the migration to clinician network management - chilmark research

The Migration to Clinician

Network Management

April 2014

MULTI VENDOR SPONSORED REPORT

THE MIGRATION TO CLINICIAN NETWORK MANAGEMENT

2

© 2014

Preface

This report stems from the need for the healthcare industry to look beyond the health information exchange (HIE) constructs prevalent today and begin exploring how to realize the next level of value from their massive investments in this technology. It is worth noting that HIE constructs in and of themselves are precipitated by the need to connect the silos of patient data that reside in EHRs that has accelerated under the federal Meaningful Use incentive program. With few exceptions, existing EHR and HIE efforts have not delivered the breadth of clinical or financial benefits that healthcare organizations (HCOs) had envisioned.

Having kept close watch on the HIE market for several years, Chilmark Research now seeks to redefine the value an HIE infrastructure can provide HCOs. We firmly believe that the future success of an HCO will be directly dependent upon how well it supports and manages its clinician network (both owned and affiliated) across the care continuum. In short, networks of clinicians working on standardized, evidence-based care pathways will enable providers to better manage risk, reduce variability and provide higher quality, appropri-ate, patient-centric care. Until now, the focus of HIE has been on point-to-point data exchange rather than on the information requirements of networks of clinicians working together to improve the efficiency and effec-tiveness of care. To describe the technologies and practices needed to support this level of clinical integration we have coined the term, Clinician Network Management (CNM).

Five leading health information technology vendors joined Chilmark Research to sponsor this research. Those vendors are: CareEvolution, McKesson, Optum, Orion Health and a sponsor who has chosen to re-main anonymous. It is our shared intention to shed light on the market’s readiness to move the industry to-ward CNM. For HCOs, this report provides a snapshot of the current state of the HIE and EHR deployments and how their peers perceive the move to CNM, which will enable them to assess their own position and strategies. For vendors, this report is an opportunity to evaluate their product roadmaps from the perspec-tive of a pressing, and mostly unmet need in the industry.

We are grateful to our sponsors and their desire to support this research. Like Chilmark Research, these com-panies are committed to educating the industry and laying a path forward for HCO’s to realize value from their current and future investments in HIE infrastructure.

3

APRIL 2014

© 2014

CONTENT

Preface 2

Executive Summary 5

Introduction 6

Clinician Network Management Definition 6

Macro Trends Drive Need for Clinican Network Management 7HCOs Both Large and Small Need CNM 8

CNM: A Market Perspective 8Three Categories of Strategic Objectives 10

Grow Top-line Revenue 12

Contain Costs 13

CNM, Value-Based Care, and the Data-Driven Enterprise 15

Enabling CNM 17

Conclusions and Recommendations 19

Appendix A: Scope & Methodology 22

Appendix B: Profile of Respondent HCOs 23

Appendix C: Acronyms Used 25

About Chilmark Research 26


4

© 2014

TABLES AND FIGURES

Figure 1: CNM Moves Beyond HIE to Support Numerous Ambulatory Needs. 7

Figure 2: Growth in Healthcare Spending Shifting to Outpatient Settings 8

Figure 3: Attributes of Forward-thinking HCOs 9

Figure 4: Attributes of Status quo HCOs 9

Table 1: CMS Revenue Increasingly at Risk 10

Table 2: HCO Strategies to Effectively Manage Risk and Improve Quality Across Care Continuum 11

Table 3: HCO Strategies to Maximize Revenue 13

Table 4: HCO Strategies to Align Providers and Contain Costs 14

Table 5: HCO Strategies to Deliver Data to the Point of Care 16

5

APRIL 2014

© 2014

Executive Summary

The healthcare sector is undergoing massive structural changes, driven, in large part, by the Affordable Care Act (ACA). Primary among these changes is the migration from fee-for-service (FFS) reimbursement models to value-based reimbursement (VBR). Whereas FFS did not require providers to take on risk, provider reim-bursement will increasingly be linked to quality measures and outcomes under VBR. Under VBR, reimburse-ment can be tied to 1) quality measures including outcomes-based measures and 2) cost containment due to fixed reimbursement, shared savings and capitation.

To ensure future viability, if not success, healthcare organizations (HCOs) will need to do a far better job of communicating patient clinical and administrative information across their networks of owned and affiliated physician partners. In short, networks of clinicians working on HCO-derived care pathways are essential to providers’ ability to manage risk, reduce variability and provide higher quality, appropriate, patient-centric care. This approach also offers the best way to minimize or eliminate the care process variations that drive increased costs and payment risks.

Until recently, health information exchange (HIE) deployments focused primarily on moving limited clinical datasets among a tightly circumscribed network of clinicians. Rarely have HCOs looked beyond this con-struct for their HIE deployments. As a result, a number of existing HIE efforts have failed to deliver the breadth of clinical or financial benefits that HCOs had hoped for.

In the past year, this has begun to change as HCOs look to support patient engagement and care coordination initiatives with their HIE solution suites. In light of the rapid changes taking place in the wider market, how-ever, the healthcare industry needs to engage in new thinking to increase the value proposition of its signifi-cant HIE investments.

This report looks beyond the common HIE use cases and vocabulary in use today and defines a new term, Clinician Network Management (CNM). Our goal is to encourage HCOs of all sizes to reconsider their HIEs, as something more than information exchange, namely a platform to support a variety of clinician information needs at the point of care. Using data from across the defined network of clinicians and their HIT technolo-gies, CNM should enable: patient-centric longitudinal data viewing, patient risk scoring, care-gap analysis, clinical care guidance, care team coordination and interaction, physician performance score-carding and at-tribution, and total cost of care determination for the population being served.

To assess the market’s readiness to move beyond simple exchange to CNM, we conducted a number of in-depth telephone interviews with senior executive leaders across a wide cross-section of HCOs. While the actual number of interviews conducted was limited to 13 institutions, by including extremely large academic medical centers, smaller community health systems, regional HIEs, and local IPAs, our research did uncover distinctive patterns in the industry.

There was unanimity among interviewees that the industry is undergoing massive transformation, that the move to VBR was real and not going away, and that HCOs need to form closer, clinically integrated networks to ensure future success. But there was strong divergence on how HCOs intend to accomplish the goal of creating more integrated networks. Two distinct groups represent this divergence: forward-thinking HCOs and status quo HCOs.

