The decisive shift toward value-based care and population health requires health systems to reach beyond their four walls and into the medical neighborhood to proactively coordinate care and improve population health. But that requires a new community-integration capability that complements their existing EHR investments. Think of a “CHR” (community health record) as a modernized health information exchange (HIE) designed to support value-based care.
To coordinate care, CHRs have to do more than merely exchange information between facilities. They must also empower the clinicians accountable for care to digitally communicate with each other, easily and instantly, around a common care plan that’s continually updated based on the ever-changing needs and health status of each patient.
In as much as I’ve talked about the merits of a CHR like this, I have to admit that I’ve never heard of one that’s fully operational – until I recently had the pleasure of interviewing Wesley Combs, CIO of Holston Medical Group (HMG). As he described how their 41 sites of care from Tennessee to Virginia are using their HIE, it became obvious to me that the platform HMG is using from health IT leader, Allscripts, is no ordinary HIE. Unlike most HIEs operating today, this one was designed for virtualized care teams of the future, not the past. Not only does it move information from point to point, it truly empowers clinicians to collaborate with each other and coordinate care in real time across the medical neighborhood. The following is a transcript of my conversation with Mr. Combs.
Schmuland: Before we get started, could you give me an overview of your role and the vision and scope of services at Holston Medical Group?
Combs: I’ve served as the CIO of HMG since 2012 and when I arrived, I was challenged with providing a communitywide system that enables providers to execute in a value-based world while maintaining and improving the fee for service execution that pays the bills.
Holston Medical Group is a multispecialty practice made up of 165 practitioners that serve more than 200,000 patients at 41 sites across a 100-mile radius in northeast Tennessee and southeast Virginia. Founded in 1977 by Dr. Jerry Miller, the practice grew from 5-6 providers to one of the largest multispecialty groups in the southeast and the first level 3 NCQA recognized patient-centered medical home (PCMH) in Tennessee. We believe it is important for physicians to remain independent so they can fully focus their time and resources on their patients. Our strategy is to give our physicians the tools they need to remain independent.
Schmuland: How far along on the journey from fee for service to fee for value would you say that HMG has come?
Combs: With an increasing number of incentives to move toward risk-contracting, approximately 20% of our contracts are risk-based with more than half of those including downside risk. Value-based contracts encourage physicians to think harder about the cost and quality of the care provided.
Schmuland: It sounds like HMG is a large federation of independent physician practices that are sharing risk as a clinically integrated network, right? But to share risk in Clinically Integrated Networks, each practice needs a friction-free way to share records and communicate to coordinate care and ensure care continuity. By now, most practices in CINs have organized and integrated under a local hospital system to exchange medical records and coordinate care plans. Is that the case with HMG?
Combs: Not at all – at HMG it’s just the opposite. We’ve leveraged a community record for the medical neighborhood – the dbMotion Community via OnePartner – that’s available not only to physicians practicing within HMG, but it’s open to all physicians and healthcare organizations throughout our region, including the hospitals. Currently, we have 1,820 providers contributing records to the system and nearly 1,000 of those have access to the information at the point of care. From a workflow efficiency standpoint, access to the community record nearly eliminates the staff’s time and frustration of hunting down medical records. Now, they are able to access these records instantly. Physician users can deliver higher quality care that’s also highly efficient and cost effective.
Schmuland: At a time when most physicians seem to be selling their practices to regional health systems, HMG seems to be bucking that trend by enabling physician collaboration. What are you providing to these groups that’s keeping them independent?
Combs: Independent single and multispecialty practices are inundated with clinical and financial reporting requirements thrown at them by nearly every payer contract – and they’re not consistent across contracts. The Medical Group Management Association (MGMA) issued a study last year reporting that physicians and their staff now spend about 785 hours each year dealing with quality reporting measures alone, mostly consumed by entering data. If you translate that into time taken from patient care—it’s about 9 patients per week that physicians have to surrender to administrative reporting. The cost of lost patient care for each physician amounts to $40,000 per year, not to mention the access issue it creates for patients. And that was before MACRA, Medicare’s new Quality Payment Program, which we believe could double the work burden.
We help other groups with their IT integration, data reporting and value-based contracting models. This allows these groups to maintain their independence in light of the increased complexities of the business of healthcare. Most independent physicians want to do what they went to school for – taking good care of people. Our team can help them refocus on doing exactly that with improved tools to help them succeed in the world of value.
Schmuland: How did you go about finding the platform you needed for your community record—and how did you manage to build the business case for each practice and facility to make the investment?
Combs: When we started our search five years ago, we knew that we needed real data to identify risk on patients, manage their costs, measure quality and tightly coordinate the care that required multiple specialties. We needed near real-time interfaces with nearly every type of EHR in the neighborhood. That’s where costs, complexity, and vendor lock-in can break the bank.
After conducting due diligence on nearly every vendor that came close to our criteria, we chose the dbMotion Community via OnePartner. There were two big advantages of the Allscripts dbMotion™ Solution that made the decision easy: First, it had the best and most scalable and flexible approach to connecting clinics—because a community record doesn’t matter if it isn’t connected. Second, it must work within a physician’s existing EHR workflow. Their EHR Agent Hub floats on top of the EHR and allows for single sign on for the physician user, negating the need to go outside their existing workflow to “hunt” for information. It will alert the physician user if there is new information, outside of their local EHR, within the Community Record, which may be of interest to them at the point of care. Custom physician designed analytics tools also exist within this platform and they are really geared towards population health strategies that physicians know will work.
Schmuland: Everyone says that selling technology to physicians is hard, let alone persuading them to use it. How did you make the business case for your physicians?
Combs: That wasn’t hard at all. Our physicians know that data is key in the new world of healthcare. When 20% of the patients they see are chronic complex patients under risk contracts, and are consuming 80% of the money they are at risk for, they quickly realize that this is the sweet spot of people to influence to execute on those risk contracts. By having the data, they can execute on key opportunities to engage the patient face to face on steering them to cost effective specialists, places of services and medications just to name a few. This year alone the technology has helped HMG move their risk score up by 10 points, put HMG’s admits per 1000 20% below market and helped increase ambulatory E&M visits by 4.2%. These factors help lead to better Fee for service payments and larger Value based gain shares. Add to that the patient’s satisfaction of less hospital visits and a more engaged and personalized primary care experience, we believe this is a big win.
Schmuland: It looks like you’ve turned the conventional HIE model upside down where, instead of the medical neighborhood facility as a spoke centered around a hospital system hub, the patient is truly the hub and every facility is a spoke. Do you have any hospital spokes?
Combs: Yes, our community record is integrated with the regional hospital system –so notifications of admits, transfers, and discharges are sent straight to the point of care via the EHR Agent where care providers are notified of what happened along with other metrics like LACE, Risk Score and Stratification level. Before implementing the solution, we struggled to even identify all our patients in the hospital and had a hard time hitting the 14-day mark to perform the transition of care. Now the average transition of care time is down to 5 days on 100% of identified discharges which is huge on the patient front because they are surprised we called so quickly. It led to more service revenue that wasn’t being captured and helped in some quality measures.
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