Develop your strategic goal: ?Financial stability for the strategic Goal, keep in mind the overall impact you want this goal to have on your department or the organization as a whol

Chapter 14 Health IT Leadership Case Studies

Case 1: Population Health Management in Action Although the integration of patient-centered medical homes and accountable care organizations into the health system is still emerging—as are best practices and key learnings from these early efforts—there have been myriad examples demonstrating encouraging returns and improvement in quality of care. The Patient-Centered Primary Care Collaborative recently profiled several organizations that have adopted patient health management (PHM) tools and strategies to address the preventive and chronic care needs of their patient populations.

Bon Secours Virginia Medical Group Richmond, VA Provider Type: Multispecialty group practice Locations: 140 Patients: 25,000 (Virginia) A pioneer in implementing medical home and accountable care initiatives, Bon Secours has dedicated itself to executing a sustainable care delivery model that is in alignment with health care reform across its providers and locations. Bon Secours's transformation into an organization that embraces PHM is the result of a systematic strategy to reengineer primary care practices, integrate new technologies into care team workflows, and engage patients in their care.

Bon Secours took a leap of faith in implementing these changes, acting on the belief that payers would come to them if they built a viable model. And payers did. The organization was selected as an early participant in the Medicare Shared Savings Program. It has also signed value-based contracts with two commercial payers—CIGNA and Anthem—and is in negotiations with several more. These contracts provide a financial mechanism to expand and scale the medical home initiative and support ACO models. This case study examines in more detail Bon Secours's approach to position itself to achieve quality outcomes and financial success in the changing health care environment.

Bon Secours's Care Team Model The foundation of Bon Secours's strategy for value-based care is its medical home initiative—the Advanced Medical Home Project. The project began as a pilot five years ago. Since that time, eleven practices have earned NCQA recognition as patient-centered medical homes. One of the most significant objectives of the Advanced Medical Home Project is to improve capacity—making it possible for care teams to double the size of their patient panel without overburdening themselves or sacrificing quality of care.

At the heart of this medical home strategy is the effort to reengineer practices by creating high-performance physician-led care teams, which requires changes in workflow, new care coordination activities, and designed delegation of clinical responsibilities across the care team. To facilitate this process, Bon Secours has invested significantly in embedding care managers

into the primary care team. These nurse navigators are registered nurses (RNs) who are either board-certified case managers or actively working toward certification.

Each nurse navigator is assigned a panel of approximately 150 high-risk patients. He or she cultivates a personal relationship with these patients, usually through repeated phone contacts. Although most outreach is telephonic, navigators have the skill to assess which patients require face-to-face intervention. And because they are embedded in the practice, they can spend time with these patients doing assessments, care planning, and education.

Bon Secours's eHealth Strategies An important aspect of Bon Secours's strategy is implementing health information technology that empowers the care team to efficiently manage the health of their populations. They consider this technology—standardized across the medical group—as the key to enable them to scale their system for value-based care. As a first step, Bon Secours implemented an EHR and all its modules in every practice within the system. This gave them a strong foundation for documenting care and accessing health records across the enterprise. Risk stratification. They were able to build a registry that could identify high-risk and high-utilization patients based on data such as number of medications or frequent visits to the emergency department. However, the organization recognized the need for a more robust, scalable registry that would drive efficient population health workflows in their practices and enable analytics and predictive modeling across multiple clinical conditions.

Integrating their EHR with a PHM platform, Bon Secours is able to aggregate all source data into a population-wide registry that enables the organization to implement multiple quality-improvement programs simultaneously. The registry stratifies the population by risk—providing a total population view while enabling each care team to drill down to the data they need about cohorts and individual patients. The system enables care teams within the practice to monitor their patients' health status and take action by delivering timely and appropriate care interventions. Because the system automates these interventions, care teams are able to communicate with many patients at once.

Automated outreach. A significant priority for Bon Secours has been preventing thirty-day readmissions. The medical group uses an automated outreach system to identify discharged patients, link them to a primary care provider (PCP), and pinpoint those who are at high risk for readmission. Flagged patients are then called within twenty-four to seventy-two hours to reinforce discharge instructions, make sure their medications are reconciled, and set up an appointment with the primary care team within five to ten days of discharge. Bon Secours will soon implement a readmissions solution to automate the process of calling discharged patients, asking them to complete a short assessment, and escalating cases as needed based on their feedback.

Personal health records. Another strategy for patient engagement is activating patients on an electronic personal health record (PHR), which allows patients to view clinical results and communicate conveniently with their caregivers via e-mail. Bon Secours works to gain

physician consensus on policies that drive the use of PHR: physicians agreed to allow automatic release of normal results to the PHR, but abnormal results are held for 24 hours to enable the care team to contact the patient. The organization is relying on physicians and staff members to get patients active on the PHR to help them sign up on the spot in the exam room.

Challenges and Lessons Learned Gaining physician buy-in for reengineering practice workflow. The concept of the care team can be difficult for some physicians because they see themselves as the clinician and the rest of the team as support staff members. To help physicians embrace the care team and delegate patient-care tasks, Bon Secours placed tremendous emphasis on physician education. The organization also allows physicians to adjust some of the standardized care team protocols to meet the needs of their practice, which fosters ownership of the process and assures physicians that they remain in control.