Forward-thinking HCOs, as the name implies, have fairly well-defined VBR strategies and have begun map-ping their IT requirements to support those strategies. These HCOs tend to be larger with far greater re-sources at their disposal for acquisitions. They also carry enough clout in the markets they serve to push af-filiated providers to comply with their specific requirements. They can require, for example, affiliated providers adopt one of their “approved EHRs” to participate in future VBR contracts. Whether or not their somewhat coercive strategy will work over the long term remains to be seen. It is clear that among these forward-think-


6

© 2014

ing HCOs, that physicians who want to be a part of VBR contracts will play by the HCO’s rulebook. These HCOs have a clearer vision of CNM on the horizon and are moving toward it today.

Status-quo HCOs have yet to develop a clear VBR strategy and appear to be more in a tactical mode, address-ing such pressing issues as ICD-10 compliance and preparing for meaningful use (MU) Stage 2 attestation. Whether these organizations have the leadership and vision or simply lack the resources is open to debate. What is clear is that these organizations appear not to have the clout to make demands upon their affiliated physicians and thus find themselves operating on yesterday’s HIE model of Let’s make it easier for affiliates to place orders with us and get the results quickly to build volume. For status quo HCOs it is really about trying to build a high-trust network across their affiliates that will hopefully lead, in time, to a more clinically integrat-ed network that ultimately will support a CNM model.

IntroductionThe adoption and deployment of HIEs today are primarily focused on creating a basic infrastructure that will enable clinicians to view a patient’s longitudinal record. Another objective of deploying an HIE is to drive re-ferrals to the host HCO, typically a large hospital system. However, in light of the rapid changes now taking place in the market, HCOs need to look beyond these relatively fundamental uses of their HIEs.

How we talk about HIE needs to change. Its purpose is no longer limited to simple information exchange. To-morrow’s objectives will be far more complex than today’s and HCOs need to begin rethinking what will drive their future success — success that will be directly dependent on delivering effective and efficient, high-qual-ity care to the communities they serve in all patient care venues that the HCO can influence.

This will require a new level of distributed network intelligence that may leverage an existing HIE infrastruc-ture. The information delivered through this infrastructure will be far more complex than referrals and sub-sets of a patient’s record. To ensure their success under value-based reimbursement (VBR), HCOs will need to ensure that all clinicians (hospitalists, affiliated, owned) within their network, for which they have some form of contractual agreement (ACO and other risk-bearing contracts), are receiving the information they need to collaborate and care for patients effectively to ensure that pre-defined metrics (e.g., quality) are met.

Clinician Network Management Definition

Given the growing pressures in the industry, it will no longer be sufficient for an HIE to simply exchange in-formation. HCOs need to leverage their HIE infrastructures as well as quite a few other IT resources, chief among them analytics (clinical, financial and operational) to ensure that their clinician network has the infor-mation necessary to make decisions that support mutually shared goals and objectives. Intelligence must be distributed in a complex, sophisticated manner.

We have termed this new level of distributed intelligence Clinician Network Management (CNM). Within a CNM construct, the host HCO will provide its ambulatory partners with the information they need to suc-cessfully manage their patients across the continuum of care. Going well beyond patient record look-up and in-network referrals, CNM will support ambulatory clinicians in understanding which of their patients is at highest risk, be informed of quality care gaps across their patient panel, and receive feedback from the care teams they are a part of. Ideally, through CNM, physicians will also receive guidance on appropriate clinical care pathways, understand their contractual obligations, know how well their practice is performing in rela-tion to their peers, and understand how attribution is assessed for their contributions to the health of the community they serve (see Figure 1).

7

APRIL 2014

© 2014

Macro Trends Drive Need for Clinican Network

Management

The healthcare sector is undergoing massive structural changes. Some of these changes have been evolving for the last decade or more, such as accelerating growth in outpatient care at the expense of acute care ser-vices (see Figure 2). Other changes are far more recent:

• The digitization of health in response to the HITECH Act and subsequent adoption of EHRs by both hospi-tals and providers

• The slow yet inevitable shift from fee-for-service (FFS) to value-based reimbursement, whereby providers will take on greater responsibility for managing risk

• The rise of consumerism in healthcare with the advent of high-deductible plans and shift to insurance ex-changes

While only the foolhardy will try to predict exactly the full ramifications and timing of these changes, no one will dispute the fact that these changes are occurring and require proactive planning.

Care Teams

Scorecard

Decision Support Contracts

Contract

Clinical Pathways

Patients at Risk

Attribution

Figure 1: CNM Moves Beyond HIE to Support Numerous Ambulatory Needs.


8

© 2014

HCOs are pursuing a number of strate-gies in response to these market chang-es. How aggressively HCOs pursue these strategies often correlates direct-ly to the competitiveness of the market they serve. HCOs in highly competitive, typically urban, markets are moving to-ward highly integrated care delivery systems assembled through acquisi-tions, IT infrastructure build-outs, and tighter, contractual terms with affiliated physicians. In more suburban and rural markets, the urgency is less acute and therefore, the strategies are more de-pendent on extending current operat-ing models. It is also important to note that HCOs in less aggressive markets tend to be smaller and have far fewer resources at their disposal.

In light of these macro forces, the future success of an HCO, be it large or small,

urban or rural, will depend on how well the HCO coordinates and manages care across its distributed net-work of owned and affiliated clinicians. Chilmark Research sees this capability as the next level of potential value for the health information exchanges (HIEs) that many organizations are now putting in place.

HCOs Both Large and Small Need CNM

To gain a better understanding of the current market readiness to move to a CNM model, Chilmark Research conducted extensive, in-depth, phone interviews with 13 HCOs across the country. These HCOs reflect the variability of our nation’s care system, ranging in size from a small, rural community hospital; to a large regional HIE serving a population of five million; to a very large urban IPA serving over one million patients; to a nation-al IDN delivering services through over 75 hospitals across a wide swath of the country. The interviews were conducted in late 2013 and early 2014. Following are summary findings from this extensive research effort.

CNM: A Market PerspectiveThe U.S. healthcare sector is the nation’s largest single industry sector. Despite its size, this sector remains highly fragmented and in many ways can be likened to a cottage industry. There are few truly national players among HCOs. The vast majority of the market is represented by very localized and typically small HCOs. We did find some commonalities of opinion that lead us to categorize HCOs into two distinct groups: forward-thinking and status quo.

