracts, and that will further advance the field of population health," he adds.
NEW ALIGNMENTS, NEW LEARNINGS NATIONWIDE
Certainly, the leaders at the organizations that are already charging ahead to leverage population health concepts believe that they and their colleagues nationwide are innovating for a purpose- or rather, several purposes - to lower care delivery costs, improve clinical outcomes, and enhance patient, and clinician, satisfaction, all at the same time- in other words, to create the new healthcare.
Referring to the white paper by Hopkins' Bruce Leff that inspired the Presbyterian-Albuquerque team's innovative Hospital at Home initiative, Karen Thompson, the program's director, says, "One of the things that Dr. Leff has found, and we've substantiated it, is that the patient and the family, their satisfaction with the [Hospital at Home] stay, is much higher than with an inpatient hospital stay. And we were at 97 percent satisfaction, compared with 89.4 percent for the hospital, for the fourth quarter of last year. We've taken the same CAHPS [Consumer Assessment of Healthcare Providers and Systerns] survey with our program, versus the same population in the hospital."
What's more, says Melanie Van Amsterdam, M.D., lead physician for the Hospital at Home program at Presbyterian, "From the standpoint of our referring providers, they're generally happy, one, because we get their patients out of the ER, and provide very close followup; the primary care providers and specialists are very happy, because we communicate with them. And provider satisfaction is pretty high," she says, referring to the 3.5 FTE physicians involved so far in the program. "I know I'm really happy doing this work, because I get to spend time with my patients."
Of course, a lot of careful strategic thinking and planning have to be incorporated into any population healthbased concept, whether it be a hospital-at-home program like Presbyterians, or an ACO, bundled payment initiative, or PCMH, says Mark van Kooy, M.D., director of clinical informatics at the Pittsburgh-based Aspen Advisors. At the core of all of these types of initiatives, says the Sewell, N.J.-based Van Kooy, are a number of common elements, one of them being the ability to provide physicians in practice with intensive and extremely useful real-time data on their patients.
"Which outcomes matter most? Doctors look horizontally at episodes of care, but you need to make applesto-apples comparisons with the same diagnoses," Van Kooy asserts. "If you're looking at your whole community in any ACO, you want to look at the bad outcomes, and their associations with particular drivers. So you need a disease registry function. Once you've created that, and you know the key drivers of undesirable clinical outcomes- then you need a governance structure that includes objective, collégial, and collaborative feedback at the individual provider level, followed by shared, accountable action planning."
TRANSLATING OVERALL STRATEGIC IMPERATIVES INTO IT STRATEGIES
The implications of all this are huge for healthcare IT leaders, who will be tasked with working side by side with clinician and operational leaders to make these new models of care delivery and payment work. And the data and analytics demands will be extremely intense, says Intermountain's Savitz. "You almost can't separate the strategic and IT learnings" involved, she says. "The ability to do population health at an organization like Intermountain Healthcare, because of the availability and longevity of data, allows us to do this at a certain level. Basically," she says, "what you're trying to do with population health is to use largely clinical epidemiological techniques to be able to understand patterns and flows within the patient population, and that information can then be used in multiple ways, including in better designing healthcare delivery. We know that a very small percentage of the population tend to use the most resources. They tend to have three or more chronic conditions-it does not matter which three or which came first - that includes mental health, which is why we added depression. We know, for instance, that two-thirds of our diabetes patients have a co-morbidity of depression. Population health, with this kind of information, can help us target specific care delivery interventions, and keep them out of unnecessary admissions to the hospital and unnecessary ED visits."
Savitz's advice for healthcare IT leaders? "The fundamental message is that CIOs have to work in partnership with the clinical leadership team. The old siloed approaches caused a lot of problems early on," she says. "This is a great environment" at Intermountain, she adds, "because first, there are a lot of physicians involved in informatics. Our Homer Warner Center for Biomedical Informatics has been a real leading light in that area. In fact, they'll be involved in this particular project."
MASTERING THE USE OF ANALYTICS- AND BEYOND
Keith Figlioli, senior vice president, healthcare informatics, at the Charlotte-based Premier health alliance, sees the very big picture on all this, as he and his colleagues at the national health alliance continue to develop tools and collaborations to help their thousands of hospital and medical group organizational members move forward in all areas of the new healthcare. For example, Figlioli recently helped launch PremierConnect, a data and information platform that will allow member organization leaders to share benchmarking and other data online, as they work together across a number of Premier collaborative groups ( for ACO, bundled payment, and medical home development, among others) going forward.
"Everyone has been focused on analytics," Figlioli notes; and he certainly agrees that analytics will be essential to success in the new healthcare. "But," he quickly adds, "changing payment systems involves a great deal of change management, right? And yes, certainly analytics and infrastructure are extremely important- organizations will need core transactional systems, plus that analytical layer on top of it But I think one of the unknowns is not only how you're going to connect the data; but beyond that, how you're going to connect knowledge and connect people. That's why we've created PremierConnect So many vendors out there are pushing dashboard products. The question I have is, then, did they change outcomes? We're committed to truly changing outcomes."
Figlioli says he believes strongly that "This idea of just having a dashboard is not enough. You need to put context around that data. Think about the EMR and CPOE journey, and how hard it's been to put content in there; so imagine how hard it will be to wrap rich content around these information systems more broadly? In the end, he says, the "three pillars" of the new healthcare will be "data, knowledge, and people, all connected seamlessly. And," he warns, "if the CIO does not have a foot solidly in the strategic planning process of the whole organization, and if the CIO is not in on the very first strategic meetings around ACO developments, I would argue that they're dead in the water?
In the end, all those interviewed for this article agree, the future of the new, population-based, connected healthcare is one filled with both enormous opportunities and challenges; it is one that CIOs and other healthcare IT leaders will be deeply involved in building. The only question that remains is how soon leaders at individual patient care organizations hear the call and begin to move forward.
YOU NEED A DISEASE REGISTRY FUNCTION. AND ONCE YOU'VE CREATED THAT, AND YOU KNOW THE KEY DRIVERS OF UNDESIRABLE CLINICAL OUTCOMES- AND THEN YOU NEED A GOVERNANCE STRUCTURE THAT INCLUDES OBJECTIVE, COLLEGIAL AND COLLABORATIVE FEEDBACK AT THE INDIVIDUAL PROVIDER LEVEL FOLLOWED BY SHARED, ACCOUNTABLE ACTION PLANNING. -MARK VAN KOOY, M.D.