JANUARY 2011 VOLUME 60, NO. 1 INSIDE: REPORT FROM AMGA NATIONAL SUMMIT ON ACOS

group practice journal P U B L I C A T I O N O F T H E A M E R I C A N M E D I C A L G R O U P A S S O C I A T I O N ®

Population Health Management Requires Automation

Riverside Medical Group and The Iowa Clinic Improve Quality and Coordinate Care

J A N U A R Y 2 0 1 1 GROUP PRACTICE JOURNAL 9

riverside Medical Group, a 350-physician practice based in Newport News, Virginia, has had an electronic health record (EHR) for many years. ! e EHR connects physicians with each other, and a secure web portal allows patients to contact the practice. But in 2009, as the group built its infrastructure for population health management (PHM), its leaders realized that the EHR and the portal alone were insuffi cient to help doctors engage and manage patients who needed preventive and chronic care services.

Riverside’s solution was to

invest in a service that uses

a web-based population health

registry to keep track of

patients’ health status and

their healthcare needs.

One problem was that only about 10 percent of Riverside’s patients were using the web portal. Some patients did not even have Internet access at home. Also, some patients were overdue for preventive or chronic care, but did not know it because they rarely visited their physicians. And even though the EHR could be used to identify patients who had fallen off the radar screen, it took a lot of resources to contact those patients in for follow-up.

Riverside’s solution was to invest in a service that uses a web-based

population health registry to keep track of patients’ health status and their healthcare needs. Drawing data from Riverside’s EHR and its practice management system, the service uses nationally recognized, evidence-based protocols to trigger automated telephonic messages to patients who need to visit their physicians for specifi c kinds of care.

As a result of the outbound messages, 13,420 appointments were booked in the fi rst six months; of those appointments, 9,173 would not have been made were it not for the automated messages. Aside from the extra revenue this brings in, Riverside management believes that the service will lead to improved patient care.

“What we should see is a health-ier patient population that is more compliant,” says John Stanley, senior vice president and chief information offi cer for Riverside. “We should see fewer acute episodic visits to the ER. And we should see greater compli-ance from our diabetic patients and greater satisfaction with the health care that we provide.”

Population Health Management on the Rise

Like Riverside, many group practices are realizing that they need to focus more on population health management (PHM). In the future, payers will base reimbursement on value rather than volume, and the groups that manage their patients’ health successfully—both inside and outside the offi ce—will fare the best in this new world.

All of the current trends, from

patient-centered medical homes and payment bundling to the rise of accountable care organizations and the return of global capitation, point toward the need for PHM. Large group practices, including those affi liated with healthcare systems, are in a better position than most providers to meet this challenge. But even they must address the fragmen-tation of the care delivery system, misaligned fi nancial incentives, poor handoff s between inpatient and outpatient care, and the diffi culty of tracking patients’ health status and treatments as they move across care settings.

In addition, group practices must keep track of patients who rarely come in contact with the healthcare system. Some of these patients are healthy but many are not. A land-mark study by McGlynn et al. dem-onstrated that patients receive about 55 percent of recommended care.1 In addition, overeating, smoking, lack of exercise, and other personal health behaviors are major infl uences on healthcare consumption and spending, yet physician counseling of patients is poorly reimbursed and usually confi ned to offi ce visits for unrelated problems.

Success in PHM requires physi-cians and care teams to strengthen relationships with patients, optimize the services they provide before and during offi ce visits, and extend their reach to remain in contact with patients outside of the offi ce. Automation tools can help practices achieve these goals, while reducing the administrative, clinical, and out-reach eff ort that population health

Population Health Management Requires AutomationIT Tools Can Enhance EHRs to Improve Quality and Coordinate Care

BY RICHARD HODACH, M.D., M.PH., PH.D.

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10 GROUP PRACTICE JOURNAL J A N U A R Y 2 0 1 1

management requires of physicians and care teams.

Building a PHM InfrastructurePopulation health management

has been defi ned as an approach focusing on “the health outcomes of individuals in a group and the distri-bution of outcomes in that group.”2 Disease management, focusing on chronic disease states, was an early eff ort in PHM. Pay for performance, which incentivizes physicians to improve certain kinds of preventive and chronic care, is another approach to PHM. But these other kinds of improvement in population health have focused mainly on single sites of care3 and on patients with severe forms of particular diseases.4

Eff ective PHM requires coordina-tion of care across all settings, as well as outreach to noncompliant patients. To achieve this level of performance, group practices need to:

Build teams that provide multiple levels of patient care and educa-tionProvide timely access to primary careProvide support for primary care physicians who coordinate care and guide patients through the systemEnsure that patients receive con-tinuous care prior to, during, and after offi ce visitsFocus on educating patients about appropriate health behaviorInstall interoperable EHRsUse other IT tools including elec-tronic registries and web-based risk assessment and education

The Role of AutomationTo avoid overburdening busy

practices with PHM, an electronic infrastructure can perform much of the routine, time- and labor-intensive work in the background. Fortunately, many of the tools for building such an infrastructure already exist, although they tend to

be scattered and underused; others are in development and are existing technologies that will complement population management. When these tools are implemented, assembled, and applied in a coordi-nated, focused manner, they will be a powerful force for change.