• Forward-thinking HCOs tend to be larger HCOs in more competitive urban markets (see Figure 3).

• Status quo HCOs most often operate in less competitive suburban or rural markets (see Figure 4). Com-munity hospitals, hospitals in smaller cities, smaller group practices are typical of the HCOs in this category.

Figure 2: Growth in Healthcare Spending Shifting to Outpatient Settings

Source: Center for Medicare and Medicaid Services, McKinsey and Co.

Spending Growth on Inpatient Care Slowing Fast

0

1

2

3

4

5

6

7

8

Ave

rage

An

nu

al G

row

th R

ate

(%)

Long-term and Home Care Outpatient Care Inpatient Care

Care Settings

2003—2006 2006—2009

9

APRIL 2014

© 2014

· Large urban main hospital· Numerous owned facilities both urban and suburban· Increasing percentage of salaired physicians· Operate in high competitive markets· Sophisticated IT operations· Begin to offer health plans via narrow networks

AMBULANCE

· One or three small hospitals in suburban or rural community

· Few other owned facilities· Most physicians are affiliates· Operate in low, competitive markets· Tactical, regulatory driven IT operations

These are broad characterizations. It is important to note that even among some of the smaller HCOs, there are organizations that clearly see the need to move aggressively forward. Similarly, among large HCOs, there are those who are seemingly stuck in addressing tactical issues and not thinking strategically about how they will address the onslaught of changes to the U.S. healthcare system over the long term.

Figure 3: Attributes of Forward-Thinking HCOs

Figure 4: Attributes of Status Quo HCOs


10

© 2014

Three Categories of Strategic Objectives

In alignment with broad industry trends, we have broken down our research findings into three categories of strategic objectives to which all respondents were attuned:

• Effectively manage risk while improving quality in a distributed care network

• Grow top-line revenue

• Contain costs

Nonetheless, it is difficult to break these three strategic objectives out into neat, well-defined silos. There are often interdependencies across these objectives, for instance, growing top-line revenue under VBR will be dependent on improving the quality of care and ability to manage risk.

Effectively Manage Risk and Increase Quality Across the Care Continuum

The shift from FFS to VBR carries with it the opportunity for HCOs to achieve bonuses for improving the quality of care delivered. Previously referred to as pay-for performance, these programs reward HCOs for following clinically based quality guidelines. One example is the Alternative Quality Care Contract offered by Blue Cross Blue Shield of Massachusetts, which rewards physicians for following specific, evidence-based quality guidelines.

Under VBR, there are also contracts that encourage HCOs to become Accountable Care Organizations (ACOs), in which they take on patient risk in return for even higher potential for bonus reimbursements. If patient risk is managed well over the continuum of care, (e.g., a chronic condition such as diabetes) the HCO will get higher reimbursements to share across its network of clinicians.

Beyond the bonus reimbursements associated with risk management though, there is also the potential for penalties, particularly from the largest payer in the U.S., the Center for Medicare and Medicaid Services (CMS). CMS introduced penalties in FY2013 and plans to continuously ramp-up additional penalties in the coming years (see Table 1). As HCOs typically receive roughly two-thirds or more of their acute care reve-nue from CMS, and most have operating margins at or below five percent, the potential financial risk to an organization is significant.

Began Oct. 1, 2012 (FY13)

Program % Risk $ at Risk*

Readmissions 1.0% $1MM

Value-based Purchasing 1.0% $1MM

Begins Oct. 1, 2014 (FY15)

Program % Risk $ at Risk*

Readmissions 3.0% $3MM

Value-based Purchasing 1.5% $1.5MM

Hosp. Acquired Condition 1.0% $1MM

EMR (1/15) 1.0% $1MM

Table 1: CMS Revenue Increasingly at Risk

11

APRIL 2014

© 2014

All HCOs interviewed see the need for tighter collaboration across all care venues based on standard, evi-dence-based care pathways. Healthcare executives believe that standardization can eliminate the variability that drives higher costs and help HCOs meet the quality metrics found in value-based contracts. These ex-ecutives all bemoaned the current state of care coordination offerings from HIT vendors.

Regardless of the size of an HCO, all of the organizations we surveyed had a much broader view of care coor-dination than what their HIT vendors typically support. While these HCOs certainly consider data capture and sharing during care transitions important, they are more keenly focused on how care processes and workflows can be integrated across a community of healthcare providers, be they owned or affiliated. Clini-cal executives, in particular, are highly focused on process first, and then on what technology will readily en-able clinical data capture and sharing (see Table 2).

HCO Type Strategy Tactics

Forward-thinking

• Increase number of employed ambulatory physicians

•Establish and distribute care pathways across the continuum

•Track and report actual-versus-plan attainment of pathways

•Leverage patient, payer, and device data

• Integrate care coordination into workflows

Aggregate data from numerous sources, analyze and distribute directly into workflow.

Introduce embedded clinical pathway-modeling toolsets with metrics.

Add layered care coordination capabilities across heterogeneous EHR ecosystem.

Status quo

•Strengthen relationship with community physicians and physicians with ACO patients

• Improve discharge information distribution

• Improve medications management

• Implement condition- or episode-specific transition care coordination pathways

Enable patient identification and matching to physician directories and contracts.

Leverage Direct for patient discharge distribution.

Build out simple query capabilities for medication lists.

Table 2: HCO Strategies to Effectively Manage Risk and Improve Quality Across Care Continuum

Beyond an agreement for the need to foster care coordination across care venues and putting process first, the strategies by which HCOs would accomplish such achievements diverge.

Forward-thinking HCOs are putting a higher emphasis on the use of software-based care coordination so-lutions that will span organizational boundaries. These organizations are looking for solutions that can be embedded directly into clinician workflows. A majority of these HCOs are looking to their EHR vendors to provide such capabilities, even though they have grave reservations about these vendors’ abilities to actu-ally deliver such capabilities.