Paying for the transition to value-based care. As mentioned previously, Bon Secours implemented its medical home model with the hope that payers would come to them if they built a viable program. CIGNA currently gives the organization a per-member per-month (PMPM) adjustment for care coordination. Anthem, the group's biggest payer, pays a care coordination fee and will change to PMPM in the coming year. Several more commercial payers are lined up to sign contracts with the group. However, this payer involvement is a relatively new development. For the first few years of the project, Bon Secours shouldered the expense. The organization is now poised to reap the rewards of its investment.

Bon Secours is also demonstrating significant progress managing its CIGNA population. In the first six months of their value-based contract, they have achieved a 27 percent reduction in readmissions and are $1.8 million below their projected spend. They have hit many of their care quality metrics and need to improve their gap-in-care metrics only slightly to achieve the index necessary to qualify for gain sharing with CIGNA—a development that will bring a projected annual savings of $4 million.

Bon Secours's mantra for the future is “health care without walls.” The organization is aggressively pursuing remote, noninvasive monitoring for highly acute case management. Their vision is to bring care outside the four walls of the hospital into the patient's home using technology. They are operationalizing a geriatric medical home that will enable patients to age in place with home visits for preventive and acute management. They are also expanding their implementation of the PHM platform to include performance measurement at the group, site, and provider levels; feedback to providers on variance in care; and quality reporting. This added functionality for analytics and insight on the clinical and administrative levels will help the organization ensure that it is meeting the triple aim (to improve the patient experience of care, including quality and satisfaction; to improve the health of populations; and to reduce the per capita cost of health care).

nnovation Impact Thirty-day readmission rate for medical home patients was < 2 percent for two years.

Patient engagement scores were in the 97th percentile. Patient outreach efforts generated approximately forty thousand unique patient visits for preventive, follow-up, or acute care, leading to $7 million increased revenue. Source: Shaljian, M., & Nielsen, M. (2013). Managing populations, maximizing technology: Population health management in the medical neighborhood. Patient-Centered Primary Care Collaborative. Retrieved from https://pcpcc.org/resource/managing-populations-maximizing-technology. Used with permission.

Case 2: Registries and Disease Management in the PCMH Union Health Center (UHC) New York, NY Provider Type: Community Health Center Medical Home NCQA Level 3 Patients: 11,000 Office Visits: 55,000 UHC's Care Team Model Union Health Center (UHC) embraced the patient-centered care team model very early on, which helped ease the transition to new workflows, processes, and features that are critical to change management and quality improvement. UHC clinicians and staff members are assigned to clinical care teams, composed of physicians, nurse practitioners, physician assistants, nurses, medical assistants, and administrative staff members. The practice uses a full capitation model with standard fee-for-service and a fee-for-service plus care management payment model.

Ten years ago, UHC instituted the California Health Care Foundation's Ambulatory Intensive Caring Unit (AICU) model, which emphasizes intensive education and self-management strategies for chronic disease patients. The model relies heavily on the role of medical assistants (called patient care assistants or PCAs) and health coaches. Working closely with other members of the care team, PCAs and health coaches review and update patient information in the record, conducting personal outreach and self-management support, and providing certain clinical tasks. For instance, all PCAs have been trained to review measures (e.g., HgbA1C, blood pressure, and LDL cholesterol), provide disease education, and set and review patient health goals. A subset of higher-trained health coaches works more intensely with recently diagnosed diabetic patients or those patients whose condition is not well managed.

UHC's eHealth Strategies Patient registries. UHC uses patient registries to identify patients with specific conditions to ensure that those patients receive the right care, in the right place, at the right time. In some instances, they use registries to target cases for chart reviews and assess disease management strategies. For example, patients with uncontrolled hypertension are reviewed to help identify treatment patterns, reveal any need for more provider engagement, and may indicate the need for care team workflow changes. In the future, UHC would like to construct queries that combine diagnosis groups with control groups and stratify patients by risk group.

For example, care teams could pull a report of all patients over the age of sixty-five with multiple chronic conditions or recent emergency room admissions.

Maximizing time and expertise. UHC uses technology such as custom EHR templates to support PCAs and free up clinicians for more specialized tasks and complex patients. For example, a PCA or health coach taking the blood pressure of a high-risk diabetic patient has been trained to determine whether or not BP is controlled. If it is not controlled, the health coach checks the electronic chart for standard instructions on how to proceed and may carry out instructions noted in the record. Or, if no information is available he or she will consult with another provider to adjust and complete the note. Following all visits with PCAs or health coaches, the patient's record is electronically flagged for review and signed by the primary care physician.

Working with medical neighbors. The teams also collaborate with on-site specialists, pharmacists, social workers, physical therapists, psychologists, and nutritionists to enhance care coordination and whole-patient care. UHC has also adopted curbside consultations and e-consults to reduce specialty office visits. For example, if a hypertensive patient has uncontrolled blood pressure, the record is flagged by the PCA for further follow-up with a physician or nurse practitioner, who may opt for an e-consult with the nephrologist to discuss recommendations. UHC also has a specialty coordination team—composed of two primary care physicians, one registered nurse, one PCA, and one health coach—which functions as a liaison between primary and specialty providers.