For example, the combination of a robust registry and outbound messaging capability that Riverside uses can maximize the number of patients who come in for needed preventive and chronic care. Without requiring any eff ort from the care team, these tools enhance the doctor-patient relationship while increasing practice revenues as a byproduct.

By combining data from EHRs,

registries, outside providers,

and HRAs, practices can gen-

erate actionable reports.

To get the most out of visits, patients and the care team must be prepared. One way to automate the preparation is to have patients fi ll out a health risk assessment (HRA), either online or in the offi ce, that shows the state of their health and what they are actively doing. Patients should also receive personalized educational materials, including online multimedia tools, to prepare them for the offi ce visit.

By combining data from EHRs, registries, outside providers, and HRAs, practices can generate actionable reports that show what has been done for the patient and what care gaps need to be fi lled. When patients and doctors are aware of these care gaps before a visit, more can be accomplished within the limited time they have together.

Automation tools can also help care teams stay in touch with patients between visits. For example, patients who have fi lled out an HRA could receive educational materials

tailored to their conditions, and they could be directed to community resources for help with, say, smoking or excessive weight.

Registry applications capable of integrating several data streams can also generate management reports to support PHM. For example, an entire patient population could be fi ltered by payer, activity center, provider, health condition, and care gaps. # e same fi lters could be applied to patients with a particular condition, such as diabetes, to fi nd out where the practice needs to improve its care.

Care teams could also use those reports in the care of individual patients. For example, a sum-mary report based on registry data could show the patient’s last blood pressure, her last HbA1c result, and whether she’s late for her mam-mogram. If the person comes in for a cold or a sprained ankle, this information would be available to the physician. Groups could also use standing orders to enable staff to take some of the steps needed to address preventive and chronic care needs.

How Iowa Clinic Automated PHMMany physician groups are

starting to put the necessary tools together. # e Iowa Clinic, for example, also decided that it needed an automated approach to tackle PHM. With 135 providers serv-ing more than 400,000 patients, the Iowa Clinic faced a diffi cult challenge in ensuring that all of those patients received appropri-ate preventive and chronic care. Although its physicians closely tracked patients with diabetes and hypertension who came in for visits, they were missing a large section of the population who were not engaged in their own care.

To augment the EHR, the clinic chose to use a population health registry with outbound telephonic messaging to encourage noncompli-ant patients to see their doctors. # e clinic rolled out the tools to primary

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care physicians and cardiologists fi rst and then introduced them to other specialties.

! e service retained by the Iowa Clinic successfully contacted 16,620 patients with gaps in care. Of that number, 4,452 patients scheduled appointments within 60 days and 2,251 made appointments more than 60 days after receiving the automated communications.

“We have patients who have been delinquent with their care coming back to the doctor and getting appointments in a timely manner,” noted Julie Sander, director of quality improvement at the Iowa Clinic. “We have also seen greater compliance with the protocols. ! ese protocols tie into standards of performance improvement that our payers have established.”

ConclusionPopulation health management,

as its name implies, is about keeping an entire population as healthy as

possible. ! is is health care in the fullest sense, rather than sick care that focuses only on treating people who present with health problems. So it requires an entirely diff erent approach from the one that most physicians currently take. And to change the direction of healthcare without radically changing workfl ow, practices need to automate their processes through health informa-tion technology.

! e real power of automation tools is that they perform routine tasks consistently, so that practice staff ers never have to wonder which patients with a given condition are out of compliance or whether those patients have been contacted. ! e computer will never replace a doctor, but it is wondrously effi cient when it comes to doing particular, well-defi ned tasks over and over.

! e healthcare industry can take advantage of computer-driven automation, just as other industries have. When the infrastructure is in

place to ensure that patients receive recommended care, physicians and their staff s can concentrate on delivering that care with compassion and full attention to the needs of the individual.

References1. E.A. McGlynn, S,M. Asch, J. Adams,

et al. 2003. ! e Quality of Health Care Delivered to Adults in the United States. New England Journal of Medicine, 348: 2635-2645.

2. D.M. Lawrence. 2009. How to Forge a High-Tech Marriage Between Primary Care and Population Health. Health Aff airs, 29(5): 1004-1009.

3. D.M. Berwick, T.W. Nolan and John J. Whittington. 2008. ! e Triple Aim: Care, Health and Cost. Health Aff airs, 27(3): 759-769.

4. W.R. Gold and P. Kongstvedt. 2003. How Broadening DM’s Focus Helped Shrink One Plan’s Costs. Managed Care. November 2003. Accessed October 14, 2010 at http://www.managedcaremag.com/archives/0311/0311.minnesota.html.

Richard Hodach, M.D., M.P.H., Ph.D., is chief medical offi cer of Phytel, Inc.

Reprinted with permission of The American Medical Group Association®

©Group Practice Journal January 2011