Status quo HCOs have far more modest plans. They are seeking to simplify access to patient records, typi-cally via a provider portal. To support activities such as patient discharge and follow-up, these HCOs will likely turn to email via Direct Exchange to distribute patient discharge summaries. Among status quo HCOs, there is the general belief that fostering better relationships with affiliated physicians will lead to a natural propen-sity for affiliates to follow HCO-defined clinical pathways. We also found among these organizations, greater faith that their HIEs could address these issues. Forward-thinking organizations held a more cynical view.


12

© 2014

These results are not too surprising. Forward-thinking HCOs that are larger and have greater resources at their disposal are looking to drive care coordination through a more structured, and to some degree, author-itarian approach, often framed by acquisition. Status quo HCOs are looking to establish strong and trusting partnerships with their affiliates in the hopes that this will naturally lead to more coordinated care.

Grow Top-line Revenue

The second category of strategic objectives has to do with revenue. Every HCO wants to preserve and ex-pand top-line revenue during the transition from FFS to VBR. All respondents told us they will continue to optimize FFS revenue for the time being and are beginning to evaluate how they will concurrently grow their VBR revenue during this transitional stage. Today, there are no clear-cut answers but there is a significant amount of experimentation taking place.

Among forward-thinking HCOs, the overarching strategy is to grow revenue through direct build-out of new outpatient clinics and acquisitions of smaller HCOs (e.g., private practices, community hospitals, etc.). Where they cannot acquire, these HCOs are looking for exclusive to near-exclusive contractual agreements with affiliates. They also see the need to scale operations to effectively meet their long-term strategic goals by taking direct control of their distributed clinical network (see Table 3), something that was highlighted in the previous section.

From an IT perspective, forward-thinking HCOs are looking at how their EHR/HIE infrastructure, coupled with care coordination toolsets and embedded analytics, can optimize care delivery across their tightly con-trolled networks. The belief is, this will deliver higher quality care across the care continuum that consumers and patients will appreciate, resulting in greater customer loyalty and customer referrals. This is very similar to consumer relationship management (CRM) strategies deployed in other industry sectors.

Among status quo HCOs we found a much different strategy. These HCOs are more focused on growing rev-enue by forming tighter partnerships with key physician practices in the communities they serve, especially around specific service lines for which they can compete effectively — even against their much bigger, for-ward-thinking brethren. In forming such partnerships they seek to drive service-line referrals to the HCO.

On the IT side, status quo HCOs are more interested in providing affiliated physician partners with loosely coupled tools that will make it easier for them to interact with the host HCO. Such tools are commonly found in most HIE solutions on the market today. Status quo HCOs are far more concerned with affiliated physician satisfaction, which they hope will lead to higher referrals. This has been a common strategy under FFS, but it remains to be seen how successful it will be under VBR, where far more is at risk than just referral revenue.

Any organization wants to maximize revenue — it’s how they intend to accomplish that goal where strategies diverge. Forward-thinking organizations are generally far more interested in fostering consumer loyalty. By providing a seamless healthcare experience across their continuum of care venues, they hope to provide a more satisfying patient experience that will lead to higher loyalty, referrals and subsequently higher reve-nue. Status quo HCOs, however, focus first and foremost on physicians and other clinicians. Through physi-cian loyalty, they aim to maximize revenue through referrals, a very common volume-driven strategy for many years now under FFS.

13

APRIL 2014

© 2014

HCO Type Strategic Goal Tactics

Forward-thinking

•Capture more low-acuity revenue

• Increase number of employed ambulatory physicians

•Expand capacity for facilities-based community care

•Vertically integrate services, including insurance to provide “narrow-network” health plans

Acquire practices, clinics and smaller HCOs to build out network, particularly for outpatient services.

Form tightly coupled network(s) and leverage IT to facilitate the delivery of seamless care across all venues.

Status Quo

•Maximize referrals

• Improve non-owned physician satisfaction

• Increase revenue share in shared payment panels

•Condition community portion of shared payments based on referrals

Focus on partnerships rather than acquisitions.

Create loosely coupled networks providing sufficient value to partners.

Create systems to simplify and promote in-network referrals with emphasis on specific service lines.

Table 3: HCO Strategies to Maximize Revenue

Contain Costs

With reimbursement shifting to VBR, CMS reimbursements on a slow but continual slide, and the full impact of ACA yet to be seen, HCOs must increasingly focus on cost containment, the third category of shared stra-tegic objectives. Across the industry, what is being heard is the need to contain costs by reducing variability. Reducing clinical variability has the potential added benefit of improved quality and can subsequently lead to higher, quality-based bonuses for an HCO.

With shared saving contracts, payers have created an incentive to reduce overutilization costs across the HCO. This is not exactly cost containment writ-large but all of the HCOs we interviewed are looking to rein in unnecessary utilizations across their communities of care, which will increasingly become a lost opportunity cost.

What may be most telling regarding cost containment is the simple fact that virtually all of the HCOs inter-viewed for this report have only recently begun to think about their true costs of patient care. All HCOs know their basic operating costs (facilities, labor, supplies, etc.) but delving deeper into their cost structures across their networks is very much a work in progress. For example, HCOs do not have a clear picture as to their complete costs in outpatient settings that under VBR will need to increasingly come under scrutiny, espe-cially in full-risk bearing contracts for chronic disease patients.

Today the focus appears to be on the care element of the process: ensuring that clinicians across an HCO’s network are seeing the right patients and following evidence-based, clinical guidelines to the best of their ability. The general belief is that focusing on care will reduce negative clinical variability. Accomplishing this objective in a cost-effective manner is leading HCOs to work on strengthening their provider-organization alignment (see Table 4).


14

© 2014


Forward-thinking

•Dramatically reduce number of EHRs in community

•Data sharing via HIE across community EHRs to drive alignment

•Timely, relevant and continuous physician score carding

•Care pathway T&Cs in non-owned physician contracts

•Enable EHR/HIE care coordination capabilities in clinician workflows

Higher dependency on selected EHR ven-dors — typically no more than four.

Focus on distribution and use of clinical care pathways to reduce variability across network.

Hold clinicians accountable with score-carding to guide them toward improved operational performance.

Tie physician reimbursement to process and quality measures performance.

Status Quo

•Provide medical records to community physicians

•Condition- and episode-specific transition support

•Make the hospital easy for community physicians to practice in

Accept heterogeneous EHR community and adapt systems to accommodate diverse data sources (leverage portals).

