ONC12: Health IT helps strive toward triple aim

Representatives from a range of organizations discussed how health IT is helping them achieve the triple aim of improving care quality, bettering patient outcomes and lowering healthcare costs during the Office of the National Coordinator of Health IT’s (ONC) annual meeting on Dec. 12.

The Northern New England Accountable Care Collaborative is a new entity that just started in March. “We were looking for opportunities to move away from fee for service,” said its CEO David Wennberg, MD, MPH. “We’ve been successful in bringing groups together because they are only moderately competitive and realized that if they did things together, they would have a lower cost of ownership of building an infrastructure but, more importantly, if they learn from each other, they would accelerate movement into this new world.”

Technology is necessary but not sufficient to get where we need to be, Wennberg said. The collaborative is a shared services entity supporting many more organizations as it grows. “Our mission is to deliver products and services to support providers as they migrate from fee for service to care paid for by capitation aligned with the triple aim.” Among the products the collaborative is developing is an integrated information system which includes data from a wide range of sources. Those data are integrated into a patient-centric longitudinal record that becomes the sole source of truth for  the apps that sit on top of that. Once the data are entered into the system, a variety of predictive models and triggers and alerts are available. “We are creating population health management one person at a time all built onto the same information technology.”

Karen DeSalvo, MD, MPH, MSc, Health Commissioner for New Orleans, discussed how Louisiana’s healthcare system has changed since Hurricane Katrina devastated the region in 2005. The area has high costs and poor quality when it comes to healthcare, she said. There are no data about the care received by 20 percent of the population. Katrina closed down all the hospitals which created an opportunity to work together in a different way. “We created a charter with a set of values and goals that called for everyone to have access to affordable health insurance products, to use health IT to improve care, focus the new system on primary care and prevention, and create a culture of quality.”

As a result, the area had a “lovely resurgence of primary care.” Today, 20 percent of the New Orleans’ population uses a medical home, and the uninsured have access to great quality care, she said. “Not just care but good care. We’ve been able to define that as a state.”

DeSalvo and her team decided to create “a safe place where data could be shared and conversations had about healthcare quality.” To the end, the Louisiana Healthcare Quality Forum was established and became the recipient of a multipayer database. The forum is now ready for analytics and has been a leader for two of the area’s ONC grants.

When it came to health IT, stakeholders considered how that would enable better care not just at the point of care but at the population level. When the city was flooded and shut down for 30 days, people in the midst of chemotherapy and anticoagulant treatment were scattered. That unsafe situation for certain patients led to an “acute sense that we needed to fix that. We need to be more prepared in disasters to help people maintain their care but also do a better job of that every day.”

Katrina turned out to present a tremendous opportunity, DeSalvo said, as there was no legacy system to move out of. The majority of the population now has the majority of their health information on EHRs. “That also means we could do more with respect to population management in clinics which is so critical when we have limited resources.”

The Crescent City Beacon Community has offered a chance for DeSalvo and her team to use their efforts to focus on population-level indicators. The HIE includes 170,000 lives and offers “a tremendous additional tool for providers and clinics to understand how they can do a better job of improving care.”

Meanwhile, Louisiana is experimenting with the cost of care, DeSalvo said. They have yet to achieve affordable health insurance but have worked on end arounds for primary care. “We have learned that population-based capitation is a great way to pay for primary care. We encourage development of teams, and a forward-thinking approach to health. We have encouraged providers to work together even though they are competing because they are stronger together.”

Kaiser Permanente, a vertically integrated care system with 9 million members, was very forward thinking when it established prepayment for healthcare years before other organizations were even thinking about it.

“We get our cash flow from members and deliver care,” said CEO George Halvorson, MBA. “We concluded while ago that best way of taking advantage of our organization model and taking care of our population would be to have sufficient data about the people we’re taking care of.”  The goal is to have all information about all patients available all of the time to caregivers at the point of care. That model works “incredibly well,” he said. Kaiser Permanente has cut its death rate for stroke by 40 percent, cut broken bones by one-third and its HIV patient death rate is half that of the national average, he said.

“We’ve put together a total package of care.” The organization’s database provides an outpatient safety net, he added, because it scans through the database to identify care that should have been delivered, such as medication refills and missed appointments. “We identified across the care system last year two million opportunities to do interventions,” Halvorson said, which saved about $250 million in hospital admissions. “For just about anybody else, that would be lost revenue. I believe passionately in Meaningful Use. When you put data on a computer and use it in a meaningful way, it’s an incredibly powerful and important thing to do in patient care.

In the future, care will be delivered in one of the following four sites, Halvorson predicted:

• Hospitals or hospital equivalents—places where patients are in bed and will require the best and safest care.
• Face-to-face encounters with patients in two extremes—a large mega clinic serving as a one-stop shop or a care kiosk where perhaps a nurse connected upstream provides care.
• Home. Certain patients will really benefit from care in their home, said Halvorson. “With the right technology, support, follow up and connections, home is going to replace the first two sites for many patients. The future of in-home care is very robust.”
• The internet is going to make the world flat for much care, he said. “A rich set of apps will help people and this site will be where a lot of population-level interventions will take place.”

“All four sites of care, if we do really well, care will be less expensive, more consistent and better.”

We need to go down the path of reengineering care, he said. Pre-payment allows for that. “When you live off of a fee schedule, you can only do things on the fee schedule. We have criminalized certain levels of innovation under the fee schedule model. Fee schedules cripple innovation and absolutely stifle any kind of enhancement, because they starve it.”