Customized reporting. With their most recent upgrade to a Meaningful Use–certified version of their EHR, UHC will have the capacity to generate standardized Meaningful Use reports. UHC intends to construct queries that generate reports that group diagnosis groups with control groups and identify and manage subgroups of high-risk patients (or risk stratification). For example, care teams can run a report of all patients with diabetes that have an elevated LDL and have not been prescribed a statin.

Challenges and Lessons Learned Recruiting staff members with IT and clinical informatics expertise. Over the years, UHC has faced challenges in identifying and recruiting staff members with the right mix of IT and clinical informatics skills. Although effective in troubleshooting routine issues and hardware maintenance, UHC felt there was a clinical data analysis gap. To resolve this, UHC works closely with an IT consultant and also recruited a clinical informatics professional to work with providers and performance improvement staff members.

Consistent data entry. UHC's lack of consistent data entry rules and structured data fields led to several challenges in producing reports and tracking patient subgroups. The problem stems from UHC's lack of internal data entry policies as well as the record's design. For instance, UHC cannot run reports on patients taking aspirin because this information may have been entered inconsistently across patient records. Moving forward, UHC will be implementing data entry rules and working closely with their vendor to maximize data capture.

Real-time data capture. UHC realized that by the time data reach the team, they may no longer be current. As a workaround they considered disseminating raw reports to clinical teams in real time, followed by tabulated, reformatted data. They are exploring the possibility of purchasing report writing software to streamline the process.

Managing multiple data sources. Similar to many practices, UHC pulls data from its billing system and clinical records, causing issues with data extraction. For example, pulling by billing codes does not provide the most accurate data when it comes to clinical conditions, health status, or population demographics. UHC recognized that to reduce errors in identifying patients and subgroups this will require custom reports.

Innovation Impact Forty-six percent reduction in overall annual health costs Eighteen percent reduction in total cost of care Significant decline in emergency room visits, hospitalizations, and diagnostic services Significant improvements in clinical indicators for diabetic patients Source: Shaljian, M., & Nielsen, M. (2013). Managing populations, maximizing technology: Population health management in the medical neighborhood. Patient-Centered Primary Care Collaborative. Retrieved from https://pcpcc.org/resource/managing-populations-maximizing-technology. Used with permission

Case 3: Implementing a Capacity Management Information System Doctors' Hospital is a 162-bed, acute care facility located in a small city in the southeastern United States. The organization had a major financial upheaval six years ago that resulted in the establishment of a new governing structure. The new governing body consists of an eleven-member authority board. The senior management of Doctors' Hospital includes the CEO, three senior vice presidents, and one vice president. During the restructuring, the CIO was changed from a full-time staff position to a part-time contract position. The CIO spends two days every two weeks at Doctors' Hospital.

Doctors' Hospital is currently in Phase 1 of a three-phase construction project. In Phase 2 the hospital will build a new emergency department (ED) and surgical pavilion, which are scheduled to be completed in eleven months.

Information Systems Challenge The current ED and outpatient surgery department have experienced tremendous growth in the past several years. ED visits have increased by 50 percent, and similar increases have been seen in outpatient surgery. Management has identified that inefficient patient flow processes, particularly patient transfers and discharges, have resulted in backlogs in the ED and outpatient areas. The new construction will only exacerbate the current problem.

Nearly a year ago Doctors' Hospital made a commitment to purchase a capacity management software suite to reduce the inefficiencies that have been identified in patient flow processes.

The original timeline was to have the new system pilot-tested prior to the opening of the new ED and surgical pavilion. However, with the competing priorities its members face as they deal with major construction, the original project steering committee has stalled. At its last meeting nearly six months ago, the steering committee identified the vendor and product suite. Budgets and timelines for implementation were proposed but not finalized. No other steps have been taken.

Case 4: Implementing a Telemedicine Solution Grand Hospital is located in a somewhat rural area of a Midwestern state. It is a 209-bed, community, not-for-profit entity offering a broad range of inpatient and outpatient services. Employing approximately 1,600 individuals (1,250 full-time equivalent personnel) and having a medical staff of more than 225 practitioners, Grand has an annual operating budget that exceeds $130 million, possesses net assets of more than $150 million, and is one of only a small number of organizations in this market with an A credit rating from Moody's, Standard & Poor's, and Fitch Ratings. Operating in a remarkably competitive market (there are roughly one hundred hospitals within seventy-five minutes' driving time of Grand), the organization is one of the few in the region—proprietary or not-for-profit—that has consistently realized positive operating margins. Grand attends on an annual basis to the health care needs of more than 11,000 inpatients and 160,000 outpatients, addressing more than 36 percent of its primary service area's consumption of hospital services. In expansion mode and currently in the midst of $57 million in construction and renovation projects, the hospital is struggling to recruit physicians to meet the health care needs of the expanding population of the service area and to succeed retiring physicians.

Grand has been an early adopter of health care information systems and currently employs a proprietary health care information system that provides (among

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