Encourage physicians to follow guidelines — no mandate.

Table 4: HCO Strategies to Align Providers and Contain Costs

Forward-thinking HCOs, in a move toward more tightly controlled clinician networks, are taking a much more aggressive approach to achieving physician alignment than status quo HCOs. For forward-thinking HCOs, alignment will be driven by greater standardization of technology and processes. Cost containment is first about minimizing the number of EHR interfaces (typically no more than four different ambulatory EHRs) and leveraging their HIE infrastructure to create the network. Secondly, it is about creating clinical care pathways, distributing them across the network, and ensuring they are followed. Third, it is the use of agreed-upon metrics and clinician scorecards to track performance across the network.

Ideally, forward-thinking HCOs would like for all of the above to occur within the context of a clinician’s workflow and that such capabilities be provided through their EHR vendor(s). But there was near unani-mous agreement that this remains on the distant horizon given the current capabilities of EHR and HIE ven-dors, which all consider to be severely lacking. This is forcing most executives we interviewed to look beyond their current vendors and consider best-of-breed approaches to enable their VBR strategy.

Even as most HCOs consider a best-of-breed adoption model, one EHR vendor, Epic, did stand out, but in a highly qualified way. Several organizations believe Epic has the ability to unify an extended provider commu-nity for the challenges of VBR with a standard set of applications and tools. Even clinical executives admit this, while also expressing misgivings about what they regard as the inherent limitations of Epic. Epic believ-ers were a minority among the executives we interviewed, but among hospitals using Epic, this vendor is per-ceived as being better positioned to enable CNM than any other HIT vendor in the market today, and will likely capture more of its existing customers’ “IT wallets”.

Status quo HCOs, as the name infers, approach hospital-physician alignment in a traditional way: make it easy for community physicians to refer patients to the host HCO and encourage them to follow treatment proto-cols for patients upon discharge. These organizations remain focused on the basics such as providing patient data access, typically via clinician portal, to affiliated physicians. There is no strong drive to foster uniformity across the network. As mentioned previously, status quo HCOs are simply trying to be good partners so they can foster clinician loyalty. Cost containment across their clinician network is simply not on their radar screens.

15

APRIL 2014

© 2014

CNM, Value-Based Care, and the Data-Driven Enterprise

All HCO executives interviewed agreed on one key issue: Their future success is highly dependent on their ability to aggregate data from numerous sources, apply analytics, and distribute guidance at the POC. This, they believe, will lead to more effective, higher quality care throughout their clinician networks. Thus, the ability to aggregate and normalize data, leverage an enterprise data warehouse, and apply analytics will be the cornerstone of their CNM strategies. This is, in essence, the migration to a data-driven healthcare enter-prise, an enterprise that leverages the available data to provide guidance beyond acute care and thereby en-gage all partners in reaching mutual goals and objectives.

How forward-thinking and status quo HCOs plan to transform themselves into data-driven enterprises, however, is again dramatically different. In fact, one could argue that the data-driven enterprise is but a fu-ture vision for status quo HCOs, whereas forward-thinking HCOs see the data-driven enterprise as an im-perative — an objective on their timeline that they are working toward today.

Status quo executives operate on the belief that data flows primarily downhill from hospital to the commu-nity. For these executives, the objective today is to deliver to their affiliated partners the patient data they desire (lab results, follow-up visit notes) and what the HCO needs to push to them, (discharge summaries to prevent readmits). Status quo HCOs are therefore focusing almost exclusively on the delivery of clinical data across their network via a common push model. There is very little bi-directional exchange of data.

While executives at status quo HCOs share similar beliefs about the constrained utility of portals and mes-saging-based exchange, they believe that for now, some data is better than no data at all. These organizations remain hopeful that the interoperability requirements for EHRs in stage 2 MU certification criteria will ena-ble richer, more dynamic data sharing in the future. But such data sharing will require a high degree of trust among all partners in the network, something that they are currently working to foster.

By contrast, forward-thinking HCOs see the need for the bi-directional flow of clinical data. Hospitalists need community care data as much as community care providers need acute care data. Today, these organizations believe that they are doing a reasonably good job of fostering such bi-directional data flow, provided those in the ambulatory sector are on one of the “approved” EHRs within their network. Forward-thinking HCOs will admit, however, that clinicians on other EHRs have a more difficult time accessing and receiving clinical data.

Forward-thinking HCOs are also far more interested in delivering data, whatever its source, directly into the clinician’s workflow. Clinical executives were unanimous in their distain for messaging-based exchange mech-anisms that provide large volumes of data, typically as flat files that cannot be embedded in clinical workflows or readily accessed by clinicians. The effort required to sort through documents in various formats to find relevant information is almost never worthwhile for most clinical users. These HCOs are also unenthusiastic about clinician portals that require clinicians to alt-tab between applications, and consider the cognitive bur-den of this approach too great for most clinicians.


16

© 2014


Forward-Thinking

•Reduce data clutter

• Integrate HIE-sourced data into hospital and community clinician workflow

•Expand use of query-based exchange

•Reduce reliance on directed exchange

Take responsibility to deliver “cleansed data” to point of care.

Enable patient data access and presentation within clinician’s existing workflow – do not wait for regulatory-driven interoperability.

Minimize point-to point data exchange.

Status Quo

•Stage 2 MU attestation

•Refine HIE to better serve community physicians with hospital EHR data

•Establish portals for data lookup and directed exchange

Wait for regulations to take hold and hope they’ll be enough to meet clinician needs for data delivered into workflow.

Ensure physicians have access to hospital data via a portal and Direct Messaging.

Table 5: HCO Strategies to Deliver Data to the Point of Care

Challenging New Data Requirements

Every HCO recognizes the need to exchange a growing variety of information with its physician partners. This information will require an ever-broader need for new data sources, chief among them, payer data.

To maximize shared revenues under VBR, physicians will need to know what is expected of them based on a multi-HCO care plan. Those same physicians will need timely, constructive feedback on how they deliv-ered care to specific patients and to panels. Physicians will not only need access to the patient’s care plan, but also an indication of the reimbursement effects of the care delivered at the patient and panel level. Care plan–related data, including treatment variances and payer-derived data, will need to flow between all in-network clinicians.

