Health information exchange helps medical group find success with value-based care
Wes Combs is chief information officer at Holston Medical Group in Kingsport, Tennessee, which serves northeast Tennessee, southwest Virginia, and Charlotte, North Carolina. He’s also president of OnePartner Health Information Exchange, based in Duffield, Virginia.
The HIE was started by several doctors at Holston Medical Group as an investment to support and improve the doctor-patient relationship by making it easier for providers to see all instances of care for their patients, no matter where they were treated.
“As a forward-looking and progressive healthcare organization, Holston Medical Group, one of the largest multi-specialty medical groups in the southeast, made the bet in 2012 that healthcare would make a transition toward value at a more accelerated rate than compared to the years prior,” Combs said.
The group is a company that saw the market for value-based care as an opportunity. However, in order to make the transition, the organization had to start thinking in the same terms as insurance companies, Combs explained. This required an approach to manage the highly complex patient population that consumes the majority of the avoidable healthcare dollars and how they can be addressed at alternative locations, he said.
“Holston Medical Group identified a data-driven approach as the answer to manage the risk these new payment models would bring,” Combs said. “At the time, in the Appalachia region, we had a failed Health Information Exchange and still used an outdated data transmission method – faxing.”
Understanding that this would not allow the group to be effective in the new model of care, it sought a vendor-agnostic solution that could be a safe place to aggregate and store patient data. This location had to be designed to efficiently keep patients’ records safe, protected and accessible for providers treating at the point of care.
“For any HIE or population health platform, the hardest part of the equation is the accessibility of data to the physician for treatment purposes when it matters the most – when the patient is sitting in front of the physician for an exam or checkup,” Combs explained.
“The reason is that this is the time when the physician has the ability to educate and inform the patient on care decisions that could potentially save their life or, time, frustration and money depending on the situation,” he said.
To leap the accessibility hurdle, OnePartner’s electronic health record agent removes physician barriers to review patient data in alternate systems, Combs stated.
“Some of these barriers, for example, require physicians to log-in to extra portals/systems and search patient records numerous times,” he explained. “It is made more difficult by the fact that the physician is also supposed to keep a running tally of quality and use measures in their head on each patient treated and somehow remember to use data from disparate systems to determine if the patient qualifies for the measure and has been screened properly in order to meet the measure.”
"The funding provided into the program allows value-focused organizations like Holston Medical Group to actually achieve savings on populations that otherwise would be considered healthy and funded or, compared under the benchmark."
Wes Combs, Holston Medical Group and OnePartner HIE
An example of this challenge in practice can be illustrated by the review of external charts from an optometrist or ophthalmologist that might have performed a diabetic eye exam on a diabetic patient. If the physician can’t find a record, they are supposed to refer the patient for one of these exams. If the physician doesn’t do this, they are often penalized in the new payment model.
“The value of the OnePartner HIE is that it not only makes finding this information easier, but it also analyzes the data for the physicians, indicating at the point of care whether the patient does indeed need a particular screening and why,” he added.
There are a great many healthcare information exchanges across the country that healthcare provider organizations can join.
MEETING THE CHALLENGE
In addition to improving accessibility of useful data for physicians, another factor in Holston Medical Group’s success moving toward value-based care comes from the ability to identify patients that are the highest risk or the sickest and reminding the physician to assess all current problems they are experiencing, Combs explained. These problems often are tied to hierarchical condition category codes.
“OnePartner offered a point of care HCC coding tool that not only tells the physicians what HCC codes have been assessed in the past and what might still be valid, but they also highlight potentially wrong codes that might appear in error,” he said.
“This HCC coding and review toolset uses the entire patient’s record, no matter where the treatment has taken place, to assist the physician in accurately measuring patient risk,” he added. “This in turn can adjust the amount of money the insurance company or Medicare will allocate to treat that patient.”
One example of over-coding is when a patient was previously assessed as being morbidly obese, but due to proper management of diet and exercise, their body mass index did not qualify them for that code anymore. However, out of habit, the physician reassesses the patient as morbidly obese, even though they have entered a lower category based on the BMI.
“In this case, we succeeded in working with this patient and the toolset now alerts the physician that this HCC doesn’t apply anymore, making the risk score more accurate,” Combs said.
Additionally, with regard to physicians understanding new payment models, the OnePartner HIE offered video-based instruction built directly into the toolset that is designed with physicians and clinical staff in mind. The videos describe each tab and data element along with a playbook for success on how the information is to be used in value-based care. This self-service education model is crucial to scaling a learning initiative that relies more on technology and less on classroom led instruction, Combs said.
“The OnePartner HIE also is helping us identify chronic complex patients that physicians need to see more often,” he added. “It is important to ensure they are seeing a chronic complex patient periodically in order to have a higher chance of preventing them from showing up to a high-cost care location, like a hospital or emergency room, for a condition that can be managed in an outpatient facility with high-quality, low-cost alternatives.”
OnePartner offered Holston Medical Group specific reports and dashboards that any office manager in the clinics can use to schedule these patients for routine visits without having to staff full-time report writers to deliver this information. Since OnePartner’s tools are integrated directly into the HIE, Holston Medical Group staff was easily able to integrate these processes into the normal office workflow.
“Within the Holston Medical Group community, the organization has been very fortunate and has connections and integration with all the major players running systems from Allscripts, Epic, Cerner and athenahealth,” Combs said. “It is also blessed with connections from smaller EHRs and practices.”
Using this HCC information, Holston Medical Group’s physicians moved their HCC/RAF score from .97 to 1.3 on certain populations, Combs explained.
“This accurate level of coding is one of the first steps in building a platform for success in the new payment structure like value-based care,” he said. “The funding provided into the program allows value-focused organizations like Holston Medical Group to actually achieve savings on populations that otherwise would be considered healthy and funded or, compared under the benchmark.”
These results are based on physicians understanding the new payment models and having the ability to take action on the information at the point of care. When information similar to what OnePartner offers is not delivered in real time, there is often a large back-office team that is required to work on getting conditions re-assessed by the physician so the funding can be put in place, Combs said.
“This extra back-office labor can outweigh the financial gain provided to the physician or group for identifying the complexity of the patient in the first place, and therefore is a useless effort,” he warned. “If left unchecked this can be a never-ending cycle.”
In total, more than 95% of the encounters in the region are captured within the OnePartner community record as 1,200 physicians in the region use the HIE. As a result, Holston Medical Group providers get a comprehensive view of the patient – no matter the physician they visited in the past, Combs said.
“They are able to care for patients and understand the patient’s medical history at the point of care, reducing delays, duplicated testing, harmful mixing of prescriptions and more,” he added.
Since joining the community HIE, Holston Medical Group, Combs reported, has:
- Increased pay-for-value payments by 44%, with more than $13 million in value-based revenue annually;
- Increased fee-for-service payments by 7%;
- Significantly reduced readmissions, with a decrease of nearly 7.5% through participation in an accountable care organization and decreases between 6.8% and 12.3% under contracts with payers;
- Reduced the employee-to-provider ratio by 0.7 FTEs;
- Reduced emergency department visits, with an ED utilization rate that is 25% better than that of other providers in the market.
ADVICE FOR OTHERS
“Having a common record like the OnePartner HIE levels the data playing field for all the providers and puts quality, service and cost – or value – at the forefront,” Combs advised. “This means that as an industry we can start competing on value and not control. Once a platform like this is in place, it is important for physicians and staff to fully understand its potential under the new model so that they utilize the platform and achieve meaningful outcomes.”