The executives we interviewed for this report are unanimous in saying their EHR and HIE vendors do not currently provide the capability to source and distribute the more varied and complex data requirements that in-network clinicians will need to succeed under VBR. For numerous reasons, including competition among HCOs and between HCOs and payers, there has not been sufficient market demand to enable such rich data and information sharing. EHR and HIE vendors simply delivered what the market asked for — no more, no less. With the rapid advent of VBR, however, most vendors are struggling to meet this newfound market need.

Despite the recognized need to share more data, the majority of executives we interviewed remain leery of disclosing data to competing providers. Our research also found tremendous reluctance to provide payers with access to their EHR data. They distrust payer motives and question the value and timeliness of payer data. A physician executive in a medium sized IDN summed up the general sense of most providers:

We would prefer to have a separation between the payers [and our] network of practition-ers. I guess the insurers can be providing some of that information [for our dashboards] but I do not know if they necessarily need to and I certainly do not want them to have access to the dashboard and what we are doing.

CMIO, Mid-size IDN

17

APRIL 2014

© 2014

One clinical executive expressed an interest in using payer data to compare the benefit plan designs of different payers as well as the clinical performance of community-based specialists. A more immediate and compelling use of payer data is to detect revenue leakage. This data is highly desired by provider or-ganizations but those interviewed have found payers reluctant to share. One clinical executive in a large city hospital system recounted a discussion he had with a payer in which the message to providers was:

Yeah, we have this data and it’s part of what makes us better than you.

HCOs are also unsure how to translate the quality feedback they receive from payers into beneficial changes at the POC and more broadly, for their population health management initiatives. Several provid-ers told us their physicians consider quality feedback from both CMS and private payers as nonsensical and rarely clinically relevant. But executives also acknowledge that these reports will get more attention once the expected financial penalties under VBR begin to emerge.

Enabling CNM

Clinician Network Management is not so much about directly managing clinicians as it is about providing clini-cians the most relevant information possible to help them meet organizational objectives, regardless of their location. Accomplishing this remains difficult in an acute care setting and nearly impossible today among owned and affiliated community clinicians. What has proven particularly challenging for HCOs of all sizes, re-gardless of their IT infrastructure, is delivering the right data at the right time to a clinician at the POC.

Across all of the organizations included in this study, clinical executives report a low level of satisfaction with cross-enterprise data exchange among clinicians. While the number of transactions passing through an HIE continues to increase, getting the right data to the right clinician at the point of decision remains the excep-tion and not the rule.

Clinicians need better and more reliable access to a longitudinal patient record composed of data from multi-ple sources, including competing HCOs. While clinicians want such access, they are extremely quick to say: give us the data that matters. The sheer volume of data that delivers no value to their decision-making frus-trates many clinicians. At the same time, many frustrated clinicians have no idea what data is available to them.

Today, useful data is too often obscured among large volumes of irrelevant data sets. Most front-line clini-cians conclude that useless data overwhelms the right data by a wide margin in most clinical contexts. This challenge will require HCOs to do a far better job of sorting and identifying relevant data to enable desired care processes. An enterprise data warehouse with an ability to normalize and present a longitudinal record highlighting key areas of interest to a clinician will be indispensable under VBR.

Closely coupled with delivering the right data, is delivering it in context, at that point in the clinician’s work-flow where it is most useful. Notifications about the existence of relevant data, delivered at a point in the workflow where it can be used effectively, are missing from most HIE implementations. These notifications will provide more than just patient data under VBR. They will provide clinicians with guidance and reminders


18

© 2014

about their role in treatment protocols that are part of broader multi-HCO care plans. They will help care managers keep track of and redress care gaps for patients and panels. They will help supply medical directors timely notice of information on physician performance and departmental financial performance. Unfortu-nately, such notifications are more fantasy than reality in the current most HCOs’ IT infrastructure.

The Missing Pieces

While all respondents said they would prefer to seek CNM-enabling solutions from their HIE or EHR ven-dors, most remain skeptical of these vendors’ ability to deliver such capabilities in a timely enough fashion to support their VBR strategy. The missing pieces needed to enable CNM can be broken down into three dom-inant categories: analytics, care coordination toolsets, and workflow/process management.

Analytics

As mentioned in the previous section, clinicians are often drowning in too much data, most of it not the right data/information on which they can base a decision. Using analytics to delve into large datasets from numer-ous sources and deliver what is truly useful to a clinician at the POC (the right data) is a perquisite for any CNM strategy. The use of analytics can also provide clinicians clear guidance on their performance relative to peers and ultimately assist in defining attribution for care rendered.

There is, however, a significant challenge for any HCO that wants to make analytics part of its CNM strategy. Analytics are only as capable as the data provided. The richer and more accurate the data, the more confi-dence one can have in the results. Unfortunately, relevant data resides in numerous locations: from payer to provider EHRs, to community health centers, to pharmacies, to off-site labs — and the list goes on. The ability of today’s HIEs to tap those data sources remains a work in progress, leaving HCOs the unenviable task of using a wide range of work-arounds to accomplish this goal.

Care Coordination

Clinical executives are concerned that care coordination across a community is currently unsupported by to-day’s EHRs and minimally supported by HIEs. For example, ADT-derived messages, even if digestible by tar-get EHRs, provide the barest minimum of information to PCPs and other community providers assigned the responsibility of follow-up care. There remains a lack of process tools that facilitate and present patient data about an event beyond the ADT to drive next actions for community providers.

There also is the lack of tools and capabilities to readily create and distribute shared care plans across a dis-tributed network based on internally established, evidence-based clinical pathways. These care plans need to be EHR vendor agnostic and in many cases, not rely on any EHR at all to enable their functionality. There has been a recent proliferation of third-party offerings to address this shortcoming of both EHR and HIE ven-dors, once again leading to the rise of best-of-breed solutions. Most executives would prefer not to go best-of-breed, but often feel they have no choice at this critical juncture.

Workflow & Process Management

Despite near universal agreement that approaches being deployed today to deliver the right information to a clinician at the POC are exceedingly lacking, many of the executives we interviewed do not see a clear path to solving the workflow puzzle. There is no clear answer here, though the widely held belief is that first and fore-most, relevant information must be delivered into physicians’ hands via their EHR. Today, the physician’s EHR is perceived as the workflow hub as it is where a physician spends the majority of their time when reviewing

19

APRIL 2014

© 2014

patient information. Therefore, delivering information directly into the EHR at the POC will be an area of keen focus over the next few years.

What we did not find though, which will hold equal importance, is how to deliver relevant, workflow-enabled information to care team members who may not have any need, use, or access to an EHR. From the visiting nurse, to hospice care, and the patient’s family, all will play a role in the long-term health of a patient. It may be premature to begin thinking about these players now when HCOs are struggling to deliver information to the “care quarterback” — the physician — but to ignore it will lead to peril in the future.

Conclusions and RecommendationsWithout exception, all of the HCO executives interviewed for this study agree that they will need to estab-lish much closer links to community clinicians within and outside the four walls of their institutions. These HCOs do see CNM as the next level of value realization for their HIE infrastructure, with an urgency driven by the rapid evolution from FFS to VBR models. All organizations are trying to maximize revenue under FFS while concurrently planning for the switch to VBR — a switch that will require significant cultural change across the healthcare sector.

Another finding, which was in some respects unexpected, is the animosity those interviewed continue to feel toward payer organizations. Granted, the sample size for this report was quite small, but to compensate, we included a wide cross-section of provider HCOs in our research. All interviewees had reservations abut work-ing too closely (data sharing) with payers. Yet there is increasing agreement across the industry at large that payers have datasets and skills that could prove valuable for provider HCOs under VBR. Looking ahead, it will likely be smaller, resource-constrained HCOs that form partnerships with payers to leverage payer assets, in-cluding actuarial skills.

But how HCOs intend to address the migration to VBR and form a more clinically integrated network that supports CNM using their IT infrastructures diverges significantly between forward-thinking and status quo HCOs. Forward-thinking HCOs are far more structured and strategic in fully leveraging their IT/HIE infrastructures to enable CNM. These HCOs also are taking a more authoritative approach to drive com-pliance throughout their networks, (e.g., requiring physicians in network to use a limited set of EHRs and using contract terms to ensure clinicians comply with specific clinical pathways). It should also be noted that these HCOs are more aggressive in acquiring practices and typically have more resources at their disposal to foster compliance.

Status quo organizations, by contrast, are resource constrained and typically, their VBR migration strategies are not well-formed. These HCOs are very much focused on the present and therefore looking to volume-based FFS strategies as core to their CNM strategies. Being smaller and resource constrained also leads these organizations down a logical path of looking to establish trusted relationships with their affiliates, accepting affiliates where they are (e.g., allowing the EHRs they are already using) and hope that through such trusted relationships, affiliates will “do the right thing” and follow the HCO’s clinical pathways. It is also worth noting that status quo HCOs typically have resource-constrained IT departments that are almost entirely tactically driven to meet regulatory requirements. This prevents these HCOs from looking beyond today into how to use IT strategically to enable CNM tomorrow.


20

© 2014

In reflection, these differences are not totally unexpected. The healthcare sector has always had its leaders, those highly regarded organizations at the forefront of the industry. These are your innovators that represent ten percent or less of the market. The vast majority of the healthcare sector, however, is comprised of distant followers who are unlikely to catch up anytime soon, if ever. These HCOs are prevalent in rural communities across the country where market forces have not prompted significant changes in behavior.

Despite these differences, there was commonality across all HCOs on a number of issues that pertain to ena-bling CNM. These are:

Data will be the backbone of CNM. It is simply accepted across the industry that to ensure success, HCOs must take responsibility for providing front-line clinicians the information they need to make the right decision for the patient in front of them. Ambulatory practices simply do not have the resources, and providers don’t have the time, to wade through mounds of data to get at the truth. It will be incumbent upon the HCO to proactively provide front-line clinicians in their network with “actionable analytics”.

The cognitive burden of data access is still too great for clinicians seeing patients. Today, it is still too difficult for clinicians to access the data/information they need in the context of their workflow. Clinicians need information delivered to them seamlessly without having to hunt and gather.

Attribution is a huge looming issue that no one has solved. All respondents agreed that clinician/physi-cian attribution will become increasingly critical under VBR but no one has a coherent strategy to address it across their network. In this context, declarative attribution is similar to what we have seen in PCMH settings wherein a physician (PCP) takes on responsibility for the well-being of a patient’s outcome.

Physician alignment is a process. There are no quick easy fixes to driving alignment across an HCO’s clini-cian/physician network. An organization can put in the desired IT infrastructure to support alignment, but in the end, alignment will be very much about process change.

Adoption of CNM best-of-breed solutions is the likely path forward. Most HCOs have a strong desire to leverage their existing EHR and HIE vendors to enable CNM. However, these organizations have found these vendors’ CNM-enabling solutions lacking. There is certainly an opportunity for established EHR and HIE vendors, but they will need to move more quickly to address this need.

While all of the HCO leaders interviewed for this report recognize that the industry is undergoing massive transformation, the rate at which organizations can or will respond to this transformation is highly variable. The migration to CNM will be most rapid in highly competitive markets, which typically serve large, dense populations in urban and neighboring suburban areas. In other regions, where competition is not as high, and the urgency for CNM is not as pressing, the migration will be slower.

One question that remains is which strategy will ultimately succeed? Forward-thinking organizations are tak-ing a much more prescriptive approach to driving clinician alignment. This is certainly appropriate for salaried clinicians, but will it work with affiliates? One executive of a large HCO stated that they will simply tell affiliates:

If you want to be a part of our contracts with payers, you will use the EHR we pre-scribe and discontinue the one you have today.

CIO, Large Academic Medical Center

21

APRIL 2014

© 2014

Status quo HCOs are taking a far different approach and looking to simply be great organizations to work with. By making collaboration easier for affiliates, these HCOs hope that community physicians will naturally align with them to enable CNM. Such a reliance on trust is a significant risk to take, but these resource-con-strained HCOs have few other viable options.

Regardless of which strategy proves successful, one thing is assured: Moving forward, all HCOs will seek to better align clinicians throughout the communities they serve. Leveraging their existing IT infrastruc-tures, coupled with the adoption of new solutions and functionality, all HCOs will seek to enable CNM across their networks.


22

© 2014

Appendix A: Scope & Methodology

To gather the information for this study we conducted telephone interviews with 20 individuals from 13 pro-vider organizations. These organizations included small and large city hospitals and IDNs, community hospi-tals, AMCs, large city physician practices and a large public HIE. A profile of each organization interviewed is provided in Appendix B. We have withheld the names of the organizations because most agreed to the inter-view on the condition that their names and the names of their organization not be revealed. The interviews lasted from 30—75 minutes with most taking around 40 minutes. Most of the individuals interviewed were part of the clinical organization and, of these, most were either physicians or nurses. About one third of inter-viewees were part of the IT organization and all had good visibility into wider organizational plans.

23

APRIL 2014

© 2014

Appendix B: Profile of Respondent HCOs

1. Large City IPA

a. Regional alliance of seven formerly independent physician groups. Provides primary, specialty, home health, palliative, hospice and wellness services in 200 communities. Metrics: 1,000+ physi-cians, 2,100 other clinicians, 1 million + patients, 50 locations, 3.5 million visits per year.

2. Regional IDN

Regional IDN with six acute care hospitals, two children’s hospitals, a behavioral health center, am-bulatory care facilities, geriatric centers, specialized women’s health services, and comprehensive home care and hospice services. Metrics: 4,600 physicians, 18,200 employees, 1.5 million outpa-tients, 198,000 inpatients, 452,000 ED patients, 18,300 live births.

3. Small City IDN

a. Regional IDN with three acute care hospitals, regional reference lab, home healthcare, respiratory care, hospice, primary and specialty care in 50+ locations. Metrics: annually - 43,000 inpatients, 1.3 million outpatients, 4,700 live births.

4. Large City AMC/IDN

Academic medical center with 800 employed physicians and large contracted practice association. Affiliations with four community hospitals, one rehab hospital, large practice association and net-work of community facilities. Focus on med/surg, critical care and OB/GYN. Metrics: annually - 51,000 inpatient, 550,000 outpatient, 56,000 ED, 5,000 live births.

5. National Footprint IDN

National IDN with 87 hospitals (includes 4 academic medical centers and 24 CAH). Provides com-plete range of healthcare services in hospital and communities and includes physician groups. Metrics: annually - 371,000 inpatient, 4 million outpatient, 1.3 million ED.

6. Large City AMC

a. Academic medical center with physician organization provides full range of services and an affilia-tion with a national cancer care provider. Metrics: annually - 26,400 inpatient, 77,000 ED, 490,000 outpatient.

7. Large Regional Public HIE

a. Large regional public HIE supporting a population of over 5 million people. Metrics: Over 2,800 physicians representing 21 hospitals and 25 medical groups in area served.

8. Large City AMC

a. Academic medical center with owned physician organization (1,200) spun out to MSO. Metrics: annually - 46,000 inpatient, 221,000 outpatient, 113,000 ED.


24

© 2014

9. Large city IDN

a. Regional IDN with four hospitals, rehabilitation hospital, behavioral health, home health, reference lab, community facilities, and primary and specialty physician group. Metrics: annually - 171,000 ED, 62,000 inpatient, 1,000,000 outpatient, 7,600 live births.

10. Small City Community Hospital with affiliation to teaching hospital

Regional hospital (400 bed) affiliated with medical school and the VA. Affiliated with community physicians but less emphasis on having employed physicians. Partnership with Walmart for com-munity clinics. Metrics: annually - 51,000 ED, 1,500 live births.

11. Large city AMC

1000 Physician group affiliated with academic medical center and community hospital with focus on internal medicine, OB/GYN, dermatology, pediatrics, integrative medicine and corporate health at multiple clinic locations. Metrics: annually - 60,000 inpatient, 130,000 ED, 14,000 live births.

12. Small city community hospital

a. Community hospital providing full range of med/surgical services. Metrics: annually - 53,000 ED, 13,000 inpatient, 12,500 outpatient.

13. Small city IDN

a. Regional IDN with 6 hospitals, 13 ambulatory care centers, 25 specialty care facilities and 2,300 physicians. Part of national IDN. Metrics: annually - 50,000 inpatient, 1,200,000 outpatient, 130,000 ED, 4,000+ live births.

25

APRIL 2014

© 2014

Appendix C: Acronyms Used

Acronym Definition

ACA Affordable Care Act

AMC Academic medical center

CME Continuing medical education

CMS Center for Medicare and Medicaid Services

CNM Clinician network management

ED Emergency department

EHR Electronic health record

EMR Electronic medical record

FFS Fee-for-service

HCO Health care organization

HIE Health information exchange

HIPAA Health Insurance Portability and Accountability Act

HIT Healthcare Information Technology

ICD-10 International Classification of Disease-10

IDN Integrated delivery network

IPA Independent practice association

IT Information Technology

LTPAC Long-term and post-acute care providers

MU Meaningful use

P4P Pay-for-performance

PCP Primary care provider

POC Point of care

TOC Transitions of care

VA Veterans Administration

VBR Value-based reimbursement

VDT View, download and transmit


26

© 2014

About Chilmark Research

Chilmark Research is a global research and advisory firm that focuses solely on the market for HIT solutions. Using a pragmatic, evidence-based research methodology with a strong emphasis on primary research and objectivity, we provide healthcare leaders the most in-depth and accurate portrait of the critical technology and adoption trends in the HIT sector. With an eye on the future, our research provides clients the guidance they need to shape their own HIT strategies.

Chilmark Research reports serve the needs of technology adopters, consultants, investors, and IT vendors. While there are countless HIT domains we could cover, Chilmark Research prioritizes those areas that hold the greatest promise to transform and improve patient care. These domains include: Analytics, Electronic Health Records and derivatives thereof, Health Information Exchange, Patient Engagement, Tele/Remote Monitoring including mHealth and Population Health Management.

With all of our research, our primary objective is simple: To provide healthcare leaders the information they require to make informed decisions on the assessment, adoption, deployment, and use of IT to ultimately im-prove the quality of care delivered and support better patient outcomes.


Contact

For more information please feel free to contact the authors:

John Moore [email protected]

Brian Murphy [email protected]

Chilmark Research LLC

5 JFK St., Suite 404 Cambridge, MA 02138 www.ChilmarkResearch.com [email protected] Ph. 617.615.9344

the migration to clinician network management - chilmark research